While the information contained within this video was considered correct by Intersurgical at the time of production, it in no way qualifies anyone to undertake any medical activity. Intersurgical can accept no responsibility for the medical practices of persons who directly or indirectly reference this programme.

Intersurgical Presents Nebuliser Therapy

Nebuliser Therapy Introduction

The European Respiratory Society publication 'The European Lung White Book'

states that; "Respiratory diseases are among the leading causes of death

worldwide. Lung infections (mostly pneumonia and tuberculosis) lung cancer

and chronic obstructive pulmonary disease (COPD) together accounted for nine

point five million deaths worldwide during 2008, one sixth of the global

total." The diversity of respiratory disease is often not appreciated by

those who do not work in the specialty in many countries around the world

chest physicians treat everything from tuberculosis and the pulmonary

complications of HIV to asthma, chronic obstructive pulmonary disease, cystic

fibrosis, lung cancer and many others. Lung diseases are not just smoking

related - there are a wide variety of other causes ranging from genetic

influences to nutritional, environmental and poverty related factors. Many

respiratory diseases require careful nebuliser therapy to improve the

day-to-day lives of sufferers. This therapy allows delivery of aerosolised

respiratory drugs directly to the therapeutic site, the lungs. There are

several classes of respiratory Pharmaceuticals used to treat different

respiratory conditions: Bronchodilators and anti-inflammatories which are used

to treat airway obstructions. Antibiotics which are used to treat infections.

Mucolytics which are used to treat abnormal secretions and opioids and

analgesics which are used for pain relief. Nebuliser therapy can be used to

deliver all these drugs to the patient. This video looks at how a jet nebuliser

works, nebuliser delivery systems,

nebuliser performance factors, and where nebulisers are used. We can now look at

how a nebuliser works a nebulisation system comprises four main components a

The driving force is a supply of pressurised gas which can be either air or oxygen

although oxygen should not be used if there are concerns about CO2 retention.

Oxygen is readily available from the hospital pipeline systems or pressurised

cylinders. Air is most often supplied from a small portable, electrically

driven compressor. The function of the tubing is to convey the compressed gas

from source to the nebuliser. A nebuliser is a device that can convert a liquid

solution or suspension into aerosol droplets suitable for patient inhalation.

The chamber of the nebuliser unit is filled with a drug. The flow of gas is

driven up a tube through the center of the chamber, creating an area of low

pressure, which draws the drug up to the top of the chamber itself. The aerosol

produced is then forced at very high speed against the baffle which recycles

the large particles, returning them to the nebuliser cup. This results in a mist

of appropriately sized particles of the drug, which flow out of the chamber.

The delivery system can be either; a mouthpiece, a face mask or a T-Piece.

A mouthpiece is the ideal administration device as there is no leakage and no

deposition in the nasal passage or on the face. This results in an efficient

delivery of the drug. A face mask is easy for the patient to use and is necessary

when patients are unable to use a mouthpiece. The disadvantage of using a

face mask is that drug can be deposited in the nasal passage or on the face.

Care needs to be taken to ensure that the mask is a good fit, particularly around

knows to prevent drug from getting into the eyes. The new generation of Intersurgical

EcoLite™ masks feature a soft anatomical seal that provides a greatly

improved fit compared to earlier mask designs. This minimizes the potential

of drug leaking into the eyes. A face mask should be avoided if a nebulized

steroid is administered, to avoid deposition on the skin and eyes. A face

mask should also be avoided if anticholinergenic agents are to be

administered to glaucoma patients. If delivering antibiotics the immediate

environment, staff and other patients must be protected this can be achieved

by either using an anti-pollution kit or by adding a breathing filter to the

exhalation side of the mouthpiece. A T-Piece is used for ventilated patients

and is suitable for adults, children and neonates. The nebulizer and T-Piece is

positioned in the inspiratory limb of the ventilator breathing system. Use of a

self-sealing T-Piece enables a nebuliser to be attached and detached from the

ventilator breathing system without interfering with patient ventilation or

inadvertently activating any alarms. We can now look at the factors that

influence the performance of a nebuliser. Firstly it is important to understand

the three main factors which determine where in the respiratory tract a

nebulised drug droplet is deposited, these are: the aerosol droplet size,

the breath pattern during inhalation and the age and condition of the lung. The

easiest parameter to control is the droplet size, this is also the main

factor which determines where the nebulised drug is deposited and so is a

key parameter to consider in the design of a nebuliser. In order to maximize drug

deposition in the targeted area of the lung, there are however other factors to

consider which determine nebulizer performance. These are the nebuliser:

efficiency, mass output, respirable output, nebulisation time, residual volume and

mass median diameter. The efficiency of a nebuliser is measured by the aerosol

output at varying particle sizes and is expressed as the percentage of particles

at optimum size. The optimum particle sizes are; two to five microns per

tracheobronchial deposition and nought point 5 to 2 microns for alveolar

deposition. Particles larger than 5 microns may be deposited in the nose and

mouth. Resulting in the drug being swallowed. Mass output is defined as the

total weight of drug particles produced by the nebuliser and is expressed in

grams per minute. Respirable output is the weight of drug particles produced by

the nebuliser of the optimum particle size and this is also expressed in grams

per minute. Residual volume is the volume of drug remaining at the end of the

nebulisation procedure. This may be minimised by tapping the cup when the

nebuliser begins to splutter. Probably the most simple and useful single

measure of droplet size is the mass median diameter usually abbreviated to MMD.

This is defined as half of the "mass" of nebuliser aerosol is contained in

droplets, which are larger than the MMD, and the other half are smaller.

Intersurgical offers two nebulisers which produce particles

for tracheobronchial deposition, the Cirrus 2, and the high performance Hot Top 2.

Lets look at these two options in detail. The Cirrus 2 is a conventional, closed jet

nebuliser which produces the majority of particles between 2 and 5 microns in diameter.

This versatile nebuliser can be used in all applications.

It can be used for adults and children, with a mouthpiece or

a mask and because it is a closed system it can also be used for ventilated

patients. The calibrated nebuliser cup only requires a quarter turn, for fast, accurate filling.

And a quarter turn closes the cup with a positive click to indicate the cup has sealed.

The high performance Hot Top 2 also produces the majority of particles

between 2 and 5 microns in diameter, however it has an open vent design which

uses the venturi effect to increase gas flow through the nebuliser.

This increases the output and therefore greatly reduces the nebulisation time.

It is suitable for use with compressors, which typically have lower output flows

because Hot Top 2 performance and gas flows of 6 liters per minute

approximates to a conventional closed nebuliser at 8 liters per minute.

Hot Top 2 nebuliser can also be used with a Sure-loc tube which provides a secure

connection, preventing accidental disconnections.

An adapter is attached to the flow meter which enables the Sure-loc tube to be

attached to the flow meter and the other end of the Sure-loc tube is attached to

the nebuliser. Sure-loc tubing can however also be used on a standard

nebuliser spigot and on standard tubing. Hot Top 2 is suitable for adults

and children, and could be used with a mouthpiece or a mask, but is not suitable

for ventilated patients due to the open vent design. Closed nebulisers of the

Cirrus 2 type should be used in this application. The use of nebulisers for

respiratory therapy is widespread. Their importance and practical use can be seen

in pre-hospital emergency care, in hospitals and by patients at home.

The European respiratory society guidelines on the use of nebulisers felt that it

was appropriate for ambulance staff and paramedics to institute bronchodilator

treatment as early as possible in acute asthma using nebulised bronchodilator

therapy driven by oxygen. Nebulisers are also used in accident and emergency to

deliver Salbutamol to asthma patients and ipratropium bromide to CODP patients.

Some patients who are in Intensive Care Units and who are

ventilated, require Inhalation Therapy. The required volume of drug

is put into the nebuliser. The nebuliser and a T-Piece is then placed into the

inspiratory limb of the ventilator breathing system

ideally 30 to 45 centimeters from the Y-Piece. If a heat and moisture exchanger

is fitted this must be removed and an alternative source of humidification

must be provided. Consideration should be given to placing a filter in the

expiratory and inspiratory limbs of the breathing system to protect the

ventilator from contamination. Resistance to flow should also be monitored.

The gas flow to the nebulizer should be set at 8 Liters per minute. Nebulisers can be used

to deliver aerosol therapy for patients requiring Intermittent Positive Pressure Breathing (IPPB) physiotherapy.

The aims of IPPB are to: increase lung volume,

decrease the work of breathing, mobilize secretions and increase collateral ventilation.

A nebuliser can add humidity to the dry gases coming from the

ventilator in which case 0.9% saline would be used or

it can administer a bronchodilator to patients with acute severe asthma.

Nebulisers are used extensively in hospital wards. For patients who do not

need oxygen, air is advisable as the driving force. Select a mouthpiece if

possible, unless patient preference or excessive breathlessness precludes this.

Nose breathing filters the drug and reduces drug deposition by 1/4 and

aerosol escaping from a mask can affect the eyes. If possible, have the patient

sitting upright in a chair or side-lying to maximize basal deposition. Ensure

breathless patients have support for their elbows. Filled between 2.5 and 10

milliliters depending on the nebuliser. Dilute with normal saline if appropriate,

this will reduce the amount of wasted drug. Set the flow rate to 8 liters per

minute, unless a compressor is used, which has a preset flow rate.

Advise the patient: to mouth breathe if possible, to intersperse tidal breaths with

and deep breaths and some end- inspiratory holds to improve deposition,

not to obstruct the exhalation port if using a mouthpiece or the inlet ports if

using an open vent nebulizer such as the HOT Top 2, and to allow adequate time

for completion. Patients at home use nebulisers extensively. This means that

the treatment received by the patient in hospital can be continued in the

patients home releasing valuable bed space. This treatment is supervised by

nurses of the Acute Respiratory Team.

To summarise, we have looked at: how a nebuliser works, nebuliser delivery systems, nebuliser performance factors,

and where nebulisers are used and we hope that this will help understanding in this discipline.