Respiratory Care in PICU Aerosol Therapy - thaipedlung.org · 7/10/2010 · The delivery of...
Transcript of Respiratory Care in PICU Aerosol Therapy - thaipedlung.org · 7/10/2010 · The delivery of...
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Respiratory Care in PICURespiratory Care in PICUAerosol TherapyAerosol Therapy
นน..ออ..หญิงหญิง สุพิชสุพิชชาชา แสงโขติแสงโขติ
โรงพยาบาลสมเด็จพระปนเกลาโรงพยาบาลสมเด็จพระปนเกลา
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liquid droplets or solid particles
suspended in a gas(air)
visible like fog
Aerosol
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Aerosol vs Humidity
Humiditywater in gas status (vapor),
invisible
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drug be inhaled and deposit in targeted site of respiratory system :
deposit in lungs (lung dose),responsible for pharmacologic effects at targeted site
Goals of Aerosol Therapy
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direct delivery of drug to site of actionrapid onset of actionlower dose to produce desired effects
(than systemic administration)minimizes systemic adverse effects
Advantages of Aerosol Therapy
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Indication of Aerosol Therapy
1. bronchial hygiene2. humidification3. medication
bronchodilator, vasoconstrictor, corticosteroids, mucoregulators, antimicrobial agents, surfactant, insulin, prostaglandin, vasopressinetc.
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aerosol size
mass median aerodynamic diameter (MMAD)
Median value of particle of aerosol mass ,output from nebulizer, suspended in the gas flow
Aerosol deposition in airway
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aerosol deposition in airway
size / MMAD (µm) site of aerosol deposition< 0.5 no deposition, exhaled with exp. flow0.5-2 alveoli2-5 bronchi, bronchiole5-100 mouth, nose, upper airway>100 filtered by upper respiratory tract
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Aerosol deposition in airway
MMAD (µm) aerosol deposition2-5 bronchi, bronchiole
MMAD (µm) aerosol deposition0.5-2 alveoli
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lung depositionweight-dose physiologic effect of pharmacologic aerosol
How are infants/ children different?Aerosol Therapy
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respiratory flow pattern-aerosol output fromcontinuous jet nebulization-inhaled drug
100 ml/sec
In infants/ childrenpeak inspiratory flow rate- lowtidal volume, vital capacity,functional residual capacity-low respiratory rate –highrespiratory cycle -short
Rubin BK, Fink JB. Respir Care Clin N Am 2001;7(2):175–213.
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Dolovich MB. Respir Care 2002; 47(11):1290–1301.
Inspired dose vs aerosol output from nebulizer
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Lung deposition ,the percentage of the dose delivered and the percentage of initial nebulizer dose for the nebulizers.
Fok TF, Monkman S, Dolovich M, Gray S, Coates G, Paes B, et al. Pediatr Pulmonol 1996;21(5):301–309.
amount of albuterol deposited in the lungs
nonventilated infants ventilated infants
0.67%
1.74%
0.28%
0.98% 0.95%
0.22%
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Wildhaber JH, Dore ND, Wilson JM, Devadason SG, LeSouef PN.J Pediatr 1999;135(1):28–33.
Lung deposition of albuterolwith MDI / chamber vs jet nebulizer
in nonventilated children
5.4%
11.1%
5.4%
9.6%
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Lung deposition of aerosol in nonintubated patient
Infant 0.1Infant 0.1--1 %1 %
Children< 4 y 5 %Children< 4 y 5 %Children> 4 y 10 %Children> 4 y 10 %
Adult 8Adult 8--22 % (SVN 1022 % (SVN 10--14%)14%)
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lung depositionneonate < 1% of nominal doseadult 8-22% of nominal dose
weight-dose physiologic effect of pharmacologic aerosol
How are infants/ children different?Aerosol Therapy
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lung dose / body weight
infant 2 kglung deposition 1% lung dose= 12.5-25 microgm.= 6.25 microgm./ kg
salbutamal 1 dose =2500 microgm./ dose
Adult 70 kglung deposition 10% lung dose= 250 microgm.= 3.6 microgm./ kg
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% change in total resistance (Rrs) and total compliance (Crs) of the respiratory system following administration of albuterol MDI and nebulizer
Torres A Jr, Anders M, Anderson P, Heulitt MJ. Chest 1997;112(2):484–490.
Efficacy of MDI administration of albuterol in ventilated infants
MDI & nebulizer
complianceresistance
MDI & nebulizer
physiologic effect of pharmacologic aerosol
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Aerosol: particle size &
physical characteristics
Aerosol output
Airway anatomy & pathology
Patient Ventilatory pattern
Aerosol deposition Aerosol deposition depend ondepend on
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Aerosol: particle size &
physical characteristics
Aerosol output
Airway anatomy & pathology
Patient Ventilatory pattern
Aerosol deposition Aerosol deposition depend ondepend on
MMAD sizedensity of gastemperature humidity
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Aerosol: particle size &
physical characteristics
Aerosol output
Airway anatomy & pathology
Patient Ventilatory pattern
Aerosol deposition Aerosol deposition depend ondepend on
DeviceFill volumeGas flow/ pressureNebulization time
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Aerosol: particle size &
physical characteristics
Aerosol output
Airway anatomy & pathology
Patient Ventilatory pattern
Aerosol deposition Aerosol deposition depend ondepend on
Congenital stenosis of airwayobstructive airway diseaseBPD, bronchiectasisSecretionArtificial airway
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Aerosol: particle size &
physical characteristics
Aerosol output
Airway anatomy & pathology
Patient Ventilatory pattern
Aerosol deposition Aerosol deposition depend ondepend on
Inspiratory flow rate - slow 0.5 L/min-laminar flowInspiratory volume -deep inspirationBreath holding 4 secInspiratory time -at beginningMouth breathingdeposition in sedated pt.>non-sedated pt.
หายใจเขา
ชา ลึก นาน
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Aerosol devices1. nebulizer
Jet nebulizersmall volume nebulizer-SVN large volume nebulizer-LVN
Ultrasonic nebulizerSmall particle aerosol generator
2. Metered dose inhaler (MDI)3. Dry powdered inhaler (DPI)
turbuhaler, diskhaler, swinghaler
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Aerosol therapy in nonin non--intubatedintubated children children in PICUin PICU
Aerosol therapy with small volume nebulizer (SVN)
Continuous nebulization therapy (CNT)
Aerosol therapy with EzPAP
Aerosol therapy with noninvasive positive pressure ventilation
(NPPV)
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Jet nebulizer : small volume nebulizer-SVN
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Continuous Continuous nebulizationnebulization therapy (CNT)therapy (CNT)
Indication of CNT
1. Severe asthma with asthma score > 52. Asthma patient who need nebulization frequently
(every 15 min-1 hr)
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Continuous Continuous nebulizationnebulization therapy (CNT)therapy (CNT)
•Efficiency not different from intermittent nebulization(more efficiency in severe airway obstruction case)
•Benefit in cost effectiveness•Benefit for personnel in drug administration•Decrease patient disturbance
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1.5 ชม.20 มล./ ชม.8 ลิตร/ นาที30 มล.miniHEART
Hi-Flo
8 ชม.
4 ชม.
30 มล./ ชม.
50 มล./ ชม.
10 ลิตร/ นาที
15 ลิตร/ นาที
240 มล.HEARThigh
flow
3 ชม.8 มล./ ชม.2 ลิตร/ นาที30 มล.miniHEART
Lo-Flo
low
flow
Nebulization
time
Nebulization
output
Gas flowขนาดบรรจุ
Fill volume
ตัวอยาง
ผลิตภัณฑ
ชนิด
CNT
Continuous Continuous nebulizationnebulization therapy (CNT)therapy (CNT)
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High flow CNTHigh flow CNT
(miniHEART Hi-Flo)(HEART Hi-Flo) (HOPE Hi-Flo)
Low flow CNTLow flow CNT (miniHEART Lo-Flo)
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Jet nebulizer : large volume nebulizer-LVN
continuous nebulization therapy
HEART nebulizer- high flow
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HEART nebulizer- high flow
Jet nebulizer : large volume nebulizer-LVN
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Jet nebulizer : large volume nebulizer-LVN
FloFlo--MistMist
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miniHEART high flow miniHEART low flow
Jet nebulizer : large volume nebulizer-LVN
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Aerosol therapy with Aerosol therapy with EzPAPEzPAP
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EzPAPEzPAP
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EzPAPEzPAP with with nebulizernebulizer
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EzPAPEzPAP with with nebulizernebulizer
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Jet nebulizer with NPPV
Aerosol delivery 5Aerosol delivery 5--25%25%
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Jet nebulizer with NPPV
High aerosol delivery High aerosol delivery byby
High inspiratory press.20 cmH2OLow expiratory press.5 cmH2OLow breath frequencyPosition in circuitnear patient, between leak port-patient connector
เอื้อเฟอภาพโดย ศ.พญ.อรุณวรรณ พฤทธิพันธุ รพ.รามาธิบดี
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Aerosol therapy in Aerosol therapy in intubatedintubated children children
pressurized metered dose inhaler (pMDI)jet nebulizerdry powder inhaler (DPI)
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Lung deposition ,the percentage of the dose delivered and the percentage of initial nebulizer dose for nebulizers
Fok TF, Monkman S, Dolovich M, Gray S, Coates G, Paes B, et al. Pediatr Pulmonol 1996;21(5):301–309.
amount of albuterol deposited in the lungs
ventilated infants
0.98% 0.95%
0.22%
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Dhand R, Tobin MJ. Am J Respir Crit Care Med 1997;156(1):3–10.
Factors that influence aerosol delivery Factors that influence aerosol delivery
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Ventilator related Mode: Pressure-limited vs volume-limited Continuous flow of gas through circuit Respiratory rate Tidal volume Inspiratory flow rate Inspiratory-expiratory ratio Circuit relatedDiameter Length AdaptersDensity of gasEndotracheal tube Size TypeHumidification
Factors that affect aerosol delivery and depositionFactors that affect aerosol delivery and deposition
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ventilator modes and settingventilator modes and settingwith with nebulizernebulizer
Aerosol delivery with nebulizerIMV mode = A/C mode = A/C flow synchronize mode IMV mode = A/C mode = A/C flow synchronize mode PC mode < VC modePC mode < VC mode
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ventilator modes and setting ventilator modes and setting with with pMDIpMDI
30 15
P-SIMV3.78 Xxxxxxxxx
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Trigger
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492Xxxxxxxxxerttrert
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DuoPAP
P-CMV (S)CMV
P-SIMV SIMV
APVCMVSPONT
APVSIMV
ASVAPRV
Ventilation Mode
NIV
Standby
Calibration
Patient
Additions
Aerosol delivery with pMDISIMV mode > CMV modeSIMV mode > CMV modePC mode = VC modePC mode = VC mode
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Aerosol delivery from MDI during mechanical ventilation, at different inspiratory air-flows and
duty cycles (inspiratory time to total breathing cycle time [TI/Ttot])
Fink JB, Dhand R, Grychowski J, Fahey PJ, Tobin MJ. Am J Respir Crit Care Med 1999;159(1): 63–68.
inspiratory air-flows40 L/min inspiratory air-flows
80 L/min
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Serum albuterol levels after MDI administration in mechanically ventilated patients and healthy subjects
Duarte AG, Dhand R, et al. Am J Respir Crit Care Med 1996;154(6 Pt 1):1658–1663.
MDI with chamber spacer MDI with chamber spacer had the highest had the highest
drugdrug--delivery efficiencydelivery efficiency
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Goode ML, Fink JB, Dhand R, Tobin MJ.. Am J Respir Crit Care Med 2001;163(1):109–114.
aerosol delivery with helium-oxygen mixtures during mechanical ventilation
MDI with chamber spacerMDI with chamber spacerunheated, dry ventilator circuitunheated, dry ventilator circuit
jet jet nebulizernebulizerat a constant flowat a constant flow
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The delivery of aerosol to the major airways The delivery of aerosol to the major airways is reduced by about 40% when the circuit is humidified is reduced by about 40% when the circuit is humidified
Dhand R, Tobin MJ. Am J Respir Crit Care Med 1997;156(1):3–10.
Efficiency of aerosol delivery to the lower respiratory tractin mechanical ventilation with dry and humidified ventilator circuits