Exam 2 RCP

What are Clinical Indications for Adrenergic Bronchodilators

(Relaxation of smooth airway muscle in the presence of reversible obstruction)

• Asthma

• Acute, chronic, exercise-induced

• Bronchitis

• Emphysema

• Bronchiectasis

What is the Indication for Short-Acting Agents

Acute reversible airflow obstruction

What are the Short-acting agents (rescue agents)

Albuterol

Levalbuterol

Metaproterenol

Pirbuterol

What is Levalbuterol: The (R)-Isomer of Albuterol

-Pure (R)-isomer of racemic albuterol

-Available as MDI and nebulizer solution

-Available in four doses:

• 0.31 mg/3 mL

• 0.63 mg/3 mL

• 1.25 mg/3 mL

• 1.25 mg/0.5 mL concentrate

What are Short Acting Agents onset, peak effect, duration, and receptor site

-Rate of onset

• 1 – 15 minutes

-Peak effect

• 30 – 60 minutes

-Duration

• 4 – 6 hours

-Receptor site

• Beta 2

What is indication for Long-Acting Agents

Maintenance bronchodilation, control of bronchospasm, and control of nocturnal symptoms

(Long-acting agents: Salmeterol, Formoterol, and Arformoterol)

What are Long Acting Agents onset, peak effect, duration, and receptor site

-Rate of onset

• 5 – 20 minutes

-Peak effect

• 30 – 60 minutes

-Duration

• 12 – 24 hours

-Receptor site

• Beta 2

What are Indications for Racemic Epinephrine-Ultra Short Acting Agent

-To control airway bleeding during

endoscope

-To reduce airway swelling

• Postextubation stridor

• Epiglottitis

• Croup

• Bronchiolitis

-Ultra-short acting agent that is aerosolized

What is Epinephrine- Ultra Short Acting Agent

- Brand name: Adrenaline

- Indications: severe allergic reactions (including anaphylaxis), stimulate

the heart, severe bronchospasm

- Stimulates alpha and beta receptor sites

What are Ultra – Short Acting Agents onset, peak effect, duration, and receptor site

- Rate of onset

• 3 – 5 minutes

- Peak effect

• 5 – 20 minutes

- Duration

• 0.5 – 2 hours

- Receptor site

• Alpha and Beta

What are Specific Adrenergic

Agents and Formulations

Ultrashort acting: duration < 3 hours and epinephrine and racemic epinephrine

Short acting: Duration of 4 to 6 hours and Albuterol, levalbuterol, metaproterenol, pirbuterol

Long acting: Duration of 12 hours and Salmeterol, formoterol, arformoterol

Clinical Indications for Anticholinergic Bronchodilators

-Indication for anticholinergic bronchodilator

• COPD maintenance

- Indication for combined anticholinergic and β-agonist bronchodilators

• COPD with airflow obstruction

- Anticholinergic nasal spray

• Allergic and nonallergic perennial rhinitis and the common cold

What are Anticholinergic Bronchodilators

-Agent that blocks parasympathetic nervous fibers, which allows relaxation of smooth muscle in airway

(Antimuscarinic and Parasympatholytic)

What is the difference between Atropine sulfate for respiratory 1 and cardiac 2

Decreased mucocillary clearance, Drying of the upper & lower airway, and Blocking mucus gland hypersecretion

Used to treat or manage symptomatic types of bradycardia

What are Ipratropium Bromide preparations, combination preparations, and aqueous solution

Preparations: MDI and SVN

Combination Preparations: SVN, Respimat,

Aqueous solution: Nasal Spray

What is Tiotropium Bromide

Long Acting bronchodilator: Improves FEV1, decreases COPD exacerbation, decreases hospitalizations, Improves Quality of life, and FEV1 Rate of decline decreases

DPI

Respimat

Spiriva is the brand name

What are the adverse effects of Tiotropium Bromide

Changes in BP, EKG, or HR not usually seen

No worsening of ventilation-perfusion abnormalities or tolerance/loss of protection

Side effects: Dry mouth (most common), Cough, Mydriasis (eyes should be protected), SVN: also pharyngitis, dyspnea, flulike symptoms, bronchitis, upper respiratory infection

What is Ipratropium Bromide & Albuterol

Combination Anticholinergic and Adrenergic bronchodilator

Indications: stable COPD

What are Ipratropium Bromide & Albuterol different doses and time course

Dose:

SVN (DuoNeb) Ipratropium 0.5 mg & albuterol 2.5 mg

QID

SMI (Combivent) 20μg/puff Ipratropium, 100 μg/puff albuterol 1 inhalation QID

Time Course:

– Onset

15 min

– Peak

1 – 2 hr

– Duration

6 hours

What is the Therapeutic goal of Clinical Application of Aerosolized Steroids

Inhibit the activity of inflammatory cells and mediators of inflammation

What are the different causes of Airway Inflammation in Asthma

Airway smooth muscle contraction

Airway inflammations

• Increased microvascular leakage

• Airway edema

Mucus hypersecretion

What are is action of Corticosteroids

Inhibit cytokine production responsible for the recruitment & migration of inflammatory cells

Reduces the number of inflammatory cells in the airway epithelium & submucosa along with the number of mast cells in the airway

Restores responsiveness to β-adrenergic stimulation

What are the different types of Aerosolized Corticosteroid Agents

• Beclomethazone dipropionate

• Flunisolide hemihydrate

• Fluticasone Propionate

• Fluticasone Furoate

• Budesonide (Pulmicort)

• Mometasone Furoate

• Ciclesonide

• Fluticasone Propionate/Salmeterol

• Mometasone Furoate/Formoterol

• Budesonide/Formoterol

• Fluticasone Furoate/Vilanterol

What are the different Systemic Corticosteroid Agents

Prednisone

Decadron

Deltasone

Hydrocortone

Medrol

Solu-cortef

What are Corticosteroids - Inhaled side effects

Oropharyngeal Fungal Infections (Thrush)

Bronchospasm

Dysphonia (Hoarseness)

Cough

What are Non-Steroidal Antiasthma Agents

Mast Cell-Stabilizing Agent

• Cromolyn

Antileukotrienes (Anti-LT)

Monoclonal Antibody

What is Clinical Indication for Nonsteroidal Antiasthma Agents

Prophylactic management (control) of mild persistent asthma

What are the Clinical Indications of Mucus-Controlling Drug Therapy

To reduce accumulation of airway secretions, improve pulmonary function and gas exchange, prevent repeated infection and airway damage

What is N-Acetyl-L-cysteine (NAC)

Indications for use:

• Treatment of conditions associated with viscous secretions

• Despite in vitro mucolytic activity and long history of use, no data demonstrate oral or aerosolized NAC is effective for any lung disease

• Acetaminophen overdose

Mucomyst:

• 10%

• 20%

Hazards:

• Bronchospasm

What are Indications and use in CF for Dornase Alfa (Pulmozyme)

For clearance of purulent secretions

To reduce frequency of respiratory infections requiring parenteral antibiotics

To improve or preserve pulmonary function in these subjects

What are Mucoregulatory Medications

Decrease mucus hypersecretion:

• Steroids

• Anticholinergics:

• Atropine

• Ipratropium bromide

• Tiotropium

Macrolide antibiotics

What are Surfactant Agents

Administered to replace missing pulmonary surfactant in respiratory distress syndrome (RDS) of newborn

Act on liquids to affect surface tension

Surfactant agents: Surface-active agents that lower surface tension

• Have also been termed detergents

Surface tension: Force caused by attraction between like molecules that occurs at liquid–gas interfaces and holds liquid surface intact

How do you properly perform an application to the Lung

The higher the surface tension of the liquid, the greater the compressing force inside the alveolus

This can cause collapse or difficulty in opening the alveolus

• Lowering the surface tension will ease the alveolar opening

What are Exogenous Surfactants

Natural/modified natural surfactant (Survanta, Curosurf, Infasurf), Synthetic surfactant (Lucinactant (Surfaxin)- experimental), Synthetic natural surfactant (None at this time)

Clinical Indications: Exogenous surfactants are clinically indicated for treatment or prevention of RDS in newborns

What are the different forms of Xanthines

A nitrogenous compound found in organs and in blood and urine.

Methylxanthines- Are a chemical group of drugs derived from xanthines.

• Three Methylated Xanthines

• Caffeine

• Theophylline

• Theobromine

What is the Mechanism of Action of Xanthines

•Inhibition of Phosphodiesterase

Inhibiting PDE will lead to an increase cAMP which will cause bronchial relaxation or anti-inflammatory effects

• Blockade of Adenosine Receptors

Prevents bronchoconstriction

• Production and release of Catecholimines

Which could cause muscle tremors, tachycardia, and bronchial relaxation

What are the Clinical Indications for the

Use of Xanthines: Asthma

Theophylline: maintenance therapy (step 2 or alternative in step 3 with (ICS) of mild, persistent asthma

Patients older than 5 years of age

Side effects and narrow therapeutic index may make it a poor choice vs. other agents

Use debated

Only after other relievers and controllers have failed

Usually classified as a weak bronchodilator

What are the Clinical Indications for the Use of Xanthines

Use in apnea of prematurity

• Used to stimulate breathing

• Theophylline most extensively used in the past, but caffeine citrate may be a

better choice (safer, higher therapeutic index)

• Loading dose of caffeine citrate is 20 mg/kg

• Daily maintenance dose of 5 mg/kg

What are Theophylline Toxicity

Very narrow therapeutic margin meaning that there is very little difference between the dose and serum level that give therapeutic benefit and those that cause toxic effects

Even at therapeutic ranges patients experience side effects

Reactions can be unpredictable from patient to patient

Minor side effects provide little warning before serious toxic effects

What are Non Bronchodilating Effects

Increase in force of respiratory muscle contractility, Respiratory Muscle Endurance and Strength, and Central Ventilator Drive

Cardiovascular Effects:

• Increase CO

• Decrease PVR

• Improve myocardial perfusion

Anti-inflammatory Effects

The Respiratory Care Assessment: Before Anti-infective Agent Treatment

Assess patient for the presence of a disease in which use of the agent is indicated

• Pentamidine: risk of PCP

• Ribavirin: presence of severe RSV infection

• Tobramycin: chronic P. aeruginosa infection in CF patient

• Colistin: Management of MDR Pseudomonas aeruginosa and Acinetobacter in patients with CF

• Aztreonam: chronic P. aeruginosa infection in CF patient

• Zanamivir: acute influenza infection within two days of onset

Assess equipment

Initial patient assessment

What are Clinical Indications for Ribavirin

• Treatment of hospitalized infants with severe lower respiratory tract infection caused by respiratory syncytial virus (RSV)

Classified as an antiviral drug: Active against, RSV, Influenza viruses, Herpes simplex virus

Virostatic not virucidal

Not recommended for routine RSV infection

May be considered for life-threatening infections

Given with SPAG

What are Clinical Indications for

Pentamidine

• Prevention of Pneumocystis pneumonia (PCP) in HIV-infected patients with a history of one or more episodes of PCP

(NebuPent)

• Rationale for aerosol administration: Local targeted lung delivery and fewer or less severe side effects compared with systemic administration

• Given with Respirgard II nebulizer

What are Clinical Indications for

Tobramycin and Colistin

Indications for aerosolized tobramycin:

• Management of chronic Pseudomonas aeruginosa infection in cystic fibrosis

(CF)

• Maintain present lung function or reduce rate of deterioration

Indications for aerosolized Colistin:

• Management of MDR Pseudomonas aeruginosa and Acinetobacter in patients with CF

What is Pulmonary function testing and it’s three categories

Provides valuable information about these

important individual processes that support gas exchange

Three categories of PFT measurements:

1. Dynamic flow rates of gases through the airways

2. Lung volumes and capacities

3. The ability of the lungs to diffuse gases.

What are the Purposes of PFT

To identify and quantify changes in

pulmonary function

To evaluate need and quantify therapeutic

effectiveness

To perform surveillance for pulmonary

disease

To assess patients for risk of postoperative complications

To determine pulmonary disabilities

What are the Contraindications to PFT

Patients with acute, unstable cardiopulmonary problems

Patients who have nausea and who are vomiting

Testing for patients who have had recent cataract removal surgery should be delayed

Patients with dementia or confusion may not achieve optimal or repeatable results

In patients who are acutely ill or who have recently smoked a cigarette, the test validity of measuring the forced vital capacity (FVC) may be hindered

What are the Pathophysiologic Patterns

Two major categories of pulmonary disease

exist:

•Obstructive

•Restrictive

Primary abnormality in obstructive disease is increased airways resistance

Primary problem in restrictive disease is decrease in either lung compliance or lung volumes or both

Some pulmonary diseases cause both obstructive and restrictive disease

What are the three general principles should be consider for pulmonary function

1. Test sensitivity and specificity

• Address the test’s ability to detect disease, or absence of it

2. Validity

• Relates to its meaningfulness, or the ability to measure what it is intended to measure

3. Reliability

• Consistency

What are Pulmonary Function Testing devices

Two general types of measuring devices

exist, those that:

•Measure volume

•Measure flow

Volume-measuring devices—spirometers

Flow-measuring devices- pneumotachometers

Every measuring device has capacity,

accuracy, error, resolution, precision,

linearity, and output

What are three basic tests of pulmonary

function

Spirometry, lung volumes, diffusing capacit

Spirometry: Pulmonary Function

Tests of pulmonary mechanics

•Forced vital capacity (FVC)

•Forced expiratory volume in 1 second (FEV1)

•Forced expiratory flow measurements

•Maximum voluntary ventilation (MVV)

These measurements assess ability of lungs to move large volumes of air quickly through airways

Forced Vital Capacity: Pulmonary Function

Most common test of pulmonary mechanics

Many measurements are made while patient is performing FVC maneuver

FVC is an effort-dependent maneuver

requiring careful patient instruction and

coaching and patient cooperation

To ensure validity, each patient must perform at least three acceptable FVC maneuvers

What is Maximal Voluntary Ventilation

(MVV)

Effort-dependent test; patient asked to

breathe deep and fast for 12 seconds

Results reflect:

•Patient effort

•Function of respiratory muscles

•Ability of chest wall to expand

•Patency of airways

What is the significance of results of Maximal Voluntary Ventilation

(MVV)

Normal MVV for males is 160 to 180 L/min and slightly lower in females

MVV is reduced in patients with moderate to severe obstructive lung disease

MVV may be normal or slightly reduced in patients with restrictive disease

Undernourished patients may have reduced MVV

What are the other measures of pulmonary

mechanics

FEV1—volume of gas exhaled in first 1-

second of FVC maneuver

FEV1/FVC—calculated by dividing largest

FEV1 by largest FVC

FEF200-1200—average flow rate early in FVC maneuver

FEF25-75—measure of flow during middle 50% of FVC

PEFR—highest point on flow-volume graph

What is the significance of results of FEV1

Normal FEV1 = 5.6 L for average 20-year-old man

FEV1 is reduced with both obstructive and

restrictive lung disease

FEV1/FVC should be at least 70%

•Reduced with obstructive disease

•Normal with restrictive disease

Other measures of expiratory flow are also reduced when obstructive disease is present

What is Reversibility

If obstruction is present, must be evaluated

Done by performing spirometry before and after therapy

Bronchodilator is administered by small-volume nebulizer or MDI

Indicates effective therapy

Defined as 12-15% or greater improvement in FEV1 and at least 200-ml increase in FEV

What is Bronchoprovication

Indicated when the patient’s history suggests episodic symptoms of hyperreactive airways and airway obstruction

Uses an agent to stimulate a hyperreactive airway response and to create airway obstruction

•Methacholine provocation protocol systematically exposes the patient to increasing dosages of methacholine

Difference between Lung Volumes and Capacities

Lung Volume: Tidal volume, Inspiratory reserve volume, Expiratory reserve volume, Residual volume

Lung Capacity: Total lung capacity, inspiratory capacity, functional residual

capacity, vital capacit

What are some Techniques for Measuring RV

Helium dilution: Based on fact that known amount of helium will be diluted by size of patient’s RV

Nitrogen washout: Based on fact that 79% of RV is nitrogen and Volume of nitrogen exhaled ÷ 0.79 = RV

Plethysmography: Applies Boyle’s law to measure RV

What are the effect of Various Factors on

DLCO

Factors that decrease:

Anemia, Carboxyhemoglobin, Pulmonary embolism, Diffuse pulmonary fibrosis, Pulmonary emphysema

Factors that increase:

Polycythemia, Exercise, Congestive heart failure

Significance of Results of TLC, FRC, and RV

Increase with obstructive disease and decrease with restrictive impairment

Normal tidal volume is 500 to 700 ml (5 to 8 ml/kg of predicted body weight); VT measurement alone not helpful

Normal TLC is about 6 L

Normal VC is about 4.8 L in adult; results vary with age, gender, height, and ethnicity

How should you go about forming a PFT Report Interpretation

FEV1/FVC ratio is good place to start;

reduced (<70%) with obstructive lung disease

If TLC less than 80% of predicted normal and FEV1/FVC is normal—restrictive disease is present

If DLCO is <80% of normal—diffusion defect is present

•Reduced surface area = emphysema

•Thickened AC membrane = pulmonary fibrosis

What are the Physical Methods for Airway Clearance

Chest Physical Therapy

Directed Cough

Assisted Cough (Quad Cough)

Forced Expiratory Technique (Huff Cough)

Active Cycle Breathing

Autogenic Drainage

Splinting maneuvers

What Mechanical Devices are apart of Intrapulmonary Percussive Ventilation and Oscillatory Positive Expiratory Pressure Devices

Intrapulmonary Percussive Ventilation: Percussionator IPV-IC, Percussive Neb IPPV-IPPB, Meta Neb

Oscillatory Positive Expiratory Pressure Devices: Flutter, Acapella, Quake, RC-Cornet

What Mechanical Devices are apart of High Frequency Chest Wall Devices, High Frequency Chest Wall Oscillation Devices, and Mechanical Cough Assist Devices

High Frequency Chest Wall Devices: VEST, InCourage, SmartVest

High Frequency Chest Wall Oscillation Devices: Hyak SCS

Mechanical Cough Assist Devices (Mechanical Insufflation-Exsufflation Device): Cough Assist

What is Physiology of Airway Clearance

Normal clearance:

Normal airway clearance requires a(an)

• Patent airway

• Functional mucocilary escalator

• Effective cough

Effective cough can move mucus from lower airways to upper airway

What are the four phases of a normal cough

Irritation: abnormal stimulus provokes sensory fibers

Inspiration: stimulation of respiratory muscles to initiate deep breath

Compression: glottic closure, forceful contraction of expiratory muscles

Expulsion: glottis opens with expulsion of air from lungs

What are the Mechanisms Impairing the Cough Reflex

Irritation: Anesthesia, CNS depression, Narcotics, Analgesics

Inspiration: Pain, Neuromuscular dysfunction, Pulmonary restriction, Abdominal restriction

Compression: Artificial airway, Abdominal trauma/surgery, Abdominal muscle

weakness, Laryngeal nerve damage

Expulsion: Airway obstruction, Airway compression, Abdominal weakness, Inadequate lung

What is Abnormal Clearance

The abnormalities in airway patency, mucociliary function, strength of breathing muscles, thickness of secretions or cough reflex can lead to mucus retention

(Mucus plugging can lead to atelectasis, pneumonia, & hypoxemia)

What are diseases associated with abnormal clearance include diseases affecting

Airway patency, Composition and production of mucus, Ciliary structure and function, Normal cough reflex

What is internal or external compression of airway lumen can impair airway clearance

asthma, lung cancer, Cystic Fibrosis, Bronchiectasis

What are Neuromuscular diseases can cause a weak cough

Gullian Barre, Myasthenia Gravis, Amyotropic Lateral Sclerosis, Poliomyielitis, Muscular Dystrophy

What are the General Goals & Indications for Airway Clearance Therapy

Airway clearance therapy for acute conditions:

Acutely ill patient with copious secretions

• pneumonia

Patient in acute respiratory failure with clinical signs of retained secretions

Decreased SPO2, increased WOB

•Patient with acute lobar atelectasis

•Patient with hypoxemia due to lung infiltrates

Chronic Conditions: CF, Bronchiectasis, Ciliary dyskinesia syndromes, Chronic Bronchitis

Airway clearance therapy to prevent retention of secretions: Acute disease, Immobile patients, Post op patients, Acute Exacerbations, Chronic disease

How do you Determine the Need for Airway

Clearance Therapy

Physical findings such as: Loose, ineffective cough, Labored breathing pattern, Coarse inspiratory & expiratory crackles, Tachypnea/tachycardia, Fever

Chest radiograph demonstrating atelectasis & infiltrates

What are the Airway Clearance Techniques

Loose

Collect

Mobilize

Remove

What is the Indication and Mechanism why IPV promotes clearance

Indication: Diseases that impair the body’s ability to mobilize airway secretions

Mechanism why IPV promotes clearance:

Shear forces loosen secretions from walls of airways and an asymmetrical flow pattern augments the movement of secretions cephalad.

What are the Indications, Contraindications, and Hazards of OPEP

Indications: To relieve airway obstruction in pulmonary disorders in which the production and composition of mucus are altered(CF, COPD and Bronchiectasis) as well as in mucociliary clearance disorders (Primary Ciliary Dyskinesia)

Contraindications: Untreated pneumothorax, Increased ICP (>20 mmHg), TE Fistula, Hemodynamic instability, Active hemoptysis, Recent surgery(esophageal, facial, oral, cranial), Active untreated TB, Nausea

Hazards: An active exhalation is required to perform an OPEP and May cause an increase WOB

What is Mechanical Devices: High Frequency Chest Wall Compression Devices (HFCWC)

A wrap or vest is attached to a high output compressor which rapidly inflates and deflates the encasing device

Indications: For mobilization of secretions without requiring the patient to participate in the therapy (CF, COPD, Bronchiectasis, NM Disorders)

Contraindications: (Untreated pneumothorax, Hemoptysis, Hemodynamic instability, ICP > 20 mmHg, Chest or spinal trauma, Surgical wound or healing tissue, Recent skin grafts or flaps on thorax or spine, Inability to tolerate possible increase in WOB)

Hazards: Increase WOB and Minor skin irritation or discomfort at indwelling catheter sites

What is Mechanical Devices:

High Frequency Chest Wall Oscillating

Devices (HFCWO)

Generate positive and negative pressure to the chest wall with the use of a rigid enclosure (chest curass)

Also incorporates an assist cough function

Indications: For mobilization of secretions without requiring the patient to participate in the therapy (CF, COPD, Bronchiectasis, NM Disorders)

Contraindications: Untreated pneumothorax, Hemoptysis, Hemodynamic instability, ICP > 20 mmHg, Chest or spinal trauma, Surgical wound or healing tissue, Recent skin grafts or flaps on thorax or spine, Inability to tolerate possible increase in WOB

Hazards: Increase WOB and Minor skin irritation or discomfort at indwelling catheter sites

What are Mechanical Devices:

Mechanical Cough Assist Devices (MIE)

Deliver positive and negative pressure to the airway to produce airflow changes, simulate a cough, and propel secretions toward the oropharynx for removal expectoration or suctioning

Indications: In patients with an ineffective cough

Contraindications: Untreated pneumothorax, Hemoptysis, Hemodynamic instability, ICP > 20 mmHg, Maxillofacial and/or skull surgery/trauma, Known or suspected tympanic membrane ruptureor middle ear pathology

Hazards: History of Bullous Emphysema or recent barotrauma

What are the types of Small Volume Nebulizers

Pneumatic compressor nebulizer

Ultrasonic nebulizer

Vibrating mesh/horn nebulizer

Microprocessor – controlled breath actuated nebulizer

What are Small Volume Nebulizers

Powered by high pressure air or oxygen provided by a portable compressor, compressed gas cylinder, or 50 psi outlet

Gas is directed through a restricted orifice or jet that draws the liquid up the capillary tube and into a gas stream, forming droplets

The primary spray of droplets is directed at baffles that decrease the size of the droplets

What are the Disadvantages and Advantages of Small Volume Nebulizers

Disadvantages: Treatment times may range from 5–25 minutes, Equipment required may be large and cumbersome, Need for power source (electricity, battery, or compressed gas), Contamination is possible with inadequate cleaning, Assembly and cleaning required, Variability in performance characteristics among different types, brands, and models, Wet and cold spray occurs with mask delivery, Inadvertent deposit of aerosol into eyes with mask

Advantages: Ability to aerosolize many drug solutions, Ability to aerosolize drug mixtures, Minimal cooperation or coordination required for inhalation, Useful in very young, very old, debilitated or distressed patients with face mask delivery, Effective with low inspiratory flows or volumes, Drug concentrations and dose can be modified, Normal breathing pattern can be used, and an inspiratory pause (breath-hold) is not required for efficacy

What is the difference between large and small volume Ultrasonic Nebulizers

Uses piezoelectric ceramic transducer to

produce vibrations

Vibrations produce high-density aerosol

Several applications:

-Room humidifiers

-Sputum induction

-Medication administration

Large Volume USNs: Used mainly for bland

aerosol therapy or sputum induction

Small Volume USNs: Medication is placed directly on transducer, Usually battery operated, Patient’s inspiratory flow draws the aerosol from neb into lung, Dilutent may or may not be needed, Better respirable mass than traditional nebs

What are the factors that affect Performance of SVN

1. Nebulizer design: Baffle, Fill Volume. Residual volume, Nebulizer position, Continuous vs. intermittent nebulization, Reservoirs and extensions, Vents and gas entrainment, Tolerances with manufacturing in lots

2. Gas Source: Pressure, Flow through neb, Gas density, Humidity, Temperature

3. Characteristics of Drug Formulation: Viscosity, Surface Tension, Homogeneneity

What is administration Technique

for Jet Nebulizers

Assess the patient for need, Select mask or mouthpiece, Use conserving system, Place drug in reservoir, Set gas flow to nebulizer at 6-8L/m, Coach patient to breathe slowly through mouth at normal tidal volume, Tap nebulizer to minimize residual volume, Continue treatment until no aerosol is produced, Rinse nebulizer with sterile water and run dry, Monitor patient, Assess outcome

What are Nebilizers for Specific Applications

Nebilizers for Ribavarin Administration (SPAG) and Pentamidine Administration

What are Large Volume Nebulizers

Used for patients with severe bronchospasm that don’t respond to traditional therapy referred to as Continuous bronchodilator therapy (CBT)

What are Hand Bulb Atomizers

Nasal spray pump

Produces an aerosol suspension with particle size in 5-20 um range

Used to administer sympathomimetic,

antimuscarinic, anti-inflammatory, and

anesthetic aerosols to the nasal passages,

pharynx, and larynx

What are New Generation Nebulizers

AERx

Soft mist aerosol (Respimat)

Smart Nebulizers

• I-Neb

• Akita

How do you Control Environmental

Contamination

Negative Pressure Rooms

Booths and Stations

•Emerson Containment Booth

•Enviracaire

•Aerostar Aerosol Protection Cart

Personal Protective Equipment

What are pMDI

most commonly prescribed method of aerosol delivery

they are portable, compact, and easy to use

they are used to administer bronchodilators, anticholinergics, and steroids

Pressurized canister that contains the prescribed drug which is either a micronized powder or aqueous solution in a volatile propellant combined with a surfactant and dispersing agent

What are the Advantages of pMDI

Portable, light, and compact

Drug delivery is efficient

Multiple dose convenience

Short treatment time

Easy to use

Fine particle sizes are available

Reproducible emitted doses

No drug preparation required

Difficult to contaminate

What are the Disadvantages of pMDI

Hand-breath coordination required

Patient activation, proper inhalation pattern, and breath-hold required

Fixed drug concentrations and doses

Reaction to propellants in some patients

Foreign body aspiration from debris-filled

mouthpiece

High oropharyngeal deposition

Difficult to determine the dose remaining in

the canister without dose counter

What are Basic Components of pMDI

Canister: Inert, able to withstand high internal pressures and utilize a coating to prevent drug adherence

Propellants: Liquefied compressed gases in which the drug is dissolved or suspended

Drug Formulary: Particulate suspensions or solutions in the presence of surfactants or alcohol that allocate the drug dose and the specific particle size

Metering Valve: Most critical component that is crimped onto the container and is responsible for metering a reproducible volume or dose. Elastomeric valves for sealing and preventing drug loss or leakage

Actuator: Frequently referred to as the “boot,” partially responsible for particle size based on the length and diameter of the nozzle for the various pMDIs (Each boot is unique to a specific pMDI/drug.)

Dose Counter: This component provides a visual tracking of the number of doses remaining in the pMDI

What are the Aerosol Delivery Characteristics of pMDI

Produces particles in the respirable range

MMAD 3-6um

Pulmonary deposition ranges are between

10-20%

pMDI Drug Delivery Techniques: what is Open Mouth Technique

Warm the MDI to hand or body temp, and

shake can vigorously

Assemble the apparatus

Open your mouth wide keeping tongue down

Hold the MDI with the canister oriented

downward and the outlet aimed at your

mouth

Position the MDI approximately 4cm or two fingerbreadths away from your mouth

Breathe out normally

As you slowly begin to breathe in activate the MDI

Continue inspiration to total lung capacity

Hold you breath for up to 10 seconds

Wait 1 minute between puffs

Disassemble the apparatus

What are the Factors Affecting pMDI Performance and Drug Delivery

Shaking the canister

Storage Temperature

Nozzle Size and Cleanliness

Timing and Actuation Intervals

Priming

Characteristics of patient

Breathing Technique