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Monday, January 11, 2010

How to choose best delivery device for asthma meds

I have a lot of asthma patients who inquire whether they should be using an inhaler at home or if they should get a nebulizer so they can take breathing treatments at home. This is what inspired the following post:

Nebulizer or inhaler: Which one works best for your child?
by Rick Frea Tuesday, October 27, 2009

So you have an asthmatic child at home. Chances are you also have quick-relief medicine, sometimes called "rescue inhalers" to give to him if he has an asthma attack. If so, you should also be aware of the latest recommendations for administering this medicine.

Bronchodilator is the medication in quick-relief inhalers. The most common bronchodilators that provide instant relief to a child having trouble breathing are Albuterol and Xopenex (levalbuterol). I think both these medicines work equally well, but some doctors and patients prefer one over the other.

There are two basic ways to deliver this kind of medicine: a metered dose inhaler (MDI) or a Nebulizer.

1. Metered Dose Inhaler (MDI): This is the preferred method for most asthmatics because it's easily portable and can be used anywhere. This is also the best method to deliver medicine to children who cannot tolerate a mask or mouthpiece nebulizer.

According to, using an MDI with a spacer (or spacer/mask) is just as effective as a nebulizer if proper technique is used (the only exception is with severe exacerbations).

Nebulizer: This is a device that turns a liquid form of Albuterol into a mist to inhale. A treatment usually takes several minutes to complete, but this is the easiest way of getting the medicine to anyone who has trouble with inhalers, such as young children. It's also the preferred delivery method for some asthmatics when they are having severe trouble breathing (for example, we use this method most often in the hospital).

There are three ways to give a nebulizer:

Mouthpiece: I think this is the best delivery method for nebulized medicine because the medicine is delivered right to the lungs. But the problem with the mouthpiece is some kids can't use it properly.

Mask: The second best method is to connect a mask to the nebulizer and strap the mask to the child's face. The mask acts like a reservoir and stores some of the medicine as the child breathes, resulting in good medicine distribution to the lungs. The problem with the mask is that some kids don't like them.

Blowby: This is where the parent or respiratory therapist simply prepares the nebulizer so the medicine blows by the child's mouth and nose. This method is the easiest for both child and caregiver, but studies show hardly any of the medicine actually makes it down to the lungs. And, according to Bill Pruit's article RT Magazine, "
Kids and Asthma: Making (and Teaching) the Right Choices," blowby's are "considered to be inappropriate and should not be used."

That in mind, the following are the latest recommendations by the American Association of Respiratory Care (AARC) according to 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":

  • Nebulizer with mask is recommended for children under three years of age
  • Nebulizer 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
  • Breath actuated MDI for children greater than five years of age
  • Dry Powdered Inhalers (DPI) for children greater than 4 years of age and older
  • Breath actuated nebulizers for children five and older

Here are some additional notes to keep in mind:

  • Using a mask with a nebulizer is acceptable, however Arzu notes that it's important to have a good seal, whereas "a leak as small as 0.5cm around the face mask decreases the amount of drug inhaled by children and infants by more than 50%."
  • Pruitt notes the best way to get good distribution of the medicine to the lungs is with a nice smooth, laminar flow, or simple quiet breathing.
  • Do not have your child take rapid deep breaths.
  • Encourage your child not to breath fast during the treatment as this may result in lightheadness.
  • Pruitt also notes it is a common fallacy that deep breaths with crying result in better distribution of the medicine. Calm, quiet breathing is considered best.
  • Sleeping children usually breathe calmly, and this is a great time to give a breathing treatment. However, since we can no longer use a blowby, you will have to use a mask and hope your child doesn't wake up.
  • Breath actuated nebulizers are new and are supposed to make it so your child gets more of the medicine. My experience with these is it's too hard to inhale using these, especially when an asthmatic is having trouble breathing. However this is another option for you to try.

It's up to you, your child, and your child's pediatrician whether you'll want to use an MDI or a nebulizer. For the most part you'll want to use whichever method works best for your child.


Danielle said...

Great review of delivery devices. This reminds me, I've heard snippets of rumours that breathing treatments via nebulizers can be damaging to people wearing contact lenses. Have you heard this before, what's it about?

Thanks, Danielle

Rick Frea said...

I remember when Atropine used to be nebulized, and occasionally you'd get Atropine spattered into your eyes and they'd be dilated a couple hours. Other than that, I know of no effect of breathing treatments on eyes. If I learn anything I'll let you know.