Metered Dose Inhalers with Valved Holding Chamber: A Pediatric Hospital Experience 8th Annual North Regional Respiratory Care Conference Minnesota & Wisconsin Societies for Respiratory Care Mayo Civic Center Rochester, Minnesota April 30th - May 2nd, 2012 7 John Salyer RRT-NPS, MBA, FAARC Director Respiratory Care Children s Hospital Seattle Washington May You Live in Interesting Times 1
Methods of Albuterol Administration Among Asthmatics January-May 2004 2005 2006 MDI-VHC 9% 67% 79% SVN 91% 33% 21% Acknowledgements Children s RT s and RN s Ted Carter MD Dave Crotwell RRT-NPS Charles Cowan MD Rob Diblasi RRT-NPS Children s RT Leadership Team Corey s Refrigerator 2
The Question Why use MDI-VHC? What was the scientific evidence How best to implement this plan How to measure it s impact Sacred Cows Make the Best Hamburger Children cannot cooperate enough to make MDI- VHC a viable alternative to SVN SVN is more effective at drug delivery in infants and small childre MDI-VHC is more expensive than SVH 3
Dose inhaled, mg 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Delivered Dose Facemask (in vitro) increasing distance from face Everard ML, et al. Arch Dis Child 1992;67:586-91 3.1% 1.4% 0 cm 1 cm 2 cm 0.5% Distance of mask from filter face 4 ml of 1% cromolyn; flow = 8 l/min, VT = 50 ml The Evidence Systematic Review: Bronchodilators via MDI are as effective as any other hand held delivery device stable asthma. Am J Respir Med 2003;2(4):349-365 Cochrane Database Review: MDI s with holding chamber produced outcomes that were at least equivalent to nebulizer delivery. Great Britain: Nebulizers are rarely needed for young children; spacer devices are as effective, cheaper, and less time consuming 4
Deposition The Literature Deerojanawong et al Pediatr Pulmonol 2005;39(5):466-72 Osmond et al Ann Emerg Med 2004;43:413-415 Castro-Rodriguez et al J Pediatr 2004;145:172-177 Delgado et al Arch Pediatr Adolesc Med. 2003;157(1):76-80 Cates et al Cochrane Database Syst Rev. 2003;3:CD000052 Newman et al Chest 2002;121:1036 1041 Cotterell et al J Paediatri and Child Health 2002 ;38(6)604 Leversha et al J Pediatr 2000;136(4): 497-502 Ploin et al Pediatr 2000;106(2):311-317 Bailey et al Chest 1998;113:28-33 Fok et al Pediatr Pulmonol 1996;21(5):301 309 Lyn et al Arch Dis Child 1995;72(3):214-218 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% pmdi pmdi spacer pmdi/vhc Electrostatic pmdi/vhc Non-Electrostatic SVN DPI Exhaled Device Mouth Lung Fink JB. Humidity and aerosol therapy: In: Mosby s respiratory care equipment. St. Louis MO: Mosby-Elsevier Inc.;2007: 5
Response To Albuterol in 1-5 Year Olds With Recurrent Wheezing in ED 0-1 Elapsed Time after Tx (min) 20 40 60 Median Change In Pulmonary Index -2-3 -4-5 -6 Nebulized Group (n=32) (MDI + HC) Group (n=31) Ploin D, et al. Pediatrics 2000; 106:311-317. Emergent Treatment: 1-24 Month Olds With Terbutaline Clinical Score 10 9 8 7 6 5 4 3 2 1 Initial Tx Tx @ 1 Tx @ 2 Nebulizer (n=17) MDI-spacer (n=17) Closa RM, et al. Pediatr Pulmonol 1998; 26:344-348. 6
Drug Delivery System Characteristics Characteristic Nebulizer MDI + VHC Efficacy ++ ++ Efficiency - + Time and Maintenance - ++ Cost + ++ Parent Preference - + Portability/Power - + Reliability: Adherence & Technique +/- +/- Change In % Predicted = High Dose MDI = Low Dose MDI = Nebulizer FEV 1 Ages 5-17 Yrs CHANGE % FEV 1 Schuh S. et al. J Pediatr 1999; 135:22-27 TIME (min) (n = 30/group) 30 60 90 7
And You Thought You Had a Crummy Job LOS In Asthmatic Children Treated With Bronchodilators: Nebulizer Vs. MDI-Spacer 100 80 60 40 20 n = 33 n = 29 Nebulizer MDI-Spacer Dewar AL, et al. Arch J Dis Child 1999; 80:421-423. 8
Drug Deposition (%) Clinical Scores: Admission To Discharge: 1-5 Year Old Asthmatics Mean Clinical Asthma Score 5 4 3 2 MDI (n=30) Nebulizer (n=30) Albuterol & Ipratroprium 1 Base Line 12 24 3 Time (hours) 6 48 60 Parkin PC, et al. Arch Dis Child 1995; 72:239-240. 16 MDI vs Nebulizer 14 12 10 8 6 4 2 0 Results from 13 in-vitro studies of drug deposition in neonatal and pediatric lung models during mechanical ventilation Box plots represent the % drug deposition reported in each study. Shaded triangles represent the arithmetic mean -2 Nebulizers Metered-Dose Inhalers 9
Preferences: Nebulizer Vs MDI-VHC Nebulizer MDI + VHC Preference by Parents 6-15% 85-96% Perceived Acceptance by Child 38% 62% Leversha, et al. J Pediatr 2000; 136:497-502. Ploin, et al. Pediatr 2000; 106:311-317. (N=24) Administration Technique At Home In 5-26 Month Old Children % PERFORMED Child sits upright 91 MDI is placed correctly into the spacer 100 MDI/spacer is shaken 5 s 68 Time between shaking and actuating is < 5 s? 77 Face mask is placed on face before actuation of the puff 86 There is a close fit of the face mask 73 Only one puff is actuated? 91 Child breathes for 30 s through the spacer 46 Child breathes quietly through the spacer? 64 Face mask is held on face during the 30 s? 50 Janssens et al. Eur Respir J 2000; 16:850-856. 10
Output (ug) Product Comparison of Nebulizer Output 4ml albuterol solution 0.625mg/ml, 8 L/min,Vt 600ml, 10 bpm, to sputter 1400 1270 1200 1000 800 1029 Total Mass Respirable Dose 600 400 453 371 340 262 441 335 200 168 197 191 138 0 AeroEclipse PARI LCD Alleg. Side Stream Alleg. Misty Neb Hudson Micro Mist WestMed Circulair 11
Costs of Albuterol Jan-May 2004 Jan-May 2006 Administration # Tx's # Pts # Tx's # Pts MDI-VHC 2,474 197 6,178 401 SVN 7,441 714 1,843 295 Device Costs SVN-mask $2.36 ea X 3 = $7.08 x (#Pts) $5,055 $2,089 Multi-dose vial $1.94 x (# Pts) $1,385 $572 MDI canister $2.45 ea x (# Pts) $483 $982 VHC $13.65 x (# Pts) $2,689 $5,474 Labor Costs MDI-VHC = 13.2 x $0.61 = $8.05 x (# Txs) $19,916 $49,733 SVN = 20.4 x $0.61 = $12.44 x (# Txs) $92,566 $22,927 Total Tx costs $122,094 $81,777 Total # Txs 9,915 8,021 Total cost per Tx $12.31 $10.20 Percent cost reduction 04 to 06 = 21% Methods of Albuterol Administration All Pts Receiving Albuterol January-May 2004 2005 2006 MDI 25% 63% 77% SVN 75% 37% 23% Percent of Tx s Administered via Two Methods 12
Methods of Albuterol Administration Among Asthmatics January-May 2004 2005 2006 MDI 9% 67% 79% SVN 91% 33% 21% Percent of Tx s Administered via Two Methods Asthmatic LOS (Non-ICU > 2 Yrs) 2004 2005 2006 Mean 1.4 1.4 1.5 SD 0.8 1.0 1.0 Count 471 426 315 Minimum 1 1 1 Maximum 5 9 8 13
Summary of Albuterol Treatments 2004 2005 2006 Mean* 13.6 14.6 16.1 Standard Deviation 20.5 26.4 35.9 Trimmed Mean (10%) 9.4 9.4 9.7 Median 8 7 8 Minimum 1 1 1 Maximum 173 341 587 * Kruskal-Wallis P = 0.21 john.salyer@seattlechildrens.org 14
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