Nebulizers to deliver medications

   What is an aerosol?
   Is any liquid or solid particle that is
    suspended in a gas
Characteristics of Aerosol
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
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
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)
Volume Output

   Amount of liquid that is nebulized into the air
    per unit of time
   Normal breathing treatment with SVN last ten
       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)
Aerosol Density

   Density is mass / volume
   Typical units are milligrams per liter (mg/L)
Factors that influence
   Inertial Impaction
       Ability to ‘make the turn’
   Gravity
   Particle Characteristic
       Shape, charge, hygroscopic properties
   Breathing Pattern
       Normal slow breathing with occasional breath-

   Small Volume Neb
   Metered Dose Inhaler
   Dry Powder Inhaler
   Continuous Neb
Small Volume Nebulizer

   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.
Design of SVN

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

   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)
Nebulizer Optimal Technique

   Set flow 6 to 8 L/min
   Breathe slowly through the mouth at normal
   Tap nebulizer after sputtering begins to
    reduce leftover in nebulizer
Oxygen or Air

   In hospital sometimes we have a choice
   Air MUST be used with CO2 retainers
   Mostly a matter of comvenience
Home Nebulizer
Specialty Neb (1 of many)

Respirgard II
Used with pentamidine
Specialty Neb 2

   Circulaire
   Used in morphine treatments
   Often triggers bronchospasm in therapist
   Commonly seen most everywhere
Specialty Neb 3

   Breath activated Nebulizer (AeroEclipse)
   Allows nebulization to occur only on
   Company claims better use of time
   Limited in application
       Can’t use mask, can’t use inline with ventilator
New Generation

   AERx
   Aeroneb
   Respimat
   HaloLite (Europe only)
Continuous Treatments

   Hour-long used in ER
Continuous (1 hour) Treatments

   H.O.P.E. (High Output…..)
   H.E.A.R.T.
   Used in Emergency Room
Mini-HEART Continuous Neb
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
Small Particle Generator

    Produces extra small particles to go all
    the way into the lungs and to the alveoli.
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
Ultrasonic Nebulizer
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
Ultrasonic Nebulizer
Inner workings of Ultrasonic
Small Ultrasonic (inline to vent pt)
Metered Dose Inhaler
Always use a spacer
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
Optimal Technique

   Assemble apparatus
   Shake
   Exhale
   Place holding chamber in mouth
   Activate canister
   Inhale slowly and hold breath for 5 to 10
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
Flow Triggered MDI

   An old idea that did not
   Autohaler (3M)
   Pirbuterol only
Older Units

   Rotahaler
   Spinhaler
   Turbuhaler
Aerosolization of Dry Powder
Newer Unit – Dry Powder Inhaler
Inner workings of DPI
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
Dry Powder Inhaler

   The latest and the greatest
   Need higher inspiratory flow rates

           “Works like a charm”
Advantages vs Disadvantages

   Nebulizer
   MDI
   DPI
   USN
Controlling Contamination

   Negative Pressure Rooms
   Booth and Stations
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
Booth and Stations

   Provides for containment of aerosol during
   Used for sputum inductions with suspected
    TB patients
   Used for pentamidine administration with HIV
Tx Booth
BioSafety Protection Cart
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
That’s all folks

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