journal nebulizer vs inhaler

8/12/2019 journal nebulizer vs inhaler

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hild Heal th UpdateNebulizers versus pressurized metered-doseinhalersin preschool children with wheezingChristine Smi th MBBs Ran D Goldman MD FRCPC

Abstractuestion In my office, I frequently e nco unte r children with whee zing . When prescribe inhaled broncho dilatorsfor preschool children, whatisthe recom men ded method of deliverya nebulizeror aspacer?nswer The pressurized metered-do se inhaler withaspacer isaneffective meth od of delivering inha led drugsto young children. Children youn ger th an 5 years of age will require the a dditional u se of a face m ask. It is besttogive aerosolized medications whenachildisaw ak e. Effortsto optimize the child's cooperation with medicationadministration by usingaspacer w ithanappro priate m outhp iece or face m ask will also improve drug delivery.

Nbuliseurs ou arosols doseurs chez les enfan ts d ge prscolaire qu i rlen tRsumuestion Je vois frquemment mon cabinet des enfants qui ont une respiration siffiante. Quand je prescris unbroncho dilatateur par voie inhaledes enfants d'ge prscolaire, quel est le mode d'adm inistration recom man dun nbuliseur ouunspacer?Rponse L'arosol doseur pressuris avec un spacer est une mthode efficace pour administrer des md icam entspar voie inhalede jeunes enfants. Les enfants de m oins de 5 ans on t besoin d'util iser en plus un mas quefacial. Il vaut mieux donner les mdicaments en arosol lorsque l 'enfant est veill. Des efforts pour optimiserlacoopration de l'enfant lors de l'administration d'un md icamen t en util isant un spacer comp ortant un embou tbuccal appropri ouunma squ e facial amlioreron t aussi l'administration du m dicam ent.

W heezingiscom m oninchildrenandpredom inatesintheearly yea rsoflife. By 3 y ea rsofage, 33% ofchildrenandby 6yearsof age, 49%of childrenwillhave had an il lness with wheezing. ' In a large surveyof more than 7000 households (9490 children) acrossEurope and theUnited States,^ pa ren ts repo rted thatone-third ofchildren hadexper ienced recurrent dayswith coughing, wheezing, andshor tness ofbreathinthe previous 6win ter m on ths . Eighty-five pe rcen tofthe se children visited family phy sician s and 35% visitedphysicians more than times.^W h e e z i n g and s h o r t n e s s of b r e a t h in chi ldrenyounger than 5years ofa gehas a heterogenic origin,and some of thes e children might benefit from treat-ment wi th bronchodi lators. Inhaled drug del iveryinyoung children islimitedbynarro w airways, inabilityto generate high inspiratory flow rates,andincreasedairway turbulence.^

Eur thermore, research assessing theeffect of bron-chod i l a t o r s hasbe en l imi ted ow ing to the difficul-t ies in me asu r ing drug del ivery. Asmea sur ing drugdeposit ioninlung tissueischallenging, proxy m arke rssuchas drug excretion or filtered dosesareused.Thefiltered dose is a method ofmeasu r ing emi t t ed dose

lost within theappara tus . Theemitted dos e provida more accurate est imateofthe drug available fromspecific inhaler.Drug deliveryCommonly used delivery systemsare nebulizers, presurized metered-dose inhalers (pMDIs) withorwithospacers, and dry-powder inhalers. Children younger tha5 yearsofage often ca nnot g enerate a dequ ate inspitory flowto effectively use dry-powder inhaler devices.'

The advantage of a nebulizer is thatit candelivdrugs wi thout thechi ld 's co operat ion. When usingnebulizer, less than 10% of the aerosolized drug reachthe lungs, with large deposits remaining in the appaa t us or on the face, and the remaind er lost to thsurroundings.^'*^Incomp arison, pMDIs havea drug pumonary deposit ion of 10%to40%.''''* This large rangreflects the inconsistencies in findings across studiowingto thedifficulty of measuring drug deposit ionlung tissue and the useofdifferent spa cer devices.Infants andyoun g chi ldren lack the coordinat io

required to trigger andsimul taneously inhale a druwhen using pMDIs. Theuse ofadjuncts suchasspacewith mouthpieces or face ma sks ove rcom es this dif


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Child Health Updateactivation ofthe pMDIandinhalationof the aerosol.Thevalved holding spacerhas a one-way valve withthe par-ticular advantageofallowing aerosoltomoveout of thechamber at inhalation but holding particlesin thecham-ber during exhalation. Valved spacers shouldnot beusedfor neonates or infants who areunable to generatetheinhalational f low to open the one-way valve. In gen-eral , children younger than 5yearsof age will requireface masks to assist with aerosol delivery throughthespacer.'^One of thelimitationsof the face mask is thatnose breathing might considerably reduce inhaled drugdeliveryto thelower airways.Assoonas achildcanreli-ably breathe thoughamouthpiece,he or sheshould tran-sitiontousingit tooptimize drug delivery.Nebulizer versus pMDI withaspacerTheuse ofa pMDI witha spacer (pMDI-FS)ism ore effect-ive thanuse ofa nebulizerinyou ng childrenin theemer-gency department setting.*^' ' Ameta-ana lysis reportedthat children younger than 5 yearsof age with moder-a te to severe exacerbat ion of wheezing exper i encedreduced hospital admission rates (odds ratio 0.42, 95CI0.24 to 0.72) andreduction in validated clinical sever-ity score (-0.44, 95%CI -0.68 to -0.20) with the useof pMDI-fS compared with an ebul izer .' Arandomized

s tudy of chi ldren younge r than 24 m o n t h s of ag(N=123) who presented to an emergency depar tmentwith mild to mod erate wheezing assessed par t icipantsfor clinical improvement. The Modified Tal's ClinicalScore, avalidated clinical score w ithout pulse oximetrywas usedas the outcome measure. While both groupsin this studyhad equivalent recovery after 2hours,thuse of a pMDI-FS resulted in faster symptom resolution with statistically significant improvement at 1 hour(odds ra tio 3.9, 95% CI1.5 to 10.4).Uncooperative childrenOptimizing a child's cooperation is important, as compliance with treatment affects medication delivery.**Ia randomized study, 94%of parents with children 12 t60 months old reported that spacers were easier to usthan nebulizers,and62% believed thatthepMDl-fSwabet ter accepted by their children.' Astudy of brea thing patterns in children2 to 7years old demonstratedno difference in drug delivery with3 to 9tidal b reaths'^;therefore, it is recommended tha t a child breathes aleast 3 t idal breaths through an appropr i a t e spacerMany younger children find receiving aerosolized medi-cation distressingand as a resultare notbreathing atidal volumesat thetimeofdelivery; only one-q uarte ro

The most common adverse reactions reported with OMNARIS vs.placebo in short-term clinical trials were epistaxis (2.7%vs . '2 . 1 % placebo), nasal passage irritation (2.4% vs. 2.2%placebo) and headache (1.3%vs. 0.7%placebo).The most commonadverse reactions with OMNARIS'reportedin a 52-week clinical trialofPARinpatients12yearsofage and older were epistaxis(8.4% vs. 6.3% placebo), nasal passage irritation (4.3%vs. 3.6% placebo)andheadache (1.6% vs. 0.5% placebo).OMNARIS' shouldbeused with caution,if atall,inpatients with untreated localorsystemic fungalorbacterial infections, systemic viralor parasitic infections,orocular herpes simpiex. Becauseofthe inhibitory effectofcorticosteroids on wound he aling, patients who haveexperienced recent nasal septal ulcers, nasal surgery,ornasal trauma should not use a nasal corticosteroid until healing has occurredIn patients who have asthma or other ciinical conditions requiring long-term systemic corticosteroid treatment,rapid decreases in systemic corticosteroid dosages may cause severe exacerbation of their symptoms.

omnarslitadacompiy 201 2 Nycomed C anada Inc. All rights reserved. " Registered trademark ofNycomed GmbH. Used under licence. * *?

Powerful AR ratief Excellent tolerablltly profils


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hi ld He al th Updatethe aerosolized drugisdeposited indistressed childrencompared with the amount deposited in calm infants.^Some experts have advocated administrationofaerosols during sleeptoenhance drug delivery in unco-operative children.'^ However, drug doses deliveredduring sleepvia a pMDI+Sareunpredictable, as par-ents are often reluctant tofirmlyand correctly placethe face maskon a sleeping child. Breathing patternsduring normal sleep cycles also vary,as can beseenduring rapideye movement sleep cycles. Furthermore,a feasibility study demonstrated that children wereunlikely to remain asleep during aerosol administra-tion. Sixty-nine percent of children woke upduringmedication delivery with most (7096) expressingdis-tress, which compromised drug delivery.'^ Onlyasmallsubset of children whoare particularly uncooperativewith treatment might demonstrate improvement withpMDI-i-S administration during sleep,aslongastheystay asleep during treatment.'^ Drug deliveryinthesecircumstances remains variable.ConclusionInhaled therapies are effectively adm inisteredbypMDI+S to children younger than 5 years of age.Pressurized metered-dose inhalers with spacersareportable andbetter tolerated when comp ared w ithnebulizers.Tooptimize the child's compliance withtreatmentand to achieve effective medication delivery,a mouthpieceor well-fitted face mask (Box ) should

Box 1. Face maskf itThe selection of aface mask contributes to effective drugadministration. Good fit, flexibility, and dead space in the maskare important considerations in selecting a face mask. The maskshould fit in such a way as to minimize leaks, and the deadspace in the mask should be eliminated to maximize drug deliv-ery to the lungs. In infants and neonates, dead space in a maskor a spacer might contribute to a considerable proportion oftheir tidal volumes. The flexibility of the face mask also improvesthe fit and reduces dead space by allowing gentle compressionof the mask to the child's face.

Data from Amirav and Newhouse.

be anadjunct to thepMDI+S. Children should gradu-ateto amouthpiece by about 5 yearsofage. The effectof administering aerosolized medicationsto asleepingchild is unpredictable. 0Competing interestsNone declared

CorrespondenceDr Ran D Goldm an, BC Children's Hospital, Dep artmentofPediatrics,Room K4-226, Ambulatory Care Bldg, 4480 Oak St, Vancouver, BC V6H 3V4;telephone 604 875-2345, extension 7333;fax604 875-2414;e mail rgoldman@cw bc caRef erences1.Ma rtinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan W).

Asthmaandwheezingin thefirst six ye arsoflife. The Group Health MedicaAssociates.NEnglJMed 1995;332(3):133-8.2.Bisgaard H, Szefler S. Prevalenceofasthma-like sym ptoms inyoung childr

PedrrPumono/2007;42(8):723-8.3. Brand PL, BaraldiE Bisgaard H Boner AL, Castro-Rodriguez JA,

Custovic A,et al.Definition, ass ess me nt andt r ea tm en tofwheez ingdis-orders in preschool children:anevidence-based ap proach. Eur RespirJ2008;32(4):1096-110.

4. Dolovich MB, Dhand R. Aerosol drug delivery: developments in device desand clinical use. Lancei2011;377(9770):1032 45. Epub 2010 Oct 29.

5.O'Callaghan C, Barry PW. Howtochoose delivery devicesforasthma.ArchDi s hild 2000;S2 :\85-7.

6.Rubilar L, Castro-R odriguez JA, Girardi G. Randomiz ed trialof salbutamolvia metered-dose inhaler with spacer versus nebulizerforacute wheezingchildren less than2yearsofage.Pediatr Puimonol2000;29(4):264-9.

7. HeyderJ. Depositionof inhaled particlesin the human respiratory tractandconsequences for regional targetingin respiratory drug delivery.ProcArnThorac Soc20 04;l (4):315-20.

8. lies R, Lister P, Edmu nds AT. Crying significantly redu ces absorp tionofae rsolised drugininfants.Arch D is Child1999;81(2):163-5.

9. Castro-Rodriguez JA, Rodrigo GJ. Beta-agonists through metered-doseinhaler with valved holding chamber versus nebulizer foracute exacerbatiof wheezingorasthma inchildren u nder5yearsofage:asystematic reviewith meta-analysis.;Pediatr2004;145(2):172-7.

10.Ploin D, Chapuis FR, Stamm D, Robert] ,David L, Chtelain PG,etal. Highdose albuterol by metered dose inhaler plusaspacer device versus ne bu-lizationinpreschool children with recurrent wh eezing:adouble-blind,randomized equivalence trial.Pediatrics2000;106(2Pt1):311-7.

11. Pavn D, Castro-Rodriguez JA, Rubilar L, Girardi G. Relation between pulsoximetry and clinical score inchildren with acute wheezing less than24monthsofage.PediatrPuimonol1999;27(6):423-7.

12.Schultz A, Le Souf TJ, Venter A, Zhang G, Devadason SG, Le Souf PN.Aerosol inhaiation from spacersandvalved holding chamb ers requiresfewt idal breath sforchildren.Pediatrics 2010;126(6):el493-8. Epub 2010 Nov1

13.Es posito-Festen J, Ijsselstijn H, Hop W, van Vliet F, de Jongste J, TiddensHAerosol therapy by pressured metered-dose inhaler-spacer insleeping younchildren. Chest2006 ; 130(2):487-92.

14. Amirav 1, Newhouse MT. Reviewofoptimal characteristicsofface-masksvalved-holding chambers (VHCs).PediatrPulmonoi 2008;43(3):268-74.

jp | >T~ T ^^'' ^ ^^^ '^ '^' '^'^ ' producedby theA1 1I I X l~*y X X . Pd iatrie ResearchinEmergency|f^ o. ,c. .*, t . ,c ^. ..:. = Therapeutics (PRETx) program (www.pretx

org)at theBC Children's Hospital inVancouver, BC.DrSmith isa member andDGoldman isDirectoro fthe PRETx program. The missiono f the PRETx program ispromote child health through evidence-based research intherapeutics inp diaemergency medicine.

Do you have questions aboutt hesafetyo fdrugs, chemicals, radiation,orinfections inchildren? We invite youtosubmit themto thePRETx prog rambyfax a t604 875-24 14; they wi l lbeaddressedin future Child Health Updates.Published Child Health Updatesareavailableon the anadianFamilyPhysiciwebsite (www .cfp.ca).


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journal nebulizer vs inhaler

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