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than 50 and no ABG available) - Initiate inspiratory pressure 5 cm H20 above CPAP setting and titrate up as required to maximum 25 cm H20 inspiratory pressure Assessment and Treatment Guidelines MILD MODERATE SEVERE Assessment · Dyspnea or cough on exertion, wheezing · Fine crackles heard · +/- nocturnal symptoms · Increased use of βagonist to control symptoms · good response to β agonist · Dyspnea at rest · Cough, congestion, chest tightness · Fine / coarse crackles · +/- pink frothy sputum · Nocturnal symptoms · Partial relief βagonist · β-agonist required greater than every q4h · Decreased breath sounds, may have exp wheeze · Laboured respirations · Agitated, confused · Diaphoretic, cyanotic · Difficulty speaking · No relief with β-agonist · Decreased breath sounds, may have insp/exp wheeze · Initial tachycardia · Silent chest · Oxygen saturation less than 90% Treatment · Increase oxygen to achieve and maintain Oxygen Saturation equal to or greater than 92% · Monitor vital signs · salbutamol puffer (100 mcg/puff) 4-9 puffs q15min x 3 (MDI + spacer device) or equivalent nebulized salbutamol* (up to 27 puffs) · Increase oxygen to achieve and maintain Oxygen Saturation equal to or greater than 92% · Monitor vital signs · Salbutamol (100 mcg/puff) 4-9 puffs q15min x 3 sets (MDI + spacer) or equivalent nebulized salbutamol* (up to 27 puffs) · Vital signs after each med. administration · Notify physician Stat · 100% oxygen · monitor vitals continuously · continuous Salbutamol (100 mcg/puff) / Ipratopium(20 mcg/puff) 20 puffs then reassess) or nebulized salbutamol (5 mg in 3 mL saline) and Ipratropium (0.25 mg in 3 mL saline) MEDICAL DIRECTIVE Rapid Response System (RRS) – Respiratory Distress Approved by/Date: February 26, 2013 (For LHB Pilot Only) Lakeridge Health Page 5 of 9 Salbutamol Solution (5 mg/mL) Salbutamol Inhaler via MDI (100 mcg/puff) 1.25 mg (0.25 mL) 2.5 mg (0.5 mL) 3.75 mg (0.75 mL) 5 mg (1 mL) Maximum dose is 15 mg 2 puffs 3 puffs 4 puffs 6-9 puffs Maximum dose is 27 puffs Ipratropium Solution (0.5 mg/mL) Ipratropium Inhaler via MDI (20 mcg/puff) 0.125 mg (0.5 mL) 0.25 mg (1 mL) 0.375 mg (1.5 mL) 0.5 mg (2 mL) 2 puffs 3 puffs 4 puffs 6-9 puffs Table 1 Dosage Conversion Chart Patient Description/Population: Patients who present with symptoms of shortness of breath and exhibit respiratory distress. Identify relevant Controlled Act, Delegated Control Act or Expanded/ Added Skill associated with this Directive: Administering a substance by injection or inhalation. Performing a procedure below the dermis. – IV Insertion Certificate - IO Insertion Certification Putting an instrument beyond the larynx MEDICAL DIRECTIVE Rapid Response System (RRS) – Respiratory Distress Approved by/Date: February 26, 2013 (For LHB Pilot Only) Lakeridge Health Page 6 of 9 Specific conditions/circumstances that must be met before the Directive can be implemented: · Patient must be assessed and placed into a severity category by the RRS responder. · The patient must have symptoms of crackles, wheezing, shortness of breath, cyanosis, dyspnea, tachypnea, orthopnea, and/or accessory muscle use. · Each intervention will be explained to the patient and/or family and verbal consent will be obtained. · Medications given by hospital personnel or taken by the patient just prior to the event must be included in the calculation of maximum doses. · Personal protective equipment (mask, protective eyewear or face shield) must be used by staff when within two metres of any patient on CPAP/Bipap, with or without symptoms of an acute respiratory infection Contraindications to the implementation of the Directive: · Patient refuses therapy – no consent. · Allergy to salbutamol, ipratropium or MDI propellant will prevent use of the specific agent. · Patient is in pre-morbid state (silent chest, cyanosis, confusion) – code blue must be activated. · Patient is incapable of cooperating with the procedure · Patients exhibiting signs and symptoms of acute respiratory infection must be managed with Contact/Droplet isolation in a private room to have CPAP/Bipap