Training of Inhalation Therapy

& Pediatric Asthma Management

Module 2

Devices and
Equipment
Departemen IKA FKUI-RSCM
1

Dr. Bambang Supriyatno, Sp.A(K)

Born: Jakarta, November 22, 1960
Education:
1. Faculty of Medicine University of Indonesia, 1985
2. Medical Postgraduate (Pediatrics), Faculty of
Indonesia, 1993
3. Pediatric Pulmonology Subspecialty, Faculty of
Indonesia, 2002
Recent position:

Head of Department Child Health, University of

Indonesia, Cipto Mangunkusumo Hospital

Head of Respirology WG, 2003-2008

Chairman (1) of IDAI 2005-2008

Ideal inhalation therapy devices

technical aspects

clinical aspects

patients aspects

high output

for all ages

easy to use

% respirable
aerosol >

breathing pattern
adaptive

simple maintenance

shorter time

reproducible dosing

affordable

adaptable power
sources

adjustable
particle size

attractive
appearance

ready & over alarm

including lung
function
measurement

quiet

durable

small, portable
3

Inhalation therapy devices

1. Nebulizer
2. Dry powder inhaler (DPI)
3. Metered dose inhaler (MDI)
with and without spacer
4

Nebuliser

Nebulizer
Continuously change the solution to
aerosol by pressured air or ultrasonic
wave
Jet nebulizer: aerosol is generated with
a flow of gas, provided by compressor
or compressed gas
Ultrasonic nebulizer: aerosol is
generated by vibrating fluid placed
within it
Jet neb is the most widely used
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Figure. Jet nebulizer

Jet nebulizer parts

electric compressor
connector tube
neb chamber
removable top
liquid reservoir

interface:
mouth piece
face mask
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Jet nebulizer parts

1-degree droplets

Fine droplets pass around baffle

Gas at
high
pressure

To patient

Baffle

Droplets trapped and recirculated

Feed tube

Aerosol generation by a jet nebulizer

10 286
Everard ML, et al. Pediatr Respir Med 1999;

Schematic figure of jet nebulizer

11

Jet nebulizer
advantages
less coordination
needed
can mix & formulate
the drug
high doses possible
no CFC release

disadvantages
expensive
possible
contamination
not all medication
available
more time required
need drug
instillation
12

Nebulizer
Continuously change the solution to
aerosol by pressured air or ultrasonic
wave
Jet nebulizer: aerosol is generated with
a flow of gas, provided by compressor
or compressed gas
Ultrasonic nebulizer: aerosol is
generated by vibrating fluid placed within
it
Jet neb is the most widely used

13

Figure. Ultrasonic nebulizer

14

Schematic fig of ultrasonic nebulizer

15

Ultrasonic nebulizer
advantages
less coordination
needed
high doses possible
no CFC release
small dead volume
quiet
faster delivery

disadvantages
expensive
possible
contamination
not all medication
available
bulky
need drug
instillation
16

Comparison of nebulizer
Parameters

Jet nebulizer

Ultrasonic neb

power source

electric / comp

electric

how it works

high air flow

high freq vibratn

air flow

8L/mnt (+2L)

sound

noisy

quiet

tool position

free

quite horizontal

3-5 mL

>10 mL

almost all

not steroid

price

Cheap

expensive

maintenance

simple

complex

fill volume
nebulized drug

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Fill volume
the volume of drug solution to be fill in
the reservoir chamber

Drugs

<3mL

3-5mL

>5mL

bronchodilator

steroid

+
18

Drug dosage for nebulizer

Drugs

NaCl 0.9% (ml) added until

2-agonist
Alupent sol. 2% (gtt)
Berotec 0.1% (gtt)
Ventolin nebule (mL)
Bricasma respule
(mL)
2 agonist + anti cholinergic
Combivent (mL)
Time (minutes)

Nebulizer
Jet

Ultrasonic

10

35
5
1
1

3-5
5
1
1

10 - 15

3-5
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Nebulization time
the time from starting nebulization until
continuous nebulization has ceased
hospitalization

<6

6-10

>10

< 24 hours

+ 24 hours

> 24 hours

+
20

Interface
device part directly connected to patient

mouth piece

face mask
21

Interface
device part directly connected to patient

mouth piece

22

Dry Powder Inhaler

23

Dry powder inhaler (DPI)

a tool to inhale drugs in dry powder form

1957: for inhalation of dry powder antibiotic

studies: can be used for other respiratory drugs
1970s: 1 DPI contains 1 dose (Spinhaler,Rotahaler)
1980s: 1 DPI contains more doses (Diskhaler 8)
1990-2000s: more doses in 1 DPI
Accuhaler 60 doses
Turbuhaler 120 doses
Easyhaler 200 doses
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Dry powder inhaler (DPI)

the power source is the flow of inspiration /
inhalation of the patient
breath-actuated inhaler, no propelan
effort dependent
less oropharynx deposition
not suitable for under 5 children
for older children easier to use than MDI
no need of spacer, easy to carry
25

2 different kind of DPI

The drug within the
device

The drug separated

from the device

Turbuhaler
Easyhaler
Swinghaler

Rotahaler
Cyclohaler
Handyhaler

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Turbuhaler design and operation

Mouthpiece is specially
designed with spiral
channels to deaggregate
the dose to respirable
particles
Inhalation channel
transports dosage of drug
aggregates to the
mouthpiece

Rotating dosing disc

determines the dose of
medication for delivery to
the inhalation channel

Drug reservoir holds

50,60,100 or 200 doses of
medication
Dosing scrapers ensures
precise dosing by
removing excess amounts
of drug
Twist grip loads a single
dose when turned
completely in one direction
and then back again
27

28

Easyhaler mechanism

29

DPI use, common mistakes

Not open the cap

Not exhale first
Not inhale forcefully & deeply
No deep / maximal inhalation
Not hold the breath for 10 seconds
Forget to rinse the mouth

30

Dry powder inhaler

advantages
less coordination
required
breath hold not
required
breath actuated

disadvantages
requires high
inspiratory flow
pharyngeal
deposition possible
difficult to deliver
high doses
not all medication
available
31

32

Metered Dose Inhaler

33

Metered dose inhaler (MDI)

components of MDI
canister, an aluminium can with metering
valve and valve stem, it contains
micronized drugs suspension, with multiple doses
(up to 300)
propellant, CFC or else

actuator, usually made from plastic

actuator seat, where the canister is placed
mouthpiece

the cap
34

Schematic diagram of inhalation device

Metered dose inhaler (MDI)

Dry powder inhaler (DPI)

35

Metered Dose Inhaler (MDI)

How to use it:
shake the canister, open the cap
hold it up right, exhaled slowly
put the canister mouthpiece between lips tightly,
inhaled slowly
anytime after the beginning until the middle of
inspiration, push down the canister
continue the inspiration gently until max insp
at maximal inspiration, hold the breath for 10 sec
dont forget to rinse the mouth and spill out to
wash out the rest of the drugs in oropharynx
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How to use MDI

shake well for 15

before each use

remove the cap from

the mouthpiece
37

How to use MDI

breath out through the mouth,

place the mouthpiece in the
mouth, & close the lips around it

while breathing deeply &

slowly, press the canister
firmly
38

How to use MDI

Alternatively, the
inhaler may be
positioned 1 to 2
inches away from
the open mouth

39

MDI use, common mistakes

Not shake the canister

Not open the cap
Not hold in vertical position
Up side down position
Not exhale first
Lack of coordination
Too fast and powerfull inhalation
No deep / maximal inhalation
Not hold the breath for 10 seconds
Forget to rinse the mouth
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How to measure the MDI contents

41

Metered dose inhaler

advantages

convenient
less expensive
portable
no drug preparation
no contamination

disadvantages
coordination essential
patient activation
required
large pharyngeal
deposition
difficult to deliver high
doses
not all medication
available

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43

Spacer

44

MDI with spacer

disadvantages of MDI alone
1. direct spray into the mouth: high speed &
large particle
oropharynx impaction
2. complex maneuver, need superb
coordination, difficult even for adult
to overcome: spacer - add space actuator - mouth
1. extension devices (no valve): solve the 1st
2. holding chamber: solve both problems

45

Spacer
extension devices : without valve

to lengthen the distance between actuator

mouthpiece and oropharynx
reduce aerosol speed, propellant
evaporate, large particle trapped
still need coordination, although less

holding chamber : with valve

drug reservoir with certain volume

has valves on both sides, hold the aerosol
no need coordination
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Spacer interface
extension devices : without valve

mouth piece: Volumatic, mini Spacer, Aqua

bottle
face mask : plastic cup

holding chamber : with valve

mouth piece: AeroChamber, Pocket Chamber

face mask
: AeroChamber, Babyhaler,

Pocket Chamber
47

48

MDI with spacer

49

MDI with spacer

advantages of MDI with extension device:
reduced aerosol speed when inhaled
produced smaller particles
reduced oropharyngeal deposition

advantages of MDI with holding chamber

advantages of extension device, +
less coordination needed
suitable for children, even for baby (older
children using mouthpiece, baby using
facemask)
50

MDI with spacer

advantages
less coordination
required
less pharyngeal
deposition
no drug preparation
no contamination

disadvantages
more complex for
some patient
more expensive
than MDI alone
less portable than
MDI alone

51

Lung deposition of budesonide

MDI +
spacer

MDI

DPI (Turbuhaler)
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Thorsson et al, 1998

53

54

Resume
Inhalation therapy
Nebulizer

DPI

MDI
Spacer (-)

Turbuhaler
Jet Neb

Rotahaler
UltraS Neb

Spacer (+)

Easyhaler
Cyclohaler
extension dv

holding ch
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Thanks for
your attention
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