Inhalation Therapy via a Nebuliser

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Inhalation Therapy via a Nebuliser 2017-08-22T04:27:09+00:00

Inhalation therapy using a nebuliser – Instruction Video

Medications delivered via a nebuliser for bronchiectasis:

Isotonic saline 0.9%

Hypertonic saline 6% – 7%

Antibiotics e.g. Colistin, Tobramycin

Bronchodilators e.g. Atrovent, Salbutamol

Nebuliser recommendations (ERS Guidelines 2001):

Choose a nebuliser based on the recommendations for the drug that is being prescribed

Choose a compressor that has been tested with the prescribed nebuliser brand

Instruct patients re correct use of the device and the cleaning procedure

Instruct patients that they should follow the manufacturer’s recommendations for when to purchase a new nebuliser

Nebuliser technique: see Nebuliser Therapy video

Sit in a well-supported chair with a neutral lumbar spine – this enhances the function of the diaphragm and the pelvic floor and minimises musculoskeletal stress (Fig. 1)

Use a mouthpiece *, if possible, and place it well into the mouth on top of the tongue

Instruct the patient to breathe in slowly, with varied inspiratory volumes

Hold the breath briefly before exhaling

Continue until the nebuliser bowl is empty

* A mouthpiece should always be used unless:

Only masks are provided by the hospital or clinic

The patient is physically or cognitively not able to manage a mouthpiece

The targeted area for deposition is the sinus region

Posture 2

Fig. 1 Sitting posture

The benefits of the inhaled delivery of medications via a nebuliser are:

Reducing the dose to the body and the systemic side effects

Direct delivery of an aerosolised medication to the smaller airways

Ability to humidify the lower and upper airways

The optimal system should be selected for each individual depending on:

The medication prescribed

The targeted site of deposition eg bronchioles, sinus region

Patients physical and cognitive ability

Financial constraints

Need for portability eg travel

A common clinical problem is that patients are prescribed a medication requiring a nebuliser but the nebuliser is not prescribed.

An inefficient nebuliser may considerably decrease the respirable dose by up to 10-fold (Boe 2001).

Table 1. Nebulisers recommended for people with bronchiectasis who benefit from a small aerosol particle-size to target the peripheral airways.

PARI Sprint -
(with blue insert)
image001Total Output Rate: 590 mg/min
MMD(mass median diameter):2.9µm
Mass percentage below 5µm:75%
When used with Pari SX compressor.
PARI Sprint Star -
(with red insert)
image002Total Output Rate: 450 mg/min
MMD(mass median diameter):2.2µm
Mass percentage below 5µm: 89%
When used with Pari SX compressor.

Fine particle size for targeted delivery to the peripheral regions of the lung.
PARI SX compressorimage003Warranty: four (4) years
Power supply: 230V~ 50/60Hz - 0,7 A - 80 W
Dimensions: W 19,2 x H 14,5 x D 15 cm
Weight: 1.7 kg
Replace filter every year.
Service when pressures significantly fall below 1.5 bar.
PARI eFlowimage004Total Output Rate: 500 mg/min
MMD(mass median diameter):4.1µm
Mass percentage below 5µm: 64%

See Technipro Pulmomed video for use and care of this device: http://www.pulmomed.com.au/eFlowrapidvideo.html
Max fill volume – 6mls
Weight – 300gms
PARI Sinus
(compressor can also be used with Pari Sprint and Sprint Star)
image005Total Output Rate: 220 mg/min
MMD(mass median diameter):3.2µm
Mass percentage below 5µm: 71%
Pulsed aerosol delivery to the nasal cavities
AeronebGoimage006MMAD – 3.6 µm
Medication capacity – 6mls
Portable, light and quiet.
Two power sources – AA batteries and AC/DC.
InnoSpire Deluxe compressorimage007MMAD - 3.4 µm
Fine particle fraction - 67% below 5µm
Weight – 2.2kg
To be used with the SideStream Re-usable or SideStream Plus nebulisers.

For further information on these nebulisers:

PARI nebulisers

AeronebGo nebuliser

Innospire Deluxe nebuliser

Pari Sinus Instruction video

The compressed air supplied by the compressor passes through the nebuliser nozzle and creates the aerosol at the nozzle outlet (Fig.2). The aerosol thus created can then be inhaled using the mouthpiece or a mask.

Nebuliser inside

 

 

 

 

Fig. 2 Production of aerosol

The main factors which determine where in the respiratory tract a nebulised drug droplet will deposit are:

Droplet size (see Figs. 3&4)

Ventilatory pattern

Age and/or condition of the lung

Temperature and humidity

Gravity – deposition is greatest at the bases in sitting, side lying may increase apical deposition

The easiest to control is the size of the droplets. On entering the lung, nebulised droplets may deposit by the following mechanisms:

Larger droplets can deposit by impaction on airway bifurcations

Smaller aerosols deposit by sedimentation and diffusion in the smaller airways and alveoli

Particle size

Fig. 3 Particle size and deposition

Particle size - lungs

Fig. 4 Particle size and deposition

The ventilatory pattern also effects deposition (see technique, above).  The PARI PIF (Peak Inspiratory Flow) system (found in PARI nebulisers) provides feedback to patients on the correct breathing pattern. Resistance is felt on inspiration if the flow rate is too high (above 25L/min).

Additional information when using a nebuliser:

Cleaning of all nebuliser equipment is essential and should be done daily to prevent infection. See manufacturer’s instructions for the correct procedure for each device.

Cleaning all PARI nebulisers and accessories:

Autoclavable to 136°Celsius

Dish washable

Can be sterilised in boiling water

Can be sterlised in a steam steriliser

Cleaning  the Aeroneb Go:

Boiling for up to 20mins

Cleaning with a solution of warm water & mild detergent

Sterilising in a steam baby bottle steriliser

Disinfecting in a vinegar solution

Cleaning the SideStream nebulisers:

Wash after every use with warm soapy water

Each week, boil for 10 minutes with a few drops of liquid detergent

Nebulisers should be serviced regularly and parts replaced as per the manufacturers’ instructions. A sign that replacement may be required is if it takes significantly longer to nebulise the solution.

If antibiotics are nebulised, it is advisable to either use a filter attached to the nebuliser, which will absorb over 90% of exhaled antibiotics, or use the device in a well ventilated room, for example, next to an open window. (PARI_Filter_Set_instructions). Consideration should also be given to wearing goggles over the eyes when nebulising antibiotics.

Adding PEP devices to nebulisers (Figs 5-9):

Patients may choose, or be advised, to add positive expiratory therapy to the nebuliser to save time. There is insufficient research to recommend this practice. It may be appropriate for patients with poor adherence to therapy or who are on multiple nebulised medications (Olsen 2015).

In patients with mucus plugging and lobar collapse the combination of PEP therapy and isotonic or hypertonic saline may result in effective mobilisation of mucus.

Do not use PEP with inhaled antibiotics as the addition of PEP significantly decreases the deposition of aerosol within the lungs (Laube 2005).

Sprint with PEP S 151203 Bronchiectasis-22 (1)
Fig. 5 PARI Sprint with PARI PEP S Fig. 6 PARI LC Plus with PARI PEP
Aerobika with nebuliser acapella-duet-nebulizer-amp-vibratory-pep-therapy-dd3
Fig. 7 Aerobika with nebuliser attachment Fig. 8 Acapella duet with nebuliser attachment

 

Patient with TheraPEP and nebuliser

Fig. 9 TheraPEP with nebuliser

References