GUIDELINES FOR WEANING OF BRONCHODILATOR THERAPY

Field: Health Professions (Health Sciences)

Date Month Year Dear Editor, Children's Hospitals Australasia, which includes all the major children's hospitals throughout Australia and New Zealand as well as paediatric units within general hospitals, recently conducted a clinical forum on asthma as part of its national benchmarking programme. At the forum, a working group was established to consider and advise as to how to optimally decrease or step down therapy in hospital as the clinical course improved. In particular, forum members identified that the weaning of inhaled bronchodilator treatment of inpatients with asthma is sometimes delayed unnecessarily. These delays could result in over treatment as well as prolongation of hospital stay in some children, with inherent risks of nosocomial infections. Suggested reasons for the delay included: waiting for the resident medical officer (who may be engaged elsewhere) to review the child before authorizing a change in therapy; delaying the decision to decrease intensity of therapy until the next formal ward round; uncertainty about the nurse's status in initiating change; and current prescribing practice preventing nurses from initiating change without medical authorization. As a result, the working party proposed a set of guidelines, which would essentially help to identify the roles of nurses and doctors more clearly and thereby hopefully, will improve the efficiency of this component of the management of asthma. Clearly, these guidelines may need to be modified according to the specific requirements of each institution. Essentially, the guidelines recommend that the child's bronchodilator treatment is weaned as soon as appropriate, rather than delaying this decision until the following day or the next convenient ward round. The aim of this approach is to ensure that the reduction in the frequency of bronchodilator administration parallels clinical improvement. Children who are requiring bronchodilator therapy more often than hourly need both vigilant monitoring by the nursing staff and regular review by medical staff. Children who require bronchodilator therapy between 1 and 4 hourly could have the weaning of bronchodilator administration determined by nurses who have been trained to make this judgement. The clinical variables listed in Table 1, when used collectively, would form an integral framework for the assessment of clinical improvement. Consultation with the parent and child at the time can be very helpful in this assessment and should be taken into account. In Australasia, a medical officer is required to prescribe the inhaled bronchodilator. The prescription should state the dose and frequency, for example, four puffs of salbutamol 100 μg by metered dose inhaler and spacer 1–4 hourly as per policy. Where there is clinical improvement, a nurse rather than a doctor should be able to adjust downwards the frequency of inhaled therapy. However, it is recommended that the nurse be a registered nurse with at least 12 months paediatric experience and who has either received formal training in how to assess children with asthma and how to manage step down therapy, or whose clinical experience is deemed to make them competent for step-down decisions. The nurse will review the child and perform a respiratory assessment in line with medication frequency. For example, if the child has been on hourly therapy the observations should be hourly. If the assessment indicates improvement, then the inhaled bronchodilator frequency may be decreased, but at no more than hourly intervals unless otherwise prescribed by a medical officer. If there is deterioration, then inhaled therapy should be administered and a medical officer notified. An algorithm (Fig. 1) outlines a possible protocol. Assessment of and guidelines for the reduction in the frequency of bronchodilator administration. A particular issue requiring clarification is the child who is sleeping soundly. Where the child is sleeping soundly and his/her recorded observations support the fact that the asthma is stable, the attending medical officer may consider ordering that the patient not be woken for bronchodilator treatment, provided that the child remains stable. The decision should not be regarded as delaying bronchodilator administration. If there is deterioration, the child should be woken and administered bronchodilator. If a ‘may withhold treatment if child is sleeping soundly’ order has not been made, and the attending nurse feels it is appropriate that the sleeping child should not be disturbed when the prescribed bronchodilator is due, written or verbal authorization should be obtained from the resident medical officer to allow this change. It is important that the peacefully sleeping child is differentiated from the child who is restless during sleep or whose observations remain abnormal suggesting that the asthma is still a problem. If there is any doubt, the child should be woken and the bronchodilator given.