Inhalation Therapy in Children

Diah Asri Wulandari

Rini Savitri Daulay
Respirology Coordination Working Unit
Indonesian Pediatric Society
 Introduction
Inhaled medications are the mainstay of therapy for
many pediatric pulmonary diseases
Other term: aerosol therapy

Asthma has been the primary focus of aerosol

treatment since the 1800s
For many years aerosol therapy has been used in wide
range of disease
Berlinski, A. Pediatric Aerosol Therapy. Respiratory care. 2017;62(6)
Hickey, AJ., Mansour, HM. (2019) Inhalation Aerosols: Physical and Biological basis for Therapy. 3 rd ed.
 The principles
Delivery of high local concentrations of the drug directly to the site of action with minimised This is achieved
risks of systemic effects with a much
lower dose
Rapid onset of action

Easy and convenient to administer

Painless

Drugs could be easily absorb due to large surface of the lung surface
The mechanism of pulmonary deposition

B C

A. Impaction B. Sedimentation C. Diffusion

Everard ML, et al. Pediatr Respir Med 1999; 286

Khilnani CC, Banga A. Aerosol Therapy. Indian J Chest Dis Allied Sci. 2008; 50: 209-219

4
 Particle size
Nasal cavity
IMPACTION > 10µ

SEDIMENTATION 7-10µ Trachea

Primary Bronchus

2-5µ Secondary Bronchus

SEDIMENTATION Terminal Bronchus

+
Respiratory
DIFFUSION < 2µ Bronchioles
DIFFUSION < 2µ Alveolar
Alveoli 5
Ducts & Sacs

5
 What happens to an aerosol particle after deposition in the
lungs?

(1) First contact with the lung

(3) Clearance of the undissolved lining fluid & dissolution of the
particle or drug active pharmaceutical ingredient

(2) Absorption of the API across

the pulmonary epithelium

Ruge, C.A. et al., Lancet Respir Med. 2013;1, 402–413.

Factors affecting delivery of aerosolised drugs to the lungs

Physical Characteristics of the

Aerosol Particle Host Factors
• Size • Ability
• Density • Physic
• Electrical charge
• Hygroscopy
• Shape
• Velocity of the aerosol particles
 Nebulizer
Indicated when a child is in respiratory
distress & not able to take inhaled
medication by other aerosol device

Transform liquid formulations into

droplets suspended in gas

Divided into three categories: jet

nebulizers, ultrasonic nebulizers & mesh
nebulizers

Parthasarathy, A. (2019). Iap Textbook of Pediatrics.

 Nebulizer indication

Management Diagnostic

Mainly treatment of Induction sputum for

asthma diagnosis of TB
Other disease, eg: croup,
Pulmonary hypertension
and others
 Nebulizer

No contraindication in using nebulizer

Advantages: no coordination needed,

without propellent

Disadvantages: time consuming, needed

for electricity, expensive, can’t be use for
corticosteroid (ultrasound nebulizer)
Ari A, Fink J. Guidelines for aerosol devices in infants, children and adults: which to choose, why and
how to achieve effective aerosol therapy. Expert Review of Respiratory Medicine. 2011;5(4):561-572.
Jet nebulizer

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Ultrasonic Nebulizer

12
 Mesh Nebulizer

Vibrating Mesh Nebulizer

AKITA®2 PARI APIXNEB

Static Mesh
Nebulizer
(MicroAir NE-U22V) Vibrating Mesh
Nebulizer
(AeroNeb Go)
Mesh Nebulizer
 Steps for the correct use of nebulizer
Hands should be washed prior to preparing each nebulizer treatment

Assemble tubing, nebulizer cup, and mouthpiece/mask

Place medicine into nebulizer cup

Sit upright position and hold the nebulizer vertically

Connect the nebulizer to power source

As the mist starts, encourage the child to take normal tidal breath with open mouth

Continue until the medicine is finished in the chamber. This may take 5-10 minutes
15
Parthasarathy, A. (2019). Iap Textbook of Pediatrics.
 Dry powder inhaler (DPI)
Indicated for the long term management of asthma in older
children (> 6 years of age) who can make enough
respiratory force

Advantages: easy to carry, less coordination compared

to MDI

Disadvantages: high inspiratory effort needed, more

possibility of drug deposition on the pharynx

Ari A & Fink JB. Aerosol therapy in children: challenges and solutions. Expert Rev Respir Med. 2013;7(6), 665–672.
Dry powder inhaler (DPI)
Not indicated in patients who cannot
generate an adequate inspiratory
flow rate

A DPI formulation may contain

lactose  lactose hypersensitivity
 Dry powder inhaler (DPI)

Turbuhaler Diskhaler
Swinghaler
 Steps for the correct use of DPI
1. Check the device and ensure that it is clean and mouthpiece is free from obstruction
2. Load a dose into device as directed by manufacturer
3. Breath out away from mouthpiece
4. Put mouthpiece of DPI between teeth without biting and close the lip to form a seal
5. Take a fast and deep breath through the mouth
6. Remove the device from the mouth
7. Hold breath for 5 – 10 seconds
8. Breath out gently
9. If additional dose is required, follow steps 2 – 8
10. After inhaling steroid-containing DPI—gargle/rinse the mouth
19
Parthasarathy, A. (2019). Iap Textbook of Pediatrics.
Diskhaler
Turbuhaler
 Caution patients about these device-specific mistakes!
DPI

Shaking the DPI (it’s not required with this type of device)

Forgetting to exhale gently before inhaling

Exhaling into the device (exhalation should be away from the DPI so the breath doesn’t clump
the powder)
Inhaling slowly (with most DPIs, inhalation should be rapid)

Failing to inhale at sufficient inspiratory flow rate

Failing to load the dose

Self TH, et al. Inhalation therapy:Help patients avoid these mistakes.J Fam Pract. 2011 December;60(12):714-721
 Metered dose inhaler (MDI)
• The most commonly used devices for
generation of aerosol
• Consist of a micronized form of the drug in a
propellant under pressure with surfactants to
prevent clumping of drug crystals
• As it travels through the air, the aerosol
warms up leading to evaporation of the
propellant that reduces the particle size to
the desirable range
 Metered dose inhaler (MDI)
• pMDI is indicated for long term management
of asthma and also asthma exacerbation
• pMDI with spacer/VHC is found to be equally
effective as nebulizers in acute exacerbation
 Metered dose inhaler (MDI)
• Advantages: easy to carry, could be used
with spacer (younger children)
• Disadvantages: contain propellent, good
coordination needed
• Contraindication:
• Sensitivity to propellants
 Steps for the correct use of MDI
1. Assemble the spacer and pMDI
2. Remove the cap of pMDI
3. Hold the pMDI in upright position and shake it well for 4 – 5 times
4. Stand or sit straight
5. Place the mouthpiece between teeth and close lips without leaving any gaps
6. Ask the patient to exhale into spacer
7. Actuate the pMDI in spacer
8. Take 5 – 10 tidal breaths
9. Wait for at least 60 seconds before the next puff and repeat steps 3 – 8
10. Gargle/rinse the mouth after taking steroid-containing pMDI
26
Parthasarathy, A. (2019). Iap Textbook of Pediatrics.
Steps for the correct use of MDI

27
Steps for the correct use of MDI

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 Caution patients about these device-specific mistakes!
MDI

Failing to shake inhaler well

Failing to exhale gently before inhaling
Exhibiting poor coordination (failing to press down on the canister and inhale simultaneously)
Inhaling rapidly (inhalation should be very slow)
Failing to inhale deeply or not inhaling at all
Failing to hold one’s breath long enough (10 seconds is optimal) or at all
Failing to wait long enough (≥30 sec) before the next puff
Failing to inspect the mouthpiece for foreign objects
Forgetting to periodically clean the actuator
Holding the device upside down (the mouthpiece should be on the bottom)
Leaving the cap on while pressing down
Self TH, et al. Inhalation therapy:Help patients avoid these mistakes.J Fam Pract. 2011 December;60(12):714-721
 Characteristics of the aerosol generators

Khilnani CC, Banga A. Aerosol Therapy. Indian J Chest Dis Allied Sci. 2008; 50: 209-219
Choosing age appropriate aerosol device and interface for
patients
< 3 years old 3-6 years old > 6 years old

Aerosol device Nebulizer or pMDI Nebulizer with Nebulizer mp,

with VHC with face fm/mp, pMDI and pMDI and VHC with
mask VHC with fm / mp mp and DPI

DPI: Dry powdered inhaler; pMDI: pressurized metered-dose inhaler; VHC: Valve-
holding chambers, fm: face mask, mp: mouth piece