NEBULIZATION.pptx, anesthesia, pediatric

nebulization

1. NEBULIZATION DR G SHYLAKAR REDDY MD

2.  a  nebulizer  (or  nebuliser )  is a  drug delivery device  used to administer medication in the form of a mist inhaled into the lungs. Nebulization is means of administering drugs by inhalation. Equalizer breaks up the solution to be inhaled into fine droplets which are then suspended in a stream of gas.

3. A chamber into which the dilute drug is poured. A gas (usually oxygen) is then driven through the nebulizer and the drug is forced through a narrow jet. This aerosolizes the drug so that the normal ventilation gases can carry the drug to the patient.

4. 4 Definition of an aerosol Aero air Sol solution Liquid or solid suspensions into gas medium Particles which are sufficiently small so as to remain airborne for a considerable period of time

5. 5 Why Inhalation Therapy? Targeted delivery of medication to the lungs Rapid onset of action Smaller doses Less systemic and GI adverse effects Relatively comfortable

6. 6 Oropharynx absorbtion Lung absorbtion Vena porta Hepatic inactivation Gastrointestinal absorbtion SYSTEMIC CIRCULATION Urine elimination first pass effect PHARMACOKINETICS OF INHALED DRUGS

7. Nebulizers use  oxygen ,  compressed air  or  ultrasonic  power to break up medical solutions and suspensions into small  aerosol  droplets that can be directly inhaled from the mouthpiece of the device. The definition of an aerosol is a "mixture of gas and liquid particles," and the best example of a naturally occurring aerosol is  mist , Which is formed when small vaporized water particles mixed with hot ambient air are cooled down and condense into a fine cloud of visible airborne water droplets

8. history The first "powered" or pressurized inhaler was invented in France by Sales- Girons in 1858. This device used pressure to atomize the liquid medication. The pump handle is operated like a bicycle pump. When the pump is pulled up, it draws liquid from the reservoir, and upon the force of the user's hand, the liquid is pressurized through an atomizer, to be sprayed out for inhalation near the user's mouth . The first electrical nebulizer was invented in the 1930s and called a Pneumostat n 1956, a technology competing against the nebulizer was launched by Riker Laboratories , in the form of pressurized  metered-dose inhalers ,  .  

9. In 1964, a new type of electronic nebulizer was introduced: the "ultrasonic wave nebulizer ".  Today the nebulizing technology is not only used for medical purposes. Ultrasonic wave nebulizers are also used in  humidifiers , to spray out water aerosols to moisten dry air in buildings.

10. The lung deposition characteristics and efficacy of an aerosol depend largely on the particle or droplet size. Generally, the smaller the particle the greater its chance of peripheral penetration and retention. However, for very fine particles below 0.5 µm in diameter there is a chance of avoiding deposition altogether and being exhaled. 

11. 13 Deposition of particles > 5 µ impaction 1-5 µ sedimentation < 1 µ like gas

12. Indications of Nebulization : - 1) Delivery of bronchodilator drugs : - On acute attack of asthma Nebulization is the most common means of delivery. Respiratory patients who are too short of breath to use pressurized aerosol or Rota haler effectively may be prescribed bronchodilators.

13. 2) Infants and children with asthma : - Inhalation by nebulizer is the only means of effective inhalation therapy until a child is about 4 yrs. Old . 3) Administration of antibiotics and antifungal agents. In some cases of resistant chest infections for e.g. cystic fibrosis or bronchiectasis , antibiotics may be prescribed to be inhaled directly into the lungs.

14. 4) To aid expectoration: - Inhalation of hypertonic saline has been found to increase clearance of bronchial secretions . 5) Local analgesia : - To relieve dyspnea in some terminally in patients such as those suffering from alveolar carcinoma

15. Why? Delivery of Respirable Drugs Broncho Dilators/Anti- Spasmodics/Beta Agonists/Steroids Traditional Nebulization Nebulization

16. 19 4 Types of Inhaler Devices MDI/ DPI Small volumes Ready for use Stable obstructive disease Jet /Ultrasound nebulizer High fill volume > 1 ml Preparation required Severe respiratory insufficiency (asthma attack, COPD exac., CF)

17. Types of nebulizers Mechanical Home made A nebulizer can be made at home with a sealed bottle that can be safely pumped to a moderately high air pressure. A plug is made by drilling a hole through a cork and inserting a ball inflating needle connected to a bicycle pump . A small amount of volatile liquid, such as alcohol, is placed in the bottle and the cork and bicycle pump apparatus is used to increase the pressure in the bottle. When the cork is removed, the rapid change in air pressure will vaporize the liquid .  The same effect can be achieved using less volatile substances such as water, although vaporization occurs to a lesser extent.

18. Soft Mist Inhaler Respimat   Soft Mist Inhaler  in 1997. This new technology provides a metered dose to the user, as the liquid bottom of the inhaler is rotated clockwise 180 degrees by hand, adding a build up tension into a spring around the flexible liquid container. When the user activates the bottom of the inhaler, the energy from the spring is released and imposes pressure on the flexible liquid container, causing liquid to spray out of 2 nozzles, thus forming a soft mist to be inhaled. The device features no gas propellant and no need for battery/power to operate. The average droplet size in the mist was measured to a somewhat disappointing 5.8 micrometers, which could indicate some potential efficiency problems for the inhaled medicine to reach the lungs . ]

19. Human Powered Nebulizer (HPN ) The most recent innovation in nebulizer technology . The human-powered nebulizer (HPN) is designed to provide relief to patients suffering from respiratory diseases such as asthma, TB, or chronic obstructive pulmonary disease in areas with limited access to electricity. Invented in 2009 by a team of doctors from Marquette University, HPN uses a bicycle frame and pedals—each connected to a piston and some tubing—to turn liquid medicine into mist that flows directly into a patient's lungs through an attached mouthpiece. Commercial nebulizers typically use an electric compressor to maintain their rate of airflow, but with HPN, healthcare workers achieve the same goal by pedaling the equivalent of 8 miles per hour. [7]

20. Electrical Vibrating Mesh Technology A new significant innovation was made in the nebulizer with creation of the ultrasonic Vibrating Mesh Technology (VMT). With this technology a mesh/membrane with 1000-7000 laser drilled holes vibrates at the top of the liquid reservoir, and thereby pressures out a mist of very fine droplets through the holes. This technology is more efficient than having a vibrating piezoelectric element at the bottom of the liquid reservoir, and thereby shorter treatment times are also achieved.

21. Jet nebulizer The most commonly used nebulizers are  Jet nebulizers , which are also called " atomizers ".Jet nebulizers are connected by tubing to a  compressor , that causes  compressed air  or  oxygen  to flow at high velocity through a liquid medicine to turn it into an  aerosol , which is then inhaled by the patient. Jet nebulizers are commonly used for patients in hospitals who have difficulty using inhalers, such as in serious cases of respiratory disease, or severe asthma attacks .  The main advantage of the Jet nebulizer is related to its low operational cost.

22. Today several manufacturers have also managed to lower the weight of the Jet nebulizer down to 635 grams (22.4 oz), and thereby started to label it as a portable device. Compared to all the competing inhalers and nebulizers, the noise and heavy weight is however still the biggest draw back of the Jet nebulizer.

23. A high velocity of gas is blown through a fine hole creating an area of negative pressure. Fluid is drawn from the reservoir by the Bernoille effect into the jet stream and is impacted. on a battle breaking the fluid into droplets large droplets fall back to into the reservoir while the smaller ones may be inhaled.

24. Large volume Nebulizer:- Used for long term therapy delivers heated or cool mist. Cool mist can be more comfortable for recently diagnosed patients. Cool mist also indicated for patients with trauma or recent tracheotomy, because. Heated mist increase bleeding. Heated mist is indicated for patients with artificial airway and for neonate (cold mist can cause hypothermia in neonate)

25. Side – stream Nebulizer : - It is attached to a ventilator or to an intermittent positive pressure breathing machine Mini Nebulizer or Maxi mist: - It is hand held and used to deliver aerosol medications.

26. Ultrasonic wave nebulizer Ultrasonic wave nebulizers  were invented in 1964 as a new more portable nebulizer. The technology inside an ultrasonic wave nebulizer is to have an  electronic oscillator  generate a high frequency  ultrasonic wave , which causes the mechanical vibration of a  piezoelectric  element. This vibrating element is in contact with a liquid reservoir and its high frequency vibration is sufficient to produce a vapor mist. As they create aerosols from ultrasonic vibration instead of using a heavy air compressor, they only have a weight around 170 grams (6.0 oz). Another advantage is that the ultrasonic vibration is almost silent .

27. Factors which affect nebulization Method of administration / method of inhalation. Viscosity and other physical characteristics of the liquid aerosolized. Distribution of inspired gas (degree of airflow obstruction) Flow rate of gas.

28. Preparation of articles Nebulizers Pressurized gas source Flow meter Oxygen tubing T- Piece mouthpiece or mask or other appropriate gas delivery device. Sterile normal saline solution or sterile distilled water 5 ml syringe and water.

29. Prescribed medication Suction equipment Sputum mug Kidney tray Stethoscope B.P.apparatus , TPR tray

30. Preparing solution: - It is important to use a minimum of 3 ml of solution and preferably 4 ml in order to deliver an adequate percentage of the prescribed drug. ( In an assessment of jet nebulizers when 2 ml was used only 50 % of dose was released as aerosol whereas with volume of 4 ml 60 – 80%)

31. Preparation of patient: - Explain the procedure to the patient The patient should be in a well supported position. Ask the patient Breathe slowly and deeply using the lower chest.

32. Preparation of Nurse : - Verify the order on the patient’s medication record by checking it against doctor’s order. Check the label of the medication (expiry date) Confirm patient’s identity by asking his name and by checking his name, room number, bed no . Check gas flow. Wash hands before procedure.

33. Administration of Nebulization : - Explain procedure to patient. Record patient’s vital signs to establishment a baseline. Place patient in sitting or high fowlers position to facility lung expansion an aerosol dispersion. Attach free end of the oxygen tubing to pressurized gas source . Turn on the gas source and check outflow port, usually a setting of 5 – 6 liters / min is adequate. Instruct the patient to breathe slowly deeply and evenly through his mouth.

34. After about three deep breaths he should breath gently using his lower chest (breathing control) It encouraged to breathe deeply throughout the entire treatment the patient suffer from effect of hyperventilation . It possible, remain with the patient during treatment (usually 15 – 20 minutes ) Take vital signs to detect adverse reactions to medications. Encourage and assist the patient to cough and expectorate,. Briefly stop the treatment if he needs rest. Instruct patient to report warmth discomfort or hot tubing. Check water level frequently to prevent complications from inhaling drug hot air .

35. complications Environmental Contamination Inaccurate Drug Delivery-Residual Volumes Interference with the circuit- Increased risk of VAP and other infections Cleaning and Re use of Nebulizers- Increased risk of infection Nursing Time and Device Cost Issues Not compatible with closed suctioning requires the circuit to be disrupted twice each time we nebulize , 8 times+ per day!! If oxygen is used to drive the drug then we must wait 20 mins to do ABG Additional gas being delivered can interfere with critical ventilator settings Difficult to use in IPPB, NIV and Bi Level modes of ventilation

36. Complications of Nebulization Prevention clean the container every time, fill with fresh sterile solution each time. Increased water absorption can cause over hydration leading to pulmonary edema in patients with decreased cardiac output. Ultra fine particulate can act as irritant to susceptible patients and cause bronchospasms . Monitor vital sings of Auscultate chest for wheezes during procedure. Should be used cautiously in patients with delicate fluid balance and in asthmatic patients with active or potential bronchospsm

37. Care of patient Make sure the patient is comfortable Provide a sputum mug for spiting the expectoration

38. Documentations: - Record time date and duration of therapy type, amount of medication added to nebulizer. Baseline and subsequent vital signs and breath sounds. Result of therapy such as loosened secretions. Any complications and nursing action taken. Patient’s tolerance of the treatment . Continuously watch changes.

39. An  inhaler  or  puffer  is a medical device used for delivering medication into the body via the lungs. It is mainly used in the treatment of asthma  and  Chronic Obstructive Pulmonary Disease  (COPD).  used to treat  influenza , must be administered via inhaler.

40. Metered-dose inhalers MDI  — The most common type of inhaler is the pressurized  metered-dose inhaler  (MDI). In MDIs, medication is most commonly stored in solution in a pressurized canister that contains a propellant, although it may also be a suspension .   The MDI canister is attached to a plastic, hand-operated actuator. On activation, the metered-dose inhaler releases a fixed dose of medication in  aerosol  form. The correct procedure for using an MDI is to first fully exhale, place the mouth-piece of the device into the mouth, and having just started to inhale at a moderate rate, depress the canister to release the medicine. The aerosolized medication is drawn into the lungs by continuing to inhale deeply before holding the breath for 10 seconds to allow the aerosol to settle onto the walls of the  bronchial  and other airways of the lung.

41. 45 Pressured Metered Dose Inhalers (pMDI) Canister Small reservoir Metering reservoir After pressure valve drug sprays Aerosol

42. 46 Metered Dose Inhalers (pMDI) Canister Propellent gas (liquid under pressure) Drug Dissolved or solid microparticules into the gas Surfaktant Physical stabilisation Prevent clustering Decreas valv friction Drug layer is surface of liquid propellent because more lightweight, it must be rinced before use

43. 47 Rapid application Handling Multidose MDI advantages

44. 49 Hand-breathe coordinations İneffective use in poor ventilated patiens Oropharyngeal deposition and local side effects Not include dosimeter MDI Disadvantages

45. Dry powder inhaler DPI  —  Dry powder inhalers  release a metered or device-measured dose of powdered medication that is inhaled through a DPI device

46. Short-Acting Beta-2 Agonists The two short-acting beta-2 agonist nebulizer medications on the market include albuterol sulfate and levalbuterol hydrochloride. Short-acting beta-2 agonists are a class of quick relief drugs used to treat asthma and other pulmonary diseases by relaxing the smooth muscles in the airway within a relatively short period of time. Albuterol sulfate and levalbuterol hydrochloride are U. S. Federal Drug Administration-approved generic medication.

47. Long-Acting Beta-2 Agonists The two long-acting beta-2 agonist drugs on the market include arformoterol tartrate and formoterol fumarate . Combination Nebulizer Drugs Ipratropium bromide and albuterol sulfate are bronchodilators used to prevent and treat bronchospasms . A DuoNeb contains 0.5 mg of ipratropium bromide and 3.0 mg of albuterol sulfate premeasured and premixed in a single vial.

48. Corticosteroid Budesonide , a corticosteroid, prevents wheezing and shortness of breath. Budesonide should not be mixed with other nebulized medications.