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Allied Health: Articles of Interest Overview of best practice aerosol therapy for infants and young children Inhaled medications are the route of choice to treat asthma in all ages. Historically, nebulizers were the only available modality for infants and young children, limiting both the device and medications that could be delivered. The advent of mask chambers and a corticosteroid nebulizer solution have expanded our choices. Whatever device you prefer as a clinician, teaching the proper method and promoting best practice is essential for optimal treatment efficacy. Anatomy of this age group plays a major role in aerosol delivery. The airway diameter is smaller and respiratory rate is faster than adults and older children. Also, nose breathing filters out large particles, resulting in increased medication deposition in the upper airway. Children under the age of 5 can rarely use a mouthpiece for nebulizer therapy correctly. For these patients, a properly fitting mask is the alternative, properly being the operative word. Clinical response to treatments with a close-fitting mask as compared to a mouthpiece is essentially equivalent. To substantiate the need for a close fitting mask, evidence also exists showing that a loosely fitting mask considerably reduces available aerosol. Many times when the child does not tolerate a mask, practitioners employ the “blow-by” technique, which simply directs the aerosol towards the nose and mouth with the mouthpiece or reservoir tube. Although widely utilized, there is no data that suggests that this is an effective method. Aerosol deposition studies to date suggest that minimal, if any, drug actually enters the airways. It has also been noted that it is more effective to administer the aerosol with a close-fitting mask while the child is asleep. Another common misconception is that a crying child inhales more medication than a quietly breathing child. By definition, crying is a short, rapid inhalation following a long exhalation. Evidence suggests that crying completely prevents lower airway deposition in the distressed child. Therefore, every attempt should be made to keep the child as quiet as possible during aerosol therapy. Nebulizers Ultrasonic nebulizers create an aerosol by vibrations of a crystal at high frequency. Inhalation draws the aerosol into the lungs and during exhalation the medication remains in the nebulizer. Ultrasonic devices can be both electrically and battery operated. It does create a high-density aerosol that some asthmatics find irritating to the airway. Most importantly, some medications that are in a suspension (i.e. Pulmicort respules) should not be used with ultrasonic nebulization as the high frequency vibration may alter the medication’s structure, resulting in inadequate delivery. Normal, tidal breathing is the preferred method for infants. Quiet breathing is preferred for all. As children get older, ages 4-5, begin to encourage a slight breath hold at end inspiration to provide optimal medication delivery. Most children can begin to use a mouthpiece at approximately age 5, but always caution the parents to keep a mask available for treatments when the child may not be completely cooperative (i.e. middle of the night). Metered Dose Inhalers (MDIs) There are numerous valved holding chambers available with masks in a range of sizes. Children can usually empty these devices with 5 to 6 breaths. Following the specific manufacturer’s administration instructions will assure appropriate aerosol delivery. For infants it is imperative that the dead space in the mask (area between child’s mouth and the valve) is minimal and that the valve is responsive to extremely low flow rates. The mask material and fit must be comfortable to enhance patient acceptance. Again, at about age 5, most children begin to use a spacer with mouthpiece with the understanding that the mask should be kept available for times when administration is difficult (i.e during sleep). Once again, crying will decrease airway deposition and every effort should be made to keep the child calm. Appropriate education must be targeted to the parent first, and then the child. The parent must understand and accept the purpose and proper method, and if appropriate, should be given a choice in device as their comfort level will enhance child acceptance. Utilizing techniques and devices (Bubbles the Fish Aerosol Pediatric Mask or Devilbiss Pulmo-Aide Pediatric Dragon Mask) can help make the device less threatening. Proper positioning for comfort and reassurance is also important. Use of videos during administration (i.e. Baby Breaths from Asthma and Allergy Network Mothers of Asthmatics or any other video the child enjoys) can make treatment time not only most beneficial but enjoyable as well. |
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