Nebulization in Children

Dr. KISHORE CHANDKI

Kids Care Clinic Sapna-Sangeeta Indore Annapurna Road

Nebulization: Parental Concerns

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Hospitalization
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Nebulization: Parental Concerns

Nebulization: Parental Concerns

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Fact: Many are not aware of proper way & drug dosages for nebulization!

Why Nebulization?
Oral medications donot achieve the required bronchodilation in children esp. infants

Side effects of oral bronchodilators may be unbearable e.g. insomnia, tremors, etc.
Convenient, although it may not work for the 12 hours. [required because in clinic settings it is difficult to nebulize more than twice in a day] May be more easy than inhaler for some older children Good in case of severe bronchospasm or acute severe asthma.
Inhalation therapy is always better than oral medication!

Inhalational Therapy: Devices

Aerosol devices include:
Metered-dose inhaler (MDI) or Inhaler
Metered-dose inhaler (MDI) with spacer Dry powder inhaler (DPI) e.g. Rotacaps Nebulizer/Nebuliser

Inhalational Therapy: Advantages

Aerosol doses are generally smaller than systemic doses; e.g., oral Salbutamol is 2 to 4 mg; inhaled 0.2 mg (MDI) to 2.5 mg (Nebulized) Onset of effect with inhaled drugs is faster than with oral dosing; e.g., oral albuterol is 30 min; inhaled albuterol is ~ 5 min

Drug is delivered directly to the target organ (lung), with minimal systemic exposure
Systemic side effects are less frequent and severe with inhalation compared to systemic delivery (injection, oral); e.g., less muscle tremor, tachycardia with 2-agonists; lower HPA suppression with corticosteroids Inhaled drug therapy is less painful and relatively comfortable

Inhalational Therapy: Disadvantages

Lung deposition is a relatively low fraction of the total aerosol dose A number of variables (correct breathing pattern, use of device) can affect lung deposition and dose reproducibility Lack of knowledge of correct or optimal use of aerosol devices by patients and clinicians The number and variability of device types confuses patients and clinicians Lack of standardized technical information on devices for clinicians

Nebulizers / Nebulisers
A device used to administer medication in the form of a mist inhaled into the lungs Use oxygen, compressed air or ultrasonic power to break up medical solutions/suspensions into small aerosol droplets that can be directly inhaled from the mouthpiece of the device. The definition of an aerosol is a "mixture of gas and liquid particles," [like mist] A wide variety of nebulizer are available. Nebulizers can be driven by compressed gas (jet nebulizer) or by an ultrasonically vibrating crystal (ultrasonic nebuliser). Conventional jet Nebulizers waste a great deal of the drug during expiration and ultrasonic Nebulizers are becoming more common

Nebulizers / Nebulisers
The efficiency of drug delivery depends on the type & volume of nebuliser chamber and the flow rate at which it is driven. Some chambers have reservoir and valve systems to increase efficiency of particle delivery during inspiration and reduce environmental losses during expiration. Breath-assisted open vent systems improve drug delivery but are dependent on the patient having an adequate expiratory flow. Facemasks & mouthpieces are equally effective, but breathless patients may prefer facemasks. Facemasks should be avoided or sealed very tightly when Anticholinergic drugs are administered to patients with glaucoma. Facemasks should ideally also be avoided for delivery of nebulized corticosteroids, to prevent contact with the surrounding facial skin & eyes.

Nebulizers: Development
The first powered or pressurized inhaler was invented in France by SalesGirons in 1858 In 1864 the first steam driven nebulizer was invented in Germany known as: Siegles steam spray inhaler

The first electrical nebulizer was invented in the 1930s and called a Pneumostat
In 1956 pressurized MDI was launched by Riker Laboratories (3M), with isoprenaline & adrenaline as 1st two products In 1964 Ultrasonic wave nebulizers introduced

Nebulizers: Clinical Indications

Children (<5 years) and adults (<55 years) who have difficulty coordinating the use of MDIs and DPIs In acute bronchospasm of asthma or COPD exacerbations Patients not able to or too sick or incapable of managing handheld inhalers Drugs not available in handheld inhaler (eg r-formoterol, N-acetylcysteine)

Need for a large drug dose

Patient preference: Many patients may prefer nebulizer therapy over other inhaler devices Practical convenience

Nebulizers
Advantages
Use of passive breathing: Any age Easy to teach & use Patient coordination not required High drug doses possible, Many drugs Can be used with supplemental O2 Mixtures (>1 drug), if drugs are compatible

Disadvantages
Time intensive

Inefficient & cumbersome

Equipment & power source required Cleaning required Intra-device & interdevice variability Potential for drug delivery into eyes with mask

Paraphernalia

Ultrasonic Nebulizers
Advantages
Little patient coordination required
Small dead volume Quiet Aerosol accumulates during exhalation High doses possible

Disadvantages
Expensive
Contamination possible Prone to electrical and mechanical breakdown Not all drug formulations available Drug preparation required

No chlorofluorocarbon release
Fast drug delivery

Respiratory Care 2000;45(6):609622

How to use a Nebulizer: Parts

How to use a Nebulizer

How to use a Nebulizer

The patient should be instructed to sit upright, take steady breaths (tidal breathing), and to not talk during the nebulization. Steady normal breathing interspersed with occasional deep breaths is likely to be optimal. It should be noted that the nasal passages effectively filter droplets delivered from the nebulizer. Hence, oral breathing is preferred over nasal breathing Monitor for side effects. Stop if: Increase in pulse by 20 beats per minute or Palpitations or Dizziness or Tremors or Nausea or Chest pain or Uncontrollable coughing. Rest for 5 to 10 minutes. If the sensation goes away, continue with the treatment, but at a slower pace

How to use a Nebulizer

Mouthpiece: > 8 years & older. The child places the mouthpiece between their teeth, using their lips to form a tight seal. Children as young as 6 years old can be coached to take mouthpiece treatments. This may not be effective in the middle of the night when the child is sleepy. Mask treatments should be used for children < 8 years old. An aerosol mask is placed on the nebulizer, and then secured over the nose and mouth of the child. The mist is breathed in through the childs mouth and nose. Placing a mask on a young child can be scary. One way to help children with this fear is to let them play with the mask before the treatment. If they become upset, try to calm them down. Most young children will stop crying shortly after the treatment starts.

How to use a Nebulizer

To use a nebulizer, place the child in an upright position. Turn on the nebulizer and keep it upright. Tell the older child to take deep breaths through the mouth. Depending on the amount of medication to be used, the treatment will usually last 10-15 minutes. When the nebulizer begins to sputter, shake or tap it once or twice. If it continues to sputter, the treatment is done.

Home Use: Tips

If you use your nebulizer every day, clean it every other day. Always keep an extra nebulizer on hand. Prior to using, check nebulizer parts for cracks or caking of material inside. If the treatment is longer than 10 or 15 minutes, check the mist output. The nebulizer may be clogged or a dirty filter can obstruct the airflow from the compressor. If the treatment is shorter than normal, check to see if the medicine is leaking out of the nebulizer. A nebulizer that is taken care of should last for 100 treatments.

Home Use: Tips

Treatments are better when the child is calm; however, crying may induce coughing that may help clear loose secretions. It is normal for children to cry, kick and scream when first beginning breathing treatments. Crying children usually swallow air and mucus. This can cause nausea and vomiting. Crying and coughing can stimulate the gag reflex and cause some vomiting.

Inhalational Drugs: Metabolism

The fate of an inhaled drug. The total amount of drug in the systemic circulation is the sum of the systemic absorption via the lungs and via the GI tract

Inhaler Devices & Drug Delivery

Nebulizer 1 5%

DPI
MDI

5 10%
5 10%

MDI with Spacer

Disc DPI Turbuhaler

10 15%
~15% >30%

Ultrasonic nebulizer: same efficacy as jet nebulizer. Breath actuated nebulizers may have better drug deposition in airways. Newer devices (DPI/MDI) have better deposition.
Asthma Training Module, 2011, Asthma By Consensus, IAP

Inhaler Devices & Drug Delivery

How to choose delivery devices for asthma

Nebulizer Infants & toddlers Emergency Poor coordination

Arch Dis Child 2000;82:185-187

How to choose delivery devices for asthma

Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report. Allergy. 2008 Jan;63(1):5-34

MDI with Spacer: Better than Nebulize

Inhalant Drugs: List

Bronchodilators Arformoterol Anti-inflammatory Beclomethasone Budesonide Miscellaneous Aromatic ammonia Dornase alfa

Bitolterol
Epinephrine Formoterol Ipratropium Isoetharine Isoproterenol Levalbuterol Metaproterenol Pirbuterol

Ciclesonide
Cromolyn Flunisolide Fluticasone Dexamethasone Fluticasone Mometasone Nedocromil Triamcinolone

Glutathione
Insulin Methacholine Nicotine Sodium chloride Mucolytics Ambroxol N-acetyl cysteine

Procaterol
Racepinephrine (racemic epinephrine) Salbutamol Salmeterol

Antimicrobials
Pentamidine Ribavirin Tobramycin Zanamivir

Terbutaline
Tiotropium

Nebulized Drugs available in India

Mixing of Drugs: Yes or No?

* It is strongly recommended that Mucinac respules when admixed with Ipravent, Asthalin, Levolin, Budecort or Flohale respules, should be used immediately. Any unused mixture should be discarded. # Foratec respules when admixed with Budecort, Flohale, Ipravent, Inhalex or Mucinac respules should be used within 30 minutes. Flohale respules when admixed with Ipravent, Asthalin, or Levolin respules should be used within 2 hours Budecort respules when admixed with Asthalin, Levolin or Ipravent respules should be used within 2 hours

Nebulization: Other Uses

Recombinant DNase (rhDNase): cystic fibrosis. Bronchodilator therapy not only improves airway obstruction but also increases mucociliary clearance of viscous secretions. rhDNase reduces the viscosity of sputum in cystic fibrosis by digesting DNA of extracellular neutrophils, which is present in huge quantities due to chronic epithelial inflammation. Patients should use specified nebuliser systems to ensure optimal delivery of rhDNase. Regular nebulised antipseudomonal treatment also improves lung function and reduces the frequency of exacerbations of infection in people with cystic fibrosis

Nebulization: Other Uses

Long-term nebulized antibiotics are also useful in bronchiectasis, when other methods of delivery have been unsuccessful. Nebulized antibiotic therapy should be combined with regular postural drainage and courses of oral or intravenous antibiotics for acute exacerbations. Nebulized pentamidine is occasionally used in the specialist prevention or treatment of pneumocystic pneumonia (PCP). Regular treatment is effective against mild PCP and intermittent inhalation of nebulised pentamidine is effective prophylaxis against infection.17 Many nebulized drugs are employed in palliative care but few indications are based on published evidence. However, regular nebulized normal saline helps to loosen tenacious secretions, may reduce breathlessness and is unlikely to do harm

Cleaning the Nebulizer

Note : If the equipment is not likely to be used again for a few days, it should be placed in a plastic bag with a twist tie and stored in a clean area. *Acetic acid solution is made by mixing one part white vinegar and three parts water and should be freshly prepared every day. Poor maintenance may lead to contamination of the wet parts of a nebulizer and cause bacterial respiratory tract infections

Cleaning the Nebulizer

To be cleaned daily in regular usage and after each use. The mask, mouthpiece and chamber should be disconnected, disassembled and washed in a warm detergent and water solution. The components should be left to dry overnight. Before reuse, the nebuliser should be run for a few seconds before adding medications. Maintenance Disposable components such as the mouthpiece, mask, tubing and nebuliser chamber should be changed every 3 to 4 months. Compressors require annual servicing by manufacturer or local service provider. Breakdown Patients must have a written plan describing whom to contact in the case of emergency If nebuliser times are slow, the equipment should be cleaned and treatment tried again. If it remains slow, a spare nebuliser should be used

Practical Points
Prerequisites: Optimal volume of solution in nebulizer chamber is 2 to 4 ml Particle size is 2-5 microns Driven by O2 or air

Flow is 4 to 8 L/ min
Electric (220V AC) or battery powered Respules do not need addition of NS for nebulization Saline should be used as the diluent and not distilled water. This is because hypoosmolar solutions can lead to reflex bronchospasm

Nebulization: Common Mistakes

Nebulization for wrong indications e.g. URI Combining wrong medicines with it e.g. codeine, dextromethorphan, or salbutamol by two routes Not addressing the cause/disease causing bronchospasm e.g. URI, adenoids, FBAO Giving wrong medicine in wrong dose esp. bronchodilators, or using steroids unnecessarily Wrong way of nebulization: recumbent position, etc. Using nebulizer without cleaning before each procedure Using half respule in morning, remaining at other time Diluting all respules with normal saline Diluting the medication with distilled water Using same normal saline bottle for several days Using a vaporizer for respules: by parents

Inhaled Corticosteroids: FDA-Approvals

Mometasone DPI Beclomethasone MDI Budesonide DPI

Flunisolide MDI
Triamcinolone MDI Beclomethasone MDI Fluticasone MDI Fluticasone/Salmeterol DPI

Fluticasone DPI
Budesonide Nebulization

10 11 12 13 14 15 16+

Age of Children (Years)

FDA = Food and Drug Administration; DPI = dry-powder inhaler; MDI = metered-dose inhaler

Status Asthmaticus: Approach

Indian J Pediatr (2010) 77:1417-1423

Status Asthmaticus: Medications

Indian J Pediatr (2010) 77:1417-1423

Classes of b2-agonists
Speed of onset

RESCUE MEDICATION
fast onset, long duration

fast onset, short duration

fast

inhaled terbutaline inhaled salbutamol

slow onset, short duration

inhaled formoterol

slow onset, long duration

slow

oral terbutaline oral salbutamol oral formoterol

inhaled salmeterol oral bambuterol

M A I N T E N A N C E

short

long

Duration of action

=1 full respule
=1 respule =2 respules

K+ Rich Diet

Common Preparations
Drug Salbutamol
Asthalin

Availability
Nebulizer soln 5 mg/mL, Respule 2.5 mg/2.5 mL 0.31 mg, 0.63 mg, 1.25 mg/2.5 mL Respules

Dose
0.15 mg/kg (Min 2.5 mg) as often as 20 min 3, then 0.15-0.3 mg/kg up to 10 mg q1-4h PRN, or up to 0.5 mg/kg/hr by continuous nebulization 0.075 mg/kg (Min 1.25 mg) q20 min 3, then 0.075 0.15 mg/kg up to 5 mg q1-4 h PRN, or 0.25 mg/kg/hr continuous nebulization. 0.63 mg = 1.25 mg salbutamol for both efficacy & SE Initiating dose 0.5-1 mg BD, Maintenance 0.250.5 mg BD 1 mg BD

Levosalbuta mol
Levolin

Budesonide
Budecort, Pulmicort

Respule 0.5 mg/2 mL, 1 mg/2 mL

0.5 mg/2 mL, 2 mg/2 mL Neb respirator solution 0.25 mg/ml, Respule 0.5 mg/2 mL Arformetrol 15 mcg/2 mL

Fluticasone
Flohale

Ipratropium
Ipravent Formeterol Foratec Respules

0.5 ml < 1 year, 1 ml >1 year every 20 mins for 3 doses, then every 6-8 hours solution. Limit use to 24 hrs to prevent atropine like effects. Adults: 1 respule two times a day

Common Preparations
Drug Ambroxol
Inhalex Respule

Availability
Respule 2 mL = 15 mg Acetylcysteine 20% w/v [200 mg/mL] Mucolytic (free sulfhydryl group opens up disulfide bonds in mucoproteins, lowering viscosity) Bricanyl Respule 1 mg/mL

Dose
< 5 yrs: respule BD, > 5 yrs/adults: 1 respule BD Dose: based on 10% sol or diluted 20% sol (1:1) for inhalation. Infants: 24 mL tidqid. Children: 610 mL tidqid. Adolescents: 10 mL tidqid Caution: Give a bronchodilator 1015 min before it to avoid bronchospasm. Follow treatment with chest percussion and suction to manage increased secretions. For acute asthma, rescue. <2 yrs: 0.5 mg/2.5 mL NS q4-6h PRN. 2-9 yrs: 1 mg/2.5 mL NS q4-6h PRN, >9 yrs: 1.5-2.5 mg/2.5 mL NS q4-6hr PRN Some role in Acute Bronchiolitis.

N-Acetyl Cysteine
Mucinac 2 & 5 mL

Terbutaline
Hypertonic Saline (3%7%) & Racemic Epinephrine

Tobramycin

Tobramist Respules

Available Combinations
Availability Drugs Dose
Children >1 yr: 1 respule (0.5 mg) 3-4 times a day or 1-2 respules 2 times a day Adults: 2-4 respules (1-2 for 1 mg respule/dose) Children >12 yrs & adults: 1 respule 3 times a day. Esp. for acute severe asthma Budesonide Budesal 0.5 or 1 mg + Respule Levoalbuterol 0.5 & 1 mg

1.25 mg

Duolin Respule

Ipratropium + Levosalbutam ol

Take Home Points

Nebulization are not a 1st choice device to deliver drugs in bronchospasm/asthma Nebulizers can be used in all age groups esp. young children & in emergencies

Right plan, route, drug & right method of administration are integral part of management of wheezy child

Thanks