19-Aug-15

Darmawan B Setyanto, MD
Aerosol therapy in children
common pitfalls
Born: 11 April 1961
Education:
 Medical Doctor, Faculty of Medicine, University of Indonesia, 1986
 Pediatrician, Faculty of Medicine, University of Indonesia, 1997
 Respirology Consultant, 2005

Darmawan B Setyanto
Indonesian Pediatric Society
Current position :
 Head of Respirology Division, Dept of Child Health, Faculty of
Medicine, University of Indonesia
Organization:
 Chairman of Respirology Coordination Working Unit, Indonesian
Pediatric Society 2008-2014

Common pitfalls Pitffalls in the use of

nebulizer

MDI DPI

List of nebulizer pitfalls List of nebulizer pitfalls

 Indication  Indication
o ... o Nebulization for upper airway symptoms
o… o Steroid inhalation as reliever for acute airway
 Device symptoms
o ... o ‘Package system’
o…  Device
 Drug o ...
o ...  Drug
o… o ...
 Do NOT ‘diluting’ the drug  Do NOT ‘diluting’ the drug

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 19-Aug-15

List of nebulizer pitfalls Selesma 

 Indication
o Nebulization for upper airway symptoms
o Steroid inhalation as reliever for acute airway
symptoms
o ‘Package system’
 Device
o ... Flu virus
Rhinovirus
 Drug


o ...
Do NOT ‘diluting’ the drug Flu!

PARTICLE SIZE

> 10µ
Nasal cavity List of nebulizer pitfalls
IMPACTION

 Indication
o Nebulization for upper airway symptoms
o Steroid inhalation as reliever for
SEDIMENTATION 7-10µ Trachea acute airway symptoms
Primary bronchus
o ‘Package system’
 Device
Secondary bronchus
2-5µ o ...
SEDIMENTATION Terminal bronchus  Drug
+
DIFFUSION < 2µ Respiratory
bronchiole
o ...
DIFFUSION < 2µ
Alveoli
Alveolar
Ducts & Sacs
 Do NOT ‘diluting’ the drug
Particles penetrate the respiratory tract to different degrees according to their size.
This diagram also depicts the mechanisms that operate to clear particles from 9
the Respiratory tract according to size

Asthma medication Reliever drug

Topical, Inhalation: Nebulizer or MDI+spacer
Reliever • To relieve asthma symptoms - attack
• As needed medication  Reliever inhalation drug:
drug • If the symptom relieve, stop o β2 agonist: salbutamol, terbutaline, fenoterol,
(pereda) • Drugs: -agonist & anticholinergic
procaterol
o Anti-cholinergic: ipratropium bromide
o β2 agonist + anti-cholinergic
• To control asthma inflammation
Controller  Inhaled steroid ???
• Long term medication, months - years
drug • Evaluated regularly, Systemic: enteral, parenteral
• Dose adjusment: maintain, increase,
 Systemic steroid (oral, injection)
(pengendali) decrease
• Drugs: inhaled cortico-steroid (ICS)  Xanthin: aminophylline, theophylline

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Inhaled CS for reliever List of nebulizer pitfalls

 Indication
 ICS: budesonide (Pulmicort® respule) and
o Nebulization for upper airway symptoms
fluticasone (Flixotide® nebule)
o Steroid inhalation as reliever for acute airway
 ICS is designed as ‘controller’ symptoms
 Steroid as reliever – systemic administration
o ‘Package system’
(oral OR injection)
 Device
 ICS as reliever – a very common (mis)practice
o ...
o Based on concept: wrong!
o Evidence based medicine??? – high dose!!!  Drug
o ...
o High cost!
 Not recommended as routine management  Do NOT ‘diluting’ the drug

Cough &/ wheeze Asthma medication

Reliever • To relieve asthma symptoms - attack
• As needed medication
drug • If the symptom relieve, stop
(pereda) • Drugs: -agonist & anticholinergic

Package system:
• x times • To control asthma inflammation
• pre-paid Controller • Long term medication, months - years
• Evaluated regularly,
drug
• Dose adjusment: maintain, increase,
(pengendali) decrease
• Drugs: inhaled cortico-steroid (ICS)

List of nebulizer pitfalls Nebulized ICS using ultrasonic neb

 Indication
o ...
 Device
o Using ultrasonic neb for steroid
o Interface: facemask VS mouthpiece
o Non-fitting mask Ultrasonic nebulizer:
o Suctioning • much more expensive
o Diathermy • delicate, not tough
 Drug • difficult operation & maintenance
o ... • CAN NOT DISPERSE STEROID MOLECULE
 Do NOT ‘diluting’ the drug

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List of nebulizer pitfalls Non-fitting mask

 Indication
o ...
 Device
o Using ultrasonic neb for steroid
o Non-fitting mask
o Interface: facemask VS mouthpiece
o Suctioning
o Diathermy
 Drug
crying
o ...
too big
 Do NOT ‘diluting’ the drug

List of nebulizer pitfalls Which one is better?

 Indication
o ...
 Device
o Using ultrasonic neb for steroid
o Non-fitting mask
o Interface: facemask VS mouthpiece
o Suctioning
o Diathermy
 Drug
o ...
 Do NOT ‘diluting’ the drug

List of nebulizer pitfalls Suctioning

 Indication  Do not perform routinely for
o ... all patients !!!
 Device  Traumatic:
o Using ultrasonic neb for steroid o Physiologic: bleeding, vagal reflex
o Non-fitting mask o Psychologic
o Interface: facemask VS mouthpiece  Only remove the secretion above glottis – not
o Suctioning needed as long as patient conscious and able to
o Diathermy cough properly
 Drug  Indication is very limited
o ...
 Do NOT ‘diluting’ the drug

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Where does the suction goes? List of nebulizer pitfalls

 Indication
o ...
 Device
o Using ultrasonic neb for steroid
o Non-fitting mask
o Interface: facemask VS mouthpiece
o Suctioning
o Diathermy
 Drug
o ...
 Do NOT ‘diluting’ the drug

Diathermy indications Diathermy contra-indications

 Muscle strains There are probably more contraindications listed
 Contusions for diathermy than any other therapeutic
modalities
 Ligament sprains  ...
 Tendinitis  Fever, infection
 Tenosynovitis  Acute inflammation
 Bursitis  Malignancies
 Joint contractures  ....
 Myofascial trigger points
This frightens many clinicians

List of nebulizer pitfalls ‘Routine’ mix combination

 Indication -agonist + steroid + mucolytic
o ...  Indication: NOT clear
 Device  Often: less dose for each drug
o ...
 No clinical effect
 Drug
 Unnecessary cost
o Nebulized non-nebulization drug (injection drug,
oral drug)  NO inhalation guideline mention it
o ‘Routine’ mix drug combination: -agonist, steroid,  ‘cocktail’, ‘gado-gado’
mucolytic
 Do NOT ‘diluting’ the drug

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List of nebulizer pitfalls DO NOT ‘diluting’ the drugs

 Indication  It is NOT about ‘diluting’ the drugs
o ...  Addition of normal saline is to reach the
 Device FILL VOLUME as recommended by the
o ... nebulizer manufacturer
 Drug  Usually about 5 mL (4 – 6 mL)
o Nebulized non-nebulization drug (injection drug, oral  Less volume will give less performance
drug)
o ‘Routine’ mix drug combination: -agonist, steroid,
mucolytic
 Do NOT ‘diluting’ the drug

British Thoracic Society

DO NOT ‘diluting’ the drugs

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DO NOT ‘diluting’ the drugs

Advice for nebulizer usage

 Use jet nebulizer / compressor: cheap, easy
operation and maintenance, able to break down
every type of drugs.
 If the purpose of therapy is as a reliever
medication, do not give steroid inhalation;
imprecise indication and expensive.
 Inhalation therapy as the reliever treatment can
be stop if the symptoms subside, no ‘package’
 No need of suctioning and diathermy.

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Presented at:
Thank you for listening
 Round table discussion
 IDAI Cabang Riau
 Pekanbaru
 Ahad, 23 Agt 2015