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## Complete Summary

#### GUIDELINE TITLE

Bland aerosol administration: 2003 revision and update.

#### BIBLIOGRAPHIC SOURCE(S)

Kallstrom TJ. AARC clinical practice guideline. Bland aerosol
administration\--2003 revision & update. Respir Care 2003
May;48(5):529-33. \[23 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12778893)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Association for
Respiratory Care (AARC). AARC clinical practice guideline. Bland aerosol
administration. Respir Care 1993 Nov;38(11):1196-200.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Pulmonary disease

#### GUIDELINE CATEGORY

Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Pulmonary Medicine

#### INTENDED USERS

Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

-   To improve the consistency and appropriateness of respiratory care
    and serve as a guide for education and research

-   To provide clinical practice guidelines on bland aerosol
    administration

#### TARGET POPULATION

-   Individuals with the presence of upper airway edema (i.e.,
    laryngotracheobronchitis \[LTB\]; subglottic edema; post-extubation
    edema)

-   Patients in the postoperative period for management of the upper
    airway

-   Patients with a bypassed upper airway

-   Patients requiring laboratory evaluation of sputum specimens

#### INTERVENTIONS AND PRACTICES CONSIDERED

Bland aerosol administration, which includes the delivery of sterile
water or hypotonic, isotonic, or hypertonic saline in aerosol form

**Note**: Bland aerosol administration may or may not be accompanied by
oxygen administration.

#### MAJOR OUTCOMES CONSIDERED

-   Effectiveness of bland aerosol administration for airway
    humidification

-   Effects of bland aerosol on mucus production and mucus properties

-   Complications of bland aerosol administration

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Consultants to the Working Group may review the initial draft of the
guideline. After the Working Group completes its review, the draft is
reviewed by the entire Steering Committee and then by a Review Panel
(i.e., persons engaged in all facets of the delivery of respiratory care
who have volunteered to review drafts of the Guidelines before
publication).

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Description/Definition**

For purposes of the guideline, bland aerosol administration includes the
delivery of sterile water or hypotonic, isotonic, or hypertonic saline
in aerosol form. Bland aerosol administration may or may not be
accompanied by oxygen administration.

-   The use of cool, bland aerosol therapy is primarily indicated for
    upper airway administration; therefore, a mass median aerodynamic
    diameter (MMAD) [\>]{.underline}5 microns is desirable.

-   The use of hypo- and hypertonic saline is primarily indicated for
    inducing sputum specimens; therefore, a MMAD of 1-5 microns is
    desirable.

-   The use of heated bland aerosol is indicated primarily for
    minimizing humidity deficit when the upper airway has been bypassed;
    therefore, a MMAD of 2-10 microns is desirable.

**Settings**

Bland aerosol therapy can be administered in settings that include
hospital, clinic, extended care facility, and home.

**Indications**

-   The presence of upper airway edema\--cool bland aerosol

    -   Laryngotracheobronchitis (LTB)

    -   Subglottic edema

    -   Post-extubation edema

    -   Postoperative management of the upper airway

-   The presence of a bypassed upper airway

-   The need for sputum specimens or mobilization of secretions

**Limitations of Method**

-   The efficacy of intermittent or continuous use of bland aerosol as a
    means of reducing mucus has not been established. Bland aerosol is
    not a substitute for systemic hydration.

-   The physical properties of mucus are only minimally affected by the
    addition of water aerosol.

-   Bland aerosol for humidification when the upper airway has been
    bypassed is not as efficient or effective as are heated water
    humidifiers or adequately designed heat moisture exchangers (HME)
    because of the:

    -   difficulties in maintaining temperature at patient airway

    -   possible irritation to the airway

    -   infection risk

**Assessment of Need**

-   The presence of one or more of the following may be an indication
    for administration of sterile water or isotonic or hypotonic saline
    aerosol:

    -   Stridor

    -   Brassy, croup-like cough

    -   Hoarseness following extubation

    -   Diagnosis of LTB or croup

    -   Clinical history suggesting upper airway irritation and
        increased work of breathing (e.g., smoke inhalation)

    -   Patient discomfort associated with airway instrumentation or
        insult

    -   Bypassed upper airway

-   The presence of the need for sputum induction (e.g., for diagnosis
    of *Pneumocystis carinii* pneumonia or tuberculosis) is an
    indication for administration of hypertonic saline aerosol.

**Resources**

-   Equipment\--depending upon the specific application, components may
    include:

    -   Aerosol generator

        -   Large volume nebulizer

        -   Ultrasonic nebulizer

        -   Small volume nebulizer

    -   Heater or cooling device

    -   Patient application device

        -   Mist tent

        -   Hood

        -   Mouthpiece

        -   Mask

        -   T-piece

        -   Face tent

        -   Tracheostomy collar

    -   Corrugated aerosol tubing and water trap

    -   Tissues and emesis basin or container for collecting or
        disposing of expectorated sputum

    -   Gloves, goggles, gown, and mask

    -   Suction device and catheters

    -   Oxygen analyzer

    -   Device for filtering exhaled gas during sputum induction, with
        scavenger or filter system

    -   Thermometer

-   Personnel:

    -   Level I caregiver\--may be the provider of service after Level
        II personnel have established need for a specific device by
        patient assessment and the first administration has been
        completed. Level I personnel must demonstrate:

        -   Proper preparation, measurement, and mixing of solution

        -   Proper technique for administration of solution to be
            aerosolized

        -   Proper use of equipment

        -   Effective cleaning of equipment

        -   Appropriate disposal of wastes

        -   Ability to encourage effective breathing patterns and
            coughing techniques

        -   Ability to modify techniques in response to adverse
            reactions as instructed and to appropriately communicate
            with physician, detailing the severity of symptoms

        -   Compliance with Standard Precautions and proper infection
            control procedures

    -   Level II personnel\--will supervise Level I personnel. Level II
        personnel are responsible for initial assessments and care of
        the unstable patient, and must demonstrate knowledge and skill
        related to:

        -   Indications and limitations for aerosol devices and
            associated equipment

        -   Proper use, maintenance, and cleaning of equipment,
            including filter and scavenging systems

        -   Risks inherent to the aerosolized solution and specific
            devices

        -   Procedures for safely disposing of hazardous wastes

        -   Breathing patterns and coughing techniques

        -   Modification of technique in response to adverse reactions

        -   Modification of flowrates and temperature as prescribed, in
            response to severity of symptoms

        -   Assessment of patient condition and response to therapy

        -   Auscultation, inspection, and monitoring of vital signs

        -   Determination of peak expiratory flowrate, spirometry, and
            ventilatory mechanics

        -   Recognition and response to adverse reactions and
            complications of procedure

        -   Understanding and compliance with Standard Precautions

        -   Proper disposition of medical waste

**Monitoring**

The extent of patient monitoring should be determined on the basis of
the stability and severity of the patient\'s condition:

-   Patient subjective response\--pain, discomfort, dyspnea,
    restlessness

-   Heart rate and rhythm, blood pressure

-   Respiratory rate, pattern, mechanics, accessory muscle use

-   Sputum production quantity, color, consistency

-   Skin color

-   Breath sounds

-   Pulse oximetry (if hypoxemia is suspected)

-   Spirometry equipment (if concern of adverse reaction)

**Frequency**

-   Critical care or emergency room settings that require continuous
    administration of bland aerosol necessitate close monitoring:

    -   Short duration: 4-8 hours following extubation

    -   Subglottic edema: until clinical evidence of edema has subsided

    -   Long duration: artificial airways

    -   Re-evaluation every 8 hours or with change in clinical condition

-   Acute care patients should be evaluated for response to therapy of
    continuous administration of bland cool aerosol for LTB and
    re-evaluated at least every 48-72 hours or with change in clinical
    response.

-   Home care patients should be re-evaluated periodically for response
    to therapy or with change in status.

-   Sputum induction should be performed as often as necessary to yield
    appropriate specimen for desired examination (e.g., each morning for
    3 days for acid-fast bacillus).

**Infection Control**

-   Standard Precautions for body fluid isolation are to be implemented.

-   Centers for Disease Control and Prevention recommendations for
    control of exposure to tuberculosis and droplet nuclei are to be
    implemented when the patient is known or suspected to be
    immunosuppressed, is known to have tuberculosis or has other risk
    factors for the disease.

    -   To reduce aerosol contamination of room air:

        -   Enclose and contain aerosol administration.

        -   Filter aerosols that bypass or are exhaled by patient.

        -   When aerosol release to the atmosphere cannot be routed
            through a filter:

            -   Use filtered scavenger systems to remove aerosols that
                cannot be contained.

            -   Provide local exhaust ventilation to remove aerosols
                that are released into room air.

            -   Provide frequent air exchange to dilute concentration of
                aerosol in room.

            -   Allow exchange of gas in the room to eliminate 99% of
                aerosol before the next patient enters or receives
                treatment in that area.

            -   Provide booths or stalls for sputum induction in areas
                in which multiple patients are treated. Booths or stalls
                should be designed to provide adequate airflow to draw
                aerosol and droplet nuclei from the patient and into an
                appropriate filtration system with exhaust directed to
                an appropriate outside vent. Booths should be adequately
                cleaned between patients.

        -   Filters, nebulizers, and other contaminated disposable
            components of the aerosol delivery system should be treated
            as hazardous waste.

        -   Personal protection devices should be used to reduce
            exposure when engineering alternatives are not adequate or
            in place.

            -   Use properly fitted respirator with adequate filtration
                when flow exhaust cannot control removal of aerosols.

            -   Goggles, gloves, masks, and gowns should be used to
                serve as splatter shields and to reduce exposure to body
                substances.

        -   Personnel should safely dispose of hazardous wastes.

        -   Personnel who are at high risk for adverse effects from
            exposure should be offered an opportunity for alternative
            assignments.

    -   Nebulizers should not be reused between patients without
        disinfection.

    -   Nebulizers should be sterilized, changed, or cleaned, according
        to institutional infection control policy or at conclusion of a
        procedure that is not to be repeated.

    -   Solutions should be handled aseptically.

    -   Solutions from multidose sources must be handled aseptically and
        discarded after 24 hours.

#### CLINICAL ALGORITHM(S)

> None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

> The type of evidence supporting the recommendations is not
> specifically stated. The guideline is developed from a thorough review
> of the literature, surveys of current practice, and the expertise of
> the members of the Working Group.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate clinical utilization of bland aerosol administration

-   Desired patient outcomes with administration of water or hypotonic
    or isotonic saline, including decreased work of breathing; improved
    vital signs; decreased stridor; decreased dyspnea; improved arterial
    blood gas values; improved oxygen saturation as indicated by pulse
    oximetry (S~pO2~).

-   With the administration of hypertonic saline, successful attainment
    of adequate sputum sample for analysis

#### POTENTIAL HARMS

-   Wheezing or bronchospasm

-   Bronchoconstriction when artificial airway is employed

-   Infection

-   Overhydration

-   Patient discomfort

-   Caregiver exposure to droplet nuclei of *Mycobacterium tuberculosis*
    or other airborne contagion produced as a consequence of coughing,
    particularly during sputum induction

-   Edema of the airway wall

-   Edema associated with decreased compliance and gas exchange and with
    increased airway resistance

-   Sputum induction by hypertonic saline inhalation can cause
    bronchoconstriction in patients who have chronic obstructive
    pulmonary disease (COPD), asthma, cystic fibrosis, or other
    pulmonary diseases.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

> Contraindications to bland aerosol administration:

-   Bronchoconstriction

-   History of airway hyperresponsiveness

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

> **Outcome Assessment**

-   With administration of water or hypotonic or isotonic saline, the
    desired outcome is the presence of one or more of the following:

    -   Decreased work of breathing

    -   Improved vital signs

    -   Decreased stridor

    -   Decreased dyspnea

    -   Improved arterial blood gas values

    -   Improved oxygen saturation as indicated by pulse oximetry
        (S~pO2~)

-   With administration of hypertonic saline, the desired outcome is a
    sputum sample adequate for analysis.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

> Getting Better\
> Living with Illness

#### IOM DOMAIN

> Effectiveness\
> Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

> Kallstrom TJ. AARC clinical practice guideline. Bland aerosol
> administration\--2003 revision & update. Respir Care 2003
> May;48(5):529-33. \[23 references\]
> [PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12778893)

#### ADAPTATION

> Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

> 1993 Dec (revised 2003)

#### GUIDELINE DEVELOPER(S)

> American Association for Respiratory Care - Professional Association

#### SOURCE(S) OF FUNDING

> American Association for Respiratory Care (AARC)

#### GUIDELINE COMMITTEE

> Aerosol Therapy Guidelines Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

> *Primary Author*: Thomas J. Kallstrom, RRT, FAARC

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

> Not stated

#### GUIDELINE STATUS

> This is the current release of the guideline.
>
> This guideline updates a previous version: American Association for
> Respiratory Care (AARC). AARC clinical practice guideline. Bland
> aerosol administration. Respir Care 1993 Nov;38(11):1196-200.

#### GUIDELINE AVAILABILITY

> Electronic copies: Available in Portable Document Format (PDF) from
> the [American Association for Respiratory Care (AARC) Web
> site](http://www.rcjournal.com/contents/05.03/05.03.0529.pdf).
>
> Print copies: Available from the American Association for Respiratory
> Care (AARC), CPG Desk, 11030 Ables Ln, Dallas, TX 75229-4593; Web
> site: [www.aarc.org](http://www.aarc.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

> None available

#### PATIENT RESOURCES

> None available

#### NGC STATUS

> This summary was completed by ECRI on November 30, 1998. The
> information was verified by the guideline developer on December 15,
> 1998. This summary was updated by ECRI on August 20, 2003.

#### COPYRIGHT STATEMENT

> This NGC summary is based on the original guideline, which is subject
> to the guideline developer\'s copyright restrictions.

### DISCLAIMER

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> © 1998-2008 National Guideline Clearinghouse
>
> Date Modified: 11/3/2008
>
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