1
Seattle Children’s Hospital
Metered Dose
Inhalers with Valved
Holding Chamber:
A Pediatric Hospital
Experience
John Salyer RRT-NPS, MBA, FAARC
Director Respiratory Care
Children’s Hospital
Seattle Washington
8th Annual North Regional
Respiratory Care Conference
Minnesota & Wisconsin Societies for
Respiratory Care
Mayo Civic Center
Rochester, Minnesota
April 30th - May 2nd, 2012
7
May You Live in Interesting Times
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Seattle Children’s Hospital
Methods of Albuterol Administration
Among Asthmatics
January-May
2004 2005 2006
MDI-VHC 9% 67% 79%
SVN 91% 33% 21%
Seattle Children’s Hospital
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
3
Seattle Children’s Hospital
• Why use MDI-VHC?
• What was the scientific evidence
• How best to implement this plan
• How to measure it’s impact
The Question
Seattle Children’s Hospital
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
4
Seattle Children’s Hospital
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Do
se i
nh
ale
d,
mg
0 cm 1 cm 2 cm
Delivered Dose – Facemask (in vitro)
increasing distance from “face”
Everard ML, et al. Arch Dis Child 1992;67:586-91
Distance of mask from filter ‘face’
4 ml of 1% cromolyn; flow = 8 l/min, VT = 50 ml
0.5%
1.4%
3.1%
Seattle Children’s Hospital
The Evidence
Great Britain:
• Nebulizers are rarely needed for young children; spacer
devices are as effective, cheaper, and less time
consuming
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.
5
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
Seattle Children’s Hospital
Fink JB. Humidity and aerosol therapy: In: Mosby’s respiratory care equipment. St. Louis MO: Mosby-Elsevier Inc.;2007:
100%
90%
70%
80%
60%
50%
40%
30%
20%
10%
0%
Dep
osi
tio
n
pMDI pMDI
spacer
pMDI/VHC
Electro-
static
pMDI/VHC
Non-Electro-
static
SVN DPI
Exhaled
Device
Mouth
Lung
6
20 40 60
Median
Change In
Pulmonary
Index
Elapsed Time after Tx (min)
Response To Albuterol in 1-5 Year Olds With
Recurrent Wheezing in ED
Ploin D, et al. Pediatrics 2000; 106:311-317.
(MDI + HC) Group (n=32) (n=31)
-6
-5
-4
-3
-2
-1
0
Nebulized Group
Seattle Children’s Hospital
Emergent Treatment: 1-24 Month Olds With Terbutaline
Closa RM, et al. Pediatr Pulmonol 1998; 26:344-348.
Clinical
Score
Nebulizer (n=17)
MDI-spacer (n=17)
Tx @ 1°
1
2
3
4
5
6
7
8
9
10
Initial Tx Tx @ 2°
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Seattle Children’s Hospital
Drug Delivery System Characteristics
Characteristic Nebulizer MDI + VHC
Efficacy ++ ++ Efficiency - +
Time and Maintenance - ++ Cost + ++
Parent Preference - + Portability/Power - +
Reliability: Adherence & Technique +/- +/-
Seattle Children’s Hospital
CH
AN
GE
% F
EV
1
TIME (min)
Schuh S. et al.
J Pediatr
1999; 135:22-27
= High Dose MDI
= Low Dose MDI
= Nebulizer
(n = 30/group)
Change In
% Predicted
FEV1
Ages
5-17 Yrs
30 60 90
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And You Thought You Had a Crummy Job
Seattle Children’s Hospital
Dewar AL, et al. Arch J Dis Child 1999; 80:421-423.
LOS In Asthmatic Children Treated With
Bronchodilators: Nebulizer Vs. MDI-Spacer
20
40
60
80
100
Nebulizer MDI-Spacer
n = 33
n = 29
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Seattle Children’s Hospital
Clinical Scores: Admission To Discharge:
1-5 Year Old Asthmatics
Albuterol &
Ipratroprium
Parkin PC, et al. Arch Dis Child 1995; 72:239-240.
Mean
Clinical
Asthma
Score
MDI (n=30)
Nebulizer (n=30)
60 48 3
6
24 12 Base
Line
1
2
3
4
5
Time (hours)
-2
0
2
4
6
8
10
12
14
16
Nebulizers
Metered-Dose
Inhalers
Dru
g D
ep
os
itio
n (
%)
MDI vs Nebulizer
• 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
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Seattle Children’s Hospital
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.
Preferences: Nebulizer Vs MDI-VHC
Seattle Children’s Hospital
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.
(N=24)
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Seattle Children’s Hospital
Product Comparison of Nebulizer Output 4ml albuterol solution 0.625mg/ml, 8 L/min,Vt 600ml, 10 bpm, to sputter
1270
1029
453
371340
262
441
168
335
197 191138
0
200
400
600
800
1000
1200
1400
Ou
tpu
t (u
g)
AeroEclipse™ PARI LCD Alleg. Side
Stream
Alleg. Misty
Neb
Hudson Micro
Mist
WestMed
Circulair
Total Mass
Respirable Dose
Seattle Children’s Hospital
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Seattle Children’s Hospital
Costs of Albuterol
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%
Jan-May 2004 Jan-May 2006
Seattle Children’s Hospital
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
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Seattle Children’s Hospital
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
Seattle Children’s Hospital
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
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Seattle Children’s Hospital
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
Seattle Children’s Hospital
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