Nebulizer therapy technique. Nebulizer therapy in the practice of a therapist

• Distress syndrome in adults and children

  Inhalation of surfactant preparations is performed.

• Primary pulmonary hypertension

  Inhalation administration of iloprost (a stable analogue of prostacyclin) using a nebulizer 6 to 12 times a day is effective method therapy of primary pulmonary hypertension. Such treatment leads to improved hemodynamics, increased physical performance, and, possibly, an improved prognosis.

• Acute respiratory diseases.
• Pneumonia.
• Bronchiectasis.
• Bronchopulmonary dysplasia in newborns.
• Viral bronchiolitis.
• Respiratory tuberculosis.
• Chronic sinusitis.
• Idiopathic fibrosing alveolitis.
• Post-transplant obliterating bronchiolitis.

In palliative therapy, the tasks of which are to alleviate the symptoms and suffering of terminal patients, inhalation therapy is used to reduce refractory cough (lidocaine), incurable dyspnea (morphine, fentanyl), delayed bronchial secretion (physiological saline), bronchial obstruction (bronchodilators).

Promising areas of use of nebulizers are such areas of medicine as gene therapy (a gene vector - adenovirus or liposomes is injected in the form of an aerosol), administration of certain vaccines (for example, measles), therapy after heart-lung complex transplantation (steroids, antiviral drugs), endocrinology ( administration of insulin and growth hormone).

• Contraindications
  • Pulmonary bleeding and spontaneous pneumothorax against the background of bullous emphysema of the lungs.
  • Cardiac arrhythmias and heart failure.
  • Individual intolerance to the inhalation form of medications.

• Factors determining the effectiveness of using nebulizers

  Conventionally, all factors affecting the production of aerosol, its quality and deposition in the patient's airways, i.e. determining the effectiveness of nebulizer technology can be divided into three large groups:

  • Factors associated with the inhalation device

    The objective of inhalation therapy with a nebulizer is to produce an aerosol with a high proportion (\u003e 50%) of respirable particles (less than 5 μm) over a fairly short time interval (usually 10-15 minutes).

    Aerosol production efficiency, aerosol properties and delivery to the respiratory tract depend on:

    • The type of nebulizer, its design features

      Despite the similar design and construction, different models of nebulizers may differ significantly. When comparing 17 types of jet nebulizers, it was shown that the differences in the aerosol yield reached 2 times (0.98-1.86 ml), in the respirable aerosol fraction - 3.5 times (22-72%), and in the speed delivery of particles of the respirable fraction of drugs - 9 times (0.03-0.29 ml / min). In another study, the average deposition of the drug in the lungs differed 5 times, and the average oropharyngeal deposition - 17 times.

      The main factor that determines the deposition of particles in the respiratory tract is the size of the aerosol particles. Conventionally, the distribution of aerosol particles in the respiratory tract, depending on their size, can be represented as follows:

      • More than 10 microns - deposition in the oropharynx.
      • 5-10 microns - deposition in the oropharynx, larynx and trachea.
      • 2-5 microns - deposition in the lower respiratory tract.
      • 0.5-2 microns - deposition in the alveoli.
      • Less than 0.5 microns - no deposition in the lungs.

      In general, the smaller the particle size, the more distally their deposition occurs: at a particle size of 10 μm, the deposition of aerosol in the oropharynx is 60%, and at 1 μm, it approaches zero. Particles with a size of 6-7 microns are deposited in the central airways, while the optimal size for deposition in the peripheral airways is 2-3 microns.

      In addition, the effectiveness of nebulizer therapy depends on the type of nebulizer. For example, when using ultrasonic nebulizers, the use of medicines in the form of suspensions and viscous solutions, and heat-sensitive medications may deteriorate due to heating in ultrasonic nebulizers. Conventional (convection) compressor nebulizers require relatively high working gas flows (over 6 l / min) to achieve adequate aerosol output. In patients with cystic fibrosis, it was shown that Venturi nebulizers, in comparison with conventional nebulizers, made it possible to achieve twice the deposition of the drug in the respiratory tract: 19% versus 9%.

    • Residual volume and filling volume

      The drug cannot be used completely, as part of it remains in the so-called “dead” space of the nebulizer, even if the chamber is almost completely drained.

      The residual volume depends on the design of the nebulizer (ultrasonic nebulizers have a larger residual volume), and usually ranges from 0.5 to 1.5 ml. The residual volume is independent of the fill volume, however, based on the residual volume, recommendations are made on the amount of solution to be added to the nebulizer chamber. Most modern nebulizers have a residual volume of less than 1 ml, for which the filling volume must be at least 2 ml. The residual volume can be reduced by lightly tapping the nebulizer chamber towards the end of the procedure, while large drops of solution return from the chamber walls to the working area, where they are again nebulized.

      The filling volume also affects the aerosol yield, for example, with a residual volume of 1 ml and a filling volume of 2 ml, no more than 50% of the drug can be converted into aerosol (1 ml of solution will remain in the chamber), and with the same residual volume and filling volume of 4 ml up to 75% of the drug can be delivered to the respiratory tract. However, with a residual volume of 0.5 ml, an increase in the filling volume from 2.5 to 4 ml leads to an increase in the drug yield by only 12%, and the inhalation time increases by 70%. The higher the selected initial volume of solution, the greater the fraction of the drug can be inhaled. However, this also increases the nebulization time, which can significantly reduce patient compliance with therapy.

    • Working gas flow rates

      The working gas flow for most modern nebulizers is in the range of 4-8 l / min. An increase in flux results in a linear decrease in aerosol particle size, as well as an increase in aerosol yield and a decrease in inhalation time. The nebulizer has a known flow resistance, therefore, in order to adequately compare the compressors with each other, the flow must be measured at the nebulizer outlet. This "dynamic" flux is the true parameter that determines the particle size and nebulization time.

    • Nebulization time

      The release of the drug differs from the release of the solution due to evaporation - by the end of inhalation, the drug solution in the nebulizer is concentrated. Therefore, early cessation of inhalation (for example, at the moment of "splashing" (the moment when the aerosol formation process becomes intermittent) or earlier) can significantly reduce the amount of drug delivery.

      There are several ways to determine the nebulization time:

      • "Total nebulization time" - the time from the start of inhalation to complete drying of the nebulizer chamber;
      • "Spray time" - the time of the start of spraying, the hissing of the nebulizer, that is, the point when air bubbles begin to enter the working area, and the aerosol formation process becomes intermittent;
      • "Clinical nebulization time" is the average time between "total" and "spray time", that is, the time at which the patient usually stops inhalation.

      Too long inhalation time (more than 10 minutes) can reduce the patient's compliance with therapy. It is rational to recommend the patient to inhale for a fixed time, based on the type of nebulizer, compressor, filling volume and type of drug.

    • Aging nebulizer

      Over time, the properties of a compressor (jet) nebulizer can change significantly, in particular, wear and expansion of the venturi hole is possible, which leads to a decrease in the "working" pressure, a decrease in the speed of the air stream and an increase in the diameter of aerosol particles. Washing the nebulizer can also lead to a faster "aging" of the nebulizer, and with rare cleaning of the chamber, the outlet can be blocked by crystals of drugs, leading to a decrease in aerosol output. In the absence of processing (cleaning, washing) of the nebulizer, the quality of aerosol production decreases, on average, after 40 inhalations.

      A class of "durable" nebulizers is distinguished, the service life of which can reach 12 months with regular use (Pari LC Plus, Omron CX / C1, Ventstream, etc.), but their cost is an order of magnitude higher than nebulizers with a shorter service life.

    • Compressor-nebulizer system combinations

      Each compressor and each nebulizer has its own characteristics, so the random combination of any compressor with any nebulizer does not guarantee optimal performance of the nebulizer system and maximum effect... So, for example, when combining the same nebulizer (Cirrus) with 6 different compressors using 2 of them, the aerosol particle size and "dynamic" flow were outside the recommended limits.

      Examples of some optimal nebulizer-compressor combinations:

      • Pari LC Plus + Pari Boy.
      • Intersurgical Cirrus + Novair II.
      • Ventstream + Medic-Aid CR60.
      • Hudson T Up-draft II + DeVilbiss Pulmo-Aide.
    • Solution temperatures

      The temperature of the solution during inhalation when using a jet nebulizer can decrease by 10 ° C or more, which can increase the viscosity of the solution and reduce the release of aerosol. To optimize nebulization conditions, some nebulizer models use a heating system to raise the solution temperature to body temperature (Paritherm).

  • Patient factors Aerosol deposition can be influenced by factors such as:
    • Breathing pattern

      The main components of the respiratory pattern (cycle) that affect the deposition of aerosol particles are tidal volume, inspiratory flow and inspiratory fraction - the ratio of the inhalation time to the total duration of the respiratory cycle. The average inspiratory fraction in a healthy person is 0.4-0.41, in patients with severe exacerbation of chronic obstructive pulmonary disease (COPD) - 0.34-0.36.

      When using a conventional nebulizer, aerosol is generated throughout the entire respiratory cycle, and its delivery to the respiratory tract is possible only during inhalation, that is, it is directly proportional to the inspiratory fraction.

      A rapid inhalation and aerosol spray into the mid- and late-inspiratory stream of air increases central deposition. In contrast, inhaling slowly, inhaling aerosol at the beginning of inspiration, and holding the breath at the end of inspiration, increase the peripheral (pulmonary) deposition. Increasing minute ventilation also increases the deposition of aerosol particles in the lungs, but this may also be reduced due to increased inspiratory flow.

      A particular problem in children is an irregular breathing pattern associated with dyspnea, coughing, crying, etc., which makes aerosol delivery unpredictable.

    • Breathing through the nose or mouth

      Inhalation with a nebulizer is carried out through a mouthpiece or face mask. Both interface types are considered effective, but nasal breathing can significantly reduce aerosol deposition when breathing through a mask. The mask approximately halves the delivery of aerosol to the lungs; in addition, at a distance of 1 cm from the face, the aerosol deposition falls by more than 2 times, and at a distance of 2 cm, by 85%.

      Due to its narrow cross-section, steep airflow direction and hairiness, the nose creates ideal conditions for inertial collision of particles and is an excellent filter for most particles larger than 10 microns. The nasal deposit increases with age: in children aged 8 years, about 13% of the aerosol is deposited in the nasal cavity, in children 13 years old - 16%, and in adults (average age 36 years) - 22%.

      Given these findings, wider use of mouthpieces is recommended, and face masks play a major role in children and in intensive care. To avoid getting the drug in the eyes when using a mask, it is recommended, if possible, to use mouthpieces when inhaling corticosteroids, antibiotics, anticholinergic drugs (cases of exacerbation of glaucoma are described).

    • Airway geometry

      There are significant differences in airway geometry from person to person.

      Central (tracheobronchial) deposition is higher in patients with a smaller diameter of the conducting airways. Narrowing of the airway from any cause can affect the distribution of particles in the lungs. In most broncho-obstructive diseases, an increase in central and a decrease in peripheral deposition is noted. For example, in patients with cystic fibrosis, delivery to the tracheobronchial regions increases by 200-300%, and the pulmonary peripheral deposition of β-DNase is directly proportional to the FEV 1 index. A similar phenomenon is observed in COPD and bronchial asthma. Have cOPD patients the peripheral aerosol deposition was the less, the more pronounced the bronchial obstruction.

      Inhalation of terbutaline with a predominant distribution in the central or peripheral respiratory tract leads to the same bronchodilatory effect.

    • Body position

      In HIV patients receiving regular inhalation of pentamidine to prevent Pneumocystis carini infection, Pneumocystis pneumonia can nevertheless develop in the upper zones of the lungs, since with calm breathing in a sitting position, only a small part of the aerosol reaches these regions.

  • Factors associated with the drug

    Most often in clinical practice, solutions of medicinal substances are used for inhalation with nebulizers, but sometimes medications for inhalation can be in the form of suspensions. The principle of aerosol generation from suspensions has significant differences. The suspension consists of insoluble solid particles suspended in water. When nebulizing a suspension, each aerosol particle is a potential carrier of a solid particle, therefore it is very important that the particle size of the suspension does not exceed the size of the aerosol particles. The average particle diameter of the budesonide suspension (Pulmicort) is about 3 microns. An ultrasonic nebulizer is ineffective for delivering medicinal suspensions.

    Viscosity and surface tension affect the aerosol yield and performance. A change in these parameters occurs when substances are added to the dosage forms that increase the dissolution of the main substance - co-solvents (for example, propylene glycol). An increase in propylene glycol concentration leads to a decrease in surface tension and an increase in aerosol yield, but at the same time an increase in viscosity occurs, which has the opposite effect - a decrease in aerosol yield. Optimal content of co-solvents allows improving aerosol properties.

    When inhaled antibiotics are prescribed to patients with chronic lung disease, the best deposition is achieved with nebulizers that produce very small particles. Antibiotic solutions have a very high viscosity, so powerful compressors and inhalation nebulizers must be used.

    The osmolarity of the aerosol affects its deposition. When passing through a humid airway, an increase in the size of particles of a hypertonic aerosol and a decrease in a hypotonic one can occur.

• Rules for the preparation and conduct of inhalations
  • Preparation for inhalation

    Inhalation is carried out 1-1.5 hours after a meal or physical activity... Smoking is prohibited before and after inhalation. Before inhalation, do not use expectorants, gargle with antiseptic solutions.

  • Preparation of solution for inhalation

    Solutions for inhalation should be prepared on the basis of physiological solution (0.9% sodium chloride) in compliance with the rules of antiseptics. It is forbidden to use tap, boiled, distilled water, as well as hypo- and hypertonic solutions for these purposes.

    Syringes are ideal for filling nebulizers with an inhalation solution; pipettes are also possible. It is recommended to use 2-4 ml filling volume of the nebulizer. The container for preparing the solution is preliminarily disinfected by boiling.

    Store the prepared solution in the refrigerator for no more than 1 day, unless otherwise provided by the annotation for the use of the drug. Before starting inhalation, it is recommended to heat the prepared solution in a water bath to a temperature of at least + 20C °. Decoctions and herbal infusions can only be used after thorough filtration.

  • Inhalation
    • During inhalation, the patient should be in a sitting position, not talking and keep the nebulizer upright. During inhalation, it is not recommended to lean forward, since this position of the body makes it difficult for the aerosol to enter the respiratory tract.
    • In case of diseases of the pharynx, larynx, trachea, bronchi, the aerosol should be inhaled through the mouth. After a deep breath with your mouth, you should hold your breath for 2 seconds, then exhale completely through your nose. Better to use a mouthpiece or mouthpiece than a mask.
    • In case of diseases of the nose, paranasal sinuses and nasopharynx, it is necessary to use special nasal nozzles (nasal cannulas) for inhalation, inhalation and exhalation must be done through the nose, breathing is calm, without tension.
    • Since frequent and deep breathing can cause dizziness, it is recommended to take breaks in inhalation for 15-30 seconds.
    • Continue inhalation until liquid remains in the nebulizer chamber (usually about 5-10 minutes), at the end of inhalation - gently beat the nebulizer to fully utilize the drug.
    • After inhaling steroids and antibiotics, rinse your mouth thoroughly. It is recommended to rinse your mouth and throat with boiled water at room temperature.
    • After inhalation, rinse the nebulizer with clean, if possible sterile water, dry using napkins and a gas stream (hair dryer). Frequent flushing of the nebulizer is necessary to prevent drug crystallization and bacterial contamination.

• Drugs used for nebulizer therapy
  • Bronchodilators Selective short-acting β-2-adrenergic receptor agonists:
    M-anticholinergics:
    • Ipratropium bromide (Atrovent) r / r for inhalation 0.25 mg / ml
    Combined bronchodilators:
    • Fenoterol / Ipratropium bromide (Berodual) r / r for inhalation 0.5 / 0.25 mg / ml
    • Nebulizer bronchodilator therapy for bronchial asthma

      • Adults and children over 18 months: chronic bronchospasm, which cannot be corrected by combination therapy, and exacerbation of severe asthma - 2.5 mg up to 4 times a day (a single dose can be increased to 5 mg).

        For the treatment of severe airway obstruction, adults can be prescribed up to 40 mg / day (single dose not more than 5 mg) under strict medical supervision in a hospital setting.

      • Adults and children over 12 years old, for relief of an attack of bronchial asthma - 0.5 ml (0.5 mg - 10 drops). In severe cases - 1-1.25 ml (1-1.25 mg - 20-25 drops). In extremely severe cases (under medical supervision) - 2 ml (2 mg - 40 drops). Prevention of physical exertion asthma and symptomatic treatment of bronchial asthma - 0.5 ml (0.5 mg - 10 drops) up to 4 times a day.

        Children 6-12 years old (body weight 22-36 kg) for relief of an attack of bronchial asthma - 0.25-0.5 ml (0.25-0.5 mg - 5-10 drops). In severe cases - 1 ml (1 mg - 20 drops). In extremely severe cases (under medical supervision) - 1.5 ml (1.5 mg - 30 drops). Prevention of exercise-induced asthma and symptomatic treatment of bronchial asthma and other conditions with reversible airway narrowing - 0.5 ml (0.5 mg - 10 drops) up to 4 times a day.

        Children under 6 years of age (body weight less than 22 kg) (only under medical supervision) - about 50 μg / kg per dose (0.25-1 mg - 5-20 drops) up to 3 times a day.

      • Adults - treatment of exacerbations - 2.0 ml (0.5 mg, 40 drops), possibly in combination with β 2 -agonists, maintenance therapy - 2.0 ml 3-4 times a day.

        Children 6-12 years old - 1 ml (20 drops) 3-4 times / day.

        Children under 6 years old - 0.4-1 ml (8-20 drops) up to 3 times a day under medical supervision.

      • Inhalation through a nebulizer ipratropium bromide / fenoterol (combination drug)

        Adults - from 1 to 4 ml (20-80 drops) 3-6 times a day at intervals of at least 2 hours.

        Children 6-14 years old - 0.5-1 ml (10-20 drops) up to 4 times / day. In severe attacks, it is possible to prescribe 2-3 ml (40-60 drops) under the supervision of a doctor.

        Children under 6 years old - 0.05 ml (1 drop) / kg of body weight up to 3 times a day under the supervision of a doctor.

    • Nebulizer bronchodilator therapy for COPD
      • Inhalation through a salbutamol nebulizer

        2.5 mg up to 4 times during the day (a single dose can be increased to 5 mg). For the treatment of severe airway obstruction, adults can be prescribed up to 40 mg / day under strict medical supervision in a hospital setting.

        The solution is intended for use undiluted, however, if it is necessary to administer a salbutamol solution for a long time (more than 10 minutes), the drug can be diluted with sterile saline.

      • Inhalation through a fenoterol nebulizer

        Symptomatic treatment of chronic obstructive pulmonary disease - 0.5 ml (0.5 mg - 10 drops) up to 4 times a day.

        The recommended dose is diluted with physiological solution to a volume of 3-4 ml immediately before use. The dose depends on the method of inhalation and the quality of the spray. If necessary, repeated inhalations are carried out at intervals of at least 4 hours.

      • Inhalation through a nebulizer ipratropium bromide

        0.5 mg (40 drops) 3-4 times a day through a nebulizer.

        Nebulizer mucolytic therapy for COPD
        • Inhalation of acetylcysteine \u200b\u200bthrough a nebulizer

          To reduce the frequency of exacerbations and the severity of exacerbation symptoms, it is recommended to prescribe acetylcysteine, which has an antioxidant effect. Usually 300 mg x 1-2 times a day for 5-10 days or longer courses.

          The frequency of administration and the amount of dose can be changed by the physician depending on the patient's condition and therapeutic effect. Children and adults - the same dosage.

        • Inhalation of ambroxol through a nebulizer

          Adults and children over 6 years old - 1-2 inhalations of 2-3 ml of solution daily.

          Children under 6 years old - 1-2 inhalations of 2 ml of solution daily.

          The drug is mixed with a saline solution, it can be diluted in a 1: 1 ratio to achieve optimal air humidification in the respirator.

          The initial course of treatment is at least 4 weeks. The total duration of therapy is determined by the attending physician. Inhalation is carried out using a nebulizer through a face mask or mouthpiece.

        • Inhalation of budesonide through a nebulizer

          The dose of the drug is selected individually. If the recommended dose does not exceed 1 mg / day, the entire dose of the drug can be taken at a time (at a time). In case of a higher dose, it is recommended to divide it into 2 doses.

          Adults / elderly patients - 1-2 mg per day.

          Children 6 months and older - 0.25-0.5 mg / day. If necessary, the dose can be increased to 1 mg / day.

          Dose for maintenance treatment:

          Adults - 0.5-4 mg per day. In case of severe exacerbations, the dose may be increased.

          Children 6 months and older - 0.25-2 mg per day.

    • Proteolytic enzymes
      • Trypsin crystal amp. 0.005g, 0.01g
      • Ribonuclease amp., Fl. 10g
      • Deoxyribonuclease amp., Vial 10 g
    • Immunomodulators
    • Respiratory mucosa moisturizers
      • Mineral waters (Borjomi)
      • Sodium bicarbonate solution 0.5-2%

\\ ^ ffii. 1 Jt ^ ". j, 1

SCHOOL OF LIFE

Nebulizer therapy: a practical guide

Natalia Trushenko

Currently the most effective way treatment of diseases respiratory system inhalation therapy is rightfully considered. With the help of inhalation, targeted delivery is achieved - a rapid flow of the drug directly into the bronchi.

Today, one of the key positions in inhalation therapy is occupied by inhalations using nebulizers. A nebulizer (from the Latin word nebula - "fog", "cloud") is a device that converts liquid forms of drugs into tiny drops (aerosol cloud) and ensures the delivery of drugs to the lower respiratory tract.

Nebulizer therapy has a number of undeniable advantages:

Effective delivery of the drug directly to the bronchi;

Ease of performing inhalation (delivery of medication during calm breathing);

Intake of drugs into the lungs in pure form, the absence of propellants (additional impurities, for example, as in cans with metered aerosols);

Decrease in the amount of drug deposited in the oral cavity, insignificant absorption into the bloodstream and, as a result, a decrease in side effects.

Nebulizers play the greatest role in the treatment chronic diseases respiratory organs - bronchial asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis. Although, in certain situations, nebulizer therapy can be invaluable in treating pneumonia, acute bronchitis, croup and a number of other conditions.

Nebulizer model selection

When choosing a nebulizer, you need to clearly understand the goals and objectives of its use in the future: where it will be used - in a hospital, at home, on the road or at work (check the portability, weight of the device and the level of noise produced by it); what disease will be treated with it, what drugs, how much it will be used, how many family members, age of users.

Depending on the principle of operation, nebulizers are divided into the following types, each of which has its own advantages and disadvantages (Table 1). Compressor nebulizers, in which the medicinal substance is split into an aerosol by a powerful air flow, forced by a compressor. This is the most common and versatile type of nebulizer.

Table 1. Advantages and disadvantages of different types of nebulizers

Nebulizer type Advantages Disadvantages

Compressor stations Ability to use any drugs Relatively cheap Large selection of models Increased noise level Bulky

Ultrasonic Compactness (some models) Noiselessness Large chamber volume Large capacity (ml / min) Large residual volume There are drugs that can be destroyed by ultrasonic waves (budesonide!)

Mesh nebulizers (membrane) Portability (the smallest nebulizer in the world) Silence Possibility to use any medication Possibility of inhalation lying down More economical consumption of medicine Shorter inhalation time Possibility of clogging of micro-holes of the membrane with aerosol particles if the operating rules are not followed Require more careful maintenance High price

SCHOOL OF LIFE

Nebulizer device: 1 - nebulizer chamber, 2 - air-duct tube, 3 - compressor.

Ultrasonic nebulizers that break down drugs using ultrasound. They are often used in the physiotherapy departments of hospitals. Their main drawback in routine use is the inability to use a number of drugs (for example, budesonide).

Mesh nebulizers (from english word mesh - "sieve"), splitting the drug solution by sifting through a vibrating mesh-membrane (plate with multiple microscopic holes). This is a new generation of nebulizers that have several names: membrane, electronic mesh, nebulizers based on vibrating mesh technology (Vibrating MESH Technology). These nebulizers have a number of significant advantages (see Table 1). However, one should take into account the possibility of clogging of miniature holes with aerosol particles if the operating rules are not followed.

Each nebulizer consists of a nebulizer chamber for nebulization (or the nebulizer itself), which is filled with inhalation solution, a compressor (air pump) or an ul-

Table 2. Technical requirements for compressor nebulizers (European standards)

Aerosol particle size\u003e 50% should be in the range of 1-5 microns

Residual volume<1 мл

drug

Inhalation time<15 мин (для объема 5 мл)

Gas flow<10 л/мин

Working pressure 2-7 bar

Delivery rate\u003e 0.2 ml / min

Chamber volume\u003e 5 ml

ultrasonic generator (figure). The compressor and the nebulizer chamber are connected by a duct tube through which compressed air enters the chamber. In a nebulizer chamber, the medicine is converted into an aerosol that must be breathed through a face mask or mouthpiece. Pay attention to the additional equipment of the device: the presence of a nozzle for a nose (cannula), an AC adapter, the number of replaceable air filters, the length of the air tube; for children, the presence of a children's mask, distracting devices (toys-attachments for the camera or a game form of a nebulizer) are important.

When choosing a compressor device model, one should rely on the technical characteristics specified in the European standards for nebulizer therapy prEN 13544-1 (Table 2).

When sprayed, particles larger than 10 microns are deposited (and, accordingly, act) in the oropharynx, 5-10 microns - in the pharynx, larynx and trachea, 1-5 microns - in the lower respiratory tract (bronchi), 0.5-1 microns - in the alveoli (pulmonary vesicles located at the ends of small bronchi through which oxygen enters the bloodstream). And particles less than 0.5 microns remain suspended in the air, do not settle in the respiratory system and freely exit during exhalation.

Therefore, all nebulizers are required that at least 50% of the particles in the aerosol be from 1 to 5 microns in size. The main characteristic of each nebulizer is the so-called respirable fraction - the fraction of particles (in percent) with an aerodynamic diameter<5 мкм в аэрозоле. У хороших небулайзеров респирабельная фракция составляет порядка 75%, данный показатель индивидуален для каждой модели и должен быть указан в инструкции к прибору.

In some models of nebulizers, you can use certain nozzles to adjust the particle size in the therapeutic aerosol. This allows differentiated treatment of the lower (bronchi) and upper (trachea, vocal cords, nasopharynx) airways. There are nebulizers specially designed for the treatment of chronic sinusitis (sinusitis). True, these options significantly affect the final cost of the device.

Many modern nebulizers are equipped with an inspiratory and expiratory valve system, or the so-called "virtual valve" system. The degree of drug loss depends on the presence and design of the valves.

Operating rules

Each compressor and each nebulizer kit has its own characteristics,

Asthma and Allergies 4/2015

\\ ^ ffii. 1 Jt ^ ". j, 1

SCHOOL OF LIFE

therefore, the accidental combination of any compressor with any chamber does not guarantee effective nebulizer performance. The compressor and nebuliser kit must be from the same manufacturer.

In young children, it is recommended to use a face mask of the appropriate size for inhalation, while it is necessary that the mask fits as tightly as possible to the face to limit contact of drugs with the eyes, reduce drug loss. In children after 3 years of age and in adults, it is better to use a mouthpiece for inhalation through the mouth, since when using it, the delivery of medicine to the lungs is several times higher than when using a mask. Nasal cannulas are needed to deliver medication to the nasal cavity. They can be used in the complex treatment of acute and chronic rhinitis and sinusitis.

With a residual volume (the parameter specified in the instructions for the device) less than 1 ml, the total volume of the drug can be 2.0-2.5 ml, and with a residual volume of more than 1 ml, about 4 ml of the drug together with a solvent is needed. The maximum volume (medicine + solvent) is 8 ml. The recommended volume of liquid for nebulization is 3-5 ml in most nebulizers. To achieve it, a saline solution must be added to the drug. It is not necessary to use drinking and mineral water for these purposes!

In absolutely all models, liquid must not be allowed to enter the compressor and the compressor must not be covered during operation.

The average time of one inhalation is 5-10 minutes. It depends on the specific type of nebulizer (flow rate), the volume of the drug (drug + solvent), and the volume of the nebulizer chamber. Over time, the nebulizer may wear out, causing the jet speed to decrease and the particle size to increase. The service life of nebulizer chambers is different (from 3 months to 3 years). Also remember to replace the air filter on time (replacement filters are included).

It is better to store the nebulizer disassembled for greater safety of the connection points.

Inhalation technique

1. During inhalation, you must sit, not talk and hold the inhaler straight. Do not lean forward, as this will make it difficult for the aerosol to enter the respiratory tract.

2. Use only medicines prescribed by your doctor. The medicine for inhalation should be at room temperature.

3. It is necessary to fill the nebulizer only immediately before inhalation, using sterile syringes (2.0 or 5.0 ml). First, saline is poured and only then the medicine. Otherwise, the most concentrated treatment solution will remain at the bottom of the chamber.

4. Clamp the mouthpiece with your teeth, wrap your lips around. During inhalation, you need to breathe deeply, slowly, through your mouth, you can hold your breath for 1-2 seconds before exhaling. But if this recommendation is not feasible, it's okay, you can just breathe calmly. Remember that breathing too fast and deeply can cause dizziness.

5. Finish inhalation when the sound emanating from the nebulizer chamber changes (“hissing” appears), the aerosol is released from the nebulizer, and the medicine is in the chamber.

6. After inhalation of corticosteroids (budesonid), rinse your mouth with boiled water at room temperature, in case of using a mask, wash thoroughly without touching the eye area.

Nebulizer treatment

Nebulizers need care to prevent drug crystallization and bacterial contamination. Processing is especially important for mesh nebulizers. When the pores of the mesh membrane are blocked, these nebulizers may remain capable of generating aerosols, but the specific characteristics and therapeutic effect of the aerosol may be significantly impaired.

After inhalation, the nebulizer should be rinsed with warm clean water. Do not use brushes and brushes for processing. Please note that processing methods are different for different nebulizer parts. For example, in Pari nebulizers, the connecting tube must not be washed. In mesh nebulizers, the membrane cannot be rubbed with fingers or cotton swabs; it is simply cleaned under a stream of warm water.

When using the same nebulizer by several people, it is necessary to disinfect (sterilize) the nebulizer chamber after each person. With regular daily use by one person, disinfection should be carried out once a week.

The nebulizer can be sterilized in disassembled form using hot steam, for example in a steam sterilizer designed to handle baby bottles. Most parts of the nebulizer kit (with the exception of PVC masks, silicone valves, see the instructions for the specific device)

SCHOOL OF LIFE

boil. But make sure that there is enough water in the container (all parts must be immersed in water).

All parts of the nebulizer must be dried prior to assembly. Dry the nebulizer at room temperature by placing the parts of the nebulizer on a dry, clean, lint-free towel. You can use a household hair dryer to dry.

Nebulizer medicines

For nebulizer therapy, only medicinal solutions specially designed for these purposes are used. In these preparations, even a small particle of a solution in an aerosol retains all medicinal properties. They are sold in the form of bottles or plastic containers - ampoules (nebulas), which allows them to be conveniently dispensed.

Nebulizers are used to deliver bronchodilators, expectorants, inhaled corticosteroids, antibiotics, and other medicines.

To relieve bronchospasm, bronchodilator drugs from different groups are used (phenoterol, salbutamol, and ipratropium bromide) and their combinations (for example, salbutamol + ipratropium). Significant advantages of their use with a nebulizer are ample opportunities for individual selection of the dose and delivery of the drug to the bronchi even with severe bronchospasm.

In addition, the nebulizer allows active anti-inflammatory therapy with the liquid form of the corticosteroid budesonide. Inhalation of budesonide through a nebulizer allows you to achieve a rapid anti-inflammatory effect. It is much less likely to develop side effects when used than when using corticosteroids in tablets or intravenously. This is explained by the fact that after inhalation of budesonide, the systemic blood flow reaches

only 6.5% of the dose in children and 14% of the dose in adults, while all taken orally prednisolone, before entering the respiratory tract, ends up in the patient's blood. In addition, treating budesonid with a nebulizer can reduce the need for intravenous hormone tablets.

The sequence of actions (dose, frequency of administration, name of drugs) in case of a severe asthma attack should be discussed in advance with your doctor. The specific scheme is selected individually.

It is equally important to know the list of drugs that CANNOT be inhaled with a nebulizer.

1. All solutions containing oils (hazardous to health!). For inhalation of vapors of oil solutions, there are steam inhalers.

2. Suspensions - decoctions and herbal infusions, cough medicines, various rinsing solutions. Inhalation of these funds using a nebulizer is completely ineffective. In addition, using some of them can damage the nebulizer.

3. Medicines that do not have inhalation forms and do not act on the bronchial mucosa - theophylline, aminophylline, papaverine, platifillin, anti-histamines (diphenhydramine, diphenhydramine and others).

4. Systemic corticosteroids (dexamethasone, hydrocortisone, prednisolone and others). Inhalation is technically possible, but the action will not be local and will remain systemic, with all potential complications.

Today, nebulizers have become part of medical practice. The use of nebulizers significantly expands the possibilities of treating diseases of the respiratory system at home, reduces the need for hospitalization, and prevents the development of severe exacerbations, which makes them indispensable in the chronic and severe course of these diseases.

Asthma and Allergies 4/2015

The material is intended for patients

Back to number

Nebulizer therapy for bronchial asthma and chronic obstructive pulmonary disease - expanded possibilities of inhalation therapy

Bronchial asthma (BA) and chronic obstructive pulmonary disease (COPD) are among the most common diseases.

Today, in the control of asthma and the management of patients with COPD, more attention is paid to reducing symptoms and emphasizing the significant role of exacerbations. The course of BA and COPD, the progression of this pathology depends on the number and severity of exacerbations (Gina 2006-2011, GOLD-2011).

An exacerbation of asthma is an episode of a progressive increase in respiratory rate (acute or sub-acute), cough, wheezing, or chest congestion, or any combination of these symptoms. Aggravation is determined by a decrease in air flow (PSV or FEV 1 ). It can proceed in the form of an acute attack or a protracted state of bronchial obstruction. The severity of an exacerbation can range from mild to life-threatening.

According to the GOLD (2011) guideline, “exacerbation of COPD is an acute condition characterized by worsening respiratory symptoms that go beyond the usual daily fluctuations and require correction of planned drug therapy”. As a rule, a change in the basic treatment scheme occurs due to an increase in the intensity of bronchodilator therapy, the appointment of antibacterial drugs, the use of corticosteroids, including systemic ones.

The optimal inhalation technique for delivering drugs for exacerbations of asthma and COPD, especially severe ones, is nebulizers, which allow the use of highly effective inhalation technologies.

Nebulizers have a long history of use - they have been in use for almost 150 years. The word "nebulizer" comes from Latin nebula (fog, cloud) and was first used in 1874 to mean "an instrument that converts a liquid substance into an aerosol for medical purposes." One of the first portable "aerosol machines" was created by J. Sales-Giron in Paris in 1859. At this time, they were used to inhale vapors of tar and antiseptics in patients with tuberculosis.

Under the general term " nebulizer»Means a combination of a nebulizer chamber (or nebulizer itself) and a compressor or ultrasonic generator.

There are compressor and ultrasonic nebulizers.

Compressor nebulizer consists of a nebulizer chamber, in which the aerosol is generated, and an electric compressor, which forms an air flow.

Ultrasonic nebulizers are based on the formation of aerosols under the influence of ultrasonic vibrations generated by a piezoelectric element, and consist of a source of ultrasonic vibrations and a nebulizer chamber. Currently, compressor nebulizers are most common (due to the possibility of using a wider range of drugs).

Nebulizers convert solutions and suspensions into small droplets. Solutions consist of a drug dissolved in a liquid, suspensions are solid particles of a drug suspended in a liquid. The advantage of nebulizers is their ability to disperse high doses of drugs, which cannot be created using metered-dose aerosol inhalers (MDIs) and dry powder inhalers (DPIs). In addition, many nebulizers are equipped with face masks and can be used on children under 2 years of age, the elderly, and patients with severe lung disease.

Benefits of nebulizer therapy

The high clinical efficacy of nebulizer therapy is explained by the following advantages of drug delivery through a nebulizer:

- no need to coordinate inhalation with inhalation;

- the possibility of high-dose bronchodilator therapy for severe asthmatic attack and exacerbation of COPD;

- a small fraction of the drug that settles in the mouth and pharynx;

- ease of inhalation for children, the elderly and seriously ill patients;

- lack of freon and other propellants;

- the ability to be included in the oxygen supply circuit or ventilation;

- ease of use, easy inhalation technique.

In clinical practice, the benefits of nebulizer therapy are:

- the fastest possible relief of attacks of suffocation and shortness of breath due to the effective intake of a medicinal substance into the bronchi;

- the possibility of using for life-threatening symptoms;

- rare and minimally pronounced adverse reactions from the cardiovascular system;

- the ability to use at all stages of medical care (ambulance, clinic, hospital, home care).

Indications for nebulizer therapy

The goal of nebulizer therapy is to achieve the maximum local therapeutic effect with no or minimal manifestations of systemic side effects.

Absolute indications for nebulizer therapy:

1. A medicinal substance produced only in the form for nebulization, which cannot be delivered to the respiratory tract using other inhalers (surfactant preparations, anesthetics, mucolytics).

2. The need to deliver the drug to the alveoli (for example, pentamidine for pneumocystis pneumonia in AIDS patients, surfactant drugs for acute lung injury syndrome).

3. Significant severity of the patient and / or his inability to use other inhalers (elderly, children).

Relative indications for nebulizer therapy:

1. Insufficient effectiveness of basic therapy and the need to administer higher doses of drugs that have a bronchodilator effect.

2. Routine therapy for progressive asthma of moderate severity and severe course, COPD of moderate and severe severity of the disease, when control over the disease using basic therapy in standard doses is difficult to achieve.

3. Inability to coordinate inhalation and pressing the canister of a metered aerosol inhaler.

4. As the first choice in the treatment of moderate severity and severe exacerbation of asthma, severe protracted attack, status asthmaticus.

5. As the first choice in the complex therapy of exacerbation of COPD (moderate and severe course).

6. The value of FEV 1 is less than 35% of the proper values \u200b\u200bin patients with severe chronic bronchial obstruction.

7. Obtaining a good clinical effect and an increase in FEV 1 by 12% and expiratory POS by 15% in a week during a trial course of nebulizer therapy in an inpatient or outpatient setting.

8. The need to moisturize the respiratory tract simultaneously with the introduction of the drug.

9. The emergence of signs of respiratory tract irritation when using conventional MDI or DPI.

10. Patient preference (many patients during an exacerbation prefer to use different therapy and techniques than they use at home).

11. Practical convenience (simple method that does not require medical supervision).

When carrying out nebulizer therapy, it is necessary to know the full volume of the nebulizer chamber: with a residual volume of less than 1 ml, the total volume of the drug can be 2.0-2.5 ml, and with a residual volume of more than 1 ml, about 4 ml of the drug together with a solvent is needed.

The optimal technical parameters of nebulizers are:

- respiratory fraction - at least 50%;

- air flow rate - 6-10 l / min;

- particle size - less than 5 microns;

- nebulization time - 5-10 minutes.

The treatment of exacerbations of BA and COPD is based on bronchodilators and glucocorticosteroids (GCS)

Selectiveb 2 -agonists: have a powerful bronchodilator effect (throughout the entire bronchial tree), which develops in 5-10 minutes and lasts 4-5 hours. Sympathomimetics have the following therapeutic effects: relax the smooth muscles of the bronchi throughout the bronchial tree, being the most powerful and fast-acting bronchodilators; activate mucociliary clearance due to the attraction of chlorine and water ions into the lumen of the bronchial tree, as well as an increase in the movement of cilia of the ciliated epithelium; inhibit the secretory activity of mast cells; reduce vascular permeability and edema of the bronchial mucosa; increase the contractility of the diaphragm; prevent bronchospasm caused by allergens, cold and exercise.

The British clinical guidelines for the management of AD patients emphasize that for adult patients there is no evidence that nebulizers are preferable or more effective than spacers when prescribing bronchodilators, but nebulizers are still widely used, despite the fact that the use of MDI with a spacer is cheaper and requires less time consuming.

Typically in such cases, single doses of salbutamol (Ventolin ™ Nebula ™) 2.5-5 mg are used. The effect develops, as a rule, within 10-15 minutes. If the patient's condition does not improve, then repeated inhalations are prescribed. In some cases, b 2 -agonists are used in high doses, which is explained by the peculiarity of the dose-response relationship: the more pronounced the bronchial obstruction, the higher the dose of the brocholytic is required to achieve a therapeutic effect, since edema and inflammation of the mucous membrane of the respiratory tract prevents the delivery of the drug to the receptors.

- in the first hour, three inhalations of salbutamol (Ventolin ™ Nebula ™) are carried out, 2.5 mg every 20 minutes;

- then inhalation of salbutamol (Ventolin ™ Nebula ™) in the same dose is repeated every hour until a significant improvement in the condition (until the PSV reaches 60-75% of the proper or best value for the patient). Such large doses of β 2 -agonists during exacerbation of asthma are explained by an increase in drug clearance due to a significant increase in total metabolism.

Nebulizer therapy for severe exacerbations of bronchial asthma, order No. 128:

- the use of solutions of bronchodilators using a nebulizer is recommended both at the outpatient and hospital stages;

- in hospitalized patients, at the beginning - continuous therapy through a nebulizer, with the transition to intermittent therapy as required (GINA 2006);

- inhalation use of b 2 -agonists in severe exacerbation - among the first-line measures. Their purpose is shown in almost all cases.

Treatment of exacerbations of COPD remains one of the most difficult problems of modern general therapy, and each exacerbation of the disease requires mandatory medical intervention. Incomplete reversibility of bronchial obstruction and hyperinflation syndrome, characteristic of patients with COPD, are the reason for the less pronounced effectiveness of bronchodilator therapy in patients with exacerbation of COPD compared to the effectiveness of bronchodilators in patients with asthma.

Although the morphological substrate of COPD exacerbation is an increase in the inflammatory process in the airways, mainly at the level of the peripheral bronchi, bronchodilators are the first line drugs in the treatment of exacerbations.

In all cases of exacerbation of COPD, regardless of its severity and causes, if not previously used, inhaled bronchodilator drugs are prescribed or their dose and / or frequency of administration is increased (level of evidence A).

As a rule, the dosing of β 2 -agonists is carried out empirically, based on the patient's response to treatment and the development of side effects.

The scheme of therapy for the management of patients with exacerbations of COPD:

- when prescribing sympathomimetics, the usual regimen is the administration of salbutamol (Ventolin ™ Nebula ™) at a dose of 2.5 mg (or fenoterol at a dose of 0.1 mg) using a nebulizer or salbutamol 400 μg (fenoterol 200 μg) using a metered-dose inhaler / spacer every 4-6 hours during the first 24-48 hours of therapy or until the clinical picture stabilizes. Inhalation response b 2 -agonist is usually observed within 10-15 minutes;

- if there is no relief of symptoms, then repeated inhalations are prescribed;

- in severe exacerbation of COPD, the frequency of administration of sympathomimetics can be significantly increased - it is possible to prescribe drugs every 30-60 minutes until a clinical effect is achieved. Such large doses of β 2 -agonists during exacerbation of COPD compared with the period of stable course of the disease are explained by an increase in drug clearance due to a significant increase in total metabolism.

The use of inhaled sympathomimetics may be limited by side effects that develop due to systemic absorption of drugs. The most common complication of β 2 -agonist therapy is the triad of symptoms: tachycardia, hypoxemia, and hypokalemia. The main mechanism for the increase in hypoxemia is b 2 -induced vasodilation. A significant adverse effect deserves attention in patients with RaO 2< 60 мм рт.ст., поэтому ингаляционная терапия b 2 -агонистами должна проводиться под тщательным контролем насыщения крови кислородом .

- adult patients are prescribed the equivalent of 2.5-5 mg of salbutamol (level of evidence B);

- nebulizer therapy can be repeated after a few minutes if the response to the first dose was insufficient, and can continue until the patient's condition stabilizes (level of evidence B);

- in contrast to stable COPD and exacerbation of asthma, with exacerbation of COPD, the addition of anticholinergic therapy to the b 2 -agonist does not provide additional benefits (Level of Evidence: A).

Anti-inflammatory drugs (GCS)

The group of anti-inflammatory drugs includes inhaled corticosteroids (GCS) and cromoglycic acid preparations. GCS have a pronounced anti-inflammatory effect, due to which they have the following therapeutic effects: they improve bronchial permeability and reduce bronchial hyperreactivity to allergens and nonspecific irritants, reduce the severity of clinical symptoms of asthma, increase the quality of life of patients, prevent asthma exacerbations, reduce the likelihood of hospitalization of patients, reduce mortality from asthma , prevent the development of irreversible changes in the respiratory tract. Nebulization of GCS is possible only with the help of compressor nebulizers, since the destruction of the drug occurs in ultrasonic generators.

According to research data, the appointment of systemic GCS during exacerbation of asthma leads to a decrease in obstruction, reduces the level of hospitalization and the risk of relapse of asthma exacerbation after discharge from the hospital. However, it has been shown that the effect of systemic corticosteroids occurs no earlier than 6-12 hours, and frequent courses of therapy can lead to the development of such systemic complications as hyperglycemia, osteoporosis, suppression of adrenal function.

In some studies, it has been shown that the effectiveness of prescribing high doses of inhaled corticosteroids using a metered-dose aerosol inhaler and a spacer during an exacerbation is comparable to taking oral or parenteral steroids, while the therapeutic effect develops faster. However, taking inhaled GCS during an exacerbation may be ineffective due to severe bronchial obstruction and respiratory failure, which do not allow creating a sufficient inspiratory flow and ensuring drug delivery to the distal bronchial tree.

The results of numerous controlled studies with a sufficiently high level of evidence have demonstrated that the treatment of severe exacerbations of asthma with nebulized fluticasone (2-4 mg / day) is comparable to systemic steroids (40 mg of prednisolone) in terms of the effect on functional parameters (PSV, FEV 1, SaO 2, PaO 2), and in terms of the effect on clinical indicators (the severity of shortness of breath and wheezing, participation in the respiration of auxiliary muscles) and the risk of developing side effects, it exceeds them.

The efficacy and safety of the use of nebulized fluticasone propionate (FP) and oral prednisolone (PP) in severe exacerbation of asthma was studied under the guidance of prof. S.S. Soldatchenko (www.health-ua.org/article/urgent/97.html). A randomized placebo-controlled study was conducted in which 47 patients with severe bronchial asthma (FEV 1< 30 % или ПОС < 60 %) в возрасте от 30 до 59 лет. 1-я группа (n = 23) получала перорально преднизолон в дозе 40 мг/сут, 2-я группа (n = 24) — небулизированную суспензию Фликсотид по 1-2 мг 2 раза/сут через компрессорный ингалятор Pari Master с небулайзером LL. На основании проведенного исследования были сделаны следующие выводы: терапия ФП и ПП привела к сходным изменениям ОФВ 1 ; у больных, принимавших ФП, имело место достоверно более быстрое уменьшение одышки (по шкале Борга, р < 0,05 после второго дня).

Dosing of nebulized fluticasone propionate (Flixotide ™ Nebula ™):

- adults and adolescents over 16 years old: 0.5-2.0 mg twice a day;

- children and adolescents 4-16 years old: 1.0 mg twice a day;

- The initial dose of nebulized fluticasone propionate (Flixotide ™ Nebula ™) should be appropriate for the severity of the disease. In the future, the dosage should be selected at a level that ensures disease control, or to the minimum effective dose, depending on the individual effect;

Approaches to the appointment of GCS in exacerbation of COPD have undergone significant changes in the last 5 years. If earlier recommendations for their admission were based more on expert opinion than on strict scientific evidence, then by now the role of GCS in the treatment of exacerbation of COPD is considered proven. The prerequisites for the positive effect of GCS in exacerbation of COPD are a moderate increase in the number of eosinophils in the respiratory tract mucosa and an increase in the level of inflammatory cytokines-IL-6, that is, an inflammatory response that can be suppressed by corticosteroids, while in the case of a stable course of COPD, inflammation is involved other cell populations (neutrophils, CD8 T-lymphocytes) and cytokines - (IL-8, TNF-a), which explains the low effect of steroids outside the exacerbation of the disease.

Based on a number of randomized controlled trials, the following conclusions can be drawn.

1. GCS therapy should be prescribed to all hospitalized patients with exacerbation of COPD.

2. Intravenous and oral forms of GCS significantly improve pulmonary functional parameters by the 3-5th day of therapy and reduce the risk of therapy failure.

3. The duration of administration of systemic steroids should not exceed 2 weeks.

4. Medium doses of GCS (equivalent to 30-40 mg of prednisolone per os) is sufficient to achieve a positive clinical effect.

However, there are certain concerns when prescribing systemic corticosteroids for patients with COPD: among these patients, there is a very high proportion of elderly people with concomitant diseases (diabetes mellitus, arterial hypertension, peptic ulcer), and GCS therapy, even for a short period, can lead to the development of serious side effects. In the SCOPE study, adverse reactions (especially hyperglycemia) were quite often observed in patients taking GCS. An alternative to systemic corticosteroids in exacerbation of COPD can be a nebulized corticosteroid, which has a safer clinical profile.

findings

1. Nebulizer therapy allows not only active bronchodilatory therapy, but also anti-inflammatory treatment.

2. Among all methods of aerosol delivery into the respiratory tract, the role of nebulizer therapy increases depending on the severity of the disease and becomes exclusive in severe and extremely severe cases and during an exacerbation.

3. Nebulizer therapy provides the most effective delivery of drugs, their distribution in the airways with minimal dependence on the degree of ventilation disorders.

Post for sprying

TOV "GlaxoSmіtKlyayn Pharmaceuticals Ukraine"

FXTD / 10 / UA / 11.10.2012 / 6700

List of references

1. V.P. Dubynina Nebulizer therapy for acute and chronic respiratory diseases. - M., 2011 .-- 44 p.

2. About the consolidation of clinical protocols for medical aid for the specialty "Pulmonology". Order of the Ministry of Health of Ukraine No. 128 dated 19.03.2007. - Kiev. - 2007.

3. European Respiratory Society Guidelines on the use of nebulizers // Eur. Respir. J. 2001. 18. 228-242.

4. Feschenko Yu.I., Yashina L.A., Tumanov A.N., Polyanskaya M.A. The use of nebulizers in clinical practice. Method. manual for doctors / Yu.I. Feshchenko, L.A. Yashina, A.N. Tumanov, M.A. Polyanskaya // K., 2006 .-- S. 8-23.

5. Yudina L.V. Nebulizer therapy for exacerbations of bronchial asthma - an alternative to systemic corticosteroids / L.V. Yudina // Clinical Immunology. Allergology. Infectology. - 2008. - No. 1. - S. 42-46.

6. Mark L.L. Comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care / L.L. Mark, C. Stevenson, T. Maslen // Thorax. - 1996. - No. 51. - P. 1087-1092.

7. Mason N. Nebulizers and spacers for inhalation of bronchodilators in patients with bronchial asthma in the emergency department / N. Mason, N. Roberts, N. Yard et al. // Scientific Review of Respiratory Medicine. - 2009. - No. 1. - S. 17-18.

8. Gustavo J., Rodrigo, Hall J.B. Acute asthma in adults: a review // Chest. - 2004, Mar. - 125 (3). - 1081-102.

Nebulizer therapy- is one of the types of inhalation therapy used for diseases of the respiratory system. The most widespread use of nebulizer therapy is in the treatment of bronchial asthma and COPD, as a highly effective method of drug delivery directly into the bronchi.
For nebulizer therapy, special devices are used - nebulizers. The word "nebulizer" comes from the Latin "nebula" (fog, cloud), was first used in 1874 to mean "an instrument that converts a liquid substance into an aerosol for medical purposes." One of the first portable "aerosol devices" was created by J. Sales-Girons in Paris in 1859. The first nebulizers used a stream of steam as a source of energy and were used to inhale vapors of tar and antiseptics in patients with tuberculosis. Modern nebulizers bear little resemblance to these old devices, but they fully meet the old definition - the production of an aerosol from a liquid drug.
Content:

Nebulizer therapy goals

The main goal of inhalation (nebulizer) therapy is to achieve the maximum local therapeutic effect in the respiratory tract with little or no side effects. Dispersion of the drug, which occurs during the formation of an aerosol, increases the total volume of the drug suspension, the surface of its contact with the affected tissue areas, which significantly increases the effectiveness of the action. Some medications are poorly absorbed from the gastrointestinal tract or undergo a significantly pronounced first pass effect through the liver. In such cases, local administration, and in this case, the inhalation route is the only possible one.

Nebulizer therapy objectives

The main objectives of nebulizer therapy are:



1. Reduction of bronchospasm



2. Improving the drainage function of the airways


3. Sanitation of the upper respiratory tract and bronchial tree


4. Reduction of mucosal edema


5. Reducing the activity of the inflammatory process


6. Impact on local immune responses
7. Improvement of microcirculation
8. Protection of the mucous membrane from the action of allergens and industrial aerosols

Benefits of nebulizer therapy

1. Possibility of use, starting from a very early age, for any physical condition of the patient and regardless of the severity of the disease, due to the absence of the need to synchronize inhalation with the aerosol flow (does not require forced breathing maneuvers).


2. Delivery of a larger dose of the drug and obtaining an effect in a shorter period of time


3. The ability to easily, correctly and accurately dose drugs
4. Simple technique of inhalation, including at home
5. The possibility of using a wide range of drugs (all standard solutions for inhalation can be used) and their combinations (the possibility of simultaneous use of two or more drugs), as well as infusions and decoctions of herbal teas.


6. Nebulizers are the only means of drug delivery to the alveoli
7. Ability to connect to the oxygen supply circuit


8. Possibility to be included in the ventilator circuit
9. Environmental safety, since there is no release of freon into the atmosphere

Types of nebulizers

There are two main types of nebulizers:



1. Compressor
In compressor nebulizers, aerosol formation occurs when air is supplied to the nebulization chamber by means of a compressor.
Read more (principles of operation of compressor nebulizers)
The principle of a compressor (jet) nebulizer is based on the Bernoulli effect (1732) and can be represented as follows. Air or oxygen (working gas) enters the nebulizer chamber through the narrow venturi. At the outlet of this hole, the pressure drops, and the gas velocity increases significantly, which leads to the suction of liquid into this area of \u200b\u200breduced pressure through narrow channels from the chamber reservoir. When the liquid meets the air flow, it breaks up into small particles of 15-500 microns in size (“primary” aerosol). Subsequently, these particles collide with a “shutter” (plate, ball, etc.), as a result of which a “secondary” aerosol is formed - ultrafine particles 0.5-10 microns in size (about 0.5% of the primary aerosol), which then it is inhaled, and a large fraction of the primary aerosol particles (99.5%) is deposited on the inner walls of the nebulizer chamber and is again involved in the aerosol formation process (Fig. 1).




Fig. 1. Schematic of a jet nebulizer (O "Callaghan & Barry).

Convection (general type)

This constant aerosol nebulizer is the most common. During inhalation, air is drawn in through the tube and the aerosol is diluted. The aerosol enters the respiratory tract only during inhalation, and during exhalation, most of it is lost (55-70%). Conventional nebulizers require relatively high working gas flows (more than bL / min) to achieve adequate aerosol output.



Fig. 2. Scheme and aerosol output at a convection nebulizer




Inspiratory-activated (controlled) (Venturi nebulizers)
Also, aerosol is produced constantly throughout the entire respiratory cycle, however, the release of the aerosol is enhanced during inhalation. This effect is achieved by the flow of additional air flow during inhalation through a special valve into the area of \u200b\u200baerosol production, the total flow increases, which also leads to an increase in the formation of aerosol. During exhalation, the valve closes and the patient's exhalation follows a separate pathway, bypassing the area of \u200b\u200baerosol production.
Thus, the ratio of the aerosol output during inhalation and inhalation increases, the amount of inhaled drug increases, the drug loss decreases (up to 30%), and the nebulization time is reduced. Venturi nebulizers do not require a powerful compressor (4-6 l / min is sufficient).
Their disadvantages are the dependence on the patient's inspiratory flow and the slow rate of aerosol production when using viscous solutions.
In patients with cystic fibrosis, it was shown that Venturi nebulizers, in comparison with conventional nebulizers, made it possible to achieve twice the deposition of the drug in the respiratory tract: 19% versus 9%.


Fig. 3. Aerosol layout and aerosol output for inhalation-activated nebulizer (Venturi type)



Breath-synchronized (dosimetric nebulizers)

Aerosol is produced only during the inspiratory phase. Generation of aerosol during inhalation is provided by electronic flow or pressure sensors, and theoretically the ratio of aerosol output during inhalation and exhalation reaches 100: 0. The main advantage of the dosimetric nebulizer is the reduction of drug loss during exhalation.
In practice, however, there may be a loss of the drug into the atmosphere during expiration, since not all of the drug is deposited in the lungs. Dosimetric nebulizers have undeniable advantages when inhaling expensive drugs, because reduce their loss to a minimum. Some dosimetric nebulizers were created specifically for the delivery of expensive drugs, for example, the VISAN-9 nebulizer is designed for inhalation of surfactant drugs. The disadvantages of such systems are the longer inhalation time and the high cost.

Figure: 4. Schemes and aerosol output at a dosimetric nebulizer
Adaptive delivery devices are also a type of dosimetric nebulizer, although some experts consider them a new class of inhalation devices.
Their fundamental difference is the adaptation of the production and release of aerosol to the patient's respiratory pattern. An example of this type of nebulizer is Halolite. The device automatically analyzes the patient's inspiratory time and inspiratory flow (over 3 breaths), and then provides aerosol production and release during the first half of the subsequent breath. Inhalation continues until the output of a precisely set dose of the drug is reached, after which the device beeps and stops inhalation. Advantages of the device: rapid inhalation of the dose of the drug (4-5 minutes), high patient compliance with the therapy, high respirable fraction (80%) and very high aerosol deposition in the respiratory tract - up to 60%.

2. Ultrasonic

In ultrasonic nebulizers, the transformation of a liquid into an aerosol is achieved by high-frequency vibration of piezoelectric crystals.

Read more (principles of operation of ultrasonic nebulizers)
Ultrasonic nebulizers for aerosol production use the energy of high-frequency vibration of a piezoelectric crystal. Vibration from the crystal is transmitted to the surface of the solution, where “standing” waves are formed. When the frequency of the ultrasonic signal is sufficient, the formation of a “micro-fountain” occurs at the crosshairs of these waves; aerosol formation (Fig. 3). Particle size is inversely proportional to signal frequency. As in a jet nebulizer, the aerosol particles collide with the “flap”, the larger ones return back into the solution, and the smaller ones are inhaled.
Aerosol production in an ultrasonic nebulizer is almost noiseless and faster than compressor nebulizers. However, their disadvantages are:
- inefficiency of aerosol production from suspensions and viscous solutions
- larger residual volume
- increase in the temperature of the solution during nebulization with the possibility of destruction of the structure of the drug.





Figure: 5. Diagram of an ultrasonic nebulizer (O "Callaghan & Barry).
Due to the reliability, simplicity of disinfecting treatment, lack of influence on heat-sensitive drugs and drugs containing complex molecular fractions (hormonal), compressor nebulization is considered the "gold standard" of inhalation therapy.

Basic requirements for nebulizers

- 50% or more of the generated aerosol particles must have a size of less than 5 microns (the so-called respirable fraction)


- The residual volume of the drug after inhalation is not more than 1 ml;


- Inhalation time no more than 15 minutes, volume 5 ml


- Recommended flow 6-10 liters per minute


- Pressure 2-7 Barr


- Productivity is not less than 0.2 ml / min.



The nebulizer must be tested and certified in accordance with the European standards for nebulizer therapy prEN13544-1 (using the low-flow cascade impactor method, at the present stage the most accurate method for studying the aerodynamic dimensions of aerosol particles).

Indications for the use of nebulizers

Absolute
1. The medicinal substance cannot be delivered to the respiratory tract using other inhalers


2. Delivery of the drug to the alveoli is required
3. Inspiratory flow less than 30 liters per minute


4. Decreased inspiratory vital capacity less than 10.5 ml / kg (for example,< 735 мл у больного массой 70 кг)
5. Inability to hold the breath for more than 4 seconds


6. Impaired consciousness
7. The patient's condition does not allow the correct use of portable inhalers
Relative

Diseases for which nebulizer therapy is used

7. Acute respiratory diseases
8. Pneumonia
9. Bronchiectasis
10. Bronchopulmonary dysplasia in newborns
11. Viral bronchiolitis

12. Tuberculosis of the respiratory system


13. Chronic sinusitis
14. Idiopathic fibrosing alveolitis
15. Post-transplant obliterating bronchiolitis



In palliative therapy, the tasks of which are to alleviate the symptoms and suffering of terminal patients, inhalation therapy is used to reduce refractory cough (lidocaine), incurable dyspnea (morphine, fentanyl), delayed bronchial secretion (physiological saline), bronchial obstruction (bronchodilators).

Promising areas of use of nebulizers are such areas of medicine as gene therapy (a gene vector - adenovirus or liposomes is injected in the form of an aerosol), administration of certain vaccines (for example, measles), therapy after heart-lung complex transplantation (steroids, antiviral drugs), endocrinology ( administration of insulin and growth hormone).

Contraindications

1. Pulmonary hemorrhage and spontaneous pneumothorax against the background of bullosa emphysema of the lungs
2. Cardiac arrhythmia and heart failure
3. Individual intolerance to the inhalation form of medications
Preparation of solution for inhalation
Solutions for inhalation should be prepared on the basis of physiological solution (0.9% sodium chloride) in compliance with the rules of antiseptics. It is forbidden to use tap, boiled, distilled water, as well as hypo- and hypertonic solutions for these purposes. Syringes are ideal for filling nebulizers with an inhalation solution; pipettes are also possible. It is recommended to use 2-4 ml filling volume of the nebulizer. The container for preparing the solution is preliminarily disinfected by boiling. Store the prepared solution in the refrigerator for no more than 1 day, unless otherwise provided by the annotation for the use of the drug.

Before starting inhalation, it is recommended to warm the prepared solution in a water bath to a temperature of at least + 20C. Decoctions and herbal infusions can only be used after thorough filtration. When using essential oils, it is advisable to use a separate nebulizer kit.
Inhalation


- During inhalation, the patient should be in a sitting position, not talking and hold the nebulizer upright. During inhalation, it is not recommended to lean forward, since this position of the body makes it difficult for the aerosol to enter the respiratory tract.
- In case of diseases of the pharynx, larynx, trachea, bronchi, inhale the aerosol through the mouth, after a deep breath with the mouth, hold your breath for 2 seconds, then exhale completely through the nose. Better to use a mouthpiece or mouthpiece than a mask.


- For diseases of the nose, paranasal sinuses and nasopharynx, it is necessary to use special nasal nozzles (nasal cannulas) for inhalation, inhalation and exhalation must be done through the nose, breathing is calm, without tension.



- Since frequent and deep breathing can cause dizziness, it is recommended to take breaks in inhalation for 15-30 seconds
- Continue inhalation while liquid remains in the nebulizer chamber (usually about 5-10 minutes), at the end of inhalation - gently beat the nebulizer to fully utilize the drug.
- After inhaling steroids and antibiotics, rinse your mouth thoroughly. It is recommended to rinse your mouth and throat with boiled water at room temperature.


- After inhalation, rinse the nebulizer with clean, if possible sterile water, dry using napkins and a gas jet (hairdryer). Frequent flushing of the nebulizer is necessary to prevent drug crystallization and bacterial contamination.

Drugs used for nebulizer therapy

Patient manual. You can learn about what a nebulizer is, what diseases can be treated with it, how to properly inhale, how to choose a nebulizer, and much more about the modern method of inhalation therapy, you can learn from this article.

Nebulizer therapy is modern and safe.

In the treatment of respiratory diseases, the most effective and modern method is inhalation therapy. Inhalation of drugs through a nebulizer is one of the most reliable and simple methods of treatment. The use of nebulizers in the treatment of respiratory diseases is gaining increasing recognition among doctors and patients.

To make the medicine easier to enter the respiratory tract, it must be converted to an aerosol. A nebulizer is a chamber in which a medicinal solution is sprayed to an aerosol and supplied to the patient's respiratory tract. The medical aerosol is created by certain forces. Such forces can be air flow (compressor nebulizers) or ultrasonic vibrations of the membrane (ultrasonic nebulizers).

The modern approach to the treatment of respiratory diseases involves the delivery of drugs directly into the respiratory tract through the widespread use of inhaled forms of drugs. The capabilities of the nebulizer have dramatically expanded the scope of inhalation therapy. Now it has become available to patients of all ages (from infants to old age). It can be carried out during periods of exacerbation of chronic diseases (primarily bronchial asthma), in situations where the patient has a significantly reduced inspiratory rate (young children, postoperative patients, patients with severe somatic diseases) both at home and in a hospital setting.

Nebulizer therapy has advantages over other types of inhalation therapy:

• It can be used at any age, since the patient is not required to adjust his breathing to the operation of the apparatus and at the same time perform any actions, for example, press the can, hold the inhaler, etc., which is especially important in young children.
• The absence of the need to carry out a strong breath allows the use of nebulizer therapy in cases of a severe attack of bronchial asthma, as well as in elderly patients.
• Nebulization therapy allows the use of drugs in effective doses without side effects.
• This therapy provides continuous and rapid delivery of medication using a compressor.
• It is the safest method of inhalation therapy, as it does not use propellants (solvents or carrier gases), unlike metered aerosol inhalers.
• This is a modern and comfortable method of treating bronchopulmonary diseases in children and adults.

What diseases can be treated with a nebulizer?

The drug sprayed with an inhaler begins to act almost immediately, which allows the use of nebulizers, first of all, for the treatment of diseases that require urgent intervention - asthma, allergies.

(first of all, nebulizers are used to treat diseases that require urgent intervention - asthma, allergies).

Another group of diseases for which inhalations are simply necessary are chronic inflammatory processes of the respiratory tract, such as chronic rhinitis, chronic bronchitis, bronchial asthma, chronic obstructive pulmonary disease, cystic fibrosis, etc.

But the scope of their application is not limited to this. They are good for the treatment of acute respiratory diseases, laryngitis, rhinitis, pharyngitis, fungal infections of the upper respiratory tract, the immune system.

Inhalers help with occupational diseases of singers, teachers, miners, chemists.

When is a nebulizer needed at home:

• In a family where a child is growing up, prone to frequent colds, bronchitis (including those occurring with broncho-obstructive syndrome), for the complex treatment of cough with difficult sputum separation, treatment of stenosis.
• Families with patients with chronic or often recurrent bronchopulmonary diseases (bronchial asthma, chronic obstructive pulmonary disease, chronic bronchitis, cystic fibrosis).

What medicines can be used in the nebulizer.

For nebulizer therapy, there are special solutions of drugs that are produced in vials or plastic containers - nebulas. The volume of the drug together with the solvent for one inhalation is 2-5 ml. The calculation of the required amount of medication depends on the patient's age. First, 2 ml of saline is poured into the nebulizer, then the required number of drops of the drug is added. Do not use distilled water as a solvent, as it can provoke bronchospasm, which will lead to coughing and shortness of breath during the procedure. Pharmacy packaging with medicinal products is stored in the refrigerator (unless otherwise indicated) in a closed form. After the pharmacy package has been opened, the drug must be used within two weeks. It is advisable to write down the date on which the drug began to be used on the bottle. Before use, the medicine must be warmed to room temperature.

For nebulizer therapy, the following can be used:

1. mucolytics and mucoregulators (drugs for thinning sputum and improving expectoration): Ambrohexal, Lazolvan, Ambrobene, Fluimucil;
2. bronchodilators (drugs that expand the bronchi): Berodual, Ventolin, Berotek, Salamol.
3. glucocorticoids (hormonal drugs with a multifaceted effect, primarily anti-inflammatory and decongestant): Pulmicort (suspension for nebulizers);
4. cromones (antiallergic drugs, stabilizers of mast cell membranes): Cromohexal Nebula;
5. antibiotics: Fluimucil antibiotic;
6. alkaline and saline solutions: 0.9% physiological solution, mineral water "Borjomi"

Your doctor should prescribe the drug and tell you about the rules for its use. He must also monitor the effectiveness of treatment.

All solutions containing oils, suspensions and solutions containing suspended particles, including decoctions and herbal infusions, as well as solutions of aminophylline, papaverine, platifillin, diphenhydramine and the like, as having no points of application on the mucous membrane of the respiratory tract.

What side effects are possible during nebulizer therapy?

With deep breathing, symptoms of hyperventilation (dizziness, nausea, cough) may appear. It is necessary to stop inhalation, breathe through your nose and calm down. After the symptoms of hyperventilation disappear, inhalation through the nebulizer can be continued

During inhalation, as a reaction to the introduction of a spray solution, a cough may occur. In this case, it is also recommended to stop inhalation for a few minutes.

Inhalation technique using a nebulizer

• Before working with the inhaler, you must (always) carefully
• wash your hands with soap and water. there may be pathogenic microbes on the skin.
• Collect all parts of the nebulizer according to the instructions
• Pour the required amount of the drug into the nebulizer cup, preheating it to room temperature.
• Close the nebulizer and attach the face mask, mouthpiece, or nasal cannula.
• Connect the nebulizer and compressor with a hose.
• Turn on the compressor and inhale for 7-10 minutes or until the solution is completely consumed.
• Turn off the compressor, disconnect the nebulizer and disassemble it.
• Rinse all parts of the nebulizer with hot water or 15% baking soda solution. Brushes and brushes should not be used.
• Sterilize the disassembled nebulizer in a steam sterilization device, such as a thermodisinfector (steam sterilizer) designed to handle baby bottles. Sterilization by boiling for at least 10 minutes is also possible. Disinfection must be carried out once a week.
• A carefully cleaned and dried nebulizer should be stored in a clean tissue or towel.

Basic rules for inhalation

• Inhalation is carried out no earlier than 1-1.5 hours after eating or significant physical activity.
• During the course of inhalation treatment, doctors prohibit smoking. In exceptional cases, it is recommended to stop smoking for an hour before and after inhalation.
• Inhalation should be taken in a calm state, without being distracted by reading and talking.
• Clothing should not constrict the neck and make breathing difficult.
• For diseases of the nasal passages, inhalation and exhalation must be done through the nose (nasal inhalation), breathe calmly, without tension.
• With diseases of the larynx, trachea, bronchi, lungs, it is recommended to inhale the aerosol through the mouth (oral inhalation), it is necessary to breathe deeply and evenly. After a deep breath with your mouth, you should hold your breath for 2 seconds, and then exhale completely through the nose; in this case, the aerosol from the oral cavity enters further into the pharynx, larynx and further into deeper parts of the respiratory tract.
• Frequent deep breathing can cause dizziness, therefore it is necessary to interrupt the inhalation periodically for a short time.
• Before the procedure, you do not need to take expectorants, rinse your mouth with antiseptic solutions (potassium permanganate, hydrogen peroxide, boric acid).
• After any inhalation, and especially after inhalation of a hormonal drug, it is necessary to rinse your mouth with boiled water at room temperature (a small child can be given food and drink), if using a mask, rinse your eyes and face with water.
• The duration of one inhalation should not exceed 7-10 minutes. The course of treatment with aerosol inhalations - from 6-8 to 15 procedures

What are the types of nebulizers?

Currently, three main types of inhalers are used in medical practice: steam, ultrasonic and compressor.

The action of steam inhalers is based on the effect of vaporization of the drug substance. It is clear that only volatile solutions (essential oils) can be used in them. The biggest drawback of steam inhalers is the low concentration of the inhaled substance, as a rule, below the threshold for therapeutic action, as well as the inability to accurately dose the drug at home.

Ultrasonic and compressor ones are united by the term "nebulizers" (from the Latin word "nebula" - fog, cloud), they generate not vapors, but an aerosol cloud consisting of microparticles of the inhaled solution. The nebulizer allows you to inject drugs into all respiratory organs (nose, bronchi, lungs) in pure form, without any impurities. The dispersion of aerosols produced by most nebulizers ranges from 0.5 to 10 microns. Particles with a diameter of 8-10 microns settle in the oral cavity and trachea, with a diameter of 5 to 8 microns - in the trachea and upper respiratory tract, from 3 to 5 microns - in the lower respiratory tract, from 1 to 3 microns - in the bronchioles, from 0, 5 to 2 microns - in the alveoli. Particles less than 5 microns in size are called the "respirable fraction" and have the maximum therapeutic effect.

Ultrasonic nebulizers spray the solution by high-frequency (ultrasonic) vibrations of the membrane. They are compact, quiet and do not require replacement of nebulization chambers. The percentage of aerosol entering the respiratory tract mucosa exceeds 90%, and the average aerosol particle size is 4-5 microns. Due to this, the required drug in the form of an aerosol in high concentration reaches the small bronchi and bronchioles.

The choice of ultrasonic nebulizers is more preferable in cases when the area of \u200b\u200beffect of the drug is small bronchi, and the drug is in the form of a saline solution. However, a variety of drugs, such as antibiotics, hormones, mucolytic (thinning phlegm), can be destroyed by ultrasound. These drugs are not recommended for use in ultrasonic nebulizers.

Compressor nebulizers form an aerosol cloud by forcing through a narrow opening in the chamber containing the treatment solution, a powerful stream of air forced by the compressor. The principle of using compressed air in compressor nebulizers is the “gold standard” of inhalation therapy. The main advantage of compressor nebulizers is their versatility and relative cheapness, they are more affordable and can spray almost any solution intended for inhalation.

Compressor nebulizers have several types of chambers:

• convection chambers with constant aerosol release;
• inhalation-activated chambers;
• inspiratory chambers with valve flow interrupter.

When inhaling medicinal substances through a nebulizer, it is necessary to take into account some features:

• the optimal volume of filling the nebulizer chamber is at least 5 ml;
• to reduce the loss of the drug at the end of inhalation, 1 ml of saline can be added to the chamber, after which, by shaking the nebulizer chamber, continue inhalation;
• all types of nebulizers can be used with inexpensive and readily available drugs, but with more expensive drugs, inhalation nebulizers are most effective when the patient is inhaled and equipped with a valve expiratory flow interrupter. These devices are especially effective in the treatment of broncho-pulmonary diseases.

How to choose a nebulizer?

When treated with a nebulizer, the drug is delivered to the respiratory tract. It is this treatment that is intended for those who have a disease in the respiratory tract (rhinitis, laryngitis, tracheitis, bronchitis, bronchial asthma, chronic obstructive pulmonary disease, etc.). In addition, sometimes the mucous membrane of the respiratory tract is used to inject drugs into the human body. The surface of the bronchial tree is very large, and many drugs, such as insulin, are actively absorbed through it.

The choice of an inhaler depends on the disease that you are going to treat and on your financial capabilities.

In Russia, the medical equipment market is represented by companies producing nebulizers from Germany, Japan, and Italy. Unfortunately, there are no domestic manufacturers of compressor nebulizers yet. Detailed information on the technical characteristics of certain types of nebulizers can be obtained from Russian companies that sell them. When choosing a nebulizer, the requirements for the nebulizer and compressor are taken into account. For a compressor, size, weight, operating noise, ease of use are important. For all these parameters, they differ slightly. But it should be noted that nebulizers from PARI GmbH (Germany) are distinguished by traditionally high German quality, exceptional efficiency and long service life. They provide maximum deposition of drugs in the respiratory tract due to the optimal dispersion of the aerosol.

Perhaps the main attention should be paid to the type of spray . It makes sense to use nebulizers equipped with a direct-flow nebulizer in young children, since they have insufficient inhalation force, which would allow the valves to be activated (and thereby save medicine). For inhalation for children under 3 years old, it is advisable to use a baby mask. Adults can also use this type of spray because it is initially supplied with a mouthpiece.

Breath-assisted nebulizers, activated by inhalation, have inspiratory and expiratory valves that are activated alternately during the breath. When used on exhalation, less aerosol is formed, and there is a significant savings in the medicine.

There are also nebulizers that have a nebulizer equipped with a tee tube (aerosol flow interrupter), which allows you to regulate the formation of aerosol only during inhalation by closing the side opening of the tee.

Various types of nozzles are used with the spray: mouthpieces, nasal cannulas (tubes), masks of adult and children's sizes.

• Mouthpieces (adults and children) are optimal for delivering drugs deep into the lungs, they are used for inhalation by adult patients, as well as children from 5 years old.
• Masks are convenient for treating the upper respiratory tract and allow irrigation of all parts of the nasal cavity, pharynx, as well as the larynx and trachea. When using a mask, most of the aerosols are deposited in the upper respiratory tract. Masks are needed when using nebulizer therapy in children under 3 years of age, since it is impossible to carry out inhalations in such patients through the mouthpiece - children breathe mainly through the nose (this is due to the anatomy of the child's body). An appropriately sized mask must be used. The use of a tight-fitting mask reduces aerosol loss in young children. If the child is over 5 years old, it is better to use a mouthpiece than a mask.
• Nasal cannulas (tubes) are needed to deliver a medicinal aerosol to the nasal cavity. They can be used in the complex treatment of acute and chronic rhinitis and rhinosinusitis.

To buy a nebulizer for yourself and your loved ones is the right and reasonable decision. You have acquired a reliable assistant and friend

Article author:

Kartashova N.K., Ph.D., allergist of the highest category.