Airway Clearance/Hyperinflation Therapy, Non-Pharmacological — Pharmacologic Strategies — Clinical Pathway: ICU

Airway Clearance/Hyperinflation Therapy, Non-Pharmacological Clinical Pathway — ICU and Inpatient

Pharmacologic Strategies

Class Name Indications Considerations
Bronchodilators
  • Albuterol
  • Levalbuterol
  •  
  • Ipratropium
  • Treatment and prevention of bronchospasm in patients with reversible obstructive airway disease.
  • Albuterol is used as a 1st line bronchodilator.
  • Levalbuterol can be substituted in cases of tachycardia or home regimen.
  • Ipratropium can be added as a 2nd bronchodilator to optimize airway dilatation for ease of secretion mobilization.
Mucolytics
  • Hypertonic saline
  •  
  • Dornase alfa
  • Acetylcysteine
  • Inhalation for thick secretions.
  • Adjunctive therapy in patients with abnormal or viscid mucous secretions in bronchopulmonary diseases.
  • Hypertonic saline is available in 3%, 7%, or 10% concentrations.
  • If hypertonic saline is not needed or tolerated, normal saline (0.9%) can be utilized for IPV therapy.
  • Administration of bronchodilator therapy can prevent side effects from 7% and 10% NaCl.
  • Optimizes bronchodilation for secretion clearance prior to other therapies.
  • Frequent use of hypertonic saline may lead to more secretions. Use with caution.
  • Dornase alfa is an enzyme used primarily in the cystic fibrosis population to cleave DNA in purulent mucus.
  • Caution should be exercised in children < 5 yo.
  • Acetylcysteine may be used in special circumstances for patients with highly viscid or inspissated mucous secretions.
  • Administration of bronchodilator therapy can prevent side effects from acetylcysteine.
Anticoagulants, Thrombolytics
  • Alteplase
  • Inhalation in cases of casts.
  • Most commonly utilized in plastic bronchitis, Informed consent required.
Anti-infectives
  • Tobramycin, colistin
  • Inhalation in patients with pseudomonas aeruginosa, pulmonary colonization or infection with susceptible organisms.
  • Reserved for special cases.
  • Adjuncts/part of chronic therapy.
  • Most commonly utilized in patients with bronchiectasis, pulmonary colonization/infection with susceptible organisms in cystic fibrosis and non-cystic fibrosis patients.