7 a pediatric hospital...

1

Seattle Children’s Hospital

Metered Dose

Inhalers with Valved

Holding Chamber:

A Pediatric Hospital

Experience

John Salyer RRT-NPS, MBA, FAARC

Director Respiratory Care

Children’s Hospital

Seattle Washington

8th Annual North Regional

Respiratory Care Conference

Minnesota & Wisconsin Societies for

Respiratory Care

Mayo Civic Center

Rochester, Minnesota

April 30th - May 2nd, 2012

7

May You Live in Interesting Times

2


Methods of Albuterol Administration

Among Asthmatics

January-May

2004 2005 2006

MDI-VHC 9% 67% 79%

SVN 91% 33% 21%


Acknowledgements

Children’s RT’s and RN’s

Ted Carter MD

Dave Crotwell RRT-NPS

Charles Cowan MD

Rob Diblasi RRT-NPS

Children’s RT Leadership Team

Corey’s Refrigerator

3


• Why use MDI-VHC?

• What was the scientific evidence

• How best to implement this plan

• How to measure it’s impact

The Question


Sacred Cows Make

the Best Hamburger

• Children cannot cooperate enough to make MDI-

VHC a viable alternative to SVN

• SVN is more effective at drug delivery in infants

and small childre

• MDI-VHC is more expensive than SVH

4


0

0.2

0.4

0.6

0.8

1

1.2

1.4

Do

se i

nh

ale

d,

mg

0 cm 1 cm 2 cm

Delivered Dose – Facemask (in vitro)

increasing distance from “face”

Everard ML, et al. Arch Dis Child 1992;67:586-91

Distance of mask from filter ‘face’

4 ml of 1% cromolyn; flow = 8 l/min, VT = 50 ml

0.5%

1.4%

3.1%


The Evidence

Great Britain:

• Nebulizers are rarely needed for young children; spacer

devices are as effective, cheaper, and less time

consuming

Systematic Review:

• Bronchodilators via MDI are as effective as any other

hand held delivery device – stable asthma. Am J Respir

Med 2003;2(4):349-365

Cochrane Database Review:

• MDI’s with holding chamber produced outcomes that

were at least equivalent to nebulizer delivery.

5

The Literature

Deerojanawong et al Pediatr Pulmonol 2005;39(5):466-72

Osmond et al Ann Emerg Med 2004;43:413-415

Castro-Rodriguez et al J Pediatr 2004;145:172-177

Delgado et al Arch Pediatr Adolesc Med. 2003;157(1):76-80

Cates et al Cochrane Database Syst Rev. 2003;3:CD000052

Newman et al Chest 2002;121:1036–1041

Cotterell et al J Paediatri and Child Health 2002 ;38(6)604

Leversha et al J Pediatr 2000;136(4): 497-502

Ploin et al Pediatr 2000;106(2):311-317

Bailey et al Chest 1998;113:28-33

Fok et al Pediatr Pulmonol 1996;21(5):301–309

Lyn et al Arch Dis Child 1995;72(3):214-218


Fink JB. Humidity and aerosol therapy: In: Mosby’s respiratory care equipment. St. Louis MO: Mosby-Elsevier Inc.;2007:

100%

90%

70%

80%

60%

50%

40%

30%

20%

10%

0%

Dep

osi

tio

n

pMDI pMDI

spacer

pMDI/VHC

Electro-

static

pMDI/VHC

Non-Electro-

static

SVN DPI

Exhaled

Device

Mouth

Lung

6

20 40 60

Median

Change In

Pulmonary

Index

Elapsed Time after Tx (min)

Response To Albuterol in 1-5 Year Olds With

Recurrent Wheezing in ED

Ploin D, et al. Pediatrics 2000; 106:311-317.

(MDI + HC) Group (n=32) (n=31)

-6

-5

-4

-3

-2

-1

0

Nebulized Group


Emergent Treatment: 1-24 Month Olds With Terbutaline

Closa RM, et al. Pediatr Pulmonol 1998; 26:344-348.

Clinical

Score

Nebulizer (n=17)

MDI-spacer (n=17)

Tx @ 1°

1

2

3

4

5

6

7

8

9

10

Initial Tx Tx @ 2°

7


Drug Delivery System Characteristics

Characteristic Nebulizer MDI + VHC

Efficacy ++ ++ Efficiency - +

Time and Maintenance - ++ Cost + ++

Parent Preference - + Portability/Power - +

Reliability: Adherence & Technique +/- +/-


CH

AN

GE

% F

EV

1

TIME (min)

Schuh S. et al.

J Pediatr

1999; 135:22-27

= High Dose MDI

= Low Dose MDI

= Nebulizer

(n = 30/group)

Change In

% Predicted

FEV1

Ages

5-17 Yrs

30 60 90

8

And You Thought You Had a Crummy Job


Dewar AL, et al. Arch J Dis Child 1999; 80:421-423.

LOS In Asthmatic Children Treated With

Bronchodilators: Nebulizer Vs. MDI-Spacer

20

40

60

80

100

Nebulizer MDI-Spacer

n = 33

n = 29

9


Clinical Scores: Admission To Discharge:

1-5 Year Old Asthmatics

Albuterol &

Ipratroprium

Parkin PC, et al. Arch Dis Child 1995; 72:239-240.

Mean

Clinical

Asthma

Score

MDI (n=30)

Nebulizer (n=30)

60 48 3

6

24 12 Base

Line

1

2

3

4

5

Time (hours)

-2

0

2

4

6

8

10

12

14

16

Nebulizers

Metered-Dose

Inhalers

Dru

g D

ep

os

itio

n (

%)

MDI vs Nebulizer

• Results from 13 in-vitro

studies of drug deposition

in neonatal and pediatric

lung models during

mechanical ventilation

• Box plots represent the %

drug deposition reported

in each study.

• Shaded triangles

represent the arithmetic

mean

10


Nebulizer MDI + VHC

Preference by Parents 6-15% 85-96%

Perceived Acceptance

by Child

38% 62%

Leversha, et al. J Pediatr 2000; 136:497-502.

Ploin, et al. Pediatr 2000; 106:311-317.

Preferences: Nebulizer Vs MDI-VHC


Administration Technique At Home In 5-26

Month Old Children % PERFORMED

Child sits upright 91

MDI is placed correctly into the spacer 100

MDI/spacer is shaken 5 s 68

Time between shaking and actuating is < 5 s? 77

Face mask is placed on face before actuation of the puff 86

There is a close fit of the face mask 73

Only one puff is actuated? 91

Child breathes for 30 s through the spacer 46

Child breathes quietly through the spacer? 64

Face mask is held on face during the 30 s ? 50

Janssens et al. Eur Respir J 2000; 16:850-856.

(N=24)

11


Product Comparison of Nebulizer Output 4ml albuterol solution 0.625mg/ml, 8 L/min,Vt 600ml, 10 bpm, to sputter

1270

1029

453

371340

262

441

168

335

197 191138

0

200

400

600

800

1000

1200

1400

Ou

tpu

t (u

g)

AeroEclipse™ PARI LCD Alleg. Side

Stream

Alleg. Misty

Neb

Hudson Micro

Mist

WestMed

Circulair

Total Mass

Respirable Dose


12


Costs of Albuterol

Administration # Tx's # Pts # Tx's # Pts

MDI-VHC 2,474 197 6,178 401 SVN 7,441 714 1,843 295

Device Costs SVN-mask $2.36 ea X 3 = $7.08 x (#Pts) $5,055 $2,089

Multi-dose vial $1.94 x (# Pts) $1,385 $572

MDI canister $2.45 ea x (# Pts) $483 $982

VHC $13.65 x (# Pts) $2,689 $5,474

Labor Costs MDI-VHC = 13.2 x $0.61 = $8.05 x (# Txs) $19,916 $49,733

SVN = 20.4 x $0.61 = $12.44 x (# Txs) $92,566 $22,927

Total Tx costs $122,094 $81,777

Total # Txs 9,915 8,021 Total cost per Tx $12.31 $10.20

Percent cost reduction 04 to 06 = 21%

Jan-May 2004 Jan-May 2006



All Pts Receiving Albuterol

January-May

2004 2005 2006

MDI 25% 63% 77%

SVN 75% 37% 23%

Percent of Tx’s Administered

via Two Methods

13



Among Asthmatics

January-May

2004 2005 2006

MDI 9% 67% 79%

SVN 91% 33% 21%

Percent of Tx’s Administered

via Two Methods


Asthmatic LOS

(Non-ICU > 2 Yrs)

2004 2005 2006

Mean 1.4 1.4 1.5

SD 0.8 1.0 1.0

Count 471 426 315

Minimum 1 1 1

Maximum 5 9 8

14


Summary of Albuterol Treatments

2004 2005 2006

Mean* 13.6 14.6 16.1

Standard Deviation 20.5 26.4 35.9

Trimmed Mean (10%) 9.4 9.4 9.7

Median 8 7 8

Minimum 1 1 1

Maximum 173 341 587

* Kruskal-Wallis P = 0.21


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