AeroChamber Flow works great

So I have a four year old who has asthma as bad as mine, at least during the cold, rainy and snowy days from October through May.  He main symptom is coughing at night.  If she gets really bad she  coughs, has retractions, and has mood changes  Yes, she gets grumpy; my little smiley gets grumpy.

Usually when she has these symptoms I'm up several times during the night to give her Albuterol breathing treatments.  I tend to dote on her, because I remember my mom yelling at me when I coughed at night when I was a kid.  My mom probably considered me to be an annoyance.  I don't hold any grudges against my mom, however, because how was she to know back in 1974 that nighttime coughing is one of the main signs of childhood asthma.

So we generally resort to twice a day Albuterol treatments, and during acute attacks more frequently.  Her worse attacks require Q2-3 breathing treatments, and this is where in the past we were forced to either take her to her doctor for steroids, or to the emergency room.  We only resort to the emergency room because, by coincidence, these episodes usually transpire when it's a weekend and our daughter's doctor is not on call.

A short dose of systemic steroids, followed by Pulmicort solution twice a day is what controls her asthma.  It's neat watching my kids take breathing treatments, because they use a mouthpiece and sit through the thing better than many of my adult patients.  Perhaps it's from watching their dad take treatments.  Yet I like to think it's because they need the treatment.

Like myself, my daughter doesn't like to sit through a ten minute breathing treatment when she's feeling well.  And considering her Pulmicort treatment costs $2 a day, it can get pretty expensive.  So this year we requested our daughter be switched to Qvar instead of Pulmicort.  All the studies that I've ever read say that kids do better with inhalers anyway.

So I mention this to my child's doctor, and she says she never heard of such a thing.  However, because my family has a rare case of hardluck asthma, she decided to go against tradition and grant my request.  So my next debate is: what kind of spacer to we get.  If we buy one with a mask at the pharmacy it costs $10.  Yet I have a regular AeroChamber spacer at home that I use.

So this brought about another debate:  do we need to invest in an AeroChamber with a mask, or use the regular AeroChamber.  At first we experimented with the regular AeroChamber.  It worked fine.  I was actually surprised my daughter did so well.  Although there was really no way of knowing if my daughter was getting the medicine, even though she indicated she did.

Finally we decide to just buy the AeroChamber flow.  It works like a charm.  My daughter did so well with it we wonder why we even waited.  It's nice because you place the mask over her face, you squirt, and then she takes four or five breaths.  You know when she's getting the medicine because you can see the valve move.

There are smaller masks too, so it would probably work great for neonates as well.  I can see now why studies would show that inhalers with mask and spacers work better for kids of all ages than nebulizers.  Most of the nebulizier medicine is wasted, and most of the inhaler medicine is not wasted.

Still, where I work, doctors don't want to believe this.  They think nebulizers are the best method of aerosolized inhalation for everyone.  My daughter even looks forward to her treatments now, knowing she doesn't have to sit for ten minutes.

So consider this my endorsement of the AeroChamber flow by Forest Pharmaceuticals Inc.  No, I did not get paid for this endorsement, and I have never had any contact with the company.

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

Crying NOT good during breathing tx's

When I'm giving a breathing treatment I get so tired of RNs and doctors telling moms and dads that it's okay that their kid cry during a breathing treatment. "They take in a deep breath and get more medicine that way."

"Ahhhhhhhhhhhhhhhhhhhhhhh," the RT thinks, hardly able to hold in his rage. He's sooooooooo sick and tired of stupid dummass theories.

NO! WHEN A BABY IS CRYING HE IS SPENDING MOST OF HIS TIME EXHALING. HE IS TAKING IN SHALLOW BREATHS, AND SPENDING MOST OF HIS TIME EXHALING. HE IS CAUSING TURBULENCE WITHIN HIS AIR PASSAGES, WHICH CAUSES THE MEDICINE TO IMPACT IN THE BACK OF THE MOUTH AND THE LARGE AIR PASSAGES. THUS, VERY LITTLE MEDICINE MAKES IT TO THE BRONCHIOLES. FOR BEST DEPOSITION OF MEDICINES...

...Ahem...

YOU WANT A SMOOTH LAMINAR FLOW DURING INSPIRATION FOR THE 0.2-0.5 MICRON PARTICLES IN THE BREATHING TREATMENT TO EASE THEIR WAY TO THE BRONCHIOLES AND CONNECT WITH BETA 2 RECEPTOR SITES IN THE LUNGS.

...Ahem...

A TREATMENT GIVEN WHEN A PATIENT IS CRYING IS ABSOLUTELY USELESS.

Can I make myself more clear? Of course Dr. Stanwich debated me on this, and insisted that I prove it.

Um, okay, so where the heck did I read that? What book was it in? Like you need to look at a book. What about just using some common sense. If you inhale fast, you are feeling more cool air at the back of your mouth.

Ladies and Gentlemen, boys and girls, I have found it in writing. Finally. Finally I can put an end to this Lame theory that it's okay for babies to be crying during a breathing treatment.

The breathing pattern is another consideration in using a nebulizer or inhaler with a child. Quiet tidal breathing is the best pattern for drug delivery. Crying is a problem during a nebulizer treatment due to high inspiratory flow during the short, rapid inspirations and prolonged expiration that result in a significant decrease in medication deposition in the lung.

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.

Hey, you can base what you say on facts, or some dummass theory that takes a simple mind to repeat over and over and over. Take your pick.

I prefer to base what I say on fact.

Consider this RT Cave Rule #30.

My answers to your querries

One of my favorite things to do on this RT cave is to answer your questions. What follows are web queries that lead someone to my blog, and my humble responses. I hope this can be of help to someone.

1. how does the hypoxic drive affects the brain? Lack of oxygen can kill brain cells.

2. atrovent doses to lower potassium: No.

3. use unprescribed ventolin inhaler: Unwise.

4. coarse vs snoring lung sounds: Snoring is defined well by Wikipedia: "Snoring is the vibration of respiratory structures and the resulting sound, due to obstructed air movement during breathing while sleeping. Coarse lung sounds are caused by fluid or secretions in lower or upper passageways in the lungs. If in the upper airway, the fluid may cause an audible snoring sound, hence the confusion.

5. allergy to ventolin: A very small percentage of patients claim to be allergic to ventolin, but I think most of the time someone makes this claim it is false. Most of the patients I've seen make this claim became "coincidentally" nauseous while using Ventolin and blames the Ventolin. However, nausea is not caused by allergies.

6. nebulizer tx q1 for pediatrics: If indicated it is safe for most patients. Yet this should only be done under in the hospital under the care of a physician.
7. ippb sucks: I bet. It sucks for the RT too that we know it only works to overdistend the good alveoli and doctors still order it, but more often than not at the insistence of older RTs who still believe old and outdated research.

8. do you get less respect as a respiratory therapist if you don't work in a hospital: That's a good question. I don't know. Of course, are you assuming RTs in hospital are respected? While RT respect is growing, we still lag behind respect of doctors for their nurse. But, some nurses aren't respected either, so the cycle continues.

9. nurses and respiratory therapists get paid the same: Not usually. Where I work RNs get paid way better.

10. breathing treatments one year old baby second hand smoke: Anyone who smokes in front of their kids is a pinhead. And smoking in front of kids can increase the chance of breathing complications and the need for meds like Ventolin.

Any further questions let me know: Freadom1776@yahoo.com.

Kid Albuterol season opens today

With the start of school comes the inevitable baby with cold, flu or Respiratory Syncytial Virus (RSV). And when doctors see these patients with their congested lungs and runny nose, a page to the respiratory therapist for a breathing treatment is eminent.

Amid my run of 10 p.m. breathing treatments tonight, I was called to the ER twice to give a treatment to 4-month-old babies with high respiratory rates, stuffy heads and snotty noses. I noticed no difference with either of the treatments.

"Oh, much better," the nurse said as I was finishing up the second treatment. "He should be able to go home now as soon as Rick does an RSV swab."

What evidence she used to come to that conclusion I had no idea.

Over thinking things as I usually do, I often wonder if breathing treatments even get down into a baby's little lungs. The particle size of medicines in the mist of a treatment is 5 microns, and that's the perfect size to fit into the bronchioles of an adult patient. But baby lungs are smaller than an adults, so how does the Ventolin fit in there.

I looked on the insert of a box of Albuterol, and it reads: " Albuterol... is indicated for the relief of bronchospasm in patients 2 years of age and older with reversible obstructive airway disease and acute attacks of bronchospasm... The safety and effectiveness of Albuterol... in children below 2 years of age have not been established."

Obviously they were thinking the same thing. Regardless, Albuterol is the treatment of choice for stuffy and uncomfortable children under 2.

One study I read a few years back indicated that suctioning the airway was more effective than breathing treatments in treating patients with RSV. A breathing treatment may be attempted once, but if no improvement is observed, then no further treatments are indicated. In this case, I'd simply make this patient Q4 PRN.

Since these new studies and recommendations came out, not only do we give routine breathing treatments Q4, but we also use BBG nasal aspirators, otherwise known as booger be gones. That's progress I suppose.

Reasearch by American Family physician must have shown treatments do little for RSV patients, since their clinical practice guidelines state, "routine use of bronchodilators is not recommended.", and, "Studies also have not shown that bronchodilators have a long-term impact on the disease course."

The Cincinnati Children's Hospital Medical Center came to the same conclusion. Their guidelines also call for suctioning often.

Then again, everybody is subject to their own opinion. And, as has always been the case in the medical field, trying something as safe as a bronchodilator is better than doing nothing at all.

I know that there are certain qualifications that have to be met in order for insurance to pay, and breathing treatments for diagnosis of RSV is one of the qualifications. I personally think that's a puerile policy, but that's the way it is. Quite often, other than to make the family think we are doing something, this is the only reason I think we are doing most of these treatments. And this is unfortunate for me, because it burns me out, and for my asthma and COPD patients of whom are more deserving of my Albuterol Ampules.

Likewise, upon assessing hundreds of these children, I rarely notice a change in lung sounds, nor any improvement in retractions or nasal flaring if evident. There are obviously exceptions to the rule (baby's with real bronchospasms), but I find this to be true in most cases.

In all my research, I have never come across a study that conclusively confirms treatments do anything for these kids. I wonder if doctors are privy to esoteric knowledge, are grasping at old beliefs, or are simply ordering treatments because of the philosophy, "if it's pulmonary it should be treated as bronchospasm."

There is one other theory I have on the matter, and that is that the doctor orders Q4 ATC for no better reason than to make sure a respiratory therapist is checking on the patient. Some doctors, if this theory is accurate, feel more comfortable sleeping at home when they know their patients are in the high qualified and well respected care of the respiratory therapist.