Inhalation Therapy

Basic Concepts & Principles

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Introduction

Introduction
In general, less use of Inhalation Therapy
Increasing trend of IT use
Lack of correct knowledge & skill in using it
Many misperception of IT among doctors
and patients
It is the duty of doctors to overcome
(mengatasi - menanggulangi)/ reduce the
problems

Introduction
Inhalation Therapy is a method of drugs
delivery into respiratory track
Other name: Aerosol therapy
Many respiratory drugs can be delivered
Many advantages, with some limitations

Indications
Deposition of bronchoactive aerosols
Enhancement of secretion clearance
Sputum induction
Humidification of respired gases
Prevent dehydration
Prevent or relieve bronchospasm or upper
airway inflammation

Old days nebulizer

Glass nebulizer

Semi modern nebulizer

Modern nebulizer

Muers, Thorax, 1997

Drug delivery scheme

systemic
parenteral (injection): IV, IM, IC, SC
enteral (oral): tablet, capsule, syrup, etc

topical
skin : cream, lotion
eye : drop, ointment
ear : drop,
nose : drop, spray
lung : inhalation

Respiratory drug delivery scheme

systemic
parenteral (injection): IV, IM, IC, SC
enteral (oral): tablet, capsule, syrup, etc

Inhalation
Nebulizer
Dry powder inhaler (DPI)
Metered dose inhaler (MDI)

Respiratory defense mechanism

non immunologic :
the nose : aerodynamic filtering
air conditioner (humidifier, temperature optimizer)
plexus Hesselbach, concha

particle entrapment hair, concha turbulence,

mucous layer
muco-ciliary system
respiratory reflexes: sneeze, cough reflex
respiratory epithelium

immunologic

Inhalation therapy challenge

Respiratory defense mechanism
nasal hair entrapment
nasal turbinate - turbulence
expiratory reflex
mucociliary clearance
cough reflex
tend to prevent and expelled out
foreign material !!!

Inhalation therapy challenge

Respiratory defense mechanism is
designed to prevent all kinds of foreign
bodies to come or lodge into respiratory
tract
Must find a way to overcome the
challenge of respiratory defense
mechanism
The key: particle size & deposition

Principles of inhalation therapy

to produce optimal size aerosol to be
deposited in the airways (respirable
aerosol: <10m)
aerosol is dispersion of fine liquid or solid
particle in mist form, produced by
high air flow, or
vibration, or
pressure, or
breath actuated

Principles of inhalation therapy

target: along the respiratory tract

nose,
sinus,
trachea,
bronchus,
bronchiolus, even
Alveolus

the size of aerosol determine the target

pre-requirement : the size of the particle should
be very small enough to reach each part of
respiratory tract

Dispersion of fine particle

Rain : tiny drops of water ...
Dew : tiny drops of moisture condensed on cool
surface (embun)
Fog : vapour suspended in the air, thicker than
mist (kabut)
Mist : vapour suspended ... , less thick than fog
Haze : vapour suspende ... , thinner than mist
Smoke : ...
Smog : misture of smoke and fog (asap)

RAIN in the field

FOG on the mountain

MIST in the morning

MIST of Niagara

SMOKE in the forest

SMOG in Montreal

Comparison of systemic vs inhalation drug

Aerosol delivery systems

The 3 principle types of devices widely
used are:
MDI: Metered dose inhalers
DPI: Dry powder inhalers
Nebulizers

When to try inhaled

medications
Baby with a history of wheezing
Strong family history of asthma
Moderate or severe distress
Suction, evaluate, medication, evaluate !
Use a respiratory score to evaluate
Many studies show some short term
improvement but very limited data
showing earlier discharge, decreased
hospitalization or shorter duration of
symptoms

Aerosol particle size & location

Aerosol
Size

Upper resp

Lower resp Parenchym

>10m

7 - 10m

4 - 6m

2 - 3m

1m

<1m

no deposition

How to produce fine particle ?

dispersion of liquid by high speed air flow jet nebulizer

How to produce fine particle ?

dispersion of liquid by ultrasound vibration

ultrasonic nebulizer

How to produce fine particle ?

Dry powder in very small size
particle, generated (dihasilkan)
by patients breath
dry powder inhaler (DPI)

How to produce fine particle ?

liquid + propellant in a
high pressured
container (canister)
metered dose Inhaler
(MDI)

Comparison
The
device

drug
form

need for
Actuation
/dihasilkan coordination

Nebuliser

Liquid

High flow /
vibration

DPI

Dry
Powder

Breath

MDI

liquid +
propelan

High
pressure

++

Advantages of inhalation therapy

topical

directly to
resp system

low dose
High th/
.ratio

minimal
side effects
safety of
longterm use

fast onset
reliever

controller

Aerosols, resume
Suspension of fine liquid or solid particle in air

Key to aerosol therapy is particle size

Aerosol emerge (timbul) at a velocity of 100km/h
80% drugs deposited in oropharynx
10% in the walls of the inhaler
10% in the lungs
Particle size important : determine the
mechanism; 2-5 undergo impaction,
sedimentation, or deposition in respiratory tract
or go in and out for submicronic particles

Indications
Deposition of broncho-active aerosols
Prevent or relieve bronchospasm (AB) or
upper airway inflammation (Croup Syndr)
Enhancement of secretion clearance
Sputum induction
Humidification of inspired gases
Prevent dehydration

Factors affecting inhaled drug delivery

Patient variables
Aerosol characteristics
Particle size
Particle velocity

Device type

Nebulizers
pressurized MDI
DPI

Interface / attachment
Mouthpieces
Facemasks

Spacers

Extension device
Holding chambers

Barry et al. Adv Drug Deliv Rev. 2003;55:879-923; Bisgaard et al. Chapter 12.
12. Drug Delivery to the Lung. Marcel
Dekker 2001;162:389-420.

Patient Variables
Capability and cooperation
Physical coordination
Cognitive development
Adherence
Physical features
Inspiratory flow rate
Upper airway anatomy
Degree of lower airway obstruction
Barry et al. Adv Drug Deliv Rev. 2003;55:879-923; Everard ML. Adv Drug Deliv Rev. 2003;55:869-878;
Everard ML. Paediatr Respir Rev. 2003;4:135-142

Aerosol Characteristics
Particle size
Optimal particle size range for lung
deposition
Mass median aerodynamic diameter (MMAD)
of aerosol particles should be <5 m
Respirable fraction, MMAD = 1 to 5 m
Particles <1 m may be too small for efficient
deposition
39 Barry et al. Adv Drug Deliv Rev. 2003;55:879-923; Newhouse MT. Chest.
1982;82:39S-41S.

Obstacles
Doctors perspective :
Time consuming
Self medication by patient
Reduce patient visit
Higher cost
inhalation drug
devices & equipments

Obstacles
Patients perspective :
Addicted
Disease in severe stage
Expensive
Danger

Obstacles
Drugs & devices :
Not widely distributed
Relative expensive
Complex manouver (MDI, spacer)
Not all drug available in inhalation form

Hazards of therapy
Bronchospasm
Over hydration
Overheating of inspired gases
Delivery of contaminated aerosol
Tubing condensation draining into the
airway

Comparison between MDI & DPI

contains CFC
High velocity aerosols
Requires hand breath co
ordination
Delivery of medicines
independent of external
factors
Time consuming to teach
Requires deep & slow
breathing only

No CFC
Aerosol velocity depends
on inspiratory flow rate
No hand breath
coordination needed
Delivery of medication
largely dependent on
external factors
Easy to teach
Requires high inspiratory
flow>28L/min

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