INHALATION

THERAPY
IN CHILDREN
Domiko Widyanto, MD
Pediatrician

Introduction
Inhalation therapy is a method of
drugs delivery into respiratory
tract by inhalation
widely used in Respirology
(Respiratoy medicine)
many respiratory drugs can be
delivered by this method
many advantages, with some
limitations
2

History
4000 BC: vapours and smoke
India, Egypt, Greece & Rome
1829 : Schneider & Waltz 1st aerosol
device
20th century developments

1930: Large-sized nebuliser ; jet

nebuliser

1955: pMDI (1956 : Medihaler)

1970s : DPI

1980s : breath-actuated MDI

(Turbuhaler, Easyhaler)

Principles of inhalation
therapy
to produce optimal size aerosol to
deposited in the airways (respirable
aerosol:<10m)
aerosol is dispersion of liquid or solid
small particle in mist form, produced
by pressure or breath actuated
target: along the respiratory tract
nose, sinus, trachea, bronchus,
bronchiolus, even alveolus
4

Drug delivery scheme

systemic
parenteral (injection): IV, IM, IC, SC
enteral (oral): tablet, capsule, syrup, etc

topical

skin
eye
ear
nose
lung

:
:
:
:
:

cream, lotion
drop, ointment
drop,
drop, spray
inhalation
5

Respiratory drug delivery

scheme
systemic
parenteral (injection): IV, IM, IC, SC
enteral (oral): tablet, capsule, syrup,
etc

inhalation
Nebulizer
Dry powder inhaler (DPI)
Metered dose inhaler (MDI)
6

Advantages of inhalation
therapy (astma)
topical
directly to
resp system

low dose

high
th/. ratio

safety of
longterm use

fast onset

reliever
DBS 2004

minimal
side effects

controller
7

Advantages of inhalation
therapy
rapid onset directly to target organ
minimal dose less dose needed
less side effect due to minimal dose
however there is still a systemic availability
to reduce it, rinse your mouth after spill it
out
8

A
B
C
Mechanisms of deposition within the respiratory tract.
A, Impaction. B, Sedimentation. C, Diffusion
9 286
Everard ML, et al. Pediatr Respir Med 1999;

PARTICLE SIZE

IMPACTION

SEDIMENTATION

Nasal cavity

> 10 m

5-10 m

Trachea
Primary bronchus
Secondary bronchus

2-5 m
SEDIMENTATION
+
DIFFUSION
DIFFUSION

Terminal bronchus

<2m
<2m

Respiratory
bronchiole
Alveoli

Alveolar
Ducts & Sacs

Particles penetrate the respiratory tract to different degrees according to their size.
This diagram also depicts the mechanisms that operate to clear particles from
10
the Respiratory tract according to size

Aerosol particle size &

location
aerosol
size

upper
resp

lower
resp

parenchy

>10m

7 - 10m

4 - 6m

2 - 3m

1m

<1m

no deposition
11

Factors influenced
The patient
Anatomic factor
Physiologic factor
Age (maneuver ability)

The aerosol
size
flow
12

Aerosol delivery in
children
anatomical: smaller, growth
competence: limited ability
breathing pattern: small TV, irregular
patterns

crying: increase RR, decrease TV,

longer expiration phase

less effective drugs: infants less

responsive to 2-agonis

13

Pharmacokinetics of inhaled
Metered
Delivered
Respiratory
drugs
dose
dose to
availability
patient

Systemic
availability is
the sum of the
respiratory & the
oral component

Portal
vein

Liver

Gut
Metabolism

Systemic
availability
Pedersen & OByrne,141997

Obstacles
Doctors perspective :
Time consuming
Self medication by
patient
Expensive
Reduce patient visit
15

Obstacles
Patients perspective :
Expensive
Addiction
Dangerous
Asthma in severe stage

16

Obstacles
Inhaler medication
Lack of advocacy
Availability: not widely distributed
Price / cost ?
Complex manouver (esp. MDI)
Not all drug available in inhalation
form
17

Positive impact
fnancial ability

Inhalation
therapy

oral
sums of doctors patient

to other
doctor
go abroad

trust to
Indonesian
doctor

Quality of
life
Quality of tx
Controlled asthma
Patient gets
18
patient

Inhalation therapy
devices
1.Nebulizer
2. Dry powder inhaler (DPI)
3. Metered dose inhaler
(MDI)
with and without spacer
19

Nebulizer
Continuously change the solution to
aerosol
by pressured air or
ultrasonic wave
Jet nebulizer: aerosol is generated
with
a flow of gas, provided by
compressor or compressed gas
Ultrasonic nebulizer: aerosol is
generated by vibrating fluid placed
within it
Jet neb is the most widely used
20

Figure. Jet nebulizer

21

Jet nebulizer parts

electric compressor
connector tube
neb chamber
removable top
liquid reservoir

interface:
mouth piece
face mask
22

Jet nebulizer parts

23

1-degree droplets
Fine droplets pass around baffle

Gas at
high
pressure

To patient

Baffle

Droplets trapped and recirculated

Feed tube

Aerosol generation by a jet nebulizer

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

24

Schematic fgure of jet

nebulizer

25

Figure. Ultrasonic
nebulizer

26

Schematic fg of ultrasonic
nebulizer

27

Comparison of nebulizer
Parameters

Jet nebulizer

Ultrasonic neb

power source

electric / comp

electric

how it works

high air flow

high freq
vibratn

air flow

8L/mnt (+2)

noisy

quiet

free

quite horizontal

<5 mL

>10mL

almost all

not steroid

almost none

triggering
asthma

cheap

expensive

sound
tool position
fll volume
nebulized drug
side effect
price

28

Fill volume
the volume of drug solution to be
fll in the reservoir chamber
Drugs

<3mL

3-5mL

>5mL

bronchodilat
or

steroid

+
29

Nebulization time
the time from starting nebulization until
continuous nebulization has been
ceased
hospitalizati
on
< 24 hours
+ 24 hours
> 24 hours

<6

6-10

>10

+
+
+

+
+
+

+
30

Interface

mouth
piece

face mask
31

Interface choice
the use of mouthpiece is recommended
if there is no obstacle
interface < 3 years 3-6 years > 6 years
mouth
piece

face mask

32

Inhalation therapy
devices
1. Nebulizer
2.Dry powder inhaler
(DPI)
3. Metered dose inhaler (MDI)
with and without spacer
33

Dry powder inhaler (DPI)

a tool to inhale drugs in dry powder form
1957: for inhalation of dry powder antibiotic
studies: can be used for other respiratory drugs
1970s: 1 DPI contains 1 dose
(Spinhaler,Rotahaler)

1980s: 1 DPI contains more doses (Diskhaler 8)

1990-2000s: more doses in 1 DPI
Accuhaler 60 doses
Turbuhaler 120 doses
Easyhaler 200 doses
34

Dry powder inhaler (DPI)

the power source is the flow of
inspiration / inhalation of the patient
less oropharynx deposition
breath-actuated inhaler, no propelan
effort dependent
not suitable for under 5 children
for older children easier to use than MDI
no need of spacer, easy to carry
35

DPI, 2 versions
the drug is inside
the inhaler

Turbuhaler
Easyhaler

the drug is
separated from
the inhaler

Rotahaler
Cyclohaler
36

Turbuhaler

design and

operation
Mouthpiece is specially
designed with spiral
channels to deaggregate
the dose to respirable
particles
Inhalation channel
transports dosage of drug
aggregates to the
mouthpiece
Rotating dosing disc
determines the dose of
medication for delivery to
the inhalation channel

Drug reservoir holds

50,60,100 or 200 doses of
medication
Dosing scrapers ensures
precise dosing by
removing excess amounts
of drug
Twist grip loads a single
dose when turned
completely in one direction
and then back again
37

38

Easyhaler
multidose dry powder inhaler (200
doses),
provide consistent, accurately
measured
dose delivery, by simply
Advantages:
pressing
the cap
no need coordination (actuation inhalation ) easy-to-use
more particles depositions in the lungs
accurate and consistence dosing
could be used by children 5 years
without bronchodilator side effect
lactose particles give sweet taste
39

How to use
Turbuhaler

Easyhaler

open the cap

rotate the base
clockwise, rotate
back until click, to
prepare the drug
exhale, put the
mouthpiece, inhale
fast & strongly
hold the breath 10

open the cap

shake it
exhale, put the
mouthpiece, inhale
fast & strongly
hold the breath 10

40

How to use
Rotahaler

Cyclohaler

put the capsule into

its place
rotate the inhaler,
to open the capsule
exhale, put the
mouthpiece, inhale
fast & strongly
hold the breath 10

put the capsule

into its place
push the button on
both side, to open
the capsule
exhale, put the
mouthpiece, inhale
fast & strongly
hold the breath 10
41

Schematic diagram of inhalation

device

Metered dose inhaler (MDI)

Dry powder inhaler (DPI)

42

Inhalation therapy
devices

1. Nebulizer
2. Dry powder inhaler (DPI)
3.Metered dose inhaler
(MDI)
with and without spacer
43

Metered Dose Inhaler

(MDI)
How to use it:
shake the canister, open the cap

hold it straight, exhaled slowly

put the canister mouthpiece between
lips tightly, inhale slowly
in the beginning of inspiration, push
down
the canister, continue to inhale
slowly
at maximal inspiration, hold the breath
for 10
seconds (count to 10)
dont forget to rinse afterwards & spill
out
44

How to use MDI

shake well for 15

before each use

remove the cap from

the mouthpiece
45

How to use MDI

breathe out through the

mouth, place the
mouthpiece in the mouth, &
close the lips around it

while breathing deeply

& slowly, press the
canister frmly
46

How to use MDI

Alternatively, the
inhaler may be
positioned 1 to 2
inches away from
the open mouth

47

How to measure the MDI

contents

48

MDI with spacer

49

Active agents used for

inhalation therapy
1. Normal Saline (NaCl 0,9%)
improving respiratory hygiene,
humidifcation, or mucus
hypersecretion
2. Hyperosmolar aerosol (NaCl 3%)
inducing sputum

50

Active agents used for

inhalation therapy
Epinephrine nasal decongestant,
croup, broncholiolitis. Side effect?
Beta-2 adrenergic bronchodilator,
antiinflamatory
Mucoactives agents N-acetyl-systein
Antiinfection ribavarin (RSV),
tobramycin, aztreonam (pseudomonas
aeruginosa)
51

Active agents used for

inhalation therapy
Pulmonal hypertension iloprost,
trepostinil
Insulin
Surfactant
Corticosteroids budesonide

52

Corticosteroids
Budesonide, fluticasone
The most effective anti-inflammatory
medications for asthma
Improve lung function
Decrease airway hyper-responsiveness
Reduce symptoms
Decrease frequency and severity of
exacerbations
Improve Quality of Life (QoL)
53

Inhaled Steroid + LABA

Adding LABA to BUD reduces
rate of mild exacerbations
Adding LABA to BUD reduces
rate of severe exacerbations
Adding LABA to BUD improves
FEV1
54

Corticosteroids for others

Effective in controlling the symptoms of
allergic rhinitis through a variety of
mechanisms inhibition of
proinflammatory secretions decrease
in nasal congestion, rhinorrhea,
sneezing, and itching
Adjuvant therapy rhinosinusitis

55

PEF: Peak Expiratory Flow ; FEV1: Forced Expiratory Flow in 1 second

Chian CF et al. Pulm Pharmacol Ther. 2011;24(2): 256-260

Volovitz B Respir Med. 2007;101:685-695

PEFR : Peak Expiratory Flow Rate

Volovitz B Respir Med. 2007;101:685-695

59

XX
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (Updated 2015). Available from www.ginasthma.org. Accessed on May 26, 2015

Resu
me
Nebulizer

Inhalation
therapy
DPI

MDI
Spacer (-)

Turbuhale
r

Jet Neb
UltraS Neb

Rotahaler

Spacer (+)

Easyhaler
Cyclohale
r
extension

holding ch

de
61

Jet nebulizer
advantages
less coordination
needed
high doses
possible
no CFC release

disadvantages
rather expensive
possible
contamination
not all medication
available
more time required
need drug
instillation
62

Ultrasonic nebulizer

advantages
less coordination
needed
high doses possible
no CFC release
small dead volume
quiet
faster delivery

disadvantages
expensive
possible
contamination
not all medication
available
bulky
need drug
instillation
63

Metered dose inhaler

advantages
convenient
less expensive
portable
no drug
preparation
no contamination

disadvantages
coordination
essential
patient activation
required
large pharyngeal
deposition
difficult to deliver
high doses
not all medication
available
64

MDI with spacer

advantages
less coordination
required
less pharyngeal
deposition
no drug
preparation
no contamination

disadvantages
more complex for
some patient
more expensive
than MDI alone
less portable than
MDI alone

65

Dry powder inhaler

advantages
less coordination
required
breath hold not
required
breath actuated

disadvantages
requires high
inspiratory flow
pharyngeal
deposition possible
difficult to deliver
high doses
not all medication
available
66

Matur nuwun
67