Module 2 - Devices & Equipments.pdf
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Transcript of Module 2 - Devices & Equipments.pdf
1
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