NEBULIZATION

AISHWARYA PRABHAKAR GATTY

MPT (Cardiopulmonary Sciences)
DEFINITION
Aerosol: Suspension of very fine liquid particles in the gas

• Aerosols can be used to deliver bland water solutions to the

respiratory tract or to administer drugs to the lungs, throat, or
nose for local and systemic effect.
• Bland aerosol administration may be accompanied by O2
therapy.
NEBULIZERS
• Also called as-aerosol generator
-atomizer
- nebulizing humidifier

• Device which can deliver uniform sized liquid particles in the

gas

• emits water in the form of an aerosol mist (water vapour plus

particulate water)
FUNCTIONS

HUMIDIFICATION

DELIVER drugs to the respiratory system

• The aim of aerosol therapy is to deliver a
therapeutic dose of the selected agent (drug) to
the desired site of action (nose, throat, airways,
or deep lung).

• Nebulization or aerosolization of medications

provides an opportunity to deliver high
concentrations of a therapeutic agent to lung
tissue while keeping bloodstream level low and
thus reducing systemic effects
 CHARACTERISTICS OF
THERAPEUTIC AEROSOLS
Aerosol Output
• Aerosol output is the mass of fluid or drug produced by an
aerosol generator.

• Output is described as the mass of drug or liquid emitted

(leaving) from the aerosol generator.

• For nebulizers the output rate is the mass of aerosol

generated per unit of time.
Particle Size
• Aerosol particle size depends on the substance for
nebulization, the method used to generate the aerosol, and
the environmental conditions surrounding the particle.

• Most aerosols found in nature and used in respiratory care are

composed of particles of different sizes, described as
heterodisperse.
Deposition

• When aerosol particles leave suspension in gas, they deposit

on (attach to) a surface.
• Only a portion of the aerosol generated and emitted from a
nebulizer (emitted dose) may be inhaled (inhaled dose).
• A fraction of the inhaled dose is deposited in the lungs
(respirable dose).
• A small percentage (1% to 5%) of inhaled drug may be
exhaled.
• Whether aerosol particles that are inhaled into the lung are
deposited in the respiratory tract depends on the size, shape,
and motion of the particles and on the physical characteristics
of the airways and breathing pattern.
Key mechanisms of aerosol
deposition

Inertial Gravimetric Brownian

impaction sedimentation diffusion
Inertial Impaction
• It occurs when suspended particles in motion collide with and
are deposited on a surface; this is the primary deposition
mechanism for particles larger than 5 μm.
• The greater the mass and velocity of a moving object, the
greater its inertia, and the greater the tendency of that object
to continue moving along its set path.
• When a particle of sufficient (large) mass is moving in a gas
stream and that stream changes direction, the particle tends
to remain on its initial path and collide with the airway
surface.
• Because inertia involves both mass and velocity, the higher
the flow of a gas stream, the greater the tendency for particles
to impact and be deposited in the airways.
• Turbulent flow patterns, obstructed or tortuous pathways, and
inspiratory flow rates greater than 30 L/min are associated
with increased inertial impaction.
• Turbulent flow and convoluted passageways in the nose cause
most particles larger than 10 μm to impact and become
deposited. This process produces an effective filter that
protects the lower airway from particulates such as dust and
pollen.
• However, particles 5 to 10 μm tend to become deposited in
the oropharynx and hypopharynx, especially with the
turbulence created by the transition of air as it passes around
the tongue and into the larynx.
Sedimentation
• Sedimentation occurs when aerosol particles settle out of
suspension and are deposited owing to gravity. The greater
the mass of the particle, the faster it settles (Figure 39-2).
• During normal breathing, sedimentation is the primary
mechanism for deposition of particles 1 to 5 μm.
• Sedimentation occurs mostly in the central airways and
increases with time, affecting particles 1 μm in diameter.
• Breath holding after inhalation of an aerosol increases the
residence time for the particles in the lung and enhances
distribution across the lungs and sedimentation.
• A 10-second breath hold can increase aerosol deposition 10%
and increase the ratio of aerosol deposited in lung
parenchyma to central airway by fourfold
Diffusion
• Brownian diffusion is the primary mechanism for deposition of
small particles (<3 μm), mainly in the respiratory region where
bulk gas flow ceases and most aerosol particles reach the
alveoli by diffusion.
• These aerosol particles have very low mass and are easily
bounced around by collisions with carrier gas molecules.
• These random molecular collisions cause some particles to
contact and become deposited on surrounding surfaces.
• Particles 1 to 0.5 μm are so stable that most remain in
suspension and are cleared with the exhaled gas, whereas
particles smaller than 0.5 μm have a greater retention rate in
the lungs.
Aging
• Aerosols are dynamic suspensions. Individual particles
constantly grow, shrink, coalesce, and fall out of suspension.
The process by which an aerosol suspension changes over
time is called aging.
• How an aerosol ages depends on the composition of the
aerosol, the initial size of its particles, the time in suspension,
and the ambient conditions to which it is exposed.
• Aerosol particles can change size as a result of either
evaporation or hygroscopic water absorption.
• The relative rate of particle size change is inversely
proportional to the size of a particle, so small particles grow or
shrink faster than large particles.
• Small water-based particles shrink when exposed to relatively
dry gas.
• Aerosols of water-soluble materials, especially salts, tend to
be hygroscopic, absorbing water and growing when
introduced into a high-humidity environment.
Other factors that influence where a particle of any specific size
is deposited:
• Inspiratory flow rate
• Flow pattern respiratory rate
• Inhaled volume
• Ratio of inspiratory time to expiratory time (I : E ratio)
• Breath holding
INDICATIONS
• Presence of a bypassed airway
• Postoperative management of upper airway
• Postextubation edema
• Dyspnea
• Need for sputum specimens (3 % hypertonc saline)
• Bronchial hygiene
CLASSIFICATION
Small volume
nebulizer
PNEUMATIC
(Jet)
Large volume
nebulizer
ULTRSONIC
NEBULIZER
(Electrical)

OTHER TYPES
OTHER Metred Dose
Inhaler (MDI)
TYPES
Dry Powder
Inhaler (DPI)

Hydrodynamic
(not used
anymore)
ULTRASONIC NEBULIZER PNEUMATIC NEBULIZER
PNEUMATIC NEBULIZERS
• works by pushing a jet of high pressure gas into a liquid ,
including shearing forces and breaking the water up into
fine particles.
• Also called as gas driven, jet high pressure, compressed
gas

ULTRASONIC NEBULIZERS
• produces fine mist by subjecting the liquid to a high
frequency, electrically driven ultrasonic resonator
• Frequency of oscillation determines the size of the
droplets
• No need for the driving gas
• Create denser mist than the pneumatic ones
• Nebulizers are also described in terms of their reservoir size.
• Small volume nebulizers (SVNs) most commonly used for
• medical aerosol therapy hold 5 to 20 ml of medication.
• Large volume nebulizers, also known as jet nebulizers, hold up
to 200 ml and may be used for either bland aerosol therapy
or continuous drug administration.
WORKING
PNEUMATIC NEBULIZER
Pneumatically powered attaching directly to a flow meter
and compressed gas source

Liquid particle aerosols are generated by passing gas at

high velocity through a small jet orifice

Resulting low pressure at the jet draws fluid from resovoir

up to top of the siphon tube where it is sheaterd and
broken into particles
Large unstable particles fall out of the suspension or impact on
the internal surface of the device including the fluid surface
(baffling)

Remaining small particles leave the nebulizer through the outlet

port carried in the gas stream

A variable air entrainment port allows air mixing to increase flow

rates and increase FiO2 levels
ULTRASONIC NEBULIZER
Electrically powered device that uses piezoelectric crystal
to generate aerosol

Crystal transducer converts radio waves into high

frequency mechanical vibrations

Vibrations are transmitted to a liquid surace where the

intense mechanical energy creates a ‘geyser’ of aerosol
droplets (the liquid in the chamber gets heated up as the
time pases)

Gas entering the chamber inlet picks up the aerosol

particles and exits through the chamber outlet
FACTORS AFFECTING ULTRASONIC NEBULIZATION

• Signal frequency(pre-set) inversely proportional to

particle size
• Signal amplitude alters the transducer’s vibrational
energy and thus the amount od aerosol production
• Flow of gas affects the particle size and aerosol density-
greater the flow lesser is the density
• Flow and amplitude setting determine aerosol density
and total water output
• Relative humidity and carrier gas affects particle
size,aerosol density and output
USE
PNEUMATIC NEBULIZER
• A high flow of gas must be used
• It should be placed in the fresh gas line

ULTRASONIC NEBULIZER
• Can be used in the fresh gas line or inspiratory limb
NEBULIZER PERFORMANCE
SIZE

DRIVING GAS
• Jet nebulizers operate efficiently with flow rate 0f 6-8 literes per
minute

TYPE OF NEBULIZER
FILL VOLUME
• Amount of liquid to be filled in the nebulizer
• For effective nebulization fill volume should nit exceed
the amount specified by the manufacturer

RESIDUAL VOLUME
• Volume of solution that remains in the nebulize after
nebulization has stopped
• Fill volume if 2 -2.5 ml is adequate if the residual volume
is less than 1 ml but nebulizers with higher residual
volume will require a fill volume of 4 ml
• Patient should be encouraged to tap the side of the
nebulizer to allow as much as drug to be delivered
PHYSICAL PROPERTIES OF SOLUTION
• Solutions with higher viscosity or higher surface tension are
slow to nebulize

BREATHING
Breathing at normal tidal volume with 1-2 deep breaths in
between
AIRWAY APPLIANCES

Aerosol mask- Patients

Face tent- Patients with intact
with intact upper airway
upper airway
T- tube –Patients who Tracheostomy mask-
are intubated or have a Patients with
tracheostomy tracheostomy
• Infants and small children may not readily
tolerate direct airway appliances

• So enclosures such as mini tents and aerosol

hoods are used

• Disadvantages
-Carbon dioxide build up (can be reduced by high
oxygen flow rates
- Heat retention (reduced by different cooling
strategies by different manufacturers)
ADVANTAGEs
• Nebulizers can deliver gases saturated with water without
heat
• Can produce gases carrying more water
DISADVANTAGES
• Relatively costly
• Pneumatic nebulizers require high gas flow
• Ultrasonic nebulizers requires source of electricity and may
present electrical hazards
• There may be considerable water deposition in the tubings,
water traps in both the inspiratory and exhalation tubes and
posing dangers of water draining into patient
HAZARDS
• Nebulized drugs may obstruct HME or filter in the respiratory
system
• Overhydration can occur
• If droplets are not warmed, hypothermia may result
• Infection can be transmitted because microorganisms can be
suspeneded in water droplets
Infection
• Aerosol generators can contribute to nosocomial infections by
spreading bacteria by the airborne route.

Airway Reactivity
• Cold air and high-density aerosols can cause reactive
bronchospasm and increased airway resistance, especially in
patients with preexisting respiratory disease.

Eye Irritation
• Aerosol administration via a face mask may deposit drug in
the eyes and cause eye irritation.
• In very rare cases, anticholinergic medications have been
suspected to worsen preexisting eye conditions, such as forms
of glaucoma.
Second hand Exposure to Aerosol Drugs
• Workplace exposure to aerosols may be detectable in the
plasma of bystanders and health care providers.
• Repeated secondhand exposure to bronchodilators is
associated with increased risk of occupational asthma. I
METERED DOSE INHALERS
• The pMDI (pressurized metred dose inhaler) is portable,
compact, and easy to use and provides multidose
convenience. A uniform dose of drug is dispensed within a
fraction of a second after actuation and is reproducible
throughout the canister life.

• The pMDI and actuator are designed for the specific drug
formulation and dose volume to be delivered.
• Every pMDI should be primed by shaking and actuating the
device to atmosphere one to four times (see label for the
specific device) before initial use and after storage.

• Without priming, the initial dose actuated from a new pMDI

canister contains less active substance than subsequent
actuations.

• This “loss of dose” from a pMDI occurs when drug particles

rise to the top of the canister over time (“cream”).
Factors Affecting Pressurized Metered Dose Inhaler
Performance and Drug Delivery

• Temperature: Low temperature (<10° C) decreases the output

of pMDIs. Patients with cold air–induced bronchospasm who
keep their pMDIs in outer coat pockets when outside in cold
winter weather may receive only a small percentage of drug
compared with that administered with the same pMDI at 25°
C.

• Nozzle Size and Cleanliness. Aerosol drug delivery I influenced

by nozzle size and cleanliness. Nozzle size is pMDIspecific. As
debris builds up on the nozzle or actuator orifice,the emitted
dose is reduced. pMDI canisters should never be placed under
water.
• Priming: Priming is defined as shaking the device and
releasing one or more sprays into the air when the pMDI is
new or has not been used for awhile. It is done to mix the
drug and the propellant, which can separate in the canister
over time. Priming is required to provide an adequate dose,
according to the manufacturer’s guidelines.

• Timing of Actuation Intervals: Manufacturers recommend 30

seconds to 1 minute between actuations. When propellants
are released, the device cools, changing aerosol output. The
pause allows the device to return to room temperature and
recover normal output. However, previous research showed
that pMDI output is similar at 15-second intervals. Very rapid
actuation of multiple puffs per breath reduces inhaled drug
per puff.
SPACERS AND VALVE
HOLDING CHAMBERS
• Spacers and valved holding chambers (VHCs) are designed to
reduce both oropharyngeal deposition and the need for
hand-breath coordination.

• Spacer: A spacer is a simple valveless extension device that

adds distance between the pMDI outlet and the patient’s
mouth. This distance allows the aerosol plume to expand and
the propellants to evaporate before the medication reaches
the oropharynx. Larger particles leaving the pMDI tend to
impact on the spacer walls. In combination, this phenomenon
reduces oropharyngeal impaction and increases pulmonary
deposition.

• VHCs: incorporate one or more valves that prevent aerosol in

the chamber from being cleared on exhalation. This allows
patients with a small VT to empty the aerosol from the
chamber over two or more successive breaths.
DRY POWDER INHALERS
• Never exhale into DPI
• Hold-4-10 seconds
• A DPI is typically a breath-actuated dosing system.

• With a DPI, the patient creates the aerosol by drawing air

though a dose of finely milled drug powder with sufficient
force to disperse and suspend the powder in the air.

• Dispersion of the powder into respirable particles depends on

the creation of turbulent flow in the inhaler. Turbulent flow is
a function of the ability of the patient to inhale the powder
with a sufficiently high inspiratory flow rate.

• In terms of both lung deposition and drug response, DPIs are

as effective as pMDIs.
Equipment Design and Function

• Most passive dry powder–dispensing systems require the use

of a carrier substance (lactose or glucose) mixed into the drug
to enable the drug powder to deaggregate more readily and
flow out of the device.

• Reactions to lactose or glucose seem to be fewer than

reactions to the surfactants and propellants used in pMDIs,
even though the amount of these substances is substantially
greater than the amount of the drug and can represent 98% or
more of the weight per inhaled dose in some formulations.

• The particle size of the dry powder particles of drug ranges

from 1 to 3 μm. However, the size of the lactose or glucose
particles can range from approximately 20 to 65 μm, so most
of the carrier (≤80%) is deposited in the oropharynx.
Factors Affecting Dry Powder Inhaler Performance and Drug
Delivery

• Intrinsic Resistance and Inspiratory Flow Rate: Optimal

performance for each DPI design occurs at a specific
inspiratory flow rate. The fine-particle fraction of respirable
drug from existing DPIs ranges from 10% to 60% of the
nominal dose The amount varies with inspiratory flow and
device design. The higher the resistance or the greater the
flow requirement of a DPI device, the more difficult it is for a
compromised or young patient to generate inspiratory flow
sufficient to obtain the maximum dose of drug from the
device.
• Exposure to Humidity and Moisture: The emitted dose of DPI
decreases in a humid environment, likely because of powder
clumping. The longer the exposure and the greater the level of
absolute humidity, the lower the dose emitted. New DPIs with
multiple unit-doses minimize the effects of moisture on the
powder as long as individual doses are inhaled as soon as the
seal is broken.

• Patient’s Inspiratory Flow Ability: High peak inspiratory flow

rates (>60 L/min) are required to dispense the drug powder
from most current DPI designs and result in a pharyngeal dose
comparable to the dose received from a typical pMDI without
an add-on device. If a patient does not inhale at the optimal
inspiratory flow rate for a particular device, delivery to the
lung decreases as the dose of drug dispensed decreases and
the particle size of the powder aerosol increases. (Passive DPI)
Active or powered DPI devices, which deaggregate the powder
before inhalation, are independent of patient effort. Active DPIs
use an energy source to deaggregate the powder and suspend
the powder into an aerosol,allowing the dose to be suspended
independent of patient inspiratory flow rates.

• Technique: Proper technique is essential to derive the

maximum benefit from a DPI. The most critical factor in using
a passive DPI is the need for high inspiratory flow.
Patientsmust generate an inspiratory flow rate of at least 40 to
60 L/min to produce a respirable powder aerosol. Exhalation
into a DPI before inspiration can result in loss of drug delivery
to the lung.
 MDI AND DPI
• Shake the MDI but not the DPI
• The DPI is breath actuated , whereas most MDIs are press-
and-breathe.
• Use a slow flow with the MDI but a fast flow with the DPI
• A spacer is not used with DPI
• A breath hold is more important with an MDI than with a DPI
• Do not exhale into DPI
VIBRATING MESH NEBULIZER

TYPES
ACTIVE

PASSIVE
Active VM nebulizers:
• Use a dome-shaped aperture plate, containing more than
1000 funnel-shaped apertures. The dome is attached to a
plate that is also connected to a piezoceramic element
surrounding the aperture plate.
• Electrical energy applied to the piezoceramic element vibrates
the aperture plate at a frequency of approximately 130 kHz (or
onetenth that of a USN), moving the aperture plate up and
down by approximately 1 μm, creating an electronic
micropump.
• The plate actively pumps the liquid through the apertures,
where it is broken into fine droplets. The exit velocity of the
aerosol is low (<4 m/sec), and the particle size can range from
3 to 4 μm varying with the exit diameter of the apertures
• An active VM nebulizer can nebulize single drops of 15 mcl of
formulations containing small and large molecules,
suspensions, microsuspensions, and liposomes.
Passive VM nebulizers
• Use a mesh separated from an ultrasonic horn by the liquid
solution for nebulization. A piezoelectric transducer vibrates
the ultrasonic horn, which pushes fluid through the mesh.

• The residual drug volumes with either type of VM nebulizer

range from 0.1 to 0.4 ml, in contrast to other types of liquid
aerosol generators with residual drug volumes of 0.8 to 1.5 ml.
• Because a greater percentage of standard unit doses is
emitted as aerosol, care should be exercised when
transitioning to these devices to ensure that the higher dose
does not create adverse effects.
DRUGS
• Bronchodilators- Anticholinergic- Ipratropium bromide
-Beta 2 antagonists- Salbutamol, Salmetrol

• Corticosteroids-Budesonide

• Mucokinetic -Bland aerosol

-Mucolytic
• Antibiotics

Names of drugs commonly used: Budecort, Duolin

ASSESSMENT OF OUTCOMES
• Decreased work of breathing
• Improved saturation and respiratory rate
• Decreased stridor
• Decreased dyspnea
• Improved ABG values
REFERENCES
1. Eagan's -11th edition
2. Pulmonary Rehabilitation Guidelines to Success-4th edition