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Tuesday, August 18, 2009

Improving aerosol drug delivery in children

The following are the latest recommendations for what aerosol delivery device to use for pediatrics and neonates, and at what age that device should be administered:

(Note: SVN = small volume nebulizer, and MDI = Metered Dose Inhaler, DPI = Dry-powdered Inhaler):
  • SVN with mask recommended for children under three years of age
  • SVN with mouthpiece for children greater than three years of age
  • MDI with holding chamber/spacer and mask for children less than four years of age
  • MDI with holding chamber/ spacer for children greater than 4 years of age
  • DPI for children greater than 4 years of age and older
  • MDI for children five and older
  • Breath actuated MDI for children greater than five years of age
  • Breath actuated nebulizers for children five and older
This information is from an article by ARzu Ari (PhD, PT, RRT, CPFT) in the August, 2009, issue of AARC Times, "Optimal Delivery of Aerosol Drugs in the Pediatric/Neonatal Patient Population."

Likewise, she reiterates that a child should not be crying during a breathing treatment:

"Inhaled drugs should be given to infants only when they are settled and breathing quietly. Crying children receive virtually no aerosol drug to their lungs, with most of the inhaled dose depositing in the upper airways or pharynx, which is essential for clinicians to develop approaches that minimize distress before administering aerosol drugs. These approaches may include, but are not limited to, playing games, comforting babies, and providing other effective forms of distraction."
She also notes that it is fine to give a breathing treatment while a child is asleep because, as studies show, a child gets a higher dose of the medicine during the easy, laminar flow while sleeping.

However, "An in-vivo study showed that 69% of the children woke up during aerosol administration and 75% were distressed."

Which is exactly the reason I give blowby to all my sleeping children. A blow-by breathing treatment, as most of my fellow RTs are well aware, is where you blow the treatment by the patient's face instead of using a mouthpiece or mask.

But Arzu, as expected, frowns on the practice of giving blowby's. She writes, "Although blow-by is a technique commonly used for crying babies or uncooperative children, it has been documented that it decreases aerosol drug deposition significantly as the distance from the device to the child's face is increased. Evidence has discouraged the use of blow-bys."

In the report, Arzu also notes that: "Studies suggest that the mouthpiece provides the greater lung dose than a standard pediatric aerosol mask. Consequently, the use of a mouthpiece should be encouraged, but a mask that is consistently used is better than a mouthpiece that is consistently unused."

No real surprise there.

However, while using a mask, she notes that it is important to have a good seal, whereas "a leak as small as 0.5cm around the face mask decrease the amount of drug inhaled by children and infants by more than 50%."

I'm certain there are more than a few of us RTs who use the less preferred technique that results in poor drug administration in irritated, frustrated, and crying infants and children who are not inclined to tolerate a blowby, let alone a mask or a mouthpiece.

That said, I think all us RTs can do a better job of improving our technique with children to assure that they are getting optimal deposition of the breathing treatment.


Michelle said...

It is a widely spread theory that crying children actually inhale more of the medication while crying because they are taking deeper breaths.

John Bottrell said...

It is not so much a theory but a disproved myth. For a reference see Egans, fundamentals of respiratory care.

Anonymous said...

You should add some info about pacifier use during neb treatments (pacifier > crying, and at least = no pacifier)

John Bottrell said...

If a pacifier works to calm a child during a breathing treatment, then it's perfectly fine. Pacifier = good.