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Devices and

Equipment

Module 2

Training of Inhalation Therapy

& Pediatric Asthma Management

Departemen IKA FKUI-RSCM

Dr. Bambang Supriyatno, Sp.A(K)

Born: Jakarta, November 22, 1960

Education:

1. Faculty of Medicine University of Indonesia, 1985

2. Medical Postgraduate (Pediatrics), Faculty of Indonesia, 1993

3. Pediatric Pulmonology Subspecialty, Faculty of Indonesia, 2002

Recent position:

• Head of Department Child Health, University of Indonesia, Cipto Mangunkusumo Hospital

• Head of Respirology WG, 2003-2008

• Chairman (1) of IDAI 2005-2008

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Ideal inhalation therapy devices

technical aspects clinical aspects patients aspects

high output for all ages easy to use

% respirable aerosol >

breathing pattern adaptive

simple maintenance

shorter time reproducible dosing affordable

adaptable power sources

adjustable particle size

attractive appearance

ready & over alarm including lung function

measurement

quiet

durable small, portable

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Inhalation therapy devices

1. Nebulizer

2. Dry powder inhaler (DPI)

3. Metered dose inhaler (MDI)

with and without spacer

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Nebuliser

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Nebulizer

Continuously change the solution to aerosol by pressured air or ultrasonic wave

Jet nebulizer: aerosol is generated with a flow of gas, provided by compressor or compressed gas

Ultrasonic nebulizer: aerosol is generated by vibrating fluid placed within it

Jet neb is the most widely used

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Figure. Jet nebulizer

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Jet nebulizer parts

• electric compressor

• connector tube

• neb chamber

– removable top

– liquid reservoir

• interface:

– mouth piece

– face mask

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Jet nebulizer parts

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Gas at high

pressure

1-degree droplets

Fine droplets pass around baffle

To patient

Baffle

Droplets trapped and recirculated

Feed tube

Aerosol generation by a jet nebulizer

Everard ML, et al. Pediatr Respir Med 1999; 286

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Schematic figure of jet nebulizer

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Jet nebulizer

advantages

• less coordination needed

• can mix & formulate the drug

• high doses possible

• no CFC release

disadvantages

• expensive

• possible contamination

• not all medication available

• more time required

• need drug instillation

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Nebulizer

Continuously change the solution to aerosol by pressured air or ultrasonic wave

Jet nebulizer: aerosol is generated with a flow of gas, provided by compressor or compressed gas

Ultrasonic nebulizer: aerosol is generated by vibrating fluid placed within it

Jet neb is the most widely used

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Figure. Ultrasonic nebulizer

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Schematic fig of ultrasonic nebulizer

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Ultrasonic nebulizer

advantages

• less coordination needed

• high doses possible

• no CFC release

• small dead volume

• quiet

• faster delivery

disadvantages

• expensive

• possible contamination

• not all medication available

• bulky

• need drug instillation

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Comparison of nebulizer

Parameters Jet nebulizer Ultrasonic neb

power source electric / comp electric

how it works high air flow high freq vibrat’n

air flow 8L/mnt (+2L) -

sound noisy quiet

tool position free quite horizontal

fill volume 3-5 mL >10 mL

nebulized drug almost all not steroid

price Cheap expensive

maintenance simple complex

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Fill volume

Drugs <3mL 3-5mL >5mL

bronchodilator + + +

steroid + + +

the volume of drug solution to be fill in the reservoir chamber

Drug dosage for nebulizer

Drugs Nebulizer

Jet Ultrasonic

NaCl 0.9% (ml) added until 5 10

ββββ2-agonist• Alupent sol. 2% (gtt)• Berotec 0.1% (gtt)• Ventolin nebule (mL)• Bricasma respule

(mL)

3 – 5511

3-5511

ββββ2 agonist + anti cholinergic• Combivent (mL)

1 1

Time (minutes) 10 - 15 3 - 5

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Nebulization time

hospitalization <6’ 6-10’ >10’

< 24 hours + + -

+ 24 hours + + -

> 24 hours + + +

the time from starting nebulization until continuous nebulization has ceased

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Interfacedevice part directly connected to patient

mouth piece face mask

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Interfacedevice part directly connected to patient

mouth piece

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Dry Powder Inhaler

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Dry powder inhaler (DPI)a tool to inhale drugs in dry powder form

• 1957: for inhalation of dry powder antibiotic

• studies: can be used for other respiratory drugs

• 1970s: 1 DPI contains 1 dose (Spinhaler,Rotahaler)

• 1980s: 1 DPI contains more doses (Diskhaler 8)

• 1990-2000s: more doses in 1 DPI

– Accuhaler – 60 doses

– Turbuhaler – 120 doses

– Easyhaler – 200 doses

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Dry powder inhaler (DPI)

• the power source is the flow of inspiration / inhalation of the patient

• breath-actuated inhaler, no propelan

• effort dependent

• less oropharynx deposition

• not suitable for under 5 children

• for older children easier to use than MDI

• no need of spacer, easy to carry

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2 different kind of DPI

The drug within the device

• Turbuhaler

• Easyhaler

• Swinghaler

The drug separated from the device

• Rotahaler

• Cyclohaler

• Handyhaler

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Turbuhaler® – design and operation

Inhalation channeltransports dosage of drug aggregates to the mouthpiece

Mouthpiece is speciallydesigned with spiral channels to deaggregate the dose to respirable particles

Drug reservoir holds50,60,100 or 200 doses of medication

Dosing scrapers ensuresprecise dosing by removing excess amounts of drug

Rotating dosing discdetermines the dose of medication for delivery to the inhalation channel Twist grip loads a single

dose when turned completely in one direction and then back again

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Easyhaler mechanism

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DPI use, common mistakes

• Not open the cap

• Not exhale first

• Not inhale forcefully & deeply

• No deep / maximal inhalation

• Not hold the breath for 10 seconds

• Forget to rinse the mouth

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Dry powder inhaler

advantages

• less coordination required

• breath hold not required

• breath actuated

disadvantages

• requires high inspiratory flow

• pharyngeal deposition possible

• difficult to deliver high doses

• not all medication available

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Metered Dose Inhaler

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Metered dose inhaler (MDI)

components of MDI

• canister, an aluminium can with metering valve and valve stem, it contains

– micronized drugs suspension, with multiple doses (up to 300)

– propellant, CFC or else

• actuator, usually made from plastic

– actuator seat, where the canister is placed

– mouthpiece

• the cap

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Schematic diagram of inhalation device

Metered dose inhaler (MDI) Dry powder inhaler (DPI)

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Metered Dose Inhaler (MDI)

How to use it:• shake the canister, open the cap• hold it up right, exhaled slowly• put the canister mouthpiece between lips tightly,

inhaled slowly• anytime after the beginning until the middle of

inspiration, push down the canister• continue the inspiration gently until max insp• at maximal inspiration, hold the breath for 10 sec • don’t forget to rinse the mouth and spill out to

wash out the rest of the drugs in oropharynx

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How to use MDI

remove the cap from the mouthpiece

shake well for 15shake well for 15’’

before each use before each use

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How to use MDI

while breathing deeply & slowly, press the canister

firmly

breath out through the mouth, breath out through the mouth, place the mouthpiece in the place the mouthpiece in the

mouth, & close the lips around it mouth, & close the lips around it

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How to use MDI

Alternatively, the Alternatively, the

inhaler may be inhaler may be

positioned 1 to 2 positioned 1 to 2

inches away from inches away from

the open mouththe open mouth

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MDI use, common mistakes• Not shake the canister

• Not open the cap

• Not hold in vertical position

• Up side down position

• Not exhale first

• Lack of coordination

• Too fast and powerfull inhalation

• No deep / maximal inhalation

• Not hold the breath for 10 seconds

• Forget to rinse the mouth

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How to measure the MDI contents

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Metered dose inhaler

advantages

• convenient

• less expensive

• portable

• no drug preparation

• no contamination

disadvantages

• coordination essential

• patient activation required

• large pharyngeal deposition

• difficult to deliver high doses

• not all medication available

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Spacer

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MDI with spacer

disadvantages of MDI alone

1. direct spray into the mouth: high speed & large particle � oropharynx impaction

2. complex maneuver, need superb coordination, difficult even for adult

to overcome: spacer - add space actuator - mouth

1. extension devices (no valve): solve the 1st

2. holding chamber: solve both problems

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Spacer

extension devices : without valve• to lengthen the distance between actuator

mouthpiece and oropharynx• reduce aerosol speed, propellant

evaporate, large particle trapped• still need coordination, although less

holding chamber : with valve• drug reservoir with certain volume• has valves on both sides, hold the aerosol• no need coordination

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Spacer interface

extension devices : without valve

• mouth piece: Volumatic, mini Spacer, Aqua bottle

• face mask : plastic cup

holding chamber : with valve

• mouth piece: AeroChamber, Pocket Chamber

• face mask : AeroChamber, Babyhaler, Pocket Chamber

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MDI with spacer

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MDI with spacer

advantages of MDI with extension device:• reduced aerosol speed when inhaled• produced smaller particles• reduced oropharyngeal deposition

advantages of MDI with holding chamber• advantages of extension device, +• less coordination needed• suitable for children, even for baby (older

children using mouthpiece, baby using facemask)

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MDI with spacer

advantages

• less coordination required

• less pharyngeal deposition

• no drug preparation

• no contamination

disadvantages

• more complex for some patient

• more expensive than MDI alone

• less portable than MDI alone

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Lung deposition of budesonide

MDIMDI +

spacer®

DPI (Turbuhaler)

Thorsson et al, 1998

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ResumeInhalation therapy

DPINebulizer MDI

UltraS Neb

Jet Neb

•Turbuhaler

•Rotahaler

•Easyhaler

•Cyclohaler

Spacer (-)

Spacer (+)

extension dv holding ch

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Thanks for

your attention