Small-volume nebulizer (SVN) |
“An aerosol generator is used to deliver liquid medications to the mid-to-lower airways. High-velocity pressurized airflow is used to convert liquid drug solutions or suspensions into fine mists with particles that can then be inhaled using a face mask or mouthpiece (Gregory, Elliott & Dunne, 2013, pp. 10-11 ).” |
Requires the use of compressed air, oxygen, a compressor, or an electrically powered device.
Manual dexterity of the patient is not needed to use this device.
For children older than 3 years of age who do not have an artificial airway and who are able to cooperate, a mouthpiece with an extension reservoir should be used. For children younger than 3 years of age, a face mask should be used.
An SVN with a T connector is used for children with a mechanical ventilator circuit or manual resuscitation bag.
Children with smaller tidal volumes (particularly neonates) or dyspneic children with shallow breathing may inhale less of the aerosolized agent and receive less of the dose when nebulization is continuous.
Cold, wet mist may be irritating to children and may limit the time the treatment is tolerated.
Nasal breathing will result in reduction in particle deposition.
A slow, deep inhalation with an inspiratory pause or hold is performed during SVN treatments.
A flow of 6-8 L/minute and fill volume of 4 mL (depending on brand of equipment used) provides a maximum volume of delivered drug.
The sides of the SVN are periodically tapped to minimize the dead volume.
SVNs are for single-patient use only. Between treatments on the same patient, the equipment is disinfected, rinsed with sterile water, and air-dried. In the home, cleaning and rinsing with a solution of vinegar and water and air drying is adequate.
Does not aerosolize suspensions well.
Device cleaning required.
Nebulizer is appropriate for the delivery of short-acting β2-agonists in acute care settings and to mechanically ventilated patients. |
In the inpatient and outpatient settings nebulizers are discarded after each patient use.
In the home:
Nebulizers should be disassembled and the nebulizer cup and mouthpiece cleaned after every treatment by washing in warm water with dish soap. Shake off excessive water and air dry on a clean towel. Store the cup and mouthpiece in a zip lock bag.
Ensure care is taken to not damage any part of the aerosol generator.
Remove the tubing from the compressor and set aside because the tubing should not be washed or immersed in water.
Nebulizers should be disinfected once or twice a week based on the manufacturer’s recommendations. Nebulizer parts may be soaked in one of the following solutions:
1. One-part household bleach and 50-parts water for 3 minutes
2. 70% isopropyl alcohol for 5 minutes
3. 3% hydrogen peroxide for 30 minutes
4. One-part distilled white vinegar in three-parts hot water for 1 hour (not recommended for patients with cystic fibrosis (Gregory, Elliott & Dunne, 2013, p. 53 ).
Shake off excess water and place all parts on a clean paper towel. Allow the parts to air dry.
Reassemble the nebulizer and store in a clean, dry bag container. |
Ultrasonic nebulizer |
Uses high-frequency acoustical energy for the aerosolization of a liquid |
Patient coordination not required.
High-dose administration possible and dose modification possible.
Quiet and faster delivery than jet nebulizer.
Newer designs small and portable.
No drug loss during exhalation (breath-actuated devices).
Electrical power source (wall outlet or batteries) needed for use.
Does not nebulize suspensions well.
Potential for airway irritation with some drugs. |
Ultrasonic and mesh nebulizers are cleaned and disinfected based on the manufacturer’s recommendations. Do not touch the mesh during the cleaning of mesh nebulizers as this will damage the unit. |
Pressurized metered-dose inhaler (pMDI) |
“A portable, hand-held delivery system that uses a pressurized liquid propellant to create and deliver a variety of inhaled medications, including broncho-dilators, anticholinergics, and glucocorticosteroids (Gregory, Elliott & Dunne, 2013, p. 11 ).”
A spacer device enhances delivery by decreasing the velocity of the particles and by reducing the number of large particles.
A spacer device with a one-way valve (i.e., holding chamber) eliminates the need for the child to coordinate activation and inhalation, thus optimizing drug delivery. |
Use of the device requires the child to apply pressure at the base of the canister while at the same time taking a deep inhalation. Children unable to take slow deep breaths or those with upper extremity weakness may not be able to use this device.
Children older than 3 years of age can use this with a valved-spacer device.
Children younger than 3 years of age should use a face mask.
The valved-spacer device eliminates the need for the child to coordinate inspiration and actuation.
MDI actuation occurs at the end exhalation, followed by a slow inspiration and breath hold for 10 seconds.
MDIs are for single-patient use only. Clean or replace when they appear dirty. MDI with spacer/holding chamber is appropriate for the delivery of short-acting β2-agonists in acute care settings and to mechanically ventilated patients. For treatment of asthma in the outpatient setting, the MDI, used with or without spacer/holding chamber, is appropriate for the delivery of short-acting β2-agonists, and for the delivery of inhaled corticosteroids. |
Clean the inhaler once a week and as needed.
Look at the hole where the medication sprays from the inhaler to the spacer. If there is “powder” in or around the hole, it is the time to clean the inhaler.
Remove the metal canister from the L-shaped plastic mouthpiece. Place the mouthpiece and cap in warm water and agitate gently. Rinse and allow to dry overnight. Do not place the metal canister (medication canister) in water.
Replace the canister back inside the mouthpiece and recap the mouthpiece.
Spacers:
Clean spacers per the manufacturer’s instruction. Generally, this is before the first use and weekly thereafter. When used with inhaled steroids, the spacer should be cleaned after each use. To clean the spacer, remove the back piece (do not remove the valved end) and soak both the parts in lukewarm water with liquid detergent. Before removal, agitate gently. Rinse in clean water, shake excess water from the chamber, and allow to air dry in a vertical position. Do not towel dry the spacer because this will cause a static charge and therefore reduce dose delivery. Replace the back piece when the chamber is dry and ready for use. |
Dry powder inhaler (DPI) |
“An aerosol device that delivers medication in a fine, micronized powder form. There is no propellant in the DPI. Instead, these devices direct a patient’s inhaled air through loose powder to create an aerosol. Dispersion of the powder into respirable particles is dependent on the creation of turbulent air flow in the powder container. The patient using the DPI provides the force to get the medication from the device (Gregory, Elliott & Dunne, 2013, p. 10 ).” |
The device is appropriate for children who are able to achieve an inspiratory flow greater than or equal to 30 L/minute. Children with neuromuscular weakness or altered mental state may not be able to generate sufficient inspiratory effort to achieve maximum benefit from the device.
Child must be instructed to produce a rapid inhalation in order to activate and discharge DPI fully.
DPIs are for single-patient use only. Clean or replace when they appear dirty. Data is limited regarding DPI use in acute care setting for acute conditions (e.g., asthma exacerbations), thus use in emergency situations is not recommended. For treatment of asthma in the outpatient setting, the DPI is appropriate for the delivery of short-acting β2-agonists, and for the delivery of inhaled corticosteroids. |
Each manufacturer has its own recommendations for periodic cleaning. Universal practices include wiping the DPI mouthpiece with a clean dry cloth. Keep the DPI dry and do not submerge the DPI in water. Moisture will decrease drug delivery. |
