AEROSOL THERAPY

1. AEROSOL THERAPY Nebulizers to deliver medications

3. Characteristics of Aerosol Particles

4. Tonicity (Review) Hypertonic (10%) Greater tonicity then surrounding tissues Tend to draw fluid from surroundings Isotonic (Normal Saline) 0.9% Neither gains or loses water but maintains a steady size Hypotonic Water

5. Particle Deposition Humungous in size are filtered in nose 100 microns Large in throat 10 - 20 microns Medium in small airways 2 - 5 microns Small in alveoli 1 - 3 microns

6. Size of Particles � MMAD Mass Median Aerodynamic Diameter Versus Count and Volume Median Diameter Expressed in microns 50% of particles are larger and 50% of particles are smaller Compared the Count Median Diameter (CMD)

7. Volume Output Amount of liquid that is nebulized into the air per unit of time Normal breathing treatment with SVN last ten minutes Need to put in at least 3 mL of fluid into the neb Large Volume Nebulizers can last a full hour Needs 9 to 25 mL of fluid to be placed in the nebulizer (therapist does the calculations)

8. Aerosol Density Density is mass / volume Typical units are milligrams per liter (mg/L)

9. Factors that influence DEPOSITION Inertial Impaction Ability to �make the turn� Gravity Particle Characteristic Shape, charge, hygroscopic properties Breathing Pattern Normal slow breathing with occasional breath-hold

12. Types of NEBULIZERS Small Volume Neb Metered Dose Inhaler Dry Powder Inhaler Continuous Neb SPAG Ultrasonic

13. Small Volume Nebulizer

14. SVN Called many different names Neb, acorn, peace pipe, HHN etc Used to deliver liquid medications to patient Can use mouthpiece or mask Most of the day�s workload for a floor therapist is involved with administration of these treatments.

15. Design of SVN

16. Baffle Is essential part of the design of a nebulizer Prevents large particles from being produced Keeps particles in the 2 to 5 micron range.

17. Atomizers Hand-bulb or nasal spray pump Used to produce and aerosol with large varied particles Targets the upper airway (nasal passages), pharynx and larynx) (Obviously no baffle)

18. Nebulizer Optimal Technique Set flow 6 to 8 L/min Breathe slowly through the mouth at normal size Tap nebulizer after sputtering begins to reduce leftover in nebulizer

19. Oxygen or Air In hospital sometimes we have a choice Air MUST be used with CO2 retainers Mostly a matter of comvenience

20. Home Nebulizer

21. Specialty Neb (1 of many) Respirgard II Used with pentamidine

22. Specialty Neb 2 Circulaire Used in morphine treatments Often triggers bronchospasm in therapist Commonly seen most everywhere

23. Specialty Neb 3 Breath activated Nebulizer (AeroEclipse) Allows nebulization to occur only on inspiration. Company claims better use of time Limited in application Can�t use mask, can�t use inline with ventilator

24. New Generation AERx Aeroneb Respimat HaloLite (Europe only)

25. Continuous Treatments Hour-long used in ER

26. Continuous (1 hour) Treatments H.O.P.E. (High Output�..) H.E.A.R.T. Used in Emergency Room

27. Mini-HEART Continuous Neb

28. Uniheart

29. Continuous Nebs Used for hour long treatments Also called large volume nebulizer (vs small volume neb) Patient (Status Asthmaticis) is receiving many treatments �back to back� Usually in ER, always under continuous monitoring

30. Small Particle Generator Produces extra small particles to go all the way into the lungs and to the alveoli.

31. Small Particle Used to generate particles small enough to penetrate through to the lung alveoli 1 to 3 microns Specifically designed for one medicine (ribavirin) for the treatment of Respiratory Syncytial Virus (RSV) Not used anymore anywhere

32. SPAG

33. Ultrasonic Nebulizer

34. Ultrasonic Nebulizer Introduced in 1960�s (Dr. O) Uses piezo-electric crystal that converts electricity to sound waves that really puts out a real mist to the patient Not used any more around here in hospitals as not proven superior to SVNs Is more popular as a home / portable unit

35. Ultrasonic Nebulizer

36. Inner workings of Ultrasonic

37. Small Ultrasonic (inline to vent pt)

38. MDIs

39. Metered Dose Inhaler

40. Always use a spacer

42. Spacer Use Decreases oral deposition Increases amount of medicine making the small airways Flow signal for too fast an inhalation Permits many small breaths instead of one large breath

43. Optimal Technique Assemble apparatus Shake Exhale Place holding chamber in mouth Activate canister Inhale slowly and hold breath for 5 to 10 seconds

44. Optimal Technique 2 Place mouthpiece in mouth Seal with lips (or seal mask) Activate canister Continue to breath for 3 to 6 breaths Encourage big breaths and breath holding if possible

45. Flow Triggered MDI An old idea that did not work Autohaler (3M) Pirbuterol only

46. DPIs

47. Older Units Rotahaler Spinhaler Turbuhaler

48. Aerosolization of Dry Powder

49. Newer Unit � Dry Powder Inhaler

50. Inner workings of DPI

51. Optimal Technique Open, Click, Inhale Exhale slowly to empty lungs Seal lips on mouthpiece Inhale quickly (>40 L/min) and deeply A breathhold is not necessary Repeat if needed

52. Dry Powder Inhaler The latest and the greatest Need higher inspiratory flow rates �Works like a charm�

53. Choice?

54. Advantages vs Disadvantages Nebulizer MDI DPI USN

55. Controlling Contamination Negative Pressure Rooms Booth and Stations PPE

56. Negative Pressure Rooms Needed for Respiratory Isolation Chicken Pox or TB Private Room with a set of double doors with and entry way. Air exchanged at least 6 times an hour Vented to the outside

57. Booth and Stations Provides for containment of aerosol during therapy Used for sputum inductions with suspected TB patients Used for pentamidine administration with HIV patients

58. EmmersonTx Booth

59. BioSafety Protection Cart

60. Personal Protection Equipment Airborne Precautions implemented Wear a reusable HEPA filter mask over and above gloves and gown Need to be personally fitted for mask, inserviced on it�s use and have annual compliance re-training. Students � do NOT qualify

61. That�s all folks