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In recent years, the clinical application of aerosol inhalation therapy has increased rapidly, however, many problems are not yet fully dissolved. In this symposium, most adequate condition and procedure for the inhalation therapy in terms of lesional localization and the recognition of therapeutic limitation were mainly discussed.
The aim of this clinical study was to investigate the influence of beclomethasone dipropionate (BDP) inhalation therapy on respiratory bacterial infections in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). We studied 30 patients who had been admitted twice, (before and after the beginning BDP inhalation therapy) to our hospital because of an exacerbation of COPD by respiratory tract infection. No differences were observed before and after BDP inhalation therapy in values for PaO2, PaCO2, body temperature, CRP, WBC count, number of admission days, and bacterial culture of sputum on admission. These results suggest that BDP inhalation therapy has little influence on respiratory bacterial infection during exacerbation of COPD.
BACKGROUND: Inhaled medications are the mainstay of asthma therapy, but significant deficiencies exist in the knowledge and skills of physicians regarding use of metered-dose inhalers (MDI) and spacer devices. OBJECTIVE: We developed, implemented, and evaluated the effects of a physician-targeted educational program on inhaled therapy in a group of pediatric residents in our institution. METHODS: Patient-directed instruction sheets on aerosol therapy were developed on the basis of literature review and expert guidelines. These served to establish a consistent foundation for the educational curriculum. The program was delivered through one-on-two teaching sessions (45 minutes). Residents were provided with a summary of theoretical and practical information and with devices for practice (a placebo MDI, InspirEase and AeroChamber holding chambers, and the AeroChamber device with mask). Each session included review of an educational monograph, demonstration of proper technique, and practice with the different devices. The program was evaluated by a randomized-control design. Assessment of practical skills included number of correct steps for the use of MDI (maximum score, 7), InspirEase (maximum, 7) and AeroChamber (maximum, 6). Theoretical knowledge was assessed with 25 multiple-choice questions. RESULTS: Pretest scores in the experimental group (n = 24) were 3.7 of 7, 1.9 of 7, and 0.3 of 6 steps correct for MDI, InspirEase, and AeroChamber devices, respectively, and 13 of 25 for the theoretical knowledge assessment. The control group (n = 26) had similar pretest scores. After the program the experimental group significantly improved in all parameters: 6.3 of 7, 5.9 of 7, and 4.5 of 6 steps correct for MDI, InspirEase, and AeroChamber devices, respectively, and 18 of 25 questions correct (p < 0.01 for all parameters). CONCLUSIONS: Implementation of a simple educational program among pediatric residents can significantly increase their skills in the use of inhalational therapy.
Pressurized metered-dose inhalers (pMDIs) are commonly employed for administering bronchodilator aerosols to mechanically ventilated patients. Although it is feasible to employ dry powder inhalers in ventilator circuits, the presence of humidity in the ventilator circuit could reduce their efficiency. A complex array of factors influence drug delivery from pMDIs during mechanical ventilation, and subtle differences in the method of administration can markedly alter aerosol deposition in the lower respiratory tract. However, when the technique of administration is optimized, the efficiency of drug delivery from pMDIs in mechanically ventilated patients is comparable to that in ambulatory patients. Significant bronchodilator effects are observed with as few as 4 puffs from a pMDI and cylindrical spacer. In mechanically ventilated patients, pMDIs are a cost-effective, convenient, and safe method for delivering bronchodilator aerosols.
This study evaluated the effects of steroid inhalation on the deposition pattern of Tc-99m human serum albumin (Tc-99m HSA) radioaerosols in 25 asthma patients. A total of 12 normal controls also underwent the same examination. The pattern of radioaerosol deposition was quantitatively evaluated as the percentage of total deposition (PTD) in the central, intermediate, and peripheral regions of the right lung. The baseline PTD was calculated before and after the administration of a 1-week course of inhalation therapy of 0.05 mg beclomethasone dipropionate four times daily. There were significant differences in PTD between normal controls and asthma patients. Significant differences were also found before and after corticosteroid inhalation therapy in asthma patients. In conclusion, a week-long course of beclomethasone dipropionate inhalation therapy does influence the deposition patterns of aerosols in asthma patients, based on the findings of Tc-99m HSA radioaerosol inhalation lung scintigraphy.
The amount of drug delivered from commercially available inhalation devices which reaches the lungs of preschool children is generally low. We therefore studied the efficiency of lung delivery from an optimised combination of delivery device and drug formulation based on individual patient-related factors. In six three-year-old children we compared the delivery of a radiolabelled budesonide solution with a MMD of 4.2 mm from a conventional nebuliser, with that of a radiolabelled budesonide solution with a MMD of 2.5 mm from a perforated vibrating membrane nebuliser. Lung deposition of budesonide delivered from the perforated vibrating membrane nebuliser was 36% and 38% and notably higher than from a conventional nebuliser (maximum 8%). The development of complementary combinations of delivery devices and drug formulations to meet the needs of efficient inhalation therapy in preschool children seems to be a good way of improving the efficacy of inhaled therapy in this age group.
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The aim of this clinical study was to investigate the influence of beclomethasone dipropionate (BDP) inhalation therapy on respiratory bacterial infection in patient with an asthmatic attack. We studied 267 asthmatic attack episodes of 241 patients with/without BDP inhalation therapy. There was no difference between two groups in %peak flow, body temperature, CRP, WBC count, bacterial culture of sputum on admission. BDP inhalation therapy has little influence on respiratory bacterial infection at an asthmatic attack.
Inhalation of aerosols in the mainstay of treatment of asthma and can be useful in treating children with cystic fibrosis. The most efficient method of delivering aerosol to children depends on the age and clinical condition of the child. The most rational dosage schedule for nebulized drugs appears to be to weight-correct the dose added to the nebulizer solution.
Pulmonary tuberculosis remains the commonest form of this disease and the development of methods for delivering antitubercular drugs directly to the lungs via the respiratory route is a rational therapeutic goal. The obvious advantages of inhaled therapy include direct drug delivery to the diseased organ, targeting to alveolar macrophages harbouring the mycobacteria, reduced risk of systemic toxicity and improved patient compliance. Research efforts have demonstrated the feasibility of various drug delivery systems employing liposomes, polymeric microparticles and nanoparticles to serve as inhalable antitubercular drug carriers. In particular, nanoparticles have emerged as a remarkably useful tool for this purpose. While some researchers have preferred dry powder inhalers, others have emphasized nebulization. Beginning with the respiratory delivery of a single antitubercular drug, it is now possible to deliver multiple drugs simultaneously with a greater therapeutic efficacy. More experience and expertise have been observed with synthetic polymers, nevertheless, the possibility of using natural polymers for inhaled therapy has yet to be explored. Several key issues such as patient education, cost of treatment, stability and large scale production of drug formulations, etc. need to be addressed before antitubercular inhaled therapy finds its way from theory to clinical reality.
We analysed sputum properties based on certain clinical information such as sputum volume, its gross appearance, the diagnosis, and difficulty in expectoration. We also compared sputum properties, clinical information and the effects of inhalation drugs on sputum in vitro, and on this basis evaluated the indications and limitations of inhalation therapy. It appears that inhalation therapy is limited by sputum properties, because the properties of large amounts of sputum, purulent sputum, and sputum expectorated with great difficulty are apparently different from those of other types of sputum. The effect of inhalation drugs on sputum was studied in vitro. Distilled water and normal saline showed as mucolytic agents. Bromhexine was acids in solution. The acidity caused the sputum to gel and reduced its mucolytic effect. Tyloxapole was alkaline in solution. The alkalinity decreased the mucociliary transport rate (MTR). Acetylcysteine had a marked mucolytic effect and decreased the MTR. There was a particular desire to develop drugs which improved MTR, because MTR is impaired by large amounts of sputum and sputum expectorated with great difficulty as well as in the case of sputum from diffuse panbronchiolitis patients.
The handling of the Babyhaler spacer for inhalation therapy in children 0-3 years old with asthma was tested and the perceptions of the investigators with the instruction of this device to the parents was investigated. It was an open, multicenter study of 182 patients with a treatment period of 2 weeks and a 2-week follow-up period. Thirty pediatricians in Dutch local and university hospitals participated. Using a standardized instruction, the purpose and the application of the Babyhaler were explained and demonstrated, and parents were asked to use the Babyhaler on their own child. The quality of the demonstration was scored and, if necessary, additional instruction was given. In the following treatment period of 2 weeks record card was completed; the convenience score of the Babyhaler and the symptom score were recorded. At the following evaluation visit the handling of the Babyhaler by the parents was re-evaluated. Eighty-nine percent of the parents could use the Babyhaler correctly after one instruction. The instructions of the Babyhaler were considered to be easy in 83% of the cases by the parents and the investigators. During the treatment period the handling score (6 = impossible to use, 1 = very easy) improved from 2.4 to 1.7. At the evaluation visit the correct use was similar to the result at the instruction visit (87%). No differences were found in the ease of handling between the three age groups (0-1, 1-2, and 2-3 years). The application of inhalation therapy via the Babyhaler was favored by 92% of the parents as compared to the former treatment method. We demonstrated that the Babyhaler is easy to use by the parents and that the instruction of the device by practitioners is also perceived as easy.
Special Care Units are becoming much in demand. However not every hospital can afford them. In this article financial aspects of a specific service for special care, that is inhalation therapy for sick neonates are analyzed. The study is carried out at the Neonatal Intensive Care Unit at the American University of Beirut--Medical Center. Out of 1000 consecutive deliveries, 32 neonates (3.2%) required some form of inhalation therapy. Expenses and entries are computed. Inference is made that this number (1000 deliveries per year) may be sufficient to generate enough entries to cover for expenses to hire specialized personnel.
Metered-dose inhalation therapy is the method of choice for a number of respiratory conditions including asthma and bronchitis. Correct use of the metered-dose inhaler (MDI) has been the subject of much research. Devices have been developed to assist with training in their proper use and to enhance the effectiveness of MDI therapy. However, all lack patient pulmonary state assessment. We have approached the development of an improved portable MDI device by focusing on the total system elements that contribute to a smart inhalation therapy device. Components of such a system should include assessment of the patient's therapeutic state, tracking of drug usage, and also include physician-modified alarm thresholds. Therapeutic state is best assessed with end-expiratory CO2 measurements augmented by inspiratory and expiratory flow efforts. Drug usage monitoring needs to include the time history of drug administration. Physician-modified alarms should allow configuration of the smart inhaler to account for patient condition so that appropriate alarm limits can be established; for example, raising the CO2 alarm threshold for patients with chronic lung disease.
Given its pros and cons the indication for nebulisation therapy is limited. Nebulisation is cumbersome, expensive, time-consuming and often unnecessary even during severe bronchial obstruction. Inhalation is simple with metered dose inhalers and small inhalation chambers with low or no static charge and a mask over mouth and nose. Inhalation therapy in young children can fail on many points, with the risk that treatment is considered ineffective. Good instruction and control of correct use are mandatory. Inhalation therapy for small children has to focus on effective drug delivery, particularly during conditions like dyspnoea, tachypnoea and bronchial obstruction, because otherwise the therapy will fail when most needed. Of the three inhalation chambers available for small children, viz. the Babyhaler, the Aerochamber and the metal Nebuhaler, the last two are to be preferred. Since in the near future hydrofluoroalkane (HFA) aerosols will replace chlorofluorocarbon (CFC) aerosols an increased bronchial deposition has to be taken into account.