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.

The ongoing drama of crying baby's and blowbys

I'm just curious here, but since most studies show that 90% of the aerosolized medicine is wasted when giving a blowby treatment, and a laminar flow is recommended for maximal impaction of the medicine to receptor sites in the lungs, how much of the medicine do you think a child is getting if he is wailing through the entire blowby treatment?

I bet it's less than 1%, although I'm not sure any studies have ever been done to determine this. Yet commonsense says that most of that medicine I just gave that 3 YO kid impacted outside that boy's body, and the rest never made it beyond is oral cavity.

And, sorry doc, but the treatment was pretty much useless. Although the doctor was convinced that it was my breathing treatment that cured that kid of his congested cough. Well, I've lost patience with doctors and nurses to explain again and again that crying baby's don't get the medicine, and blowby is pretty much useless.

I would give the treatment with a mask or mouthpiece to most kids who are compliant, but the blowby remains the only option for non compliant kids and babies. Now, personally, I don't think the treatment for congestion was indicated anyway, but I don't see any harm in trying. Still, he didn't get the medicine.

The irony of all this is neither the doctor nor the nurse considered any of this science. Nor the fact that my being in the room is merely causing that little boy serious anxiety, and better therapy would be for that kid to be left alone.

Although I'm not a well trained doctor, and I'm prone to be wrong from time to time, science is science, and science says blowbys and crying do not equal good impaction of aerosolized meds in the lungs.

Yet, from behind me, the nurse says, "It's okay that he's crying. He gets more of the medicine that way."

"Ahhhhhhh," I think. I say: nothing. I give up. I've already explained the science a million times. It never yet has sunk.

As soon as I stop the treatment the kid smiles at me, and says, "Thanks." Wow! That's all it took to make him better was for me to stop. Who would have thunk it? Oh, I did!

Yet, it often seems no doctor nor nurse ever seems to consider blowby and crying science as I finish the treatment. They usually simply ask this simple question: "Is he better?"

I say, "We'll have to wait and see, because I can't assess him at the moment because he don't like me much."

Blowby treatments ARE useless

To go along with what I wrote yesterday, that crying during a breathing treatment is NOT good, blowby breathing treatments are useless too.

Okay, yes, I'm going against the general consensus of doctors and nurses where I work, but IT IS TRUE.

Consider this. You put 0.5cc Ventolin into a nebulizer. You give the breathing treatment with a mouthpiece and a wide bore connector tubing conected to the other end to act as a reservoir to store some of the "wasted" medicine during exhalation.

Approximately a half of that 0.5cc dose is wasted just on passive exhalation while the treatment is going. About half of what is inhaled impacts in the mouth, the back of the throat and the large airways. The rest, the particles that are 0.2-0.5 microns, actually make it to the lungs.

So, in essense, of the original 0.5cc, about a quarter of it actually makes it to the bronchioles to conect to beta 2 cells and cause bronchodilation.

So, imagine if you are simply blowing the mist by the patient's face. That's right, you are wasting even more medicine. I would imagine, if studies were done, less than 10% of the medicine gets to where it's supposed to go -- the bronchioles.

Add to that if the patient is crying, and you waste even more.

Now you have a doctor who thinks that since a 0.5cc dose is the adult dose, he should give half of that, so he orders neb treatment by blowby 0.25cc Ventolin. So that is even less med to the bronchioles.

In essense, it has been proven that blowby treatments are useless. And when they are given you should probably give twice the dose, not half.

Add to this the fact that Ventolin hasn't even been proven effective on the small lungs of infants. They don't even know if it works. I wrote about this before.

Still, 0.25cc Ventolin is usually the given dose. A blowby is usually given, and the treatment is ordered every four hours.

If you don't believe me, check out this link to original article in the August 2008 issue of RT Magazine. The article is aptly titled, "Kids and Asthma: Making (and Teaching) the Right Choices." The author is Bill Pruitt, RRT, AE-C, CPFT.

Or Read this excerpt from the article:

The technique of directing the nebulizer output toward the patient's nose and mouth (referred to as "blow-by") is considered to be inappropriate and should not be used. The AARC CPG on aerosol delivery devices recommends that a nebulizer with a mouthpiece and an extension reservoir be used in children >3 years of age if they are cooperative, are spontaneously breathing, and do not have an artificial airway in place.

Keep in mind sometimes you have no choice but to give a blowby. This is fine so long as that "blowby" isn't considered by the doctor to be the leading cause of treatment for that child.

Consider this RT Cave Rule #31

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

I know that most people click on my site and leave two minutes later frustrated that my site is not what they were looking for. When, in actuality, if they would have hung around a bit, had a cup of coffee with me, they may have found the answer they were looking for.

This is what I'm going to make an effort to do every Monday.

1. vomiting bipap: This is a good question and something that was covered extensively in RT school. There are two types of masks patients can wear who are using BiPAP. There is a nasal mask, and a full face mask. If the patient is wearing a nasal mask, then there's no problem. However, in the hospital setting we use full face masks probably 90% of the time. And, if someone is throwing up with a mask on their face, their risk of aspiration (inhaling the vomit into the lungs and risking pneumonia) increases big time. Take the mask off if a patient is vomiting. If the patient is in the hospital and is on BiPAP to prevent him from needing a vent, intubation might need to be considered to protect the airway.
2. giving mucomyst without a bronchodilator: Mucomyst has the ability to break up thick secretions and making them easier to spit up (theoretically). It can cause bronchospasm, and should always be given with a bronchodilator, such as Albuterol.
3. vaponephrine dose for kids: At Shoreline we use 0.5cc Vaponephrine on all kids. It's safe. I have rarely ever notices an increase in heart rate as a result of this medicine, and usually if the heart rate does increase, it's because of the kid crying because he's annoyed by the RT.
4. efficacy of albuterol with chf: I've repeated this many times on this blog, but Albuterol will do nothing for CHF unless -- UNLESS -- the patient also has an underlying bronchospasm component. If you want to try one treatment to see if it does anything, go for it.
5. is a nurse above a respiratory therapist: Absolutely not. We are a team. Now, RNs are know to have a little more respect in society, but that is slowly changing. The reason is that nurses have been around since the Civil War, and RTs are only just getting started. RNs also get paid more than RTs, but that's only because of the nursing shortage and, partially, because of the respect thing. But, all in all, we are a team.
6. azthmacort: I took asthma cort for about 15 years, and never had much success with it. The main reason for this was compliance, as I was prescribed to use it four times a day. I think it's better to use a steroid inhaler that allows you to use it twice a day to increase compliance. I have better success with Flovent or Advair, but there are other options.
7. barriers to being a good respiratory therapist: Lack of respect I think is the main barrier. And lack of protocols that allow us to really excell at providing the best care to our patients at the least cost to the hospitals. However, due to lack of respect by doctors, many hospitals still do not have respiratory therapy or patient driven protocols. That's a shame, I think, and is the biggest barrier in my mind.
8. albuterol blow-by neonates: I find that most babies do not tolerate masks, however the results of using a mask may vary from patient to patient. If the child is sick enough, he or she might not care. Also, a blowby may result in the loss of 80% or more of the medicine to the atmoshphere. That said, giving a blowby is often better than doing nothing for a child who is having true bronchospasm.
9. should i give my daughter albuterol for croup: Only if there is underlying bronchospasm. Albuterol does absolutely nothing for croup.
10. cpap therapy for copd how it works: CPAP works to improve oxygenation. It helps a patient oxygenate better, and thus allows more oxygen to get into the bloodstream.
11. congestive heart failure croupiness: We hear this a lot in CHF patients. And, more often than not, RNs and RTs mistake this for a wheeze and recommend or order breathing treatments. Actually, this is caused due to increased secretions or fluid in the upper airway, and will not go away with a treatment. I would say that abaout 80% of CHF patients, patients with pulmonary edema, will have this harsh, upper airway, stridorous, croupy sound. This is something they should teach in school, but I'm not sure they do.
12. what is my internet time: Huh?
13. extra shift incentive pay respiratory: What do you mean by extra shift? Do you mean overtime. We get paid overtime for anything over 40 hours just like everybody else.
14. bad experiences with advair: Some people have bad experiences with Advair mostly becaue it has Serevent in it, which can make a person shakey and irritable. I would recommend weaning yourself onto the Advair slowly, instead of starting right out taking it twice a day. I'm patenting that idea. I recently wrote a post about this, check it out by clicking here.
15. stridor and aerosol therapy: See my answer to question #9.
16. duoneb and hyperkalemia: It would be the equivelent of taking an asprin for a heart attack. Need I say more.
17. why respiratory therapists are disrespected: I tried to explain this in my answer to #7 above. Maybe one of my fellow bloggers can word it better than me with a comment.
18. my doctor gave me potassium after an asthma attack why and what does potassium do f: Hopefully he gave potassium because lab results showed hyperkalemia, not because of some frivolous idea that one treatment of Albuterol will decrease Potassium. However, for a further answer, see #16 above.
19. definite sign of impending alcoholism: Okay, sorry sir or maam, but you had to read all of the above to learn that I do not have an answer to this question. Now, I could gather a pretty good educated guess, but I'm pretty sure you'd rather hear from a professional in that area rather than a lowly RT.
20. respiratory therapist 12 hours: I do not know of any hospitals where the RT does not work less than 12 hour shifts.
21. does albuterol breathing treatments make baby sleepy: Actually, it can be soporiphic. I know for it fact it puts some babies and even some adults asleep. Ah, maybe this gives me another idea for an 'olin.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.

New Study: Xoponex now a humidifier

Okay, this is about crazy, but Dr. Krane called me back down to ER to do another treatment on a baby with a cold. The order read: Xoponex low dose.  Okay, so I'm making this up, there is no Doctor Krane.  She is a figment of my imagination.  She is a composition doctor I made up.  But if you're an RT of any duration, you probably have met her.

Like many of you guys, I grumbled to myself of how little medicine gets to a baby during a blowby treatment to begin with, let alone when using a low dose of albuterol. But I kept my mouth shut and gave the treatment.

The baby hated me. She wailed and kicked and screamed until I gave up and gave the neb to the dad. The kid smiled. I was stupid to even try to give it on my own, I should have had dad do it from the start. My bad.  To my credit, however, most kids take treatments great.  Sometimes, however, we RTs have to get creative.

Unable to assess the baby, I watched it's breathing. There were no signs of respiratory distress.  I was essentially giving this treatment to satisfy the physician, and to make the patient's parent's think we were doing something.  I understand, however, that this time of placebo is common in medicine.  In fact, studies even show that the placebo effect amazingly cures ailments, including parental stress, in about 50 percent of cases that it's tried.

After the treatment I approached Dr. Krane.  I said:  "So, what kind of assessment did you get on this child, because she didn't like me too much."

"Oh," Dr. K said, "she was really clear down below, but up in her throat I heard a little croupy sound."

She thought a second, then continued, "Basically I just wanted her to have the humidity for her throat."

Humidity for her throat?  Did she actually say that?

"Thank you."  I said.  "I just wanted to be able to chart something."

HUMIDITY FOR THE THROAT? 

I thought I was up to date on all the latest research.  

Upon doing furher research, I found the following from my anonymous source, which actually made Dr. K. look pretty good.

New medical study shows a low dose of ventolin, once it enters the throat, enlarges to 10 microns and turns into steam. The medicine then coats the cells within the throat and soothes them. Persistent croup is not an indicator of ineffectiveness.

This new version of Xoponex is called Humidonex. To see more frivolous ventolin therapies click here.