Children and Nebulizers

  It is not easy for parents to add the use of a nebulizer to their childs’ medical care. Nebulizers are discomforting for babies and toddlers. However, for respiratory conditions, this device is better suited for infants than other devices. Other respiratory aids, such as inhalers, are more complicated for children to manage.

 “Asthma, the leading chronic illness among US children, affects approximately 6.2 million children younger than 18 years, with the highest prevalence in African American boys from birth to the age of 4 years. Management of acute asthma symptoms in children begins at home. Decisions of when and how to treat home acute asthma episodes rely on the parent’s and child’s ability to accurately identify symptoms and to implement timely and appropriate medication therapy. Yet, one third of caregivers make significant errors in accurately perceiving their child’s asthma symptom severity that may result in overuse or underuse of short-acting β-agonist or quick-relief asthma medications. In young children, nebulizers are used to deliver quick-relief medications for symptom relief and to provide some controller medications, but are only effective if properly administered. However, many families fail to properly use nebulizers. Nebulizer use in young children is common, ranging from 33% to 71% in children younger than 12 years. Although metered-dose inhalers (MDIs) are as effective as nebulized medications for asthma in young children, many families prefer nebulizers to dispense medication to their child because of the parental lack of confidence in administering MDIs to young children and the difficulty of some children in coordinating respiration with MDIs. Physician preference for nebulizer administration of asthma medications is low, but those who favor nebulizer delivery usually do so because of the perceived direct aerosolization of medication into the respiratory system vs MDIs.” (1)

 

Generalities

 

  A nebulizer is a medical device which delivers medicine in the form of a mist.  Users breathe-in the medicine (the mist) directly into their lungs. The medicine is first administered into the device in its liquid form and then is transformed into a breathable substance.

 

Nebulizers

 

  “In a jet nebulizer, air or oxygen from an electric compressor, hospital line or cylinder, passes through a narrow orifice, known as a venturi. Liquid from a reservoir is sucked up a tube and broken down into droplets. Only about 0.5% of this primary droplet mass (comprising the smallest droplets) leaves the nebulizer directly, the remaining 99.5% impacts on baffles within the nebulizer or on the internal walls. The liquid mass returns to the reservoir and is re-nebulized. Thus the nebulizer produces a continuous spray over a treatment period of several minutes.” (2)

 

  Nebulizers usually consist of:

  • A mouthpiece
  • An air compressor
  • A medication cup
  • A tubing appliance

 

  For the device to do its job, one only needs to fulfill the following steps:

  • Use the medication cup to put in the medicine needed to treat the condition
  • Use the tubing appliance to bring together the mouthpiece and the air compressor
  • Put the mask on yourself or the user
  • Turn on the air compressor

 

  “Nebulizer systems offer a great range of performance and how good or bad an individual system is depends on what it is intended to do. For example, if a system was required to deliver the maximum amount of “useful” aerosol (droplets 0.5–5 mm) in the minimum amount of time, with a minimum of inconvenience, then the characteristics of a “good” system would include the following.

  1. Fast rate of nebulization, implying that the maximum amount of nebulized aerosol is potentially available to the patient over any given time.
  2. Minimum waste of drug aerosol, implying that the maximum amount of aerosol released is delivered to the patient and not emitted into the environment.
  3. Low residual volume, implying that more of the volume fill will be delivered to the patient as aerosol.
  4. Well-defined droplet size distribution. If, however, the same system was required to deliver only a modest volume of drug aerosol, then the system described earlier becomes “bad” because such an efficient system of delivery will deliver an unnecessarily large aerosol dose with possible increased local and systemic side-effects.” (3)

 

About your Child’s Nebulization Treatment

 

  You can complete the process described above without disturbing or making your child uncomfortable, since they are only required to keep still until the device is done releasing medicine or as long as the physician recommends. This is the reason why nebulizers are great medical aids for enhancing your infant’s breathing process.

  “Children differ from adults in more than just size, they have, for example, different breathing patterns, tidal volumes and airway geometry. Most paediatric use of nebulized therapy occurs in the management of acute asthma. Because of the earlier considerations, careful attention to detail is important if nebulized therapy is given to children and infants. The findings of the Task Force were as follows.

  1. As with adults, most patients can be treated just as well with handheld inhalers and spacers.
  2. Nebulizers are frequently used for convenience or to overcome problems with inhaler technique.
  3. Adding anticholinergic therapy in severe asthma is beneficial.
  4. For long-term treatment of asthma, hand-held inhalers are as effective as nebulizers so it is very unusual for a child to require long-term, high-dose nebulized therapy for asthma.
  5. In the past, nebulizers were widely used to treat young children who were unable to use hand-held inhalers. The development of spacers with face masks has reduced this indication for nebulizer use in childhood.” (4)

 

  The medication used in nebulizers differs according to your child’s disease or how serious his/her condition is. Saline solutions are used in moderate situations, nonsteroidal drugs are used for considerably dangerous conditions, while drugs containing steroids are reserved for critical conditions.

 Nebulizers can help your child deal with a number of respiratory issues, including several asthmatic problems. These devices are able to make the affected respiratory tract wider, therefore improving your child’s condition and breathing pattern. Although nebulizing is highly advantageous, you should never auto-medicate your child. Be sure to visit a health professional to determine if nebulization is recommended and to set the proper treatment schedule, which largely depends on the seriousness of the condition. It could vary from exclusively one time during the day to every couple of hours.

  This device does not pose a threat to the user or the one administering the medication.  However, treatment may leave your child feeling nauseous, with a burning sensation in the chest, discomfort in the throat or bad aftertaste. Although these effects are uncommon, it can also cause lightheadedness, abdominal pain, and nosebleeds. It is important to highlight that all these conditions are highly unusual.

  “In spite of all the problems with nebulized therapy, nebulizers are still the delivery system of choice in the treatment of acute severe asthma in all age groups, even if the same results can often be obtained with other inhalation systems. In the acute situation, it is advantageous that oxygen can be administered through the nebulizer at the same time as the β2 agonist.” (5)

 

Nebulizing at Home vs. Nebulizing at a Healthcare Facility

 

  “The suggestions of many authors on nebulizer use are reinforced by the British Thoracic Society (BTS) Asthma Guidelines which advocate greater participation of the parent or patient in the management of asthma. The BTS guidelines for supervision of people receiving nebulized bronchodilators at home state:

  1. Oral and written instruction should be given to the patient on the method and frequency of use, the action to be taken in the event of worsening asthma, and when to attend for follow-up.
  2. Supervision should normally entail attendance at an asthma clinic or home visits by a trained asthma nurse or physiotherapist.
  3. Supervision should include evaluation of peak expiratory flow, monitoring of prescriptions, and twice yearly servicing of the compressor.” (6)

 

  Whether you purchase a nebulizer or not is your decision. However, you should be aware of the pros and cons each of these decisions bring. Nebulizing at home enhances your child’s comfort level since you will avoid having to take him or her to a healthcare facility several times.  However, these devices as well as the medication, can be costly. Nebulizing at a healthcare facility can make this process simpler since an experienced person can assist your child. Nevertheless, it might also be unpleasant for your child to be in this medical setting rather than his/her own home.

  “In addition to aerosol device selection, clinicians serve a vital role in educating patients and caregivers about nebulizer therapy in a variety of settings. This can ultimately have a major impact on drug delivery to the lungs and reduce infection risk. The quality of education or instruction may mean the difference between a patient being readmitted to the hospital or not. As such, health-care providers, patients, and family members must demonstrate competency with the proper technique and instruction of aerosol delivery systems. Differences in the physical and cognitive abilities and age of patients to effectively use a mouthpiece or mask seal or coordinate breathing efforts typically guide selection of the device and interface that will be used to deliver drug.” (7)

 

Nebulization While Screaming and Crying

 

  “Previously, it was believed that screaming and crying resulted in effective drug delivery because the patient was able to take large VT (tidal volumes) and thus receive more of the drug into the lungs. Frustrated clinicians could often be observed holding the mask tightly to the screaming child’s face for a long period of time. Although the clinician may feel that this is doing some good, it can create a very confusing and uncomfortable emotional environment for the clinician, family, and, most importantly, the patient. Infants who are distressed or crying have larger and more variable VT (tidal volumes), shorter inspiratory times, higher inspiratory flows, more prolonged expiratory times, and greater airway obstruction than at rest. These factors may result in aerosolized drug depositing on the face and upper airways or being swallowed and absorbed into the gastrointestinal tract. Several investigators have evaluated drug delivery in infants at rest and under emotional distress.” (8)

 

Nebulizers
(9)

  “Drug deposition of radiolabeled salbutamol in a young child. A: Inhaling with a pressurized metered-dose inhaler (pMDI)/spacer through a loosely fitted face mask. B: Inhaling with a nebulizer through a loosely fitted face mask. C: Inhaling with a pMDI/spacer through a tightly fitted face mask and screaming during inhalation. D: Inhaling with a nebulizer through a tightly fitted face mask and screaming during inhalation. E and F: Inhaling with a pMDI/spacer through a tightly face mask and quietly inhaling. G and H: Inhaling with a nebulizer through a tightly fitted face mask and quietly inhaling.” (10)

 

References:

(1) Effectiveness of Nebulizer Use–Targeted Asthma Education on Underserved Children With Asthma. Butz, A.M., Tsoukleris, M.G., Donithan, M., Doren, V., Zuckerman, I., Mudd, K.E., Thompson, R.E., Rand, C. & Mary Elizabeth Bollinger. Archives of Pediatric and Adolescent Medicine. 2006. https://jamanetwork.com/journals/jamapediatrics/fullarticle/205048

(2, 5) Inhalers and nebulizers: which to choose and why. S. Pedersen. 1996. (pg.6, 7) https://www.resmedjournal.com/article/S0954-6111(96)90201-2/pdf

(3, 4) European Respiratory Society Guidelines on the use of nebulizers. Bauer, T.T, Carone, M., Dautzenberg, B., Diot, P., Heslop, K., Lannefors, L., Boe, J.,  Dennis, J.H. & O’Driscoll, B.R. European Respiratory Journal. 2001. https://erj.ersjournals.com/content/18/1/228

(6) Assessment of the continued supervision and asthma management knowledge of patients possessing home nebulizers. Gregson, R. K., Warner, J.O. & Radford, M. Respiratory Medicine. 1995. [British Thoracic Society and others. Guidelines on the management of asthma. Thorax 1993; 48: Sl-S24.] https://www.sciencedirect.com/science/article/pii/0954611195901248

(7, 8, 9, 10) Clinical Controversies in Aerosol Therapy for Infants and Children. DiBlasi, R.M. Respiratory care. 2015. http://rc.rcjournal.com/content/60/6/894.full

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