Disease Treatments (consider multiple diseases when considering treatment recommendations)
Asthma:
For an acute asthmatic attack:
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Fast acting Adrenergic; either Albuterol (2.5 mg) or Xopenex (0.31,0.63 or 1.25mg); may give multiple doses or
continuously through a HEART neb. May also give via MDI/holding chamber; typically this is given with oxygen, assess
SpO2, patient response and LOC. May use Bipap for severe asthma attacks. May also use Heliox
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Anti-cholinergic; given along with an adrenergic, Atrovent 0.5mg
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Systemic Steroid may be warranted, Solumederol or Prednisone.
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Assess breath sounds, cough, vital signs, Peak flow measurements
o Once stabilized: Conduct asthma education including severity of symptoms, allergies and spirometry
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For status asthmaticus; patient will require intubation and mechanical ventilation
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Once admitted, deliver round the clock frequencies of an adrenergic; either Q4-6, wean from this as the patient
improves. Check Peak flow measurements BID, give an ICS/LABA BID. Check Esionphil level
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Recommend follow up spirometry testing after discharge and allergy testing if not done previously
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Patient will receive a systemic steroid upon discharge for 3-5 days; avoid triggers and allergens, check air quality daily
Treatment for NON attacks
Mild Intermittent:
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Albuterol or Xopenex MDI PRN with holding chamber
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Take 1 hour before exertion for sports induced asthma
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Avoid known allergens, perform peak flow meter to determine severity of symptoms
Mild persistent:
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Albuterol or Xopenex MDI PRN with holding chamber
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Take 1 hour before exertion for sports induced asthma
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Avoid known allergens, perform peak flow meter to determine severity of symptoms
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Anti-allergen such as a mast cell inhibitor like Intal or Tilade OR a Leukotriene inhibitor such as Singular or Accolate
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If patient has seasonal allergens recommend nasal sprays, may also require monthly allergy shot Xolair
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Patient may replace allergen medication with a mild ICS/LABA such as Advair or symbicort
Moderate persistent
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Albuterol or Xopenex MDI PRN with holding chamber
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Take 1 hour before exertion for sports induced asthma
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Avoid known allergens, perform peak flow meter to determine severity of symptoms
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Anti-allergen such as a mast cell inhibitor like Intal or Tilade OR a Leukotriene inhibitor such as Singular or Accolate
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If patient has seasonal allergens recommend nasal sprays, may also require monthly allergy shot Xolair
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Patient should take a moderate dose of ICS/LABA such as Advair, Symbicort, Asmanex, Qvar… Along with a LABA such
as Serevent, Foradil or Brovona
Severe Persistent
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Albuterol or Xopenex MDI PRN with holding chamber
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Take 1 hour before exertion for sports induced asthma
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Avoid known allergens, perform peak flow meter to determine severity of symptoms
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If patient has seasonal allergens recommend nasal sprays, may also require monthly allergy shot Xolair
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Patient should take a high dose of ICS/LABA such as Advair, Symbicort, Asmanex, Qvar… Along with a LABA such as
Serevent, Foradil or Brovona
Chronic Bronchitis
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Smoking cessation
Daily/continuous use of low concentration oxygen; an Adrenergic and Anti-cholinergic; such as Combivent or DuoNeb.
Frequency depends on severity. For exacerbations may be given Q4. For home use BID, TID, QID
May give multiple treatments during an exacerbation. You will assess CXR, ABG, Labs and history to help assess cause
of exacerbation
Treat all underlying or contributing problems; such as infection
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May use BiPAP for exacerbation
May use Spiriva in place of Atrovent. If using Spiriva they should not also use Atrovent.
Mucolytics for episodes of congestion. May use Mucomyst 10-20% 3-5ml along with adrenergic.
Anti-biotic, used during acute infections, but may be recommended on a daily basis for prevention of infection
May use PEP devices to deliver medications, Use breathing techniques such as pursed lip breathing, diaphragmatic
breathing and Huff cough; give bronchial hygiene to manage secretions
Daily ICS/LABA such as Advair or Symbicort
Recommend pulmonary rehabilitation, exercise and proper nutrition
Emphysema
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Smoking cessation
Daily/continuous use of low concentration oxygen; Adrenergic and Anti-cholinergic; such as Combivent or DuoNeb.
Frequency depends on severity. For exacerbations may be given Q4. For home use BID, TID, QID
May give multiple treatments during an exacerbation. You will assess CXR, ABG, Labs and history to help assess cause
of exacerbation
May use BiPAP for exacerbation
May use Spiriva in place of Atrovent. If using Spiriva they should not also use Atrovent.
Anti-biotic, used during acute infections, but may be recommended on a daily basis for prevention of infection
May use PEP devices to deliver medications, Use breathing techniques such as pursed lip breathing, diaphragmatic
breathing and Huff cough; give bronchial hygiene to manage secretions
Daily ICS/LABA such as Advair or Symbicort
Recommend pulmonary rehabilitation, exercise and proper nutrition
Surgery available but not common
For Alpha 1-Antitrypsin, avoid inhaling toxic particles, avoid air pollution
o May use drugs such as Prolastin
Cystic Fibrosis
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Daily/continuous use of low concentration oxygen; Adrenergic and Anti-cholinergic; such as Combivent or DuoNeb.
Frequency depends on severity. For exacerbations may be given Q4. For home use BID, TID, QID
May give multiple treatments during an exacerbation. You will assess CXR, ABG, Labs and history to help assess cause
of exacerbation
May use BiPAP for exacerbation
May use Spiriva in place of Atrovent. If using Spiriva they should not also use Atrovent.
Anti-biotic, used during acute infections, but may be recommended on a daily basis for prevention of infection
May use PEP devices to deliver medications, Use breathing techniques such as pursed lip breathing, diaphragmatic
breathing and Huff cough; give bronchial hygiene to manage secretions; IPV/IPPB/Flutter/CPT with Vest…
Daily ICS/LABA such as Advair or Symbicort
Recommend pulmonary rehabilitation, exercise and proper nutrition
Surgery available but not common
Pulmozyne (Dornase Alfa) BID
Dietary supplements. Vitamins
Pneumonia
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If patient has no underlying pulmonary disease, treat judiciously based on symptoms and patients ability to cough and
maintain their airway
If patient has increased pulmonary congestion, give bronchial hygiene, such as a CPT, Flutter, IPV, IPPB, Suctioning…
Recommend bronchoscopy (therapeutic) if patient has tenacious impissiated secretions
Anti-biotics, may be broad initially but once the bacteria is identified will become specific
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Treat fever with cooling measures and Tylenol
Treat congestion with Mucolytics such as Mucomyst 10-20% and a Adrenergic via HHN or PEP device or hyperinflation
therapy such as IPPB or an IS
Administer continuous heated aerosol or humidity
Ensure proper IV Hydration
Treat any underlying condition or precipitating conditions such as pleural effusions/thorencentesis. May require
positive pressure for shunts
Patient may get steroids systemically
Assess Labs (WBC, lactic acid), Cultures, vitals… Suspect ARDS development with increasing O2 demand and
worsening compliance and shunting; watch for developing Sepsis
Croup
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Treat cold like symptoms
Isolate from other children
May give Racemic Epi (0.25 ml or 0.5ml) for upper airway constriction
May give a systemic or aerosolized steroid such as Decadron
Cool humidity or aerosol continuously
May obtain neck x-ray
If patient has underlying pneumonia or asthma, treat appropriately
Severe Croup may require intubation
Epiglottitis
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An emergent situation, sedate and intubate
Deliver systemic steroids once intubated and assess level of swelling by checking neck x-rays and check cuff pressures
of ETT if cuff is present (baby ETT have no cuffs), check leak around airway
Neuromuscular diseases
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If no underlying pulmonary disease, assess patients muscle strength by assessing VC, MEP and MIP BID or more
frequent as condition worsens
Assess ABG to assess ventilation
May use night CPAP or BIPAP, eventually leading to continuous use then intubation and tracheotomy
Give bronchial hygeiene using PEP, IPV, IPPB, CPT, suctioning, mucolytics and heated aerosol/humidity as the patients
cough will be limited
Treat underlying and developing conditions such as pneumonia
Depending on type of neuromuscular disease may treat with plasmophoresis, immunoglobulins, cholinergics (don’t
use if patient has lung disease), steroids…
Renal problems
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Treat with diruretics, hemodialysis/continous dialysis, blood transfusions
BiPAP or mechanical ventilation for pulmonary edema
Oxygen to support low CaO2
Assess GFR, BUN, Creatnine, Electrolytes, blood pressure, metabolic acidosis, lactic levels, inputs and outputs, renal
ultrasounds
Steroids, Albumin, proteins, electrolytes, blood pressure medications…
Treat underlying conditions, pleural effusions, anemia, lethargy, electrolyte imbalances and cardiac arrhythmias
Ensure patent airway if patient develops metabolic encephalopathy
CHF
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Treat with inotropics, BiPAP/CPAP for pulmonary edema, diuretics
Treat underlying problems
Assess CXR, BNP, Echocardiogram, Ejection fraction, Cardiac output, renal output…
EKG
Treat Pleural effusion, diet control/obesity, low salt diets, fluid restriction
Treat possible hypertension
Pulmonary Hypertension
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Treat with vasodilators such as Nitric Oxide
Inhaled iloprost, Prostacyclin
Treat underlying disease if one exists
Orders for RT medications should include:
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Medication
Dose
Frequency; with a PRN frequency and reason for PRN
Modality of delivery
Examples:
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Albuterol 2.5 mg with 3ml NS QID & Q4 PRN for wheezing via SVN
o OR
Xopenex 1.25 mg, TID & Q2 PRN for wheezing via EZPAP
o OR
Albuterol 90 mcg MDI x 2 puffs BID & Q4 PRN for wheezing.
Additional therapies are also listed, such as CPT, Suctioning, Pulse Oximeter checks, ABG, other RT medications, OXYGEN amount
and modality, ranges to keep SpO2…
GIVE THE APPROPIATE RT MEDICATION, MODALITY AND FREQUENCY TO YOUR PATIENTS. IF THERE IS NO INDICATION FOR A
PARTICULAR DRUG, THEN DO NOT RECOMMEND ITS USE. ALWAYS SELECT THE APPROPIATE MODALITY PER THE PATIENTS
ABILITY. IF THEY CAN NOT PERFORM A MDI OR DPI FOR EXAMPLE GET IT CHANGED TO A SVN! RECOMMEND MEDICATION
AND FREQUENCY CHANGES WHEN APPROPIATE
ALWAYS ASSESS YOUR PATIENTS BEFORE, DURING AND AFTER THERAPY; THIS INCLUDES BREATH SOUNDS, HEART RATE,
RESPIRATORY RATE, COUGH, PEAK FLOWS, CHEST EXURSION, GENERAL APPEARANCE…
IDENTIFY RISKS AND STOP THERAPY IF THE PATIENT’S HR OR OTHER FACTORS BECOME DANGEROUSLY OUT OF RANGE. HR IS
TYPICALLY MONITORED SO THAT IF IT INCREASES MORE THAN 20, TREATMENT IS HELD.
ALWAYS EDUCATE YOU PATIENTS. LEAVE THEM KNOWING WHY THEY RECEIVED THEIR MEDS AND WHAT SIDE EFFECTS MAY
OCCUR. EDUCATE THEM ON THE PROPER USE OF THEIR MEDS AND DEVICES AND THEIR DISEASE.
IF THE PATIENT REQUIRES MORE OR LESS THERAPY THAN THEY ARE CURRENTLY RECIEVEING CHANGE THE THERAPY! USE
PROPER CLINICAL JUDGMENT AND ISOLATION PERCAUTIONS. USE CRITICAL THINKING TO PROPERLY ASSESS YOUR
PATIENTS. NEVER STACK TREATMENTS.