Module 3 - Pediatric Consideration.pdf

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Pediatric

Consideration

Module 3

Training of Inhalation Therapy

& Pediatric Asthma Management

Departemen IKA FKUI-RSCM

Dr. Darmawan Budi Setyanto, Sp.A(K)

Born: 11 April 1961

Education:

1. Faculty of Medicine University of Indonesia, 1986

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

3. Pediatric Pulmonology Subspecialty, Faculty of Indonesia, 2002

Recent position :Recent position :

� Head of Division of Respirology, Dept of Child of Medicine, University of Indonesia

� Lecturer on Pediatric Respirology, Dept of Child Health, Faculty of Medicine University of Indonesia

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Introduction -1

• widely used in respirology (respiratory med)

• Aerosol therapy: drug form

• Inhalation therapy: delivery form

• Indonesia, medical HW & public getting familiar

• Pediatric respirology, the last decade

• developed countries, mainstream therapy

• BPD, wheezy infants, croup, bronchiolitis

• Indonesia, raising trend, esp for asthma

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Introduction -2

• more complicated than oral therapy

• special device, special maneuver

• difficult, especially for children

• children, wide range:

– very small neonates to adult size teenager

– body surface area: 2m2 – 12m2

– incompetent baby – competent teenager

• Pediatric aerosol therapy, special challenge

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Introduction -3

• Aerosol therapy technology: developed fast

• many studies in many medical journals

• mostly in adults, rarely in children

• reasons:

– pediatric, not a promising market

– small portion

– too wide range needs

– more money for studies

– ethical issues

• result: pediatrics, relative neglected group

6Carveth, Medscape, 1999

Comparison of systemic vs inhalation drug

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Pediatric special problems

• extrapolation from adult

• children # small adults; many differences

• Growth & Development

– Growth: �size, quantity

– Development: �quality, maturation

• small children: lack of competence

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Aerosol therapy devices

1. Nebulizer – easiest

2. Dry Powder Inhaler

3. Metered Dose Inhaler – most difficult

fortunately: spacer (addition closed

space between device and mouth)

– extension device

– holding chamber

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1 - Nebulizer

• Preparation of the device and the drug

• Place the interface

• Patient breath normally, sometimes with deep breathing

� no problem for children

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2 - Dry powder inhaler (DPI)

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

• breath-actuated inhaler, no propelan

• fast & strong inspiration, 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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3 - MDI, how to use• 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 maximal inspiration

• at maximal inspiration, hold the breath for 10 seconds

• rinse the mouth and spill it out

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Challenges of IT for young children

• Small tidal volume

• Small airways

• Rapid respiration

• Inability to hold breath with inhaled medication

• Nose breathing

• Aversion to masks

• Cognitive ability

• Fussiness and crying

Everard ML. Adv Drug Deliv Rev. 2003;55:869-878; Murakami G. Ann Allergy. 1990;64:383-387;Newman SP. J Aerosol Med.1995(suppl 3);S18-22; Geller DE. Curr Opin Pulm Med. 1997;3:414-419; Newhouse MT. Chest. 1982;82(suppl 1):39S-41S.

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Special consideration

Child factor– Anatomic

– Ventilation

– Cooperation, crying

– Coordination, competence

Device factor– Choices of devices

– Easiness procedure

– Spacer choices

– Interface choices

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Child factor

Anatomic

• Weaker respiratory muscle

• Smaller airway diameter

• Higher respiratory resistance

• Less bronchial branching

Ventilation

• Nose breather, turbulence, rhinitis

• Dynamic & irregular respiratory pattern

• Higher respiratory rate

• Smaller tidal volume

• Low inspiratory flow rate

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Smaller airway diameter

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Pediatric factor disadvantages

high RR small TV

low insp flow rate

less / no breath holding

proximal deposition

less distal drug depositionDBS 2006

dynamic breath pattern

nose breather

weak resp muscles

high resp resistance

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– Ventilation





– Spacer choices


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Crying

significantly reduces absorption of aerosolized drug in infants

Iles R, ADC, 1999

• fighting, non fitted mask

• higher respiratory rate

• decrease tidal volume

• shorter inspiratory phase

• longer expiratory phase

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– Ventilation





– Spacer choices


Lack of competence:

• inspiration through the mouth

• superb coordination between actuation and inhalation

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Special consideration in children THE DEVICE

• the choice

– nebulizer

– MDI + spacer

• spacer

– holding chamber

– electrostatic charge

• interface choice

– facemask

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Inhalation device choice

• Children, lack of competence

• Easiness: nebulizer & MDI with spacer

• No need special maneuver; cooperation, calmness and quietly breathing

• In most situation, MDI + spacer is recommended instead of nebulizer

• MDI spacer at least as effective as nebulizer

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Inhalation device choice

Age Short acting ββββ2-agonist

Steroid

LABA

<3 yr MDI-hc-fm

Nebulizer

MDI-hc-fm

Nebulizer

3-6 yr MDI-hc-mp/fm

Nebulizer

MDI-hc-mp/fm

Nebulizer

>6 yr MDI-hc-mp

DPI

Nebulizer

MDI-hc-mp

Nebulizer

hc: holding chamber; fm: face mask; mp: mouth piece

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Spacer problem

Usually made of plastic � electrostatic charge

To over come:

• Metal spacer, not available

• Rinse in home detergent, dry it up

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Interfacedevice part directly connected to patient

face mask

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Interface choice

interface < 3 years 3-6 years > 6 years

mouthpiece

- + +

face mask + + -

•the use of mouthpiece is recommended,if there is no obstacle

•mouth piece: inspiration through mouth, expiration through nose

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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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Spacer extension devices, mouth piece

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Spacer holding chamber, mouth piece

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Spacer holding chamber, face mask

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Spacer interface

face mask mouth piece

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Facemask

Hayden, ADC, 2004

• Must be really tight

• Small leakage, decrease significantly

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Other choice

• for small babies, face mask could be replace by hood

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Pediatric drug doses

• Safety is the 1st issue

• Safety principles: smallest dose, response dependent

• Systemic drug: mg/kgBW � systemic dilution � �side effect

• Aerosol therapy, pediatric dose similar with adult

• Pediatric factor disadvantages � each patient adjust the dose

• A study: same dose, similar systemic level

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Pediatric factor dis/advantages ?

high RR small TV

low insp flow rate

less / no breath holding

proximal deposition

less distal drug depositionDBS 2006

dynamic breath pattern

nose breather

weak resp muscles

high resp resistance

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Smaller tidal volume - smaller dose

O’Callaghan, Thorax, 1999

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Wildhaber JH: Nebuliser therapy in children

Business briefing: Global health care 2003

37Inhaling through a loose-fitting face-mask

38Inhaling through a loose-fitting face-mask

Lung depositionof 0.1%

39Screaming during inhalation

40Screaming during inhalation

Lung depositionof 1%

41Quietly inhaling

42Quietly inhaling


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Schuepp KG, et al.: A complimentary combination of delivery device and drug

formulation for inhalation therapy in preschool children

Swiss Med Weekly 2004;134:198-200

44Not tightly fitting face mask

45Not tightly fitting face mask

Lung depositionof 0.1%

46Crying during inhalation

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Crying during inhalation


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Quietly inhaling with a tightly fittingface mask

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Quietly inhaling with a tightly fittingface mask


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Inhaling quietly with a tightly fitting face maskfrom a perforated vibrating membrane nebuliser

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Inhaling quietly with a tightly fitting face maskfrom a perforated vibrating membrane nebuliser

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Thanks for

your attention

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Thanks for

your attention

Module 3 - Pediatric Consideration.pdf

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Transcript of Module 3 - Pediatric Consideration.pdf