Respiratory Care in PICU Aerosol Therapy - thaipedlung.org · 7/10/2010 · The delivery of aerosol to the major airways is reduced by about 40% when the circuit is humidified Dhand

Respiratory Care in PICURespiratory Care in PICUAerosol TherapyAerosol Therapy

นน..ออ..หญิงหญิง สุพิชสุพิชชาชา แสงโขติแสงโขติ

โรงพยาบาลสมเด็จพระปนเกลาโรงพยาบาลสมเด็จพระปนเกลา

liquid droplets or solid particles

suspended in a gas(air)

visible like fog

Aerosol

Aerosol vs Humidity

Humiditywater in gas status (vapor),

invisible

drug be inhaled and deposit in targeted site of respiratory system :

deposit in lungs (lung dose),responsible for pharmacologic effects at targeted site

Goals of Aerosol Therapy

direct delivery of drug to site of actionrapid onset of actionlower dose to produce desired effects

(than systemic administration)minimizes systemic adverse effects

Advantages of Aerosol Therapy

Indication of Aerosol Therapy

1. bronchial hygiene2. humidification3. medication

bronchodilator, vasoconstrictor, corticosteroids, mucoregulators, antimicrobial agents, surfactant, insulin, prostaglandin, vasopressinetc.

aerosol size

mass median aerodynamic diameter (MMAD)

Median value of particle of aerosol mass ,output from nebulizer, suspended in the gas flow

Aerosol deposition in airway

aerosol deposition in airway

size / MMAD (µm) site of aerosol deposition< 0.5 no deposition, exhaled with exp. flow0.5-2 alveoli2-5 bronchi, bronchiole5-100 mouth, nose, upper airway>100 filtered by upper respiratory tract

Aerosol deposition in airway

MMAD (µm) aerosol deposition2-5 bronchi, bronchiole

MMAD (µm) aerosol deposition0.5-2 alveoli

lung depositionweight-dose physiologic effect of pharmacologic aerosol

How are infants/ children different?Aerosol Therapy

respiratory flow pattern-aerosol output fromcontinuous jet nebulization-inhaled drug

100 ml/sec

In infants/ childrenpeak inspiratory flow rate- lowtidal volume, vital capacity,functional residual capacity-low respiratory rate –highrespiratory cycle -short

Rubin BK, Fink JB. Respir Care Clin N Am 2001;7(2):175–213.

Dolovich MB. Respir Care 2002; 47(11):1290–1301.

Inspired dose vs aerosol output from nebulizer

Lung deposition ,the percentage of the dose delivered and the percentage of initial nebulizer dose for the nebulizers.

Fok TF, Monkman S, Dolovich M, Gray S, Coates G, Paes B, et al. Pediatr Pulmonol 1996;21(5):301–309.

amount of albuterol deposited in the lungs

nonventilated infants ventilated infants

0.67%

1.74%

0.28%

0.98% 0.95%

0.22%

Wildhaber JH, Dore ND, Wilson JM, Devadason SG, LeSouef PN.J Pediatr 1999;135(1):28–33.

Lung deposition of albuterolwith MDI / chamber vs jet nebulizer

in nonventilated children

5.4%

11.1%

5.4%

9.6%

Lung deposition of aerosol in nonintubated patient

Infant 0.1Infant 0.1--1 %1 %

Children< 4 y 5 %Children< 4 y 5 %Children> 4 y 10 %Children> 4 y 10 %

Adult 8Adult 8--22 % (SVN 1022 % (SVN 10--14%)14%)

lung depositionneonate < 1% of nominal doseadult 8-22% of nominal dose

weight-dose physiologic effect of pharmacologic aerosol

How are infants/ children different?Aerosol Therapy

lung dose / body weight

infant 2 kglung deposition 1% lung dose= 12.5-25 microgm.= 6.25 microgm./ kg

salbutamal 1 dose =2500 microgm./ dose

Adult 70 kglung deposition 10% lung dose= 250 microgm.= 3.6 microgm./ kg

% change in total resistance (Rrs) and total compliance (Crs) of the respiratory system following administration of albuterol MDI and nebulizer

Torres A Jr, Anders M, Anderson P, Heulitt MJ. Chest 1997;112(2):484–490.

Efficacy of MDI administration of albuterol in ventilated infants

MDI & nebulizer

complianceresistance

MDI & nebulizer

physiologic effect of pharmacologic aerosol

Aerosol: particle size &

physical characteristics

Aerosol output

Airway anatomy & pathology

Patient Ventilatory pattern

Aerosol deposition Aerosol deposition depend ondepend on



Aerosol output




MMAD sizedensity of gastemperature humidity



Aerosol output




DeviceFill volumeGas flow/ pressureNebulization time



Aerosol output




Congenital stenosis of airwayobstructive airway diseaseBPD, bronchiectasisSecretionArtificial airway



Aerosol output




Inspiratory flow rate - slow 0.5 L/min-laminar flowInspiratory volume -deep inspirationBreath holding 4 secInspiratory time -at beginningMouth breathingdeposition in sedated pt.>non-sedated pt.

หายใจเขา

ชา ลึก นาน

Aerosol devices1. nebulizer

Jet nebulizersmall volume nebulizer-SVN large volume nebulizer-LVN

Ultrasonic nebulizerSmall particle aerosol generator

2. Metered dose inhaler (MDI)3. Dry powdered inhaler (DPI)

turbuhaler, diskhaler, swinghaler

Aerosol therapy in nonin non--intubatedintubated children children in PICUin PICU

Aerosol therapy with small volume nebulizer (SVN)

Continuous nebulization therapy (CNT)

Aerosol therapy with EzPAP

Aerosol therapy with noninvasive positive pressure ventilation

(NPPV)

Jet nebulizer : small volume nebulizer-SVN

Continuous Continuous nebulizationnebulization therapy (CNT)therapy (CNT)

Indication of CNT

1. Severe asthma with asthma score > 52. Asthma patient who need nebulization frequently

(every 15 min-1 hr)


•Efficiency not different from intermittent nebulization(more efficiency in severe airway obstruction case)

•Benefit in cost effectiveness•Benefit for personnel in drug administration•Decrease patient disturbance

1.5 ชม.20 มล./ ชม.8 ลิตร/ นาที30 มล.miniHEART

Hi-Flo

8 ชม.

4 ชม.

30 มล./ ชม.

50 มล./ ชม.

10 ลิตร/ นาที

15 ลิตร/ นาที

240 มล.HEARThigh

flow

3 ชม.8 มล./ ชม.2 ลิตร/ นาที30 มล.miniHEART

Lo-Flo

low

flow

Nebulization

time

Nebulization

output

Gas flowขนาดบรรจุ

Fill volume

ตัวอยาง

ผลิตภัณฑ

ชนิด

CNT


High flow CNTHigh flow CNT

(miniHEART Hi-Flo)(HEART Hi-Flo) (HOPE Hi-Flo)

Low flow CNTLow flow CNT (miniHEART Lo-Flo)

Jet nebulizer : large volume nebulizer-LVN

continuous nebulization therapy

HEART nebulizer- high flow

HEART nebulizer- high flow



FloFlo--MistMist

miniHEART high flow miniHEART low flow


Aerosol therapy with Aerosol therapy with EzPAPEzPAP

EzPAPEzPAP

EzPAPEzPAP with with nebulizernebulizer

EzPAPEzPAP with with nebulizernebulizer

Jet nebulizer with NPPV

Aerosol delivery 5Aerosol delivery 5--25%25%

Jet nebulizer with NPPV

High aerosol delivery High aerosol delivery byby

High inspiratory press.20 cmH2OLow expiratory press.5 cmH2OLow breath frequencyPosition in circuitnear patient, between leak port-patient connector

เอื้อเฟอภาพโดย ศ.พญ.อรุณวรรณ พฤทธิพันธุ รพ.รามาธิบดี

Aerosol therapy in Aerosol therapy in intubatedintubated children children

pressurized metered dose inhaler (pMDI)jet nebulizerdry powder inhaler (DPI)

Lung deposition ,the percentage of the dose delivered and the percentage of initial nebulizer dose for nebulizers

Fok TF, Monkman S, Dolovich M, Gray S, Coates G, Paes B, et al. Pediatr Pulmonol 1996;21(5):301–309.

amount of albuterol deposited in the lungs

ventilated infants

0.98% 0.95%

0.22%

Dhand R, Tobin MJ. Am J Respir Crit Care Med 1997;156(1):3–10.

Factors that influence aerosol delivery Factors that influence aerosol delivery

Ventilator related Mode: Pressure-limited vs volume-limited Continuous flow of gas through circuit Respiratory rate Tidal volume Inspiratory flow rate Inspiratory-expiratory ratio Circuit relatedDiameter Length AdaptersDensity of gasEndotracheal tube Size TypeHumidification

Factors that affect aerosol delivery and depositionFactors that affect aerosol delivery and deposition

ventilator modes and settingventilator modes and settingwith with nebulizernebulizer

Aerosol delivery with nebulizerIMV mode = A/C mode = A/C flow synchronize mode IMV mode = A/C mode = A/C flow synchronize mode PC mode < VC modePC mode < VC mode

ventilator modes and setting ventilator modes and setting with with pMDIpMDI

30 15

P-SIMV3.78 Xxxxxxxxx

erttrert

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Trigger

492

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Xxxxxxxxxerttrert

Xxxxxxerttrert

492Xxxxxxxxxerttrert

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Xxxxxxerttrert

DuoPAP

P-CMV (S)CMV

P-SIMV SIMV

APVCMVSPONT

APVSIMV

ASVAPRV

Ventilation Mode

NIV

Standby

Calibration

Patient

Additions

Aerosol delivery with pMDISIMV mode > CMV modeSIMV mode > CMV modePC mode = VC modePC mode = VC mode

Aerosol delivery from MDI during mechanical ventilation, at different inspiratory air-flows and

duty cycles (inspiratory time to total breathing cycle time [TI/Ttot])

Fink JB, Dhand R, Grychowski J, Fahey PJ, Tobin MJ. Am J Respir Crit Care Med 1999;159(1): 63–68.

inspiratory air-flows40 L/min inspiratory air-flows

80 L/min

Serum albuterol levels after MDI administration in mechanically ventilated patients and healthy subjects

Duarte AG, Dhand R, et al. Am J Respir Crit Care Med 1996;154(6 Pt 1):1658–1663.

MDI with chamber spacer MDI with chamber spacer had the highest had the highest

drugdrug--delivery efficiencydelivery efficiency

Goode ML, Fink JB, Dhand R, Tobin MJ.. Am J Respir Crit Care Med 2001;163(1):109–114.

aerosol delivery with helium-oxygen mixtures during mechanical ventilation

MDI with chamber spacerMDI with chamber spacerunheated, dry ventilator circuitunheated, dry ventilator circuit

jet jet nebulizernebulizerat a constant flowat a constant flow

The delivery of aerosol to the major airways The delivery of aerosol to the major airways is reduced by about 40% when the circuit is humidified is reduced by about 40% when the circuit is humidified

Dhand R, Tobin MJ. Am J Respir Crit Care Med 1997;156(1):3–10.

Efficiency of aerosol delivery to the lower respiratory tractin mechanical ventilation with dry and humidified ventilator circuits

Documents

Respiratory Care in PICU Aerosol Therapy - thaipedlung.org · 7/10/2010 · The delivery of aerosol to the major airways is reduced by about 40% when the circuit is humidified Dhand