*Pediatric ConsiderationModule 3Training of Inhalation Therapy & Pediatric Asthma ManagementUKK Respirologi PP IDAI

*Introduction -1 widely used in respirology (respiratory med)Aerosol therapy: drug formInhalation therapy: delivery formIndonesia, medical HW & public getting familiar

Pediatric respirology, the last decadedeveloped countries, mainstream therapyBPD, wheezy infants, croup, bronchiolitisIndonesia, raising trend, esp for asthma

*Introduction -2more complicated than oral therapyspecial device, special maneuver difficult, especially for childrenchildren, wide range: very small neonates to adult size teenager body surface area: 2m2 12m2incompetent baby competent teenagerPediatric aerosol therapy, special challenge

*Introduction -3 Aerosol therapy technology: developed fastmany studies in many medical journalsmostly in adults, rarely in childrenreasons:pediatric, not a promising marketsmall portiontoo wide range needsmore money for studiesethical issuesresult: pediatrics, relative neglected group

*Carveth, Medscape, 1999Comparison of systemic vs inhalation drug

*Pediatric special problems extrapolation from adultchildren # small adults; many differencesGrowth & DevelopmentGrowth: size, quantity Development: quality, maturationsmall children: lack of competence

*Aerosol therapy devices Nebulizer easiestDry Powder InhalerMetered Dose Inhaler most difficult

fortunately: spacer (addition closed space between device and mouth)extension deviceholding chamber

*1 - Nebulizer Preparation of the device and the drug Place the interfacePatient breath normally, sometimes with deep breathing

no problem for children

*2 - Dry powder inhaler (DPI)the power source is the flow of inspiration / inhalation of the patientbreath-actuated inhaler, no propelanfast & strong inspiration, effort dependentless oropharynx deposition not suitable for under 5 childrenfor older children easier to use than MDIno need of spacer, easy to carry

*3 - MDI, how to useshake the canister, open the caphold it up right, exhaled slowlyput the canister mouthpiece between lips tightly, inhaled slowlyanytime after the beginning until the middle of inspiration, push down the canistercontinue the inspiration gently until maximal inspirationat maximal inspiration, hold the breath for 10 secondsrinse the mouth and spill it out

*MDI with spacerdisadvantages of MDI alonedirect spray into the mouth: high speed & large particle oropharynx impactioncomplex maneuver, need superb coordination, difficult even for adultto overcome: spacer - add space actuator - mouth extension devices (no valve): solve the 1st holding chamber: solve both problems

* Challenges of IT for young childrenSmall tidal volume Small airwaysRapid respirationInability to hold breath with inhaled medication Nose breathingAversion to masks Cognitive abilityFussiness and cryingEverard ML. Adv Drug Deliv Rev. 2003;55:869-878; Murakami G. Ann Allergy. 1990;64:383-387; Newman SP. J Aerosol Med.1995(suppl 3);S18-22; Geller DE. Curr Opin Pulm Med. 1997;3:414-419; Newhouse MT. Chest. 1982;82(suppl 1):39S-41S.

*Special consideration Child factorAnatomicVentilationCooperation, crying Coordination, competenceDevice factorChoices of devicesEasiness procedureSpacer choicesInterface choices

*Child factor Anatomic Weaker respiratory muscleSmaller airway diameterHigher respiratory resistanceLess bronchial branching Ventilation Nose breather, turbulence, rhinitisDynamic & irregular respiratory patternHigher respiratory rateSmaller tidal volumeLow inspiratory flow rate

*Smaller airway diameter

*Pediatric factor disadvantageshigh RRsmall TV low insp flow rate less / no breath holdingproximal depositionless distal drug depositionDBS 2006dynamic breath patternnose breatherweak resp muscleshigh resp resistance

*Special consideration Child factorAnatomicVentilationCooperation, crying Coordination, competenceDevice factorChoices of devicesEasiness procedureSpacer choicesInterface choices

*Cryingsignificantly reduces absorption of aerosolized drug in infantsIles R, ADC, 1999fighting, non fitted maskhigher respiratory ratedecrease tidal volumeshorter inspiratory phaselonger expiratory phase

*Special consideration Child factorAnatomicVentilationCooperation, crying Coordination, competenceDevice factorChoices of devicesEasiness procedureSpacer choicesInterface choicesLack of competence:inspiration through the mouthsuperb coordination between actuation and inhalation

*Special consideration in children THE DEVICEthe choicenebulizerMDI + spacerspacerholding chamberelectrostatic chargeinterface choicefacemask

*Inhalation device choiceChildren, lack of competenceEasiness: nebulizer & MDI with spacerNo need special maneuver; cooperation, calmness and quietly breathingALAP, MDI + spacer is recommended instead of nebulizerMDI spacer at least as effective as nebulizer

*Inhalation device choice

Age Short acting 2-agonistSteroidLABA6 yrMDI-hc-mpDPINebulizerMDI-hc-mpNebulizer

*MDI with spacer

*Spacer problemUsually made of plastic electrostatic chargeTo over come:Metal spacer, not availableRinse in home detergent, dry it up

*Interface device part directly connected to patientmouth pieceface mask

*Interface device part directly connected to patientface mask

*Interface choicethe use of mouthpiece is recommended, if there is no obstaclemouth piece: inspiration through mouth, expiration through nose

interface< 3 years3-6 years> 6 yearsmouth piece-++face mask++-

*Spacer interfaceextension devices : without valvemouth piece: Volumatic, mini Spacer, Aqua bottleface mask : plastic cup

holding chamber : with valvemouth piece: AeroChamber, Pocket Chamberface mask: AeroChamber, Babyhaler, Pocket Chamber

*Spacer extension devices, mouth piece

*Spacer holding chamber, mouth piece

*Spacer holding chamber, face mask

*Spacer interfaceface mask mouth piece

*FacemaskHayden, ADC, 2004Must be really tightSmall leakage, decrease significantly

*Other choicefor small babies, face mask could be replace by hood

*Pediatric drug dosesSafety is the 1st issueSafety principles: smallest dose, response dependent Systemic drug: mg/kgBW systemic dilution side effectAerosol therapy, pediatric dose similar with adultPediatric factor disadvantages each patient adjust the doseA study: same dose, similar systemic level

*Pediatric factor dis/advantages ?high RRsmall TV low insp flow rate less / no breath holdingproximal depositionless distal drug depositionDBS 2006dynamic breath patternnose breatherweak resp muscleshigh resp resistance

*Smaller tidal volume - smaller doseOCallaghan, Thorax, 1999

*Wildhaber JH: Nebuliser therapy in childrenBusiness briefing: Global health care 2003

*Inhaling through a loose-fitting face-mask

*Inhaling through a loose-fitting face-maskLung depositionof 0.1%

*Screaming during inhalation

*Screaming during inhalationLung depositionof 1%

*Quietly inhaling

*Quietly inhalingLung depositionof 5%

*Schuepp KG, et al.: A complimentary combination of delivery device and drug formulation for inhalation therapy in preschool childrenSwiss Med Weekly 2004;134:198-200

*Not tightly fitting face mask

*Not tightly fitting face maskLung depositionof 0.1%

*Crying during inhalation

*Crying during inhalationLung depositionof 1%

*Quietly inhaling with a tightly fittingface mask

*Quietly inhaling with a tightly fittingface maskLung depositionof 8%

*Inhaling quietly with a tightly fitting face maskfrom a perforated vibrating membrane nebuliser

*Lung depositionof 36%Inhaling quietly with a tightly fitting face maskfrom a perforated vibrating membrane nebuliser

*Thanks for your attention

*Thanks for your attention

*Slide 10. Challenges of Inhaled Therapies for Young ChildrenDelivery of inhaled therapy to infants and young children is associated with unique challenges due to anatomy, physiology, and cognitive development in this patient population.2Because infants have small airways, it is likely that drug deposition will be greatest in the upper and central airways; however, lower inspiratory volumes and flows in infants may lessen drug impaction in the upper and central airways.2 High inspiratory flow rates (>30 L/min) can increase drug impaction in the upper airways and reduce the lung deposition.A breathing pattern comprising slow inhalation coupled with breath holding can improve lung deposition of medication administered via a pMDI.20 Infants and young children prefer nasal to mouth breathing; filtering of aerosolized drug in the nose may reduce deposition in the lungs.21 Distress caused by the use of a face mask by infants and young children can lead to breaking of the face mask seal or alteration in breathing pattern, both of which may reduce the efficiency of lung deposition.2Drug deposition studies demonstrate greatly reduced drug deposition in the lungs of crying infants.21,22