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Neininger MP, Kaune A, Musiol J, Kiess W, Bertsche A, Prenzel F, Bertsche T. Handling Errors in the Use of Inhalation Devices: Inhalation Technique Skills and Knowledge in Pediatric Nurses. J Nurs Care Qual 2022; 37:180-187. [PMID: 34320513 DOI: 10.1097/ncq.0000000000000587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children suffering from bronchial diseases need assistance from nurses in the use of inhalation devices. PURPOSE We aimed to assess nurses' skills and knowledge concerning drug administration with inhalation devices in hospitalized pediatric patients. METHODS An expert panel defined medication errors in drug administration with inhalation devices in children. We monitored 241 inhalation procedures to investigate nurses' inhalation technique skills. Twenty-nine nurses completed a questionnaire to assess nurses' knowledge. RESULTS Skills: In 93 of 241 (39%) inhalation procedures, the mask/mouthpiece did not fit airtight. In none of the 11 inhalations administering a glucocorticoid, the patient's mouth was thoroughly cleaned afterward. Knowledge: Ten of 29 nurses (34%) thought a distance between mask and the patient's face was acceptable. Only 16 of 29 (55%) knew that it is necessary to thoroughly clean the patient's mouth after the inhalation of budesonide. CONCLUSIONS We found that education on inhalation procedures including practical training is required to increase patient safety.
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Affiliation(s)
- Martina Patrizia Neininger
- Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University and Drug Safety Center, Leipzig University and University Hospital, Leipzig, Germany (Drs Neininger and T. Bertsche and Mss Kaune and Musiol); University Hospital for Children and Adolescents, Center for Pediatric Research, Leipzig, Germany (Drs Kiess, A. Bertsche, and Prenzel); and Neuropediatrics, University Hospital for Children and Adolescents, Rostock, Germany (Dr A. Bertsche)
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Zeinali F, Mohammad Karimi N, Jafari M, Akbarzadeh Moghadam E. Rapid and Deep versus Normal Breathing in Salbutamol Inhalation Effectiveness; a Letter to Editor. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e42. [PMID: 34223187 PMCID: PMC8221548 DOI: 10.22037/aaem.v9i1.1122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Faeze Zeinali
- Emergency Medicine Department, Shahid Sadoughi Hospital ,Shahid sadoughi University of Medical Sciences, Yazd, Iran
| | - Naser Mohammad Karimi
- Emergency Medicine Department, Shahid Sadoughi Hospital ,Shahid sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohamadali Jafari
- Emergency Medicine Department, Shahid Sadoughi Hospital ,Shahid sadoughi University of Medical Sciences, Yazd, Iran
| | - Ebrahim Akbarzadeh Moghadam
- Emergency Medicine Department, Shahid Sadoughi Hospital ,Shahid sadoughi University of Medical Sciences, Yazd, Iran
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Ari A. A path to successful patient outcomes through aerosol drug delivery to children: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:593. [PMID: 33987291 PMCID: PMC8105845 DOI: 10.21037/atm-20-1682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/03/2020] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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4
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Csonka P, Tapiainen T, Mäkelä MJ, Lehtimäki L. Optimal administration of bronchodilators with valved holding chambers in preschool children: a review of literature. Eur J Pediatr 2021; 180:3101-3109. [PMID: 33877400 PMCID: PMC8055476 DOI: 10.1007/s00431-021-04074-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/06/2021] [Accepted: 04/08/2021] [Indexed: 11/30/2022]
Abstract
Our aim was to synthesize the published literature on factors that potentially affect the delivery of bronchodilators using valved holding chambers (VHC) in preschool children. We also aimed to identify those attributes that are not yet incorporated or clearly stated in the guidelines and those topics that are still lacking sufficient data. There is strong evidence supporting several recommendations in current guidelines. Based on present knowledge, bronchodilators should be delivered by VHC administering each puff separately. Face mask should be omitted as soon as the child can hold the mouthpiece of the VHC tightly between the lips and teeth. Based on the review, we suggest adding a specific note to current guidelines about the effect of chamber volume and the impact of co-operation during drug administration. Calming the child and securing a tight face-to-mask seal is critical for successful drug delivery. There is not enough evidence to make specific recommendations on the most reliable VHC and face mask for children. There is an urgent need for studies that evaluate and compare the effectiveness of VHCs in various clinical settings in wide age-groups and respiratory patterns. In addition, there is insufficient data on ideal chamber volume, material, and effective antistatic treatment. What is Known: • Valved holding chambers (VHC) should not be considered interchangeable when used with pressurized metered dose inhalers (pMDI). • Drug delivery is influenced by VHC volume, aerodynamic and electrostatic properties; mask fit; respiratory pattern and co-operation during inhalation; and the number of puffs actuated. What is New: • The impact of co-operation, VHC volume, and good mask-to-face fit during drug inhalation is not stressed enough in the guidelines. • Studies are urgently needed to evaluate the effectiveness of different VHCs in various clinical settings focusing on VHC electrostatic properties, respiratory patters, face masks, and ideal pMDI+VHC combinations.
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Affiliation(s)
- Péter Csonka
- Centre for Child Health Research, Tampere University and Tampere University Hospital, Kalevantie 4, 33014 Tampereen yliopisto, Tampere, Finland. .,Terveystalo Healthcare, Tampere, Finland.
| | - Terhi Tapiainen
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital and PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Mika J. Mäkelä
- Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland ,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Csonka P, Lehtimäki L. Antistatic treatment and salbutamol dosing have variable effect on drug delivery of valved holding chambers. Pulm Pharmacol Ther 2019; 59:101857. [DOI: 10.1016/j.pupt.2019.101857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/26/2019] [Accepted: 10/27/2019] [Indexed: 11/28/2022]
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6
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Csonka P, Lehtimäki L. In vitro drug delivery performance of five valved holding chambers with and without facemasks. Pediatr Pulmonol 2019; 54:1457-1465. [PMID: 31254459 DOI: 10.1002/ppul.24425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/11/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Valved holding chambers (VHCs) are essential for efficient pulmonary delivery of inhaled medication in preschool children. The numerous devices in the market vary in material, aerodynamic characteristics, volume, valve properties, and mask design. Drug delivery is affected by the VHC characteristics as well as by the age and breathing pattern of the child. METHODS We measured the drug delivery efficacy of five VHCs widely available in the market, evaluated the effect of facemasks and tested the differences between manufacturing lots. A breathing simulator was used to mimic normal (respiratory rate [RR] 25/minute and tidal volume (VT ) 200 mL) and obstructive (RR 50/minute and VT 50 mL) breathing of infants and toddlers. RESULTS Salbutamol output was significantly higher with a normal breathing pattern compared to the obstructive breathing pattern in most VHCs. Without masks, the differences in the median in vitro filter doses of salbutamol were mainly from 2 to 10-fold among different types of VHCs. With masks, there was a greater than 20-fold difference in drug delivery capacity between the most and least effective devices. Most VHCs had a notable variation of performance between individual devices from different lots within the same brand. CONCLUSIONS There was an extreme variation in the salbutamol delivery performance among different types of VHCs for both normal and obstructive pediatric breathing patterns with and without masks. This magnitude of performance variability can have significant and unpredictable clinical implications.
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Affiliation(s)
- Péter Csonka
- Centre for Child Health Research, Tampere University and Tampere University Hospital, Tampere, Finland.,Terveystalo Healthcare Oy, Tampere, Finland
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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7
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Csonka P, Lehtimäki L. Valved holding chamber drug delivery is dependent on breathing pattern and device design. ERJ Open Res 2019; 5:00158-2018. [PMID: 30740461 PMCID: PMC6360210 DOI: 10.1183/23120541.00158-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/28/2018] [Indexed: 11/06/2022] Open
Abstract
Small children with airway obstruction breathe with very low tidal volumes (VT) and high respiratory rates (RRs). These extreme respiratory patterns affect drug delivery unpredictably through valved holding chambers (VHCs). We compared in an in vitro study the effectiveness of two VHCs, one small (140 mL, Optichamber Diamond) and one large (350 mL, Babyhaler) without facemasks, to deliver salbutamol to filters positioned between the VHC mouthpieces and a breathing simulator. Different tidal volumes (from 30 mL to 200 mL) and RRs (25·min-1 and 50·min-1) were applied through a breathing simulator. The amount of salbutamol delivered increased with increasing VT in both VHCs for both RRs (ρ>0.87 and p<0.001 for both devices at both rates). The effect of RR was not as evident, but drug delivery tended to be higher at the higher rate. Drug delivery was significantly higher through the Optichamber Diamond as compared with the Babyhaler at every combination of RR and VT up to a 12-fold difference. We found marked differences in salbutamol delivery between the Babyhaler and Optichamber Diamond VHCs. The delivered dose of salbutamol increased with increasing VT and RR with both VHCs but with differences related to valve dead spaces. Instead of considering all VHCs equal in clinical paediatric practice, each device should be tested in vitro with respiratory patterns relevant to small children with respiratory difficulties. Children with respiratory problems are treated with inhaled drugs given via valved holding chambers (VHCs). Efficacy can vary up to 12-fold between devices. The effectiveness of VHCs should be tested in all age groups with different respiratory patterns.http://ow.ly/2Aca30mT2Pa
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Affiliation(s)
- Péter Csonka
- Centre for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.,Terveystalo Healthcare Oy, Tampere, Finland
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Vincken W, Levy ML, Scullion J, Usmani OS, Dekhuijzen PNR, Corrigan CJ. Spacer devices for inhaled therapy: why use them, and how? ERJ Open Res 2018; 4:00065-2018. [PMID: 29928649 PMCID: PMC6004521 DOI: 10.1183/23120541.00065-2018] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/18/2018] [Indexed: 11/05/2022] Open
Abstract
We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.
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Affiliation(s)
- Walter Vincken
- Respiratory Division, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | | - Chris J Corrigan
- Faculty of Life Sciences and Medicine, King's College London/Guy's and St Thomas's NHS Foundation Trust, London, UK
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Berlinski A, von Hollen D, Hatley RHM, Hardaker LEA, Nikander K. Drug Delivery in Asthmatic Children Following Coordinated and Uncoordinated Inhalation Maneuvers: A Randomized Crossover Trial. J Aerosol Med Pulm Drug Deliv 2016; 30:182-189. [PMID: 27977309 DOI: 10.1089/jamp.2016.1337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Valved holding chambers (VHCs) are used in children to deliver pressurized metered dose inhalers (pMDI). In vitro data suggest that uncoordinated use decreases the amount of drug available for inhalation. We hypothesize that in an ex vivo study, the coordinated maneuver will deliver more drug than the uncoordinated one. PATIENTS AND METHODS Thirty-two clinically stable asthmatic children, ages 5-8 years, completed the study. An aerosol filter was interposed between a small-volume nonelectrostatic VHC and a mouthpiece to capture the drug emitted by one puff of Flovent® 220 mcg during tidal breathing. Inhalation and actuation parameters were measured by an electronic monitor, and the number of breaths required to empty the VHC was calculated. Subjects completed three coordinated and three uncoordinated (actuation at the beginning of inhalation and exhalation, respectively) runs in random order. Drug content from the filter and VHC was measured by high-performance liquid chromatography and expressed as percentage of emitted dose. RESULTS [mean (99% confidence interval)] Filter dose was higher during coordinated technique 46% (43%-50%) than during uncoordinated technique 41% (37%-44%) (p < 0.001). Peak inspiratory flow and tidal volume were 23.2 L/min (21.3-25.1 L/min) and 281 mL (251-311 mL), respectively. Subjects required three breaths to empty the VHC in 96% of the tests. CONCLUSIONS Actuating the pMDI into a small-volume nonelectrostatic VHC during exhalation reduced by 11% the amount of fluticasone captured at the exit of the VHC. Asthmatic children (5-8 years old) need three or less breaths to empty the small-volume VHC (NCT01714063).
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Affiliation(s)
- Ariel Berlinski
- 1 Pulmonology Section, Department of Pediatrics, UAMS/COM , Pediatric Aerosol Research Laboratory, Little Rock, Arkansas
| | - Dirk von Hollen
- 2 Respironics, Inc. , a Philips Healthcare Company, Murrysville, Pennsylvania
| | - Ross H M Hatley
- 3 Respironics Respiratory Drug Delivery (UK) Ltd , a Business of Philips Electronics UK Ltd, Chichester, United Kingdom
| | - Lucy E A Hardaker
- 3 Respironics Respiratory Drug Delivery (UK) Ltd , a Business of Philips Electronics UK Ltd, Chichester, United Kingdom
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10
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Mitchell JP, Suggett J, Nagel M. Clinically Relevant In Vitro Testing of Orally Inhaled Products-Bridging the Gap Between the Lab and the Patient. AAPS PharmSciTech 2016; 17:787-804. [PMID: 27173990 DOI: 10.1208/s12249-016-0543-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 04/26/2016] [Indexed: 11/30/2022] Open
Abstract
Current pharmacopeial methods for in vitro orally inhaled product (OIP) performance testing were developed primarily to support requirements for drug product registration and quality control. In addition, separate clinical studies are undertaken in order to quantify safety and efficacy in the hands of the patient. However, both laboratory and clinical studies are time-consuming and expensive and generally do not investigate either the effects of misuse or the severity of the respiratory disease being treated. The following modifications to laboratory evaluation methodologies can be incorporated without difficulty to provide a better linkage from in vitro testing to clinical reality: (1) examine all types of OIP with patient-representative breathing profiles which represent normal inhaler operation in accordance with the instructions for use (IFU); (2) evaluate OIP misuse, prioritizing the importance of such testing on the basis of (a) probability of occurrence and (b) consequential impact in terms of drug delivery in accordance with the label claim; and (3) use age-appropriate patient-simulated face and upper airway models for the evaluation of OIPs with a facemask. Although it is not necessarily foreseen that these suggestions would form part of future routine quality control testing of inhalers, they should provide a closer approximation to the clinical setting and therefore be useful in the preparation for in vivo studies and in improving guidance for correct use.
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11
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Shaw N, Le Souëf P, Turkovic L, McCahon L, Kicic A, Sly PD, Devadason S, Schultz A. Pressurised metered dose inhaler-spacer technique in young children improves with video instruction. Eur J Pediatr 2016; 175:1007-12. [PMID: 27251668 DOI: 10.1007/s00431-016-2738-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/16/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
Abstract
UNLABELLED The importance of good device technique to maximise delivery of aerosolised medications is widely recognised. Pressurised metered dose inhaler (pMDI)-spacer technique was investigated in 122 children, aged 2-7 years, with asthma. Eight individual steps of device technique were evaluated before and after viewing an instructional video for correct device technique. Video measurements were repeated every three months for nine months. Device technique improved directly after video instruction at the baseline study visit (p < 0.001) but had no immediate effect at subsequent visits. Additionally, pMDI-spacer technique improved with successive visits over one year for the group overall as evidenced by increases in the proportion of children scoring maximal (p = 0.02) and near-maximal (p = 0.04) scores. CONCLUSION Repeated video instruction over time improves inhaler technique in young children. WHAT IS KNOWN • Correct device technique is considered essential for sufficient delivery of inhaled medication. • Poor inhaler use is common in young asthmatic children using pressurised metered dose inhalers and spacers. What is New: • Video instruction could be used as a strategy to improve device technique in young children.
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Affiliation(s)
- Nicole Shaw
- Clinical Sciences, Telethon Kids Institute, Subiaco, Western Australia, Australia, 6008
| | - Peter Le Souëf
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia, 6008.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia, 6009
| | - Lidija Turkovic
- Clinical Sciences, Telethon Kids Institute, Subiaco, Western Australia, Australia, 6008
| | - Lucy McCahon
- Clinical Sciences, Telethon Kids Institute, Subiaco, Western Australia, Australia, 6008
| | - Anthony Kicic
- Clinical Sciences, Telethon Kids Institute, Subiaco, Western Australia, Australia, 6008.,Department of Respiratory Medicine, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia, 6008.,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia, 6009.,Centre for Cell Therapy and Regenerative Medicine, The University of Western Australia and Harry Perkins Institute, Nedlands, Western Australia, Australia, 6009
| | - Peter D Sly
- Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia, 4029
| | - Sunalene Devadason
- School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia, 6009
| | - André Schultz
- Clinical Sciences, Telethon Kids Institute, Subiaco, Western Australia, Australia, 6008. .,Department of Respiratory Medicine, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia, 6008. .,School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia, 6009.
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12
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Nikander K, Nicholls C, Denyer J, Pritchard J. The evolution of spacers and valved holding chambers. J Aerosol Med Pulm Drug Deliv 2015; 27 Suppl 1:S4-23. [PMID: 25054481 DOI: 10.1089/jamp.2013.1076] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Spacers and valved holding chambers (VHCs) are pressurized metered dose inhaler (pMDI) accessory devices, designed to overcome problems that patients commonly experience when administering aerosol via a pMDI. Spacers were developed in direct response to patient-related issues with pMDI technique, particularly, poor coordination between actuation and inhalation, and local side-effects arising from oropharyngeal deposition. Current clinical guidelines indicate the need for widespread prescription and use of spacers, but, despite their apparent ubiquity, the devices themselves are, unfortunately, all too commonly "disused" by patients. An understanding of the background from which spacers developed, and the key factors influencing the optimization of the spacer and the later VHC, is crucial to developing an appreciation of the potential of these devices, both contemporary and future, for improving the delivery of pressurized aerosols to patients. This review, informed by a full patent search and an extensive scientific literature review, takes into account the clinical and laboratory evidence, commercial developments, and the sometimes serendipitous details of scientific anecdotes to form a comprehensive perspective on the evolution of spacers, from their origins, in the early days of the pMDI, up to the present day.
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13
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Minh KT, von Hollen D, von Königslöw AJ, Nikander K, Janssens HM. An instrumented valved holding chamber with facemask to measure application forces and flow in young asthmatic children. J Aerosol Med Pulm Drug Deliv 2015; 27 Suppl 1:S55-62. [PMID: 25054482 DOI: 10.1089/jamp.2014.1129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pressurized metered dose inhalers (pMDIs), combined with a valved holding chamber (VHC) and facemask, are often used for young asthmatic children. When using a VHC with facemask, a tight seal between the facemask and the patient's face is crucial for efficient pulmonary aerosol delivery. Realistic parameters for in vitro bench testing are not well known. A custom instrumented OptiChamber Diamond VHC, known as the Facemask Datalogger, was developed to measure the real-time application of force and the air flow through the VHC and facemask. METHODS Thirty asthmatic children aged 1-4 years from the Kinderhaven outpatient clinic, who were prescribed a pMDI/VHC with facemask for regular use, were included in the study. Using the Facemask Datalogger, the parent applied the facemask to the face of the child during normal tidal breathing, and force and flow were recorded. This was repeated three times. A video of the procedure was made and scored on cooperation (scale of 1-5). RESULTS Mean application force was 4 N (± 1.5) equal to 411 g (± 156) when expressed as a weight equivalent; intrasubject variability in application force was 23% (± 23); intersubject variability in application force was 39%; time needed to empty the VHC was 4.5 sec (± 2.9); breaths needed to empty the VHC were 2.9 (± 1.1); and mean cooperation score was 4.3 (± 0.8). Age was correlated with time (r=-0.49; p=0.006) and breaths needed to empty the VHC (r=-0.75; p<0.001), and observer cooperation score (r=0.65; p<0.001). CONCLUSIONS The Facemask Datalogger is useful for measuring application force and air flow in vivo. Mean application force was lower than assumed in other studies. Older children emptied the VHC faster, with fewer breaths and better cooperation. The data from this study can be used in the future development and testing of new facemasks and VHCs.
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Affiliation(s)
- Kirby Tong Minh
- 1 Department of Pediatric Pulmonology, Erasmus Medical Center/Sophia Children's Hospital and Kinderhaven/Havenziekenhuis , Rotterdam, The Netherlands
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14
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Amirav I, Borojeni AAT, Halamish A, Newhouse MT, Golshahi L. Nasal versus oral aerosol delivery to the "lungs" in infants and toddlers. Pediatr Pulmonol 2015; 50:276-283. [PMID: 24482309 DOI: 10.1002/ppul.22999] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 01/05/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The oral route has been considered superior to the nasal route for aerosol delivery to the lower respiratory tract (LRT) in adults and children. However, there are no data comparing aerosol delivery via the oral and nasal routes in infants. The aim of this study was to compare nasal and oral delivery of aerosol in anatomically correct replicas of infants' faces containing both nasal and oral upper airways. METHODS Three CT-derived upper respiratory tract ("URT") replicas representing infants/toddlers aged 5, 14 and 20 months were studied and aerosol delivery to the "lower respiratory tract" (LRT) by either the oral or nasal route for each of the replicas was measured at the "tracheal" opening. A radio-labeled (99mDTPA) normal saline solution aerosol was generated by a soft-mist inhaler (SMIRespimat® Boehringer Ingelheim, Germany) and aerosol was delivered via a valved holding chamber (Respichamber® TMI, London, Canada) and an air-tight mask (Unomedical, Inc., McAllen, TX). A breath simulator was connected to the replicas and an absolute filter at the "tracheal" opening captured the aerosol representing "LRT" dose. Age-appropriate mask dimensions and breathing patterns were employed for each of the airway replicas. Two different tidal volumes (Vt ) were used for comparing the nasal versus oral routes. RESULTS Nasal delivery to the LRT exceeded that of oral delivery in the 5- and 14-month models and was equivalent in the 20-month model. Differences between nasal and oral delivery diminished with "age"/size. Similar findings were observed with lower and higher tidal volumes (Vt ). CONCLUSION Nasal breathing for aerosol delivery to the "LRT" is similar to, or more efficient than, mouth breathing in infant/toddler models, contrary to what is observed in older children and adults. Pediatr Pulmonol. 2015; 50:276-283. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Israel Amirav
- Pediatric Department, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada.,University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Michael T Newhouse
- Firestone Institute for Respiratory Health, St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
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15
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van Aalderen WM, Garcia-Marcos L, Gappa M, Lenney W, Pedersen S, Dekhuijzen R, Price D. How to match the optimal currently available inhaler device to an individual child with asthma or recurrent wheeze. NPJ Prim Care Respir Med 2015; 25:14088. [PMID: 25568979 PMCID: PMC4532150 DOI: 10.1038/npjpcrm.2014.88] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/22/2014] [Accepted: 08/24/2014] [Indexed: 12/05/2022] Open
Abstract
Inhaled medications are the cornerstone of treatment in early childhood wheezing and paediatric asthma. A match between patient and device and a correct inhalation technique are crucial for good asthma control. The aim of this paper is to propose an inhaler strategy that will facilitate an inhaler choice most likely to benefit different groups of children. The main focus will be on pressurised metered dose inhalers and dry powder inhalers. In this paper we will discuss (1) practical difficulties with the devices and with inhaled therapy and (2) the optimal location for deposition of medicines in the lungs, and (3) we will propose a practical and easy way to make the best match between the inhaler device and the individual patient. We hope that this paper will contribute to an increased likelihood of treatment success and improved adherence to therapy.
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Affiliation(s)
- Wim M van Aalderen
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children’s Hospital AMC, Amsterdam, The Netherlands
| | | | - Monika Gappa
- Department of Pediatrics, Marine Hospital gGmbH Wesel, Wesel, Germany
| | - Warren Lenney
- University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Søren Pedersen
- University of Southern Denmark, Paediatric Research Unit, Kolding Hospital, Kolding, Denmark
| | - Richard Dekhuijzen
- Department of Pulmonary Diseases (454), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - David Price
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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16
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Pooled analysis of tiotropium Respimat® pharmacokinetics in cystic fibrosis. Pulm Pharmacol Ther 2014; 29:217-23. [DOI: 10.1016/j.pupt.2014.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 08/12/2014] [Accepted: 08/15/2014] [Indexed: 11/22/2022]
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17
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Chawes BL, Govoni M, Kreiner-Møller E, Vissing NH, Poorisrisak P, Mortensen L, Nilsson E, Bisgaard A, Dossing A, Deleuran M, Skytt NL, Samandari N, Piccinno A, Sergio F, Ciurlia G, Poli G, Acerbi D, Singh D, Bisgaard H. Systemic exposure to inhaled beclometasone/formoterol DPI is age and body size dependent. Respir Med 2014; 108:1108-16. [PMID: 24993817 DOI: 10.1016/j.rmed.2014.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 05/05/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
Abstract
AIM Prescription of inhaled corticosteroids to children with asthma is recommended at half the nominal dose of adults in order to reduce the risk of systemic side effects. However, there is a lack of pharmacokinetic trials supporting such dose reduction regimens. Therefore, we aimed to compare the systemic exposure to the active ingredients of a fixed dose combination of beclometasone-dipropionate (BDP) and formoterol after dry powder inhaler (DPI) administration in children, adolescents and adults. METHODS The pharmacokinetic profiles of formoterol and beclometasone-17-monopropionate (B17MP; active metabolite of BDP) were evaluated over 8 h from two independent studies comprising children (6-11yrs, n = 27), adolescents (12-17 yrs, n = 28) and adults (≥18 yrs, n = 30) receiving a single, fixed dose of BDP/formoterol (children: 200 μg/24 μg, adolescents and adults: 400 μg/24 μg) via DPI. RESULTS The systemic exposure (AUC) for children versus adults was almost doubled for formoterol and similar for B17MP despite the halved BDP dose administered in children. In adolescents the AUC for formoterol and B17MP were approximately one third higher than in adults for both compounds. Upon normalization for the BDP/formoterol dose in the three populations the AUC and peak concentration (C(max)) correlated inversely with age and body surface area of the patients (r ≤ -0.53; p < 0.0001). CONCLUSION The systemic exposure to the active ingredients of BDP/formoterol administered as DPI correlates inversely with age and body size suggesting that dry powder dosage regimens should be adjusted for age and body size to avoid high systemic drug levels in children.
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Affiliation(s)
- B L Chawes
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark.
| | - M Govoni
- Department of Clinical Pharmacology, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - E Kreiner-Møller
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - N H Vissing
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - P Poorisrisak
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - L Mortensen
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - E Nilsson
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - A Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - A Dossing
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - M Deleuran
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - N L Skytt
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - N Samandari
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark
| | - A Piccinno
- Department of Clinical Pharmacology, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - F Sergio
- Department of Clinical Pharmacology, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - G Ciurlia
- Department of Clinical Pharmacology, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - G Poli
- Department of Clinical Pharmacology, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - D Acerbi
- Department of Clinical Pharmacology, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - D Singh
- University of Manchester, The Medicines Evaluation Unit, Manchester, United Kingdom
| | - H Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood, Health Sciences, University of Copenhagen & Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Denmark.
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Pörksen G, Kopp M. Inhalationstherapie bei Atemwegserkrankungen im Kindesalter. Monatsschr Kinderheilkd 2014. [DOI: 10.1007/s00112-013-3076-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Amirav I, Newhouse MT, Luder A, Halamish A, Omar H, Gorenberg M. Feasibility of aerosol drug delivery to sleeping infants: a prospective observational study. BMJ Open 2014; 4:e004124. [PMID: 24670428 PMCID: PMC3975762 DOI: 10.1136/bmjopen-2013-004124] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Israel Amirav
- Pediatric Department,Ziv Medical Center, Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Pediatric Department, University of Alberta, Edmonton, Canada
| | | | - Anthony Luder
- Pediatric Department,Ziv Medical Center, Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Asaf Halamish
- Nuclear Medicine Department, Ziv Medical Center, Safed, Israel
| | - Hamza Omar
- Firestone Institute for Respiratory Health, St Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Miguel Gorenberg
- Firestone Institute for Respiratory Health, St Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
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Slator L, von Hollen D, Sandell D, Hatley RHM. In vitro comparison of the effect of inhalation delay and flow rate on the emitted dose from three valved holding chambers. J Aerosol Med Pulm Drug Deliv 2014; 27 Suppl 1:S37-43. [PMID: 24476047 DOI: 10.1089/jamp.2013.1061] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Valved holding chambers (VHCs) are accessory devices for pressurized metered dose inhalers (pMDIs). Use of a VHC may help overcome coordination issues associated with drug delivery via the pMDI alone. Previous work has established that aspects of VHC use, including the time between actuation and inhalation (inhalation delay) and inhalation flow rate, can influence the amount of drug available to inhalation. This study compared the impact of inhalation delay and flow rate on the in vitro delivery of aerosol from different VHC brands. METHODS A custom-built inhalation delay test rig, which enabled automation of controlled inhalation delays (0, 5, or 10 sec), was developed. Extraction air flow was set to 5, 15, or 30 L/min. Delivery of albuterol (ProAir HFA 90 μg) to a filter (emitted dose) was assessed using three commercially available VHC brands (one conventional, two antistatic). Emitted dose under 27 different combinations of inhalation delay, flow rate, and VHC brand was determined in order to assess the effects of inhalation delay and flow rate. Pairwise comparisons of the different VHC brands with different inhalation delay/flow rate combinations were conducted to assess in vitro equivalence. RESULTS Emitted dose increased with flow rate and decreased with longer inhalation delays. Dependence on flow rate was similar for the two antistatic VHCs and more pronounced for the conventional VHC. The two antistatic VHCs showed equivalent results for the emitted dose of albuterol, across a range of flow rates and using different inhalation delays; the relation between the two antistatic VHCs fell within the ± 15% acceptance interval criteria for in vitro equivalence. CONCLUSIONS The different inhalation delays and flow rates had similar effects on the delivery of drug via the three VHCs. The two antistatic VHCs were shown to be equivalent in vitro in terms of emitted dose of albuterol.
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Affiliation(s)
- Lois Slator
- 1 Respironics Respiratory Drug Delivery (UK) Ltd. , a business of Philips Electronics UK Limited, Chichester, West Sussex, UK
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Abstract
The principal aims of asthma management in childhood are to obtain symptom control that allows individuals to engage in unrestricted physical activities and to normalize lung function. These aims should be achieved using the fewest possible medications. Ensuring a correct diagnosis is the first priority. The mainstay of asthma management remains pharmacotherapy. Various treatment options are discussed. Asthma monitoring includes the regular assessment of asthma severity and asthma control, which then informs decisions regarding the stepping up or stepping down of therapy. Delivery systems and devices for inhaled therapy are discussed, as are the factors influencing adherence to prescribed treatment. The role of the pediatric health care provider is to establish a functional partnership with the child and their family in order to minimize the impact of asthma symptoms and exacerbations during childhood.
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Affiliation(s)
- André Schultz
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Australia
- Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Perth, Australia
| | - Andrew C. Martin
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
- Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Perth, Australia
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Goncalves TM, Alhanout K, Nicolay A, Dubus JC, de Santana DP, Andrieu V. Comparative in vitro performance of three small-volume valved holding chambers with beclomethasone/formoterol pressurized metered dose inhaler. J Aerosol Med Pulm Drug Deliv 2012; 26:223-7. [PMID: 23094686 DOI: 10.1089/jamp.2011.0952] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of valved holding chambers (VHCs) with pressurized metered dose inhalers (pMDIs) is reported to reduce the oral deposition of inhaled drugs and to facilitate the handling of these devices by patients, especially children. Although the number of commercially available VHCs is increasing, the correct choice of VHC in clinical practice is important, because VHCs are not equally effective regarding medication delivery. Hence, we aimed to evaluate the use of three small-volume VHCs-Vortex(®), AeroChamber(®) Plus (ACP), and Able Spacer™ (AS)-along with a commercial pMDI containing a combination of beclomethasone and formoterol (Innovair(®)) frequently used by asthma patients. METHODS Evaluation of the delivered dose of both drugs and analysis of particle size distribution of aerosols emitted for the inhaler were performed using the Next Generation Impactor with and without the tested VHCs. RESULTS The VHCs retained significant quantities of both drugs and dramatically reduced the quantity of drugs deposited in the throat of the impactor, indicating that particles with large size were preferably retained in the VHCs. Interestingly, although the delivered dose of both drugs was reduced by the use of VHCs, the use of the Vortex and the ACP resulted in comparable fine particle doses (FPDs) to that obtained when the pMDI was used alone, whereas the AS VHC significantly reduced the FPDs of both drugs. This may be due to the fact that, unlike the AS VHC, the Vortex and the ACP VHCs are made of antistatic materials that minimize the electrostatic interaction with emitted aerosols, enhancing medication delivery. CONCLUSION The Vortex and the ACP VHCs present interesting advantages over the AS VHC to be used with Innovair pMDI. However, these results are based on an in vitro evaluation and need to be validated in an in vivo study in order to clinically assess the performance of these VHCs.
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Affiliation(s)
- Talita Mota Goncalves
- Aix Marseille Université, Laboratoire de Pharmacie Galénique Industrielle et Cosmétologie, Faculté de Pharmacie, 13385 Marseille, France
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Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med 2012; 107:37-46. [PMID: 23098685 DOI: 10.1016/j.rmed.2012.09.017] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 09/20/2012] [Accepted: 09/26/2012] [Indexed: 11/24/2022]
Abstract
Whilst the inhaled route is the first line administration method in the management of asthma, it is well documented that patients can have problems adopting the correct inhaler technique and thus receiving adequate medication. This applies equally to metered dose inhalers and dry powder inhalers and leads to poor disease control and increased healthcare costs. Reviews have highlighted these problems and the recent European Consensus Statement developed a call to action to seek solutions. This review takes forward the challenge of inhaler competence by highlighting the issues and suggesting potential solutions to these problems. The opportunity for technological innovation and educational interventions to reduce errors is highlighted, as well as the specific challenges faced by children. This review is intended as a policy document, as most issues faced by patients have not changed for half a century, and this situation should not be allowed to continue any longer. Future direction with respect to research, policy needs and practice, together with education requirements in inhaler technique are described.
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