AEROSOL THERAPY

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AEROSOL THERAPY

• Nebulizers to deliver medications

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Definitions

• What is an aerosol?
• Is any liquid or solid particle that is suspended
  in a gas

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Characteristics of Aerosol Particles
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Tonicity (Review)

• Hypertonic (10)
• Greater tonicity then surrounding tissues
• Tend to draw fluid from surroundings
• Isotonic (Normal Saline) 0.9
• Neither gains or loses water but maintains a
  steady size
• Hypotonic
• Water

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Particle Deposition

• Humungous in size are filtered in nose
• 100 microns
• Large in throat
• 10 - 20 microns
• Medium in small airways
• 2 - 5 microns
• Small in alveoli
• 1 - 3 microns

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Size of Particles MMAD

• Mass Median Aerodynamic Diameter
• Versus Count and Volume Median Diameter
• Expressed in microns
• 50 of particles are larger and 50 of particles
  are smaller
• Compared the Count Median Diameter (CMD)

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Volume Output

• Amount of liquid that is nebulized into the air
  per unit of time
• Normal breathing treatment with SVN last ten
  minutes
• Need to put in at least 3 mL of fluid into the
  neb
• Large Volume Nebulizers can last a full hour
• Needs 9 to 25 mL of fluid to be placed in the
  nebulizer (therapist does the calculations)

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Aerosol Density

• Density is mass / volume
• Typical units are milligrams per liter (mg/L)

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Factors that influence DEPOSITION

• Inertial Impaction
• Ability to make the turn
• Gravity
• Particle Characteristic
• Shape, charge, hygroscopic properties
• Breathing Pattern
• Normal slow breathing with occasional breath-hold

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Types of NEBULIZERS

• Small Volume Neb
• Metered Dose Inhaler
• Dry Powder Inhaler
• Continuous Neb
• SPAG
• Ultrasonic

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Small Volume Nebulizer
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SVN

• Called many different names
• Neb, acorn, peace pipe, HHN etc
• Used to deliver liquid medications to patient
• Can use mouthpiece or mask
• Most of the days workload for a floor therapist
  is involved with administration of these
  treatments.

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Design of SVN
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Baffle

• Is essential part of the design of a nebulizer
• Prevents large particles from being produced
• Keeps particles in the 2 to 5 micron range.

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Atomizers

• Hand-bulb or nasal spray pump
• Used to produce and aerosol with large varied
  particles
• Targets the upper airway (nasal passages),
  pharynx and larynx)
• (Obviously no baffle)

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Nebulizer Optimal Technique

• Set flow 6 to 8 L/min
• Breathe slowly through the mouth at normal size
• Tap nebulizer after sputtering begins to reduce
  leftover in nebulizer

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Oxygen or Air

• In hospital sometimes we have a choice
• Air MUST be used with CO2 retainers
• Mostly a matter of comvenience

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Home Nebulizer
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Specialty Neb (1 of many)

• Respirgard II
• Used with pentamidine

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Specialty Neb 2

• Circulaire
• Used in morphine treatments
• Often triggers bronchospasm in therapist
• Commonly seen most everywhere

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Specialty Neb 3

• Breath activated Nebulizer (AeroEclipse)
• Allows nebulization to occur only on inspiration.
• Company claims better use of time
• Limited in application
• Cant use mask, cant use inline with ventilator

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New Generation

• AERx
• Aeroneb
• Respimat
• HaloLite (Europe only)

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Continuous Treatments

• Hour-long used in ER

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Continuous (1 hour) Treatments

• H.O.P.E. (High Output..)
• H.E.A.R.T.
• Used in Emergency Room

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Mini-HEART Continuous Neb
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Uniheart
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Continuous Nebs

• Used for hour long treatments
• Also called large volume nebulizer (vs small
  volume neb)
• Patient (Status Asthmaticis) is receiving many
  treatments back to back
• Usually in ER, always under continuous monitoring

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Small Particle Generator

• Produces extra small particles to go all the way
  into the lungs and to the alveoli.

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Small Particle

• Used to generate particles small enough to
  penetrate through to the lung alveoli
• 1 to 3 microns
• Specifically designed for one medicine
  (ribavirin) for the treatment of Respiratory
  Syncytial Virus (RSV)
• Not used anymore anywhere

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SPAG
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Ultrasonic Nebulizer
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Ultrasonic Nebulizer

• Introduced in 1960s (Dr. O)
• Uses piezo-electric crystal that converts
  electricity to sound waves that really puts out a
  real mist to the patient
• Not used any more around here in hospitals as not
  proven superior to SVNs
• Is more popular as a home / portable unit

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Ultrasonic Nebulizer
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Inner workings of Ultrasonic
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Small Ultrasonic (inline to vent pt)
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MDIs
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Metered Dose Inhaler
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Always use a spacer
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Spacer Use

• Decreases oral deposition
• Increases amount of medicine making the small
  airways
• Flow signal for too fast an inhalation
• Permits many small breaths instead of one large
  breath

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Optimal Technique

• Assemble apparatus
• Shake
• Exhale
• Place holding chamber in mouth
• Activate canister
• Inhale slowly and hold breath for 5 to 10 seconds

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Optimal Technique 2

• Place mouthpiece in mouth
• Seal with lips (or seal mask)
• Activate canister
• Continue to breath for 3 to 6 breaths
• Encourage big breaths and breath holding if
  possible

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Flow Triggered MDI

• An old idea that did not work
• Autohaler (3M)
• Pirbuterol only

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DPIs
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Older Units

• Rotahaler
• Spinhaler
• Turbuhaler

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Aerosolization of Dry Powder
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Newer Unit Dry Powder Inhaler
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Inner workings of DPI
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Optimal Technique

• Open, Click, Inhale
• Exhale slowly to empty lungs
• Seal lips on mouthpiece
• Inhale quickly (gt40 L/min) and deeply
• A breathhold is not necessary
• Repeat if needed

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Dry Powder Inhaler

• The latest and the greatest
• Need higher inspiratory flow rates
• Works like a charm

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Choice?
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Advantages vs Disadvantages

• Nebulizer
• MDI
• DPI
• USN

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Controlling Contamination

• Negative Pressure Rooms
• Booth and Stations
• PPE

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Negative Pressure Rooms

• Needed for Respiratory Isolation
• Chicken Pox or TB
• Private Room with a set of double doors with and
  entry way.
• Air exchanged at least 6 times an hour
• Vented to the outside

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Booth and Stations

• Provides for containment of aerosol during
  therapy
• Used for sputum inductions with suspected TB
  patients
• Used for pentamidine administration with HIV
  patients

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EmmersonTx Booth
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BioSafety Protection Cart
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Personal Protection Equipment

• Airborne Precautions implemented
• Wear a reusable HEPA filter mask over and above
  gloves and gown
• Need to be personally fitted for mask, inserviced
  on its use and have annual compliance
  re-training.
• Students do NOT qualify

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Thats all folks