Recent Recommendation For Nasal

Nebulization

Monika V. Pawar

M.Pharm – I

Guided by : Dr.Indira Parab.

1

Nebulization

Nebulization is means of administering drugs by inhalation.

Liquid Nebulisation is a common method of medical aerosol generation.

A nebuliser is a device that converts liquid into aerosol droplets (fine mist) suitable for inhalation.

Nebulisers use oxygen, compressed air or ultrasonic power to break up medication solutions and deliver a therapeutic dose of Aerosol particles directly to the lungs.

2

Indications of Nebulization

Delivery of bronchodilator drugs :

On acute attack of asthma Nebulization is the most common

means of delivery.

Administration of antibiotics and anti antifungal agents:

In some cases of resistant chest infections for eg.cystic fibrosis

antibiotics may be prescribed to be inhaled directly into the lung.

To aid expectoration :

Inhalation of hypertonic saline has been found to increase

clearance of bronchial secretions.

Local analgesia:

To relieve dyspnea in patients such as those suffering from

alveolar carcinoma.3

Contraindications

In some cases, nebulization is restricted or avoided due to

possible untoward results or rather decreased effectiveness

such as:

Patients with unstable and increased blood pressure

Individuals with cardiac irritability (may result to

dysrhythmias)

Persons with increased pulses

Unconscious patients (inhalation may be done via mask but the

therapeutic effect may be significantly low)

4

History

1858- First Pressurised inhaler ,invented in France by Sales

Girons,it used pressure to atomize the liquid medication.

1864-First steam driven nebulizer,invented in Germany known

as “Siegles steam spray inhaler”,it used the venturi principle to

atomize liquid medication.

1930-First electric nebulizer called a Pneumostat,it used a

medical fluid was made to aerosol by the power from an

electric compessor.

1956- A technology competing against nebulizer launched by

Riker Laboratory it used pressurised metered dose inhalers.

1964- New type of electronic nebulizer was introduced called

the ultrasonic wave nebulizer.

5

Ideal Nebulizer

A minimum residual volume(< 0.5 ml)

Aerosol delivered only during inhalation.

No waste aerosol released to the environment.

Small and portable.

Aerosol delivered with a droplet size distribution suitable for

pulmonary deposition.

Rapid treatment time,quite and unobtrusive in use.

Finally,perhaps also a means to monitor patient compliance.

6

Changes made

OLD NEW

1. Large and bulky 1.Smaller in size

2.Plain on the ouside (white

plastic)

2.Does not look like a machine

(Design /Patterned exterior)

3.Long cords in the way. 3.Rectangular tubing

4.Large face mask and tube 4.Redesigned mouthpiece that

mixes medicine instead of

filters.

5.Noisy 5.Less noise

6.Runs on battery

7. Shut off machine by itself7

Particle size

Mass median aerodynamic diameter

≤ 1μm : Reach up to the alveoli,

0.5-5μm: Beyond the 10th generation

of bronchi (respirable particles),

≥ 5 μm : oropharynx

8

NEBULIZERS

Solution or suspensions can be nebulized by ultrasonics or an air

jet and administered via a mouthpiece, ventilation mask or

tracheostomy.

Types of nebulizers :

Jet nebulizer

Ultrasonic wave nebulizer

Vibrating mesh Nebulizers

9

Siegle Steam Spray Nebulizer

A spirit burner in the base boils water in the reservoir which

passes across the top of a tube suspended in the medication

solution.

The passage of the steam draws the medication into the

vapour.

The patient inhales the vapour

through the glass mouthpiece.

10

Silbe Atomizer : A hand held nebulizer with a bulb syringe

that had to be squeezed

Colossol Nebulizer : A glass nebulizer with a rubber squeeze

ball.

This took a lot of time, coordination, and even muscle strength

to get an adequate amount of medicine to be aerosolized.

11

Air jet Nebulizer

12

• In air jet nebulizer compessed air is

forced through an orifice,an area of low

pressure is formed where the air jet exists.

• A liquid may be withdrawn from a

perpendicular nozzle (the Bernoulli effect)

to mix with the air jet to form droplets.

•A baffle within the nebulizer is often

used to facilitate the formation of the

aerosol cloud.

• Carrier gas (oxygen) can be used to

generate the “air jet”.

• Jet nebulizers are the most commonly prescribed because they are

easy to use and inexpensive.

• Disadvantages:

Less portable than inhalers

Delivery may take 5 to 10 mins or

longer.

Require power sources,

maintanance,cleaning.

Traditional jet nebulizers are often

bulky and require an electrical source, which can be a problem in

traveling.

Noisy

13

PARI Breath-Enhanced Jet Nebulizers

Continuous gas flow to neb chamber combined with patients

inspired air.

Exhaled air does not mix with aerosol, amount of solution

wasted is minimized

14

ADVANTAGES DISADVANTAGES

High output ,short treatments. Cannot be used in ventilator

circuits.

Higher dose than T-Neb or MDI

is possible.

Not cost effective for short term

use.

Multiple one –way valve reduce

waste.

Not readily adaptable to

tracheostomy masks.

Dishwasher safe, may be boiled

or autoclaved

Cost effective for long -term

15

PARI LCPlus Jet Reusable Nebulizer

The only Reusable Nebulizer approved for use with TOBI.

Breath – enhanced delivery

Balance of fast treatment time and

optional treatment efficiency

16

PARI LC SPRINT Reusable Nebulizer

10-20% Faster treatment times than PARI LC PLUS.

Higher aerosol output.

Simple,ergonomic,compact design.

Inspiratory valve cap cantbe lost.

Design prevent medication from spilling.

Easy view medication level indicator.

Robust ,flexible nozzle construction.

Medication cup self-drains when

upside down.

17

Breath Actuated Nebulizer

Breath-actuated devices produce aerosol when the patient

inhales and do not when the patient exhales.

Because the drug is not constantly being aerosolized, delivery

is more efficient and less of the drug is wasted.

Disposable

18

Bottom Load Aerosol Mask

• Does not directs aerosol towards

the mouth.

• Inefficient because of impaction

of aerosol onto bridge of mask

19

PARI Aerosol Mask

Adult and Pediatric Masks

Polyvinylchloride (PVC) soft Plastic

Efficient and effective

Directs aerosol to mouth

Prevent impaction of aerosol.

Minimizes eye and face deposition.

Elongated mass “snout” create a “reservoir” where the aerosol

velocity slows down and congregated before inhalation by the

patients which increases “respirable” dose.

20

Ultrasonic Nebulizer

Ultrasound waves are formed in an ultrasonic nebulizer

chamber by a ceramic piezoelectric crystal that vibrate when

electrically excited.

These set up high-energy waves in the solution,within the

device chamber ,of a precise frequency that generates an

aerosol cloud at the solution surface.

21

Ultrasonic nebulisers (i.e. aerosonic nebulisers) are

characterised by fast nebulisation of medicine particles into

extra small size for enhanced absorption in the very depth of

the respiratory system, helping to increase the effects of

medication.

Ultrasonic nebulisers are fast and discreet with reduced noise

levels.

They can be used at home and during travel as many modern

ultrasonic nebulisers are not only mains powered, but also

battery powered for convenience.

Car adaptors are also used for nebulisation on the move or for

recharging batteries.

The only drawback is medication restrictions because heat is

transferred to the medication

22

Vibrating Mesh Nebulizer

In this technology a mesh/membrane with

1000-7000 laser drilled holes vibrates at the

top of the liquid reservoir, and thereby

pressures out a mist of very fine droplets

through the holes.

This technology is more efficient than having

a vibrating piezoelectric element at the bottom

of the liquid reservoir, and thereby shorter

treatment times are also achieved.

The high nebulization capacity (>0.25 ml/min)

device offers short inhalation time.

23

The old problems found with the ultrasonic wave

nebulizer, having too much liquid waste and undesired

heating of the medical liquid, have also been solved by

the new Vibrating Mesh nebulizers.

A partial list of available VMT nebulizers includes: Pari

eFlow, Respironics i-Neb,Omron,Beurer Nebulizer IH50,

and Aerogen Aeroneb.

24

PARI eFlow nebulizer

Advantages :

A high respirable fraction due to the precisely defined perforations

High liquid output rate combine to produce a highly efficient and fast administration of inhaled medications.

Portability, ease of handling and noiseless operation have a positive effect on patient compliance,

Reduction of residual drug volumes left in the nebulizer, creating possible cost savings when administering expensive medications.

25

Aerosonic MicroMesh Nebulizer HL100 features :

Portable, pocket sized and easy to carry

Battery operated with low power consumption

One touch, simple to operate, noiseless and discreet

Can nebulise effectively for up to 10 seconds in all directions

(i.e. upside down or rotated to any angle)

Automatically shuts down at the end of

inhalation

26

Beurer IH 50 Ultrasonic Nebulizer

Beurer IH50 ultrasonic nebulizer is effective and versatile and

can be used at home and during travel, when access to mains

power supply is not possible.

Low levels of noise generated by the Beurer IH 50 ultrasonic

nebulizer make it pleasant and discreet in use.

It is a perfect nebuliser for

adults as well as children.

27

Schill Mobil Aerosonic Nebulizer

Schill Mobil Aerosonic Nebulizer utilises innovative advanced

electronic technology to deliver effective and safe inhalation

therapy to adults and children.

It can be powered directly from the mains or by rechargeable

battery.

effective with optimum droplet size.

suitable for a broad spectrum of medicines

comfortable, simple, quick and quiet

light and mobile for use anywhere

28

DigiO2 Micro Nebulizer

Vibrating Mesh TechnologyCreates mist-like droplets for better absorption and reduces medicinal waste

Light and easy to clean

USB Power SupplyAllows easy charging in cars or traveling

One Button OperationStart and stop medicine delivery

with just one button

Unique Capsule DesignStops automatically when

delivery is complete

29

New Generation Nebulizer

AERx

Advantages of the AERx System

• Small hand-held devices

• Very short administration time

(typically 1-2 breaths)

• Highly efficient, precise aerosol delivery

• Breath control to ensure reliable

drug delivery to lung

• Simple to use.

30

Nebulizer Solution Formulations

Nebulizers are designed primarily for use with aqueous

solution or suspension.

Drug suspension use primary particles in the range of 2-5

microns.

Nebulizer solutions are usually formulated in water, although

other cosolvent for eg. Glycerin, propylene glycol,and ethanol

may be used.

Nebulizer solution pH be greater than 5.0 to show that

bronchoconstriction is a function of hydrogen ion

concentration.

31

Method of Administration

Nebulized aerosol is introduced to the patient by compressed air from a device known as positive pressure ventilator.

A mouthpiece may be inserted in the mouth may be attached tightly to the face.

A face tent fits more loosely around the patients mouth,allowing speech.

A tracheostomy mask may be fitted to the patients tracheostomy tube directly and require T shaped adapter.

32

• Face masks should be avoided or sealed very tightly when

anticholinergic drugs are administered to patients with

glaucoma.

• Face masks should ideally also be avoided for delivery of

nebulized corticosteroids, to prevent contact with the

surrounding facial skin and eyes.

33

Nebulizer Design

Present induction pneumatic nebulizer designs fit into 5

categories:

1. Concentric:Concentric Nebulizers have a central capillary

with the liquid and an outer capillary with the gas.

2. Cross Flow: Gas flow at right angles to the Liquid flow;

3. Entrained: Gas and Liquid mixed in the system and emitted as

a combined flow.

4. Babington and V Groove: Liquid is spread over a surface to

decrease the surface tension, and passed over a gas orifice;

5. Parallel Path: Liquid is delivered beside a gas orifice and

induction pulls the liquid into the gas stream.

34

Non-induction nebulizers

Enhanced parallel path nebulizers :

This allows the gas and liquid to interact in the center of the

gas flow where the gas flow speed is highest, producing a

better transfer of energy from the gas to the liquid, and

producing a finer droplet size.

35

List of Medication

Brand Name Generic Name Category

Proventil Albuterol Bronchodilator

Ventolin Albuterol Bronchodilator

Atrovent Ipratropium bromide Bronchodilator

DuoNeb Ipratropium and

Albuterol

Bronchodilator

Mucosil Acetyl Cysteine Mucolytics

Intal Cromolyn Sodium Anti-inflammatory

agent

36

Practical Issues

Cleaning :

Nebulizers should be cleaned daily in regular usage and after each

use in intermittent use.

The mask, mouthpiece and chamber should be disconnected,

disassembled and washed in a warm detergent and water solution.

The components should be left to dry overnight.

Before reuse, the nebuliser should be run for a few seconds before

adding medications.

Maintenance :

Disposable components such as the mouthpiece, mask, tubing and

nebulizer chamber should be changed every three to four months.

Compressors require annual servicing by manufacturer or local

service provider.37

Physicochemical Aspects and Efficiency of Albuterol

Nebulization: Comparison of Three Aerosol Types in an

In Vitro Pediatric Model

METHODS:

The following nebulizers were tested: Sidestream Disposable

jet nebulizer, Multisonic Infra Control ultrasonic nebulizer, and

the Aerogen Pro and Aerogen Solo vibrating mesh nebulizers.

Aerosol duration, temperature, and drug solution osmolality

were measured during nebulization.

Albuterol delivery was measured by a high-performance liquid

chromatography system with fluorometric detection.

The droplet size distribution was analyzed with a laser

granulometer.

38

RESULTS:

The ultrasonic nebulizer was the fastest device based on the duration of nebulization; the jet nebulizer was the slowest.

Solution temperature decreased during nebulization when the jet nebulizer and vibrating mesh nebulizers were used, but it increased with the ultrasonic nebulizer.

Osmolality was stable during nebulization with the vibrating mesh nebulizers, but increased with the jet nebulizer and ultrasonic nebulizer, indicating solvent evaporation.

Albuterol delivery was 1.6 and 2.3 times higher with the ultrasonic nebulizer and vibrating mesh nebulizers devices, respectively, than with the jet nebulizer.

Particle size was significantly higher with the ultrasonic nebulizer.

39

CONCLUSIONS

The in vitro model was effective for comparing nebulizer

types, demonstrating important differences between nebulizer

types.

The new devices, both the ultrasonic nebulizers and vibrating

mesh nebulizers, delivered more aerosolized drug than

traditional jet nebulizers.

Different nebulizer/compressor combinations have markedly

different performance characteristics which could result in

different efficacy and safety profiles of the medications being

administered via these devices

40

References

Anthony J. Hickey,Pharmaceutical Inhalation

Aerosol Technology,Second edition,Vol 134,pp-280-291.

K.Nikandar,M.Sanders,The early evolution of nebulizers,pp: 1-7

Ruben D Restrepo,Effect of Face Mask Design on Inhaled Mass

of Nebulized Albuterol, Using a Pediatric Breathing

Model,pp:1-6

Evaluation and Design of

Nebulizers,N.Sankagiri,G.A.Ruff,pp:1-5

Mark Sanders,Inhalation therapy : an historical review,

Primary care Respiratory Journal(2007),pp: 71-81

LeBrun PP, de Beor AH A review of the technical aspects of

drug nebulization.pp:1-7

http://justnebulizers.com/general-nebulizer-information 41

Pyung heum yeon, young min cho, and yong-nam

pak,development of an ultrasonic nebulizer using a domestic

humidifier,bull. Korean chem. Soc. 1999, vol. 20, pp:1-4

C.J. Harvey,m.J. O'doherty,comparison of jet and ultrasonic

nebulizer pulmonary aerosol deposition during mechanical

ventilation,pp:1-5

Siraj Shaikh,recent advances in pulmonary drug

delivery system,International journal of Applied

Pharmaceutics,pp-1-5.

P.W. Barry,Drug output from nebulizers is dependent on the

method of measurement ,pp:1-4

http://www.healthline.com/health/copd/nebulizers-for-severe-copd#1

http://www.webmd.com nebulizer-therapy /asthma/guide/home 42

43