Transcript MDI with Chamber - Armstrong Medical

Spirale® DDS - Drug Delivery System
Setting the Scene
Setting the scene
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Inhaled bronchodilators reduce airway resistance, reduce the work of breathing and
play a vital role in the care of patients with obstructive lung disease.
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Immediate and effective bronchodilator therapy is pivotal to successful stabilization
and weaning of mechanically ventilated patients.
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It is not intuitively obvious to clinicians with ICU experience that many bronchodilator
treatments given to intubated patients appear to have any clinical effect whatsoever.
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This probably is often a result of very poor drug delivery to the lungs.
– RESPIRATORY CARE • JULY 2010 VOL 55 NO 7
Optimal Particle Size
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Particles with a mass of 1-5 μm are optimal for drug deposition.
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Particles >5μm simply coat the Ventilator tubing and ET Tube.
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0.5 μm are too small for deposition and are exhaled again.
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2 - 5 μm are deposited inside the tracheobronchial airways.
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1- 2 μm are deposited in the alveolar.
Optimal Particle Size
Drug Delivery for the Mechanically Ventilated
What are the Patient,
Options?
Nebulisers
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A nebuliser is a device used to administer medication in the form of a mist inhaled
into the lungs .
Three different types of nebulizers are used for aerosol drug delivery during
mechanical ventilation.
– Jet nebulizers
– Ultrasonic wave nebulizers
– Vibrating Mesh nebulizers
Jet Nebulisers
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Connected by tubing to a compressor
that causes compressed air or oxygen
to flow at high velocity through a
liquid medicine to turn it into an
aerosol.
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Jet nebulisers create a particle mass of
JN 2-5 μm.
Jet Nebulisers
Jet Nebulisers
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Unit cost is relatively cheap but as they should be single use can be expensive
practice.
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Disconnection between use is an issue for loss of PEEP and VAP.
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Large drug wastage with residual volume.
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Time consuming.
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Out put affected by flow rate.
Ultrasonic Nebulisers
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An electronic oscillator generates a high frequency ultrasonic wave using a
piezoelectric crystal. This vibrating element is in contact with a liquid reservoir and its
high frequency vibration is sufficient to produce a vapour mist.
Ultrasonic Nebulisers
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Capital equipment required.
Drug wastage with residual volume.
Noisy.
Out put affected by medication volume,
flow rate and position.
Increase in temperature over time with
risk of drug degradation.
Vibrating Mesh Nebulisers
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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.
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This technology has shorter treatment times, less liquid waste and undesired heating
of the medical liquid.
Vibrating Mesh Nebulisers
Vibrating Mesh Nebulisers
Vibrating Mesh Nebulisers
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Particle size: 2.1µm MMAD.
Consistent drug delivery.
Does not heat or degrade medication.
Inline.
Heavy.
Expensive. With ongoing maintenance
, reprocessing or disposable costs.
May require connectors.
Still only 14% drug deposition.
Although they have invested they may
not always have enough machines
available for every bed space.
Nebulisers Summary
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JNs are less efficient than ultrasonic and VM nebulizers.
– (Harvey et al., 1993; Dhand, 2002,2004; Ari et al., 2009, 2010a; Waldrep and Dhand, 2008).
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Although JNs are less expensive, both ultrasonic and VM nebulizers provide a higher
rate of nebulization in a shorter period of time.
– (Ari et al., 2010a; Dhand 2002, 2004; Harvey, 1993).
Metered Dose Inhaler
MDI cannister is depressed…
…releasing a high velocity mixture of drugs and propellant.
MDI in the hospital
Identical Function
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Different Adapter
Adapter is inserted into the breathing circuit.
MDI canister is inserted into adapter.
Canister is depressed (in synchronization with patient
inspiration).
Performance of other MDI’s
MDI with Chamber
MDI with Chamber
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MDI with Chamber (also commonly referred to as Spacer or Reservoir)
– Large Particle mixture of drugs and propellant deposited within the chamber
– As the mixture travels through the chamber the propellant evaporates and particle size
decreases
– Inhaled aerosol is enriched in small particles that travel deeper in the respiratory system and
are absorbed by the lungs
MDI with Chamber
Particle Size How important is it???
A. Lung and oralpharyngeal deposition of large particle drug delivered through MDI
B. Lung and oralpharyngeal deposition of small particle drug delivered through same MDI
Particle Size is
EVERYTHING!
Leach CL, Davidson PJ, Boudreau RJ; Improved airway targeting with the CFC-free HFA-beclomethasone metered-dose inhaler compared
with CFC-beclomethasone, Eur Respir J 1998 126 1346-1353
MDI with Chamber
J L Rau, R J Harwood and J L Groff
Chest 1992;102;924-930
MDI with Chamber
(HOW IT WORKS)
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MDI with Chamber
The Chamber - How does it work?
As time and distance travelled increases…
•Smaller particles travel further into the lungs
•Smaller particles are more easily absorbed by lung tissue.
speed and particle size decrease.
•The larger the chamber the smaller the particle
Nebuliser Versus MDI
Nebulizer vs MDI
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DRUG
NEBULISER
MDI
Savings
Salbutamol
€0.13
€0.01
€0.12
Ipratropium
€0.43
€0.02
€0.41
Combivent
€0.54
€0.04
€0.50
– Prices are per single dose.
– (British Medical Association & Royal Pharmaceutical Society of Great Britain, 2007)
Nursing Time Savings
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It takes nurses 18 minutes to prepare, deliver, dismantle, wash and dry nebulisers.
It takes one minute to administer MDI on patient with respiratory rate of 12/min.
– (Salford Royal Hospitals NHS Trust, 2004)
What the Papers Say
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MDI & spacer = greater efficiency of aerosol deposition in lungs than nebulisers.
– Fuller et al (1990)
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MDI & spacer = most effective method of delivering inhaled bronchodilators in
ventilated patients.
– Marik et al (1999)
What the Papers Say
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“The use of a reservoir showed a significant increase in the amount of drug
delivered.”
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“Using a chamber spacer with the pMDI reduces losses in the circuit and increases
drug delivery up to six fold.”
– Ari et al. Factors Affecting Bronchodilator Delivery in Mechanically Ventilated Adults. 2010
British Association of Critical Care Nurses.
Challenges for introduction
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DRIVING FORCES
Cost Effective
RESTRAINING FORCES
Staff Resistance
Easy to Use
Saline Nebs Cannot be delivered via MDI
Reduced Risk of Infection
Less Nursing Time Spent
Little Evidence on MDI
for Steroid Inhalation
More Effective Dose Delivered
Not required by all ventilator patients
Less interference with
Ventilation parameters
Setting the scene
Sales Strategy Implementation
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Multidisciplinary protocol
Involve all groups
Clinician, Nurse, Microbiology
Pharmacy and Procurement
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Present Strongly on…
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Drug Delivery Efficacy
Infection Control, reduced risk
Savings, Device, Drug and Time
Customisation
Areas for discussion
Understand first your customers practice
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Do we know how much drug we are giving the patient? What about residual
volumes?
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Breaking of the patient circuit with the obvious infection control issues….query
storage of the patients nebulizer between treatments. Also consider loss of PEEP
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Introducing cold fresh gas….upsetting volume settings….creating a delay period for
patient tests e.g. blood gases.
Why Spirale®
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Spirale® DDS eliminates/reduces the need to break the
circuit reducing the risk of VAP and other infections.
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Spirale® DDS eliminates risk from environmental
contamination.
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Spirale® DDS can stay in the circuit for 7 days, requires no
driving gas and therefore does not interfere with
Ventilator settings.
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Spirale® DDS provides accurate drug delivery.
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Spirale® DDS allows for immediate blood gas analysis,
assisting with early diagnosis and treatment of the
patient.
Why Spirale
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Spirale® DDS reduces drug delivery costs.
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Spirale® DDS saves nursing time – Ease of Use.
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Spirale® DDS designed for use with the new generation
of drug counter MDI’s.
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Spirale® DDS reduces hospitals waste, less nebulizers
thrown out.
Setting the scene
Features
and Benefits
Count the Doses…
Only device on the market that accepts dose
counter, allowing greater accuracy drug delivery
Closed Circuit
Internal locking mechanism seals to ensure a closed
breathing circuit
Easy to Use
Self expanding when opened.
Locks closed with a simple twist!
Very Low Dead Space
16ml when collapsed
Customized Solutions
Available with a wide variety of catheter
mounts, breathing circuits, HME filters, masks
and other respiratory disposables from Armstrong
Spirale® DDS - Drug Delivery System