Nebuliser hood compared to mask in wheezy infants: aerosol therapy without tears!

Safety and Efficacy of 2.5 mg and 1.25 mg Nebulized Salbutamol Compared with Placebo on Transient Tachypnea of the Newborns: A Triple-Blind Phase II/III Parallel Randomized Controlled Trial

Background: To evaluate the safety and efficacy of 2.5 and 1.25 mg nebulized salbutamol on Transient Tachypnea of the Newborn (TTN) compared with placebo. Methods: We conducted a triple-blind, phase II/III parallel randomized controlled trial in two university-affiliated hospitals with neonatal intensive care units. Newborns with a confirmed diagnosis of TTN, with gestational age >35 weeks and gestational weight >2 kg were included. Cases of asphyxia, meconium aspiration syndrome, and persistent pulmonary hypertension were excluded. Ninety eligible patients were randomly allocated in three intervention groups (2.5 mg salbutamol, 1.25 mg salbutamol, and placebo), and a single-dose nebulized product was prescribed 6 hours after the birth. Safety outcomes included postintervention tachycardia, hyperglycemia, hypokalemia, and changes in blood pressure. To evaluate the efficacy, the duration of postintervention tachypnea, TTN clinical score, and clinical and paraclinical respiratory indices were assessed. Parents, Outcome assessors, and data analyzer were blind to the intervention. Results: There was no adverse reaction, including tachycardia, hypokalemia, and jitteriness. Both groups of salbutamol recipients showed significant improvement regarding respiratory rate, TTN clinical score, and oxygenation indices compared with the placebo (p-values <0.001). Nonstatistically significant higher hospital stay was observed in the placebo group. Single 2.5 mg salbutamol nebulization showed a little better outcome than the dose of 1.25 mg, although we could not find statistical superiority. Conclusion: The newly applied single high dose of 2.5 mg nebulized salbutamol is safe in treating TTN and leads to notable faster improvement of respiratory status without any considerable adverse reaction. Registry code: IRCT20190328043133N1.

Individualized aerosol medicine: Integrating device into the patient

Pulmonary drug delivery is complex due to several challenges including disease-, patient-, and clinicians-related factors. Although many inhaled medications are available in aerosol medicine, delivering aerosolized medications to patients requires effective disease management. There is a large gap in the knowledge of clinicians who select and provide instructions for the correct use of aerosol devices. Since improper device selection, incorrect inhaler technique, and poor patient adherence to prescribed medications may result in inadequate disease control, individualized aerosol medicine is essential for effective disease management and control. The components of individualized aerosol medicine include: (1) Selecting the right device, (2) Selecting the right interface, (3) Educating the patient effectively, and (4) Increasing patient adherence to therapy. This paper reviews each of these components and provides recommendations to integrate the device and interface into the patient for better clinical outcomes.

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Reconciling Oxygen and Aerosol Delivery with a Hood on In Vitro Infant and Paediatric Models

This study aimed to evaluate optimal aerosol and oxygen delivery with a hood on an infant model and a paediatric model. A facemask and a hood with three inlets, with or without a front cover, were used. A small-volume nebuliser with a unit-dose of salbutamol was used for drug delivery and an air entrainment nebuliser was used to deliver oxygen at 35%. Infant and paediatric breathing patterns were mimicked; a bacterial filter was connected to the end of a manikin trachea for aerosol drug collection, and an oxygen analyser was used to measure the oxygen concentration. For the infant model, inhaled drug dose was significantly higher when the nebuliser was placed in the back of the hood and with a front cover. This was verified by complementary computational simulations in a comparable infant-hood model. For the paediatric model, the inhaled dose was greater with a facemask than with a hood. Oxygen delivery with a facemask and a hood with a front cover achieved a set concentration in both models, yet a hood without a front cover delivered oxygen at far lower concentrations than the set concentration.

A path to successful patient outcomes through aerosol drug delivery to children: a narrative review

Although using aerosolized medications is a mainstay of treatment in children with asthma and other respiratory diseases, there are many issues in terms of device and interface selection, delivery technique and dosing, as well as patient and parental education that have not changed for half a century. Also, due to many aerosol devices and interfaces available on the market and the broad range of patient characteristics and requirements, providing effective aerosol therapy to children becomes a challenge. While aerosol delivery devices are equally effective, if they are age-appropriate and used correctly, the majority of aerosol devices require multiple steps to be used efficiently. Unfortunately, many children with pulmonary diseases have problems with the correct delivery technique and do not gain therapeutic benefits from therapy that result in poor disease management and increased healthcare costs. Therefore, the purpose of this paper is to review the current knowledge on aerosol delivery devices used in children and guide clinicians on the optimum device- and interface-selection, delivery technique, and dosing in this patient population. Strategies on how to deliver aerosolized medications in crying and distressed children and how to educate parents on aerosol therapy and promote patient adherence to prescribed medications are also provided. Future directions of aerosol therapy in children should focus on these issues and implement policies and clinical practices that highlight the potential solutions to these problems.

Modified Small-Volume Jet Nebulizer Based on CFD Simulation and Its Clinical Outcomes in Small Asthmatic Children

The small-volume jet nebulizer (SVJN) is an aerosol device used to treat respiratory illnesses. Major problems for aerosol treatment in small children include the penetration of particles to the lower lungs due to irregular and small volume of a child patient's breath while the nebulizers used are the same models intended for adults. This adult SVJN produces a huge number of particles at a higher speed than small children can intake. To solve this problem, computational fluid dynamics (CFD) was used to redesign the device by adding 6-inch corrugated tube with 80 ml capacity (equal to one inhale capacity of a small child) into the traditional SVJN. Results revealed that the undulations of the corrugated tube were the important parts that change the direction of aerosol flow, slowing down the produced speed of aerosol up to 31.48% (mean speed = 0.37 m/s via modified SVJN vs 0.54 m/s via traditional which were close to measured results). The modified SVJN was tested for the effectiveness on how it could accommodate bronchodilator drug to the lower lungs by 3 clinical researches with 238 asthmatic children aged 1–5 years. The results revealed that the experimental group reported higher bronchodilatating effects: higher mean score of change in oxygen saturation and degree of wheezing and greater reduction in respiratory rate per minute than the control group with statistical difference (p < 0.05). Meanwhile, heart rate and physical attributes (dead volume and duration of aerosol treatment) were indifferent. Moreover, small children showed more acceptance behavior towards this modified SVJN than the traditional one. Modified SVJN might be a good choice for aerosol treatment in small children because it slows down the speed of aerosol production, makes them well spread all over the reservoir, and is ready for small children to inhale for better clinical outcomes while physical attributes are the same.

Alternatives to systemic postnatal corticosteroids: Inhaled, nebulized and intratracheal

Concern about adverse outcomes with the use of systemic postnatal corticosteroids (PCS) for bronchopulmonary dysplasia (BPD) have led to the widespread use of alternative methods of administration in research and clinical care. Theoretically, administration of topical (directly to the lung) corticosteroids may allow for beneficial effects on the pulmonary system with a lower risk of undesirable side effects compared with systemic administration. Current evidence suggests that inhaled corticosteroids may be an effective therapy in the management of developing BPD in preterm infants, but questions about their safety remain. An alternative to inhalation is the intratracheal administration of corticosteroids using surfactant as a vehicle, but this approach has only been studied in a limited number of infants. We review the evidence for the short-term clinical efficacy and safety of inhaled, nebulized and intratracheal PCS for the prevention and treatment of BPD.

Drug delivery interfaces: A way to optimize inhalation therapy in spontaneously breathing children

There are several different types of drug delivery interfaces available on the market. Using the right interface for aerosol drug delivery to children is essential for effective inhalation therapy. However, clinicians usually focus on selecting the right drug-device combination and often overlook the importance of interface selection that lead to suboptimal drug delivery and therapeutic response in neonates and pediatrics. Therefore, it is necessary to critically assess each interface and understand its advantage and disadvantages in aerosol drug delivery to this patient population. The purpose of this paper is to provide a critical assessment of drug delivery interfaces used for the treatment of children with pulmonary diseases by emphasizing advantages and problems associated with their use during inhalation therapy.

In Vitro Evaluation of a Device for Intra-Pulmonary Aerosol Generation and Delivery

For infants born with respiratory distress syndrome (RDS), liquid bolus delivery of surfactant administered through an endotracheal tube is common practice. While this method is generally effective, complications such as transient hypoxia, hypercapnia, and altered cerebral blood flow may occur. Aerosolized surfactant therapy has been explored as an alternative. Unfortunately, past efforts have led to disappointing results as aerosols were generated outside the lungs with significant pharyngeal deposition and minimal intrapulmonary instillation. A novel aerosol generator (Microjet™) is evaluated herein for intrapulmonary aerosol generation within an endotracheal tube and tested with Curosurf and Infasurf surfactants. Compared with other aerosol delivery devices, this process utilizes low air flow (range 0.01-0.2 L/min) that is ideal for limiting potential barotrauma to the premature newborn lung. The mass mean diameter (MMD) of the particles for both tested surfactants was less than 4 μm, which is ideal for both uniform and distal lung delivery. As an indicator of phospholipid function, surfactant surface tension was measured before and after aerosol formation; with no significant difference. Moreover, this device has an outside diameter of <1mm, which permits insertion into an endotracheal tube (of even 2.0 mm). In the premature infant where intravenous access is either technically challenging or difficult, aerosol drug delivery may provide an alternative route in patient resuscitation, stabilization and care. Other potential applications of this type of device include the delivery of nutrients, antibiotics, and analgesics via the pulmonary route.

Effect of inhaled hypertonic saline on hospital admission rate in children with viral bronchiolitis: a randomized trial

Objective:

We sought to determine whether inhaled 3% hypertonic saline (HS) reduces admission to hospital in ambulatory children with moderately severe viral bronchiolitis. Secondary objectives compared changes in respiratory scores before and after treatment and assessed the need for unscheduled medical intervention within 7 days.

Methods:

Children under the age of 2 years presenting with moderately severe viral bronchiolitis to the emergency department of 4 general hospitals from November 2008 to March 2009 were randomly assigned to receive 3 consecutive 4-mL doses of nebulized 3% HS (treatment group) or 0.9% normal saline (NS; control group) in a double blind fashion, each coadministered with 1 mg salbutamol. Outcome measures included the difference in hospital admission rate and changes in respiratory distress scores.

Results:

A total of 81 children (mean age 8.9 mo, range 0.7–22 mo) were assessed over 88 visits on an intention-to-treat basis. No statistically significant differences were found between treatment groups. Children in the HS group had a nonsignificant trend toward greater improvement compared with NS controls with a same-day admission rate of 18% (95% confidence interval [CI] 9%–32%) versus 27% (95% CI 16%–42%), respectively. Respiratory Assessment Change Scores (RACS) favoured the HS group over NS controls (mean RACS 4.7 [95% CI 3.6–5.8] v. 3.7 [95% CI 2.5–4.9], respectively), although the CIs overlap and these differences were not statistically significant.

Conclusion:

The short-term use of nebulized 3% HS did not result in any statistically significant benefits, although a nonsignificant trend toward a decrease in admission rate and improvement in respiratory distress was found. A larger study would be required to determine whether these trends arise from a clinically relevant treatment effect.

Pediatric in vitro and in silico models of deposition via oral and nasal inhalation

Respiratory tract deposition models provide a useful method for optimizing the design and administration of inhaled pharmaceutical aerosols, and can be useful for estimating exposure risks to inhaled particulate matter. As aerosol must first pass through the extrathoracic region prior to reaching the lungs, deposition in this region plays an important role in both cases. Compared to adults, much less extrathoracic deposition data are available with pediatric subjects. Recently, progress in magnetic resonance imaging and computed tomography scans to develop pediatric extrathoracic airway replicas has facilitated addressing this issue. Indeed, the use of realistic replicas for benchtop inhaler testing is now relatively common during the development and in vitro evaluation of pediatric respiratory drug delivery devices. Recently, in vitro empirical modeling studies using a moderate number of these realistic replicas have related airway geometry, particle size, fluid properties, and flow rate to extrathoracic deposition. Idealized geometries provide a standardized platform for inhaler testing and exposure risk assessment and have been designed to mimic average in vitro deposition in infants and children by replicating representative average geometrical dimensions. In silico mathematical models have used morphometric data and aerosol physics to illustrate the relative importance of different deposition mechanisms on respiratory tract deposition. Computational fluid dynamics simulations allow for the quantification of local deposition patterns and an in-depth examination of aerosol behavior in the respiratory tract. Recent studies have used both in vitro and in silico deposition measurements in realistic pediatric airway geometries to some success. This article reviews the current understanding of pediatric in vitro and in silico deposition modeling via oral and nasal inhalation.

Nebulizers for drug delivery to the lungs

INTRODUCTION

Nebulizers are the oldest modern method of delivering aerosols to the lungs for the purpose of respiratory drug delivery. While use of nebulizers remains widespread in the hospital and home setting, certain newer nebulization technologies have enabled more portable use. Varied fundamental processes of droplet formation and breakup are used in modern nebulizers, and these processes impact device performance and suitability for nebulization of various formulations.

AREAS COVERED

This review first describes basic aspects of nebulization technologies, including jet nebulizers, various high-frequency vibration techniques, and the use of colliding liquid jets. Nebulizer use in hospital and home settings is discussed next. Complications in aerosol droplet size measurement owing to the changes in nebulized droplet diameters due to evaporation or condensation are discussed, as is nebulization during mechanical ventilation.

EXPERT OPINION

While the limelight may often appear to be focused on other delivery devices, such as pressurized metered dose and dry powder inhalers, the ease of formulating many drugs in water and delivering them as aqueous aerosols ensures that nebulizers will remain as a viable and relevant method of respiratory drug delivery. This is particularly true given recent improvements in nebulizer droplet production technology.

Interactions between caregivers and young children: exploring pedagogical tact in nebulizer treatment

Although research in health care suggests that one of the most important factors for efficient medical delivery is the child's willingness to cooperate, little is known about how caregivers facilitate cooperation with young children during medical treatment. In this article, we explore interactions between parents, nurses, and young children during pediatric nebulizer treatment in terms of tact as a pedagogical concept. Based on our analysis, which followed a hermeneutic approach and included video observations of five hospitalized children aged between 15 and 30 months, we present four themes related to pedagogical tact of caregivers and children's willingness to cooperate, and discuss the role that medical products can play in this cooperation. The results benefit pediatric health personnel, as well as product designers.

Aerosol therapy in children: challenges and solutions

Using aerosolized medications for the treatment of children has gained importance over the years. However, aerosol drug delivery to infants and pediatrics is not an easy task as it has been influenced by many challenges. Most aerosol devices have been designed for use in adults not for children. Therefore, they require some critical assessment in device selection and often a level of adaptation for use with smaller children. It is well documented that each aerosol device and interface that have been used for the treatment of children has its own advantages and challenges in drug delivery. This paper provides a comprehensive review of dosing, drug-device combination, aerosol devices and interfaces used for drug delivery to children with pulmonary diseases. Solutions to the challenges with the aim of optimizing aerosol therapy in this patient population are also discussed.

Breathing easier: addressing the challenges of aerosolizing medications to infants and preschoolers

An increasing number of patients are dependent on aerosolized therapy to manage pulmonary diseases, including asthma, cystic fibrosis, and pulmonary arterial hypertension. An aerosol therapy is only useful if it can be appropriately and consistently delivered in the desired dose to the lower respiratory tract. Many factors affect this deposition in young children, including anatomical and physiologic differences between adults and children, patient-mask interface issues, the challenge of administering medication to uncooperative children, and behavioral adherence. Moreover, the techniques used to assess aerosol delivery to pediatric patients need to be carefully evaluated as new therapies and drug-device combinations are tested. In this review, we will address some of the challenges of delivering aerosolized medications to pediatric patients.

Feasibility of aerosol drug delivery to sleeping infants: a prospective observational study

OBJECTIVES

Delivery of inhaled medications to infants is usually very demanding and is often associated with crying and mask rejection. It has been suggested that aerosol administration during sleep may be an attractive alternative. Previous studies in sleeping children were disappointing as most of the children awoke and rejected the treatment. The SootherMask (SM) is a new, gentle and innovative approach for delivering inhaled medication to infants and toddlers. The present pilot study describes the feasibility of administering inhaled medications during sleep using the SM.

DESIGN

Prospective observational study.

SETTING

Out patients.

PARTICIPANTS

13 sleeping infants with recurrent wheezing who regularly used pacifiers and were <12 months old.

INTERVENTION

Participants inhaled technetium99mDTPA-labelled normal saline aerosol delivered via a Respimat Soft Mist Inhaler (SMI) (Boehringer-Ingelheim, Germany) and SM + InspiraChamber (IC; InspiRx Inc, New Jersey, USA).

OUTCOMES

The two major outcomes were the acceptability of the treatment and the lung deposition (per cent of emitted dose).

RESULTS

All infants who fulfilled the inclusion criteria successfully received the SM treatment during sleep without difficulty. Mean lung deposition (±SD) averaged 1.6±0.5% in the right lung.

CONCLUSIONS

This study demonstrated that the combination of Respimat, IC and SM was able to administer aerosol therapy to all the sleeping infants who were regular pacifier users with good lung deposition. Administration of aerosols during sleep is advantageous since all the sleeping children accepted the mask and ensuing aerosol therapy under these conditions, in contrast to previous studies in which there was frequent mask rejection using currently available devices.

CLINICAL TRIAL REGISTRY

NCT01120938.

Hood nebulization: effects of head direction and breathing mode on particle inhalability and deposition in a 7-month-old infant model

BACKGROUND

Aerosol drug delivery to infants is a strong function of their behavior. Infants can be active during medication administration, changing head position or breathing mode. The objective was to evaluate the influence of the head direction and breathing mode on the hood drug delivery in a 7-month-old girl airway model by using an approach that couples imaging with computational fluid dynamics (CFD). Three head directions, i.e., face up, face side, and sitting (face front), and two breathing modes, i.e., oronasal and nasal breathing, were studied.

METHODS

The face-airway model was developed from computed tomography scans of a 7-month-old girl. Respiratory airflows and particle transport were simulated with the low Reynolds number κ-ω turbulence model and Lagrangian tracking approach. Three pharmaceutical aerosol sizes (1, 2.5, and 5 μm) via hood nebulization were considered under quiet breathing conditions (5 L/min).

RESULTS

Both head direction and breathing mode can noticeably affect aerosol inhalability and lung delivery efficiency. A maximum of 20% difference in inhalability is observed among the three head positions. Facial-ocular depositions are predominantly influenced by head position, but not breathing mode. The facial-ocular deposition rate with the face-up position is about threefold that with the sitting position for 5-μm particles. Nasal breathing gives about 17.8% lower lung deposition and about 65% higher facial-ocular deposition than the oronasal breathing.

CONCLUSION

The face-side position has less facial-ocular deposition than the face-up position, while still achieving similar lung delivery efficiency. Because aerosols deposited around the eyes may cause irritation to the eyes, the face-side position appears to be a better option than the face-up position for comfort and safety reasons.

Deposition of small particles in the developing lung

Infancy is a time of marked and rapid changes in respiratory tract development. Infants (0-1 year of age) and young children (1- 3 years of age) are a unique subpopulation with regard to therapeutic aerosols. Anatomical, physiological and emotional factors, peculiar to these age groups, present significant challenges for aerosol delivery to the respiratory tract. Most studies with inhaled corticosteroids (ICS) have administered aerosols with relatively large particles, frequently > 3 μm in mass median aerodynamic diameter (MMAD). These drugs were designed for use in adults and older children and were administered with masks which were frequently rejected by children under age 3-4 years. We review the reasons that large-particle aerosols are likely to be less effective in infants and young children. We suggest that the benefit of inhaled medications in this age group requires further evaluation to determine if better therapeutic outcomes might be achieved using smaller particles and more patient-friendly delivery systems.

Guidelines for aerosol devices in infants, children and adults: which to choose, why and how to achieve effective aerosol therapy

Multiple types of aerosol devices are commonly used for the administration of medical aerosol therapy to patients with pulmonary diseases. All of these devices have been shown to be effective in trials where they are used correctly. However, failure to operate any of these devices properly has been associated with poor clinical response and limited patient adherence to therapy. Therefore, the selection of the best aerosol device for the individual patient is very important for optimizing the results of medical aerosol therapy. This article presents the rationale for selecting the most appropriate aerosol device to administer inhaled drugs in specific patient populations, with emphasis on patient-, drug-, device- and environment-related factors and with a comparison between the available devices. The following recommendations for the selection of the 'best' aerosol device for each patient population are intended to help clinicians gain a clear understanding of the specific issues and challenges so that they can optimize aerosol drug delivery and its therapeutic outcomes in patients.

Aerosol delivery to ventilated newborn infants: historical challenges and new directions

There are several aerosolized drugs which have been used in the treatment of neonatal respiratory illnesses, such as bronchodilators, diuretics, and surfactants. Preclinical in vitro and in vivo studies identified a number of variables that affect aerosol efficiency, including particle size, aerosol flows, nebulizer choice, and placement. Nevertheless, an optimized aerosol drug delivery system for mechanically ventilated infants still does not exist. Increasing interest in this form of drug delivery requires more controlled and focused research of drug/device combinations appropriate for the neonatal population. In the present article, we review the research that has been conducted thus far and discuss the next steps in developing the optimal aerosol delivery system for use in mechanically ventilated neonates.

Aerosol therapy in infants and toddlers: past, present and future

Infants and toddlers are a unique subpopulation with regard to aerosol therapy. There are various anatomical, physiological and emotional factors peculiar to this age group that present significant difficulties and challenges for aerosol delivery. Most studies on the factors determining lung deposition of therapeutic aerosols are based on data from adults or older children, which cannot simply be extrapolated directly to infants. The present review describes why infants/toddlers are very different with respect to two major issues - namely their anatomy/physiology and their behavior. We suggest possible solutions and future research directions aimed at improving clinical outcomes of aerosol therapy in this age group.

Factors that affect the efficacy of inhaled corticosteroids for infants and young children

Infants (0-1 years of age) and young children (1-3 years of age) are a unique subpopulation with regard to inhaled therapies. There are various anatomic, physiological, and emotional factors peculiar to this age group that present significant difficulties and challenges for aerosol delivery. Most studies of therapeutic aerosols that have been performed with patients of this age group, particularly recent studies with inhaled corticosteroids (ICSs), administered aerosols with relatively large particles (ie, >3 microm in mass median aerodynamic diameter). These drugs were designed for use in adults and older children and were administered with masks, which are frequently rejected by patients. Based on these studies, it was recently suggested that ICSs might not be as therapeutically effective in infants and young children as in adults. We review the reasons that large-particle corticosteroid aerosols are not likely to be effective in infants and young children. This patient population differs from adults in airway anatomy and physiology, as well as in behavior and adherence to therapy. We suggest that the benefit of ICSs in this age group requires further evaluation to determine whether better therapeutic outcomes might be achieved with smaller particles.

Inhaled corticosteroid therapy with nebulized beclometasone dipropionate

Inhaled corticosteroids (ICS) are the most effective anti-inflammatory agents for the management of chronic persistent asthma and are therefore recommended as first-line antiasthmatic therapy in children and adults. In various settings, the administration of ICS via nebulizer rather than hand-held inhaler (HHI) may have certain advantages, as many patients with HHI fail to use these devices properly or efficiently. In particular, young children, the elderly, the acutely ill, and those with restricted dexterity may be unable to coordinate inhalation with actuation of the device or to generate sufficient inspiratory flow to operate breath-actuated devices effectively. Compliance with nebulized therapy may also be better than that with a pressurized metered-dose inhaler (pMDI) plus spacer. Systematic reviews conclude that there is no significant difference in clinical effects between nebulizers and HHI. Performance and clinical effect of nebulization are influenced by several technical aspects such as the nebulizer-drug combination, nebulizer type, output and lung deposition. Among the currently available ICS, nebulized beclometasone dipropionate (BDP) has been in clinical use for more than 35 years, and has demonstrated marked clinical efficacy and a favorable tolerability profile in children and adults with chronic persistent asthma. The clinical efficacy of nebulized beclometasone is discussed in the present review using data from 13 published studies, which included a total of 1250 patients. Three multicenter, randomized, double-blind studies showed that nebulized BDP is as effective as BDP via pMDI plus spacer in a 2:1 dose ratio. Controlled trials involving 497 adults and children demonstrated similar clinical efficacy between nebulized BDP and either nebulized fluticasone propionate or nebulized budesonide. In all these trials, treatment-related adverse effects were generally uncommon, most were mild-to-moderate in severity, and most were associated with the respiratory system. Meta-analyses show that BDP, like other inhaled corticosteroids, has no major influence on patient height, urinary cortisol concentration, or bone metabolism, thus suggesting the absence of growth retardation or any marked effect on adrenal function or the hypothalamic-pituitary-adrenal axis when used in the approved dose range. Overall, nebulized BDP appears to have a particularly important place in asthma therapy: as a general alternative to HHIs (e.g. in patients with poor HHI compliance); when patients such as children or the elderly are unable to operate HHIs because of poor hand-lung coordination, lack of cooperation, or low inspiratory flow rate; and when high dosages of ICS are required, such as in adults with severe, corticosteroid-dependent asthma.

Medical treatment of lung collapse in children

This study was aimed to establish non-invasive (medical) treatment of lung collapse for children who are admitted to PICU of Tabriz Children's Hospital. During a period of 48 months (from March 2004 to February 2008), an interventional pre-experimental study carried out on 90 children suffering from lung collapse who received non-invasive treatment; which mainly consists of postural drainage, chest physiotherapy and inhalation of aerosols (fluid as floating droplets in air) and bronchodilators. Eighty six out of 90 studied patients (94.5%) with the average age of 22 months, responded to this treatment within the average duration of 3.4 days, as collapsed area of lung reexpanded. Because of simplicity and easy availability of this method of treatment and also its efficacy and scientific base; it can substitute bronchoscopic treatment and its usage be generalized to small hospitals.

Aerosol delivery of nebulised budesonide in young children with asthma

BACKGROUND

Lung deposition of inhaled steroids, likely to be of benefit in the anti-inflammatory treatment of asthma in young children, is low. This is explained by age specific anatomical and physiological characteristics as well as poor cooperation with aerosol therapy. However, total lung deposition and the ratio of lung deposition to oropharyngeal deposition are key determinants of clinical efficacy and of systemic side effects of aerosolized drugs.

OBJECTIVES

The aim of this study was to determine lung deposition and ratio of lung deposition to oropharyngeal deposition using a modified vibrating membrane nebuliser to deliver budesonide with a small particle size, taking into account the needs of young children.

PATIENTS AND METHODS

Ten asthmatic children (5 males), mean age 20.3 months (range 6-41 months) inhaled radiolabelled budesonide (MMD 2.6microm) through a modified vibrating membrane nebuliser (modified PARI e-Flow). Lung deposition expressed as a percentage of the emitted dose was measured using scintigraphy and the ratio of lung deposition to oropharyngeal deposition was calculated.

RESULTS

Mean lung deposition (SD) expressed as percentage of emitted dose and mean lung to oropharyngeal deposition ratio (SD) in quietly breathing children (n=5) and in children crying during inhalation were 48.6% (10.5) versus 20.0% (10.9), and 1.0 (0.3) versus 0.3 (0.2), respectively.

CONCLUSIONS

We have shown that by using an improved age-adjusted complementary combination of delivery device and drug formulation to deliver small particles, lung deposition and ratio of lung deposition to oropharyngeal deposition in young asthmatic children is highly improved. But the main factor limiting aerosol delivery in this age group remains cooperation.

Numerical investigation of aerosol deposition at the eyes when using a hood inhaler for infants--a 3D simulation

A numerical investigation of a hood inhaler is presented, aiming at the assessment of the amount of aerosol that reaches the eyes of the patient when administering medications with such a device. Using a hood for aerosol therapy for infants was already found to be effective and friendly to handle over the commonly used face mask. Using a hood device may adversely deliver unwanted medications to the eyes of the infant. The current study addresses the extent of aerosol deposition at the infant's eye zone. We describe the development and utilization of a numerical simulation for studying the transport and fate of the aerosol particles within a 3D realistic representation of the hood and the infant's head, with a focus on the eye zone. The governing equations were solved using the commercial software, FLUENT 6.1, which is based on the finite volume method. The computational domain was created using the GAMBIT package. The computational geometry was built separately for each configuration of the hood and the infant. It is shown that under optimal working conditions (i.e., when the infant's head is aligned to the funnel) the percentage of aerosol reaching the eye zone is 0.48%. However, when the funnel is tilted toward the eyes the amount of aerosol reaching the eyes zone is predicted to be 4.7%. In general, the results obtained in this study are in good agreement with available in vitro data. It can be concluded that using the hood for aerosol therapy results in minimal deposition at the infant's eye area.

Inhaled furosemide in hospitalized infants with viral bronchiolitis: a randomized, double-blind, placebo-controlled pilot study

OBJECTIVE

To evaluate the short and long-term clinical effects and the treatment-feasibility of inhaled-furosemide (IF) as compared with placebo via hood in hospitalized infants with viral-bronchiolitis (VB).

STUDY-DESIGN

A randomized, double-blind, placebo-controlled pilot-study was performed in previously healthy infants (0-12 months). Enrolled infants were randomized to receive either IF (2 mg/kg), or placebo nebulized by hood three times daily throughout the hospitalization. Clinical assessment (respiratory distress assessment instrument [RDAI]) was performed before, 30 and 60 min after the 1st daily inhalation. The short-term effects were evaluated by the RDAI, respiratory assessment change score (RACS) and oxygen requirement and the long-term effects by time to be weaned off oxygen, time to full enteral feeding, length of stay, and "ready to discharge" time.

RESULTS

Both groups (16 infants each) had comparable characteristics at study entry. Mean (+/-SD) age was 72 +/- 43 days, and 29/32 infants were RSV positive. Oxygen requirement (FiO(2)) decreased significantly at 30 min post-inhalation (30 +/- 9.2% to 26 +/- 7.1%, P < 0.05) only in the IF group. RACSs and long-term effects of both groups were comparable. Analysis of IF particles generated by the hood-nebulizer demonstrated that 36% and 49% of the particles were <3 and 5 microm, respectively. No side effects were observed during IF treatment.

CONCLUSION

Based on our pilot study, IF has no significant clinical effects in hospitalized infants with VB. IF via hood seems to be feasible and safe.

Guidelines for lung scintigraphy in children

The purpose of this set of guidelines is to help the nuclear medicine practitioner perform a good quality lung isotope scan. The indications for the test are summarised. The different radiopharmaceuticals used for the ventilation and the perfusion studies, the technique for their administration, the dosimetry, the acquisition of the images, the processing and the display of the images are discussed in detail. The issue of whether a perfusion-only lung scan is sufficient or whether a full ventilation-perfusion study is necessary is also addressed. The document contains a comprehensive list of references and some web site addresses which may be of further assistance.

Clinical Side Effects during Aerosol Therapy: Cutaneous and Ocular Effects

Aerosolized medications maximize clinical benefit by targeting the airways and minimize side effects by reducing (though not eliminating) systemic exposure. Aerosolized drugs delivered with a facemask may inadvertently deposit on the face and in the eyes, raising concerns about cutaneous and ocular side effects with these drugs. Cases of anisocoria have been reported from exposure of the eyes to aerosol bronchodilators. Whether inhaled corticosteroids (ICS) can cause skin and eye problems like those seen with systemic or topical steroids is more difficult to answer. Patients who take ICS may have other corticosteroid exposures, or have other conditions that predispose them to side effects, making the analysis of the ICS risk challenging. Also, many studies were not designed to search for cutaneous or ocular effects, or may have been too short to detect these effects. Nevertheless, ICS have been associated with an increased risk of skin thinning, bruising, cataracts and possibly glaucoma in adults, but not in children. The risks increase with advanced age, higher doses, and longer duration of use. In children, the risks of cataracts and glaucoma were negligible with ICS, whether a mouthpiece or a mask interface was used. Side effects like skin rash and conjunctivitis occurred at low frequencies similar to placebo or comparator drugs. We do not know whether exposed children will have increased risks from ICS later in life. Therefore, it is wise to avoid face and eye deposition when possible, and to use the minimally effective dose.

Nebulisers comparison with inhaled tobramycin in young children with cystic fibrosis

BACKGROUND

This randomised cross-over pilot study was undertaken in 10 cystic fibrosis children aged 10 to 63 months to describe lung absorption of tobramycin delivered by the PariLC+/PariTurboboyN (Pari GmbH) and the disposable NL9M/AtomisorBoxPlus (Diffusion Technique Française) nebulising systems.

METHODS

Each child inhaled 300 mg tobramycin delivered with one or the other apparatus via a facemask in two separate and standardised sessions. Urine was collected for 6 h. Tobramycin concentrations determined by immunoprecipitation were expressed in mg per g of creatinine and compared by a Wilcoxon test for matched pairs. The influences of age, weight and Brasfield score on this parameter were evaluated by correlation tests, and those of sex, previous nebulisation treatment, and crying or coughing were evaluated by Student's t-test.

RESULTS

The amount of tobramycin measured in urines was low and variable. Median values for urinary tobramycin concentration were 47.6 mg/g (14.9-79.6) with the PariLC+ and 42.6 mg/g (6.3-112.8) with the NL9M (p=0.6). PariLC+ delivered tobramycin in 22 min and NL9M in 12 min (p=0.005). Crying or coughing dramatically reduced the amount of tobramycin collected.

CONCLUSION

This pilot study shows that evaluation of nebulisers based on tobramycin renal excretion is feasible in young children with cystic fibrosis.

Administration of aerosolized drugs to infants by a hood: a three-dimensional numerical study

Using a hood for aerosol delivery to infants was found to be effective and user-friendly compared to the commonly used face mask. The currently available hood design has an even greater potential in terms of efficiency, and a numerical simulation can serve as a tool for its optimization. The present study describes the development and utilization of a numerical simulation for studying the transport and fate of the aerosol particles and the carrier gas within a three-dimensional realistic representation of the hood and the infant's head. The study further incorporates realistic breathing patterns, with a longer expiration phase than an inspiration phase. Both nose and mouth breathing are simulated. While the base case assumes that the funnel that delivers the aerosol within the hood is perpendicular to the infant's face, more realistic scenarios include a funnel that is slanted with respect to the infant face, the infant's head taking a general position with respect to the funnel, and the funnel and the head being both tilted. A good agreement is found between computation and experimental results. As expected, the most efficient drug delivery, 18%, is achieved when the funnel is normal to the infant's face. The quantitative evaluation of different scenarios presented in this work increases the knowledge of physicians, nurses, and parents regarding the efficacy of the treatment, in terms of the actual amount of drug inhaled under various modes of function of the device.

Hood versus mask nebulization in infants with evolving bronchopulmonary dysplasia in the neonatal intensive care unit

OBJECTIVE

To compare infants' discomfort, nursing-time and caregiver preference, and assess the clinical efficiency (as a secondary outcome) of hood versus facemask nebulization in infants with evolving bronchopulmonary dysplasia (BPD) in the neonatal intensive care unit.

STUDY DESIGN

A prospective, open, randomized, controlled crossover clinical trial. In total, 10 infants with BPD who were on inhaled beta-agonist bronchodilators and corticosteroids were randomly assigned to receive their nebulized treatments either by a facemask, or by a hood for 2-3 days, and then crossover to receive the same treatments with the other technique for another 2-3 days. Infants' discomfort, nursing-time, caregiver preference and clinical efficiency were compared.

RESULTS

At baseline there was no significant clinical difference between the groups. Nurse-time required for administering the hood nebulization (mean+/-s.e.m.: 1.9+/-0.1 min) was significantly shorter than the time for mask nebulization (12.0+/-0.6 min, P<0.0001). Infants' discomfort score was significantly lower (0.1+/-0.04) for hood versus mask nebulization (2.5+/-0.2, P<0.0001). Nurses and parents unequivocally preferred the hood treatment. During both mask and hood nebulization therapies (2-3 days) clinical efficiency was comparable. While both methods caused an immediate (20 min post) clinical improvement, the immediate respiratory assessment change score was significantly greater for the hood versus the mask nebulization (0.62+/-0.27 versus 0.13+/-0.14, P<0.05).

CONCLUSIONS

Nebulization of aerosolized medications in infants with evolving BPD by hood was less time-consuming for caregivers and was much better tolerated by the infants while being at least as effective as the conventional facemask nebulization.

Aerosol delivery in respiratory syncytial virus bronchiolitis: hood or face mask?

OBJECTIVES

To compare the utility of the hood versus the face mask for delivery of inhaled medications to infants hospitalized with viral bronchiolitis.

STUDY DESIGN

Randomized, double-blinded, controlled trial; 49 hospitalized infants with viral bronchiolitis, age 2.75 +/- 2.2 months (mean +/- SD), were grouped to either the hood (n = 25) or the mask (n = 24). Each subject received inhalation treatments with the use of both devices. Half of the Hood Group received the active drug treatment (1.5 mg epinephrine in 4 mL saline [3%]) via hood followed immediately by placebo treatment (normal saline) via mask, whereas the other half received the opposite order. Half of the Mask Group received the active drug treatment via mask followed immediately by placebo treatment via hood, whereas the other half received the opposite order. Therapy was repeated 3 times daily until discharge. Outcome measures included clinical scores and parental preference.

RESULTS

Percent improvement in clinical severity scores after inhalation was significant in both groups on days 1, 2, and 3 after admission (Hood Group: 15%, 15.4%, and 16.4%, respectively; Mask Group: 17.5%, 12.1%, and 12.7%, respectively; P < .001). No significant difference in clinical scores improvement between groups was observed. Eighty percent (39/49) of parents favored the hood over the mask; 18% (9/49) preferred the mask and 2% (1/49) were indifferent.

CONCLUSIONS

In infants hospitalized with viral bronchiolitis and in whom aerosol treatment is considered, aerosol delivery by hood is as effective as by mask. However, according to parents, the tolerability of the hood is significantly better than that of a mask.

[Nebulisation in childhood asthma]

The inhaled route way, which directly brings an appropriate amount of drug in the right place, is at the present time the recommended route for asthma treatments. The development of spacer devices, easier to use, has reduced the indications of nebulised treatments, but these are still essential in some situations. Nebulisation of short acting beta-2-agonists, which usually requires oxygen administration, is still the first line treatment of a severe acute asthma attack. Ipratropium bromide can be added in the nebulisation, depending on the severity of the attack and the response to beta-2-agonists. Sodium cromoglycate is not used in the prophylactic treatment of childhood asthma any more, but nebulised budesonide is still very useful in moderate to severe persistent asthma in children under 5 years of age, after failure of a treatment with a spacer device. The quality of nebulisation is fully dependent on the equipment used, and on the practical conditions of its realization. It is of most extreme importance to use a compressor/nebulizer couple which is validated for the delivered drug, and that the child breathes, depending on age, via a mouth peace or a facial mask.

Numerical simulation of air flow and medical-aerosol distribution in an innovative nebulizer hood

The use of a hood to administer therapeutic aerosols to wheezy infants has many advantages and was found as efficient as administration using a mask. The aim of the present study is to investigate numerically the airflow induced drug dispersion inside the hood. Drug droplet dispersion is examined with respect to three breathing phases: inspiration, expiration, and apnea. The governing equations describing the airflow and the trajectories of drug droplets were solved using the FLUENT 6.1 Computational Fluid Dynamics (CFD) software package. The geometry and mesh were generated with the GAMBIT package. The velocity field of the air and the trajectories of drug droplets inside the funnel--the tube that delivers the drug from the nebulizer to the infant's mouth--and close to its exit are robust and do not show any appreciable differences among the three breathing phases studied. However, in other parts of the hood, air velocity, and particle motion largely depend on the infant's breathing and physiological state. The efficiency of drug delivery to the mouth during inspiration is found to be as high as 84%, whereas it is much smaller in the other two (common) breathing phases examined. Our results may be utilized to improve the hood design and to increase its efficacy for administration of aerosolized medications to infants.

Factors guiding the choice of delivery device for inhaled corticosteroids in the long-term management of stable asthma and COPD: focus on budesonide

Inhaled corticosteroids (ICSs) have become the mainstay of chronic controller therapy to treat airways inflammation in asthma and to reduce exacerbations in chronic obstructive pulmonary disease. An array of ICSs are now available that are aerosolized by a range of delivery systems. Such devices include pressurized (or propellant) metered-dose inhalers (pMDIs), pMDIs plus valved holding chambers or spacers, breath-actuated inhalers, and nebulizers. More recently, dry-powder inhalers (DPIs) were developed to help overcome problems of hand-breath coordination associated with pMDIs. The clinical benefit of ICSs therapy is determined by a complex interplay between the nature and severity of the disease, the type of drug and its formulation, and characteristics of the delivery device together with the patient's ability to use the device correctly. The ICSs budesonide is available by pMDI, DPI, and nebulizer-allowing the physician to select the best device for each individual patient. Indeed, the availability of budesonide in three different delivery systems allows versatility for the prescribing physician and provides continuity of drug therapy for younger patients who may remain on the same ICSs as they mature.