Aerosol therapy: The special needs of young children

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Summary

Efficient aerosol therapy in young children is a challenge. The aerosol administration method requires special features, because young children can not perform an inhalation manoeuvre, breath usually through the nose and may be distressed during the administration. The prescribing clinician should be aware of the advantages and disadvantages of the different inhalation devices available, in order to select the proper device for each individual patient. For maintenance asthma therapy in young children the pressurized metered dose inhaler (pMDI) combined with spacer is the first choice for delivering aerosols. A facemask can be attached if a child is unable to breath through the mouth. A small leak of the facemask can reduce the dose delivered dramatically, therefore a good seal is crucial. Lung deposition can be improved by using a pMDI with extra-fine particles. However, even if the most optimal device is chosen, cooperation during administration remains the most important determinant for efficient drug delivery. During crying the dose to the lungs is minimal. Optimal aerosol delivery to the lungs of young children can be achieved with a good facemask seal, good cooperation of the child, with quiet breathing and an aerosol with small particles.

Introduction

Aerosol therapy in the treatment of paediatric respiratory disorders has gained importance over the last decades. Aerosol therapy is now the mainstay of asthma management in children, and is increasingly important for the treatment of other respiratory disorders such as cystic fibrosis and bronchopulmonary dysplasia. Delivering aerosolized drugs to young children is a challenge. Several conditions should be taken in consideration when selecting an administration method for these children. Firstly, about one third of young children under 2 years of age are distressed during the administration method.1 Secondly, the administration method must be suitable for tidal breathing inhalation. Thirdly, the administration method must be suitable for both nasal and oral breathing since young children have preferential nasal breathing. Most children below the age of 6 months are even obligatory nose breathers. In addition, most young children are not able to breath through the mouth on command. There is a large number of aerosol delivery devices on the market each with its own specifications and limitations. Unfortunately, there is a limited number of studies that focus on factors that influence aerosol deposition of these various delivery devices in young children. For effective aerosol therapy in young children the prescribing clinician should match the proper aerosol delivery device to the patient. To do this correctly detailed knowledge is needed about the devices and about patient-related aspects.

Section snippets

Delivery systems

The current methods to deliver therapeutic aerosols can be classified in three categories: nebulizers (jet or ultrasonic); pressurized metered dose inhalers (pMDI's) that can be used with a press-and-breathe technique, as a breath actuated device, or in combination with a spacer; and dry powder inhalers (DPI's).

Many DPI's are not suitable for young children. Most children below the age of 8, or older children in case of severe dyspnoea, are not able to generate an inspiratory flow through the

Selection of delivery device

To select the proper aerosol delivery device for a patient is not an easy task. One needs to be well informed about the following aspects. Firstly, of the pathophysiology and the severity of the lung disease in the patient. Secondly, about the pharmacological aspects of the various drugs that can be used for the treatment. Thirdly, about the technical qualities of the delivery devices. This includes literature on the aerosol characteristics of the delivery device both in vitro as in vivo.

Summary

Aerosol therapy is complex, especially in young children. Therefore, the prescribing physician needs detailed knowledge about: aerosol and deposition characteristics of the various aerosol delivery systems; the pathophysiology of the lung disease; the skills of the patient in various age groups. Only when this knowledge is available the appropriate delivery device for the child can be selected and the proper instructions can be given. Optimal aerosol delivery to the lungs can be achieved with a

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