Comparison of albuterol delivered by a metered dose ...



Nebulizer and MDI use in the CMG officesMarch 19, 2020Situation:Outpatient clinics currently use nebulizers to deliver albuterol, atrovent, and racemic epinephrine in children with asthma or respiratory distress. There is a concern that nebulization may aerosolize SARS COV2 particles.Background:SARS COV2 is currently thought to be limited to droplet spread. There is some evidence of fecal spread.Nebulizer use is currently rated as a Medium Risk respiratory intervention to potential aerosolize particles.CHKD Division of Allergy/Immunology has been using multidose MDI inhalation and single use spacers for routine PFT procedures for some time.On May 17, 2020 the CHKD Division of Allergy/Immunology suspended the use of nebulizers in the clinic setting in favor of using MDI even in children with wheezing.Assessment:The risk of aerosolization of SARS COV2 particles during nebulization is not completely defined at this time. We should standardize these best practices.Recommendation: (Compilation of information from Lisa Kopecko, Dr. Cindy Kelly, Dr. Kelly Maples, Melinda Boltz, Donna Stewart, Dr. Cauley,et al)CMG offices will make every attempt to suspend use of nebulizers in the office unless clinical care dictates the need. You can always ask the patient to bring MDIs and spacers to the clinic visit. MDIs can be reused. See guidance below. Allergy/Immunology keeps 3 MDI available to be used, cleaned and rotated. We can get paid for this medication administration. Spacers can NOT be reused. We need to plan on ordering and sending home with the patient. We may not get paid for the actual spacer. See additional guidance below. Consider the relatively low cost of the spacer compared to cost of nebulizer masks and weigh that with the risk of the potential (?) exposure and need to furlough staff (?). All unknowns at this time. DOSING (from ED and UCC with support of allergy/Immunology)Suggested orders: Children with mild to low moderate asthma (AS < 8) should preferentially be given MDIs for their wheezing, especially if suspicion for COVID.Children with respiratory distress and high moderate to severe asthma (AS > 9 ) may not cooperate with an inhaler and can be given nebulizer treatments.Albuterol : 5-10kg : 4 puffs??????????????????? 10-20kg: 6 puffs???????????????????? >20kg: 8 puffsIpratropium: : 5-10kg : 4 puffs????????????????????????? 10-20kg: 6 puffs??????????????????????? >20kg: 8 puffsSo essentially the same doses for both.ORDERING IN POWERCHARTOur existing orders in powerchart will already apply. Nothing new needs to be built at this time. BILLING (brief version, see attachment 2 for details)When you order either a neb treatment or one of the MDI orders, the same “inhalation treatment” task fires to the pletion of that task is what drops the “94640” charge – so this is ideal, because there is nothing than needs to be separately built to charge for administration of albuterol via an MDI.Users just need to document “Inhaler” vs. “Nebulizer”.SUPPLIESAlbuterolOrder through normal supplier or local pharmacySpacersIt is important to have spacers with one way valves. McKesson has robust supply of spacers without mask (approx. $6/mask). Each practice can order their own desired quantity.Spacers with mask are in very short supply and very expensive. Attachment 2Billing detailsFrom a coding perspective albuterol MDI in the office would utilize the same CPT code as performing a nebulizer.?? 94640 = Pressurized or non-pressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) deviceFor spacers, that would be a supply code for the actual product.? 94664 for the Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device cannot be reported with 94640 IF THE DEMO/EVAL/TEACHING is for the same type of equipment used to treat the patient (because demo would be included).? ?There is a bundling edit for reporting 94640 and 94664 – if both were performed together we would report the 94640 as the value is higher.? If the DEMO/EVAL/TEACHING was for a different type of equipment (say we did a neb and then did demo/eval/teaching of MDI – then we could report both but a -59 modifier would need to be reported by the coder attached to the 94664.Coding Tip per AAPC Coder:TipsCode 94664 is usually used once or at rare intervals as a stand–alone procedure code.Remember that insurers consider 94664 a component of 94640. So, if you report 94640, you cannot also list 94664 and expect payment if the provider performed the two procedures on the same patient and on the same day.For example, the provider provides the patient with a breathing treatment, such as a nebulizer, to relieve symptomatic airway obstruction, and instructs the patient on how to use the nebulizer at home. You would report only 94640 for the treatment, which also includes the training. But if the patient only needed a review of educational issues concerning nebulizer use, you could use 94664.ATTACHMENT 3 ReferenceJ Pediatr. 1999 Jul;135(1):22-parison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma.Schuh S1, Johnson DW, Stephens D, Callahan S, Winders P, Canny GJ.Author information1Divisions of Emergency, Clinical Pharmacology, Chest, and Clinical Epidemiology, the Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.AbstractOBJECTIVE: In children with mild acute asthma, to compare treatment with a single dose of albuterol delivered by a metered dose inhaler (MDI) with a spacer in either a weight-adjusted high dose or a standard low-dose regimen with delivery by a nebulizer.STUDY DESIGN: In this randomized double-blind trial set in an emergency department, 90 children between 5 and 17 years of age with a baseline forced expiratory volume in 1 second (FEV1 ) between 50% and 79% of predicted value were treated with a single dose of albuterol, either 6 to 10 puffs (n = 30) or 2 puffs (n = 30) with an MDI with spacer or 0.15 mg/kg with a nebulizer (n = 30).RESULTS: No significant differences were seen between treatment groups in the degree of improvement in percent predicted FEV1 (P =.12), clinical score, respiratory rate, or O2 saturation. However, the nebulizer group had a significantly greater change in heart rate (P =.0001). Our study had 93% power to detect a mean difference in percent predicted FEV1 of 8 between the treatment groups.CONCLUSION: In children with mild acute asthma, treatment with 2 puffs of albuterol by an MDI with spacer is just as clinically beneficial as treatment with higher doses delivered by an MDI or by a ment inAsthma therapy with aerosols: are nebulizers obsolete? A continuing controversy. [J Pediatr. 1999]PMID:10393599DOI:10.1016/s0022-3476(99)70322-7[Indexed for MEDLINE] ATTACHMENT 4 CleaningAllergy Guideline for Clinic Use of stock Albuterol MDI with spacerSupplies needed:Clean and dry Albuterol MDI from stock med cabinetOne way valve spacer appropriate to child’s ability (mask or mouthpiece)Administer Albuterol per provider orderInstruct /Review patient on proper technique and use of Spacer with MDINurse to administer, (pt. does not actuate the MDI)Spacer Without Mask- slow deep inhalation, Hold breath 10 seconds before exhale, wait 1 minute between puffsSpacer With Mask- tight seal over nose and mouth, 6 breaths per puff, wait 1 minute between puffsDisconnect MDI for cleaning and leave spacer with patient Cleaning protocol for Albuterol MDI unitRemove MDI canister from plastic holder/mouth pieceUse Oxivir? Tb Wipe to clean all areas of canisterUse separate Oxivir? Tb Wipe to wipe all areas inside and out of the holder and cap.Allow to dry on clean/barrier surface for 1 hour prior to putting back together and rotating back into use. Allow for 2-3 stock inhalers to rotate for administration and allow for cleaning and drying time during clinic. Medications to be secured at all times ................
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