Inhalation Therapy in Children:

Pediatric
Consideration
Respirology Division – Child Health Department
Faculty of Medicine University of Indonesia
Introduction
• 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
• 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
• 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

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Comparison of systemic vs inhalation drug

Carveth, Medscape, 1999

5
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 (DPI)
3. Metered Dose Inhaler (MDI) –
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
11 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.
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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 Pediatric factor disadvantages
high resp
resistance high RR small TV

weak resp
muscles
low insp proximal
flow rate deposition
dynamic
breath pattern

less / no nose breather

breath holding

DBS 2006 less distal drug deposition

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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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 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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 Special consideration
Child factor
– Anatomic
– Ventilation
– Cooperation, crying
– Coordination, competence
Device factor Lack of competence:
– Choices of devices • inspiration through the
– Easiness procedure mouth
– Spacer choices • superb coordination
between actuation and
– Interface choices
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 Steroid
2-agonist LABA
<3 yr MDI-hc-fm MDI-hc-fm
Nebulizer Nebulizer
3-6 yr MDI-hc-mp/fm MDI-hc-mp/fm
Nebulizer Nebulizer
>6 yr MDI-hc-mp MDI-hc-mp
DPI Nebulizer
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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Interface
device part directly connected to patient

face mask
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 Interface choice
•the use of mouthpiece is recommended,
if there is no obstacle
•mouth piece: inspiration through mouth,
expiration through nose

interface < 3 years 3-6 years > 6 years

mouth
piece
- + +

face mask + + -
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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
• Must be really tight
• Small leakage, decrease significantly

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Hayden, ADC, 2004
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 not depend
on body weight or age
• Pediatric factor disadvantages  each
patient adjust the dose
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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

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Not tightly fitting face mask
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 Lung
deposition
of 0.1%

Not tightly fitting face mask

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Crying during inhalation
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 Lung
deposition
of 1%

Crying during inhalation

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Quietly inhaling with a tightly fitting
face mask 37
 Lung
deposition
of 8%

Quietly inhaling with a tightly fitting

face mask 38
 Inhaling quietly with a tightly fitting face mask
from a perforated vibrating membrane nebuliser
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 Lung
deposition
of 36%

Inhaling quietly with a tightly fitting face mask

from a perforated vibrating membrane nebuliser
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Thanks for

your attention 41