Paediatric Pulmonary Delivery

  • Created by: LBCW0502
  • Created on: 16-03-19 16:14
What is the most common cause of mortality in children in underdeveloped economies and the commonest cause of morbidity in developed economies?
Respiratory disease. Asthma (most common, more prevalent). Bronchiolitis, CF, acute respiratory infections, TB, infant respiratory distress syndrome
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Describe features of the infant lung (1)
Pre-term/born before due date - 2 years old. At pre-term, lungs not fully developed (main bronchi, no branching). Birth on due date (able to breath better). 10 fold increase in number of alveoli. Some branching. Larger alveoli sacs
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Describe features of the infant lung (2)
Nasal breathing (diaphragm driven). Narrow airways, high airway resistance. High breathing frequency. Laryngeal braking. Ratio of tongue to oral cavity large. Pulmonary function tests are difficult to carry out in this age group (e.g. flow rate)
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Describe features of the infant lung (3)
Need to use mask (mainly breath through nose). Dose of drug will slow down faster due to high airway resistance.
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Describe features of lung development in pre-school children (1)
2-5 years old. Volume increase due to alveolar enlargement. Branching developed. Decrease ratio of tongue to oral cavity (still large). Nasal/oral breathing, diaphragm driven. Narrow airways, high airway resistance, high breathing frequency
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Describe features of lung development in pre-school children (2)
Pulmonary function tests can be carried out with some difficulty. Recommend use of inhaler and spacer (with mask) for this age group
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Describe features of lung development in school children (1)
5-11 years old. Lung growth parallels skeletal growth (lungs not growing as fast as before). Girls have larger airways than boys. Airway diameter increases, airway resistance decreases. Breathing becomes slower and deeper
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Describe features of lung development in school children (2)
Ratio of tongue to oral cavity decreases. Pulmonary function tests can be carried out reliably.
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Describe features of adolescent lung (1)
11-16 or 18 years old. Completion of growth and anatomical development. Airways of boys become larger than girls. Boys' airways do not complete growth until 2-3 years after skeletal maturation. Larger airways, low airway resistance
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Describe features of adolescent lung (2)
Excellent control of breathing. Pulmonary function tests are routine in this age group. Can use any device
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Outline the paediatric classification systems
1. Pre-term newborn infants, 2. Term newborn infants (0-28d). 3. Infants and toddlers (1m-2y). 4. Children (pre-school 2-5y). 5. Children (school 6-11y). 6. Adolescents (12-16/18y)
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Outline the cognitive and motor skills of each age group - neonates and infants (0-2)
No breath control, no co-ordination, no cognitive maturity. Full dependence on caregiver
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Outline the cognitive and motor skills of each age group - preschool (2-5)
Some breath control. Some co-ordination. Some cognitive maturity. High dependence on caregiver
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Outline the cognitive and motor skills of each age group - children and adolescents (5-18)
Good breath control. Good co-ordination. Good cognitive maturity. Partial dependence on caregiver
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Describe the inhaler choice for children (1)
Up to 90% of patients fail to understand how to use pMDIs and DPIs. 25% of patients didn't receive instructions on how to use device (information provided was poor quality). No specific criteria for which device is best based on age
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Describe the inhaler choice for children (2)
Need to consider patient on case-by-case basis and take into account personal preference and ability to use a device
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What is the inhaler choice for children (aged 0-3 and 4-6 years?)
pMDI + aerochamber spacer (tidal breathing possible but unable to hold breath)
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What is the inhaler choice for children (7+ years?)
pMDI + spacer or breath actuated inhaler (should be able to created enough airflow to get dose)
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What is the advantage of using a spacer?
Gives time for particles to slow down and allows patient to inhale particles
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Give examples of aerochamber spacers
Infant aerochamber plus (0-6 months), child aerochamber plus (6+ months), adult aerochamber plus with mask (4+ years), aerochamber plus with mouthpiece (4+ years, need to be able to hold breath for 10s)
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Nebulisers would be used for which paediatric oral inhaled products (drug)?
Beta-2 agonists, corticosteroids (pulmicort respules), anti-infectives, mucolytics, anti-protozoals
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pMDIs would be used for which paediatric oral inhaled products (drug)?
Beta-2 agonists, corticosteroids, combi-products
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DPIs would be used for which paediatric oral inhaled products (drug)?
Beta-2 agonists, corticosteroids, combi-products, anti-infectives
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Why can't the paediatric population use DPIs?
Cannot generate enough air flow to form turbulence for the DPIs (more suitable for 7+ years, check with pulmonary function tests)
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What are the design issues for paediatric pulmonary delivery? (1)
Dosing uncertainties, lack of clinical data (drug deposition, efficacy, safety). Lack of paediatric deposition models (healthy/diseased airways). Devices and formulations are designed for adults then adapted for children (no design for children)
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What are the design issues for paediatric pulmonary delivery? (2)
Decrease particle size? Lower resistance devices? Paediatric-specific safety devices e.g. IS
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What is the SAINT? (1)
Sophia Anatomical Infant Nose-Throat Model (paediatric deposition model). Generated from 3D CT scan of 9 month old female infant
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What is the SAINT? (2)
Inhaler placed on model (and spacer) and measure the drug deposition profile in paediatric population
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Describe features of CFD analysis
Measure drug deposition of powder getting to the lungs. Younger children (4-6y) have larger tongue and narrow oral cavity, shorter pharynx, smaller larynx narrower/shorter trachea, compared to 10-12y. Changes continue until 15y
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Outline the PARI-radiolabelled deposition study in wheezing children (3y)
Decreasing the MMAD, the percentage deposition is higher in the paediatric population (smaller particles of 1-3 microns, higher deposition)
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Where does the medicine go when using good inhaler techniques?
20% deposited in lung (absorption from lung). 80% swallowed (GI absorption, first pass metabolism, systemic circulation)
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Where does the medicine go when using bad inhaler techniques?
5% deposited in lung and 95% swallowed (more GI absorption). Current inhalers are neither used regularly nor efficiently
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What are the common errors and age dependence? (1)
Nebulisers (caregiver not educated, infant face mask doesn't fit, infants cry during inhalation, preschool children talking during inhalation, panting). pMDI (device not shaken before use, spacer not used, no co-ordination or breath hold)
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What are the common errors and age dependence? (2)
DPI (inhalation into DPI, insufficient inspiratory flow through DPI, insufficient monitoring of self-administration, adolescent rebellion against medication)
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What are the strategies for improving adherence? (1)
Nebulisers (educational training programmes for physicians and caregivers, faster nebulisation times, making it a game, breath-actuated devices). pMDI (patient training and school monitoring, fun/portable spacers)
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What are the strategies for improving adherence? (2)
DPIs (patient training/school monitoring, training whistles, school monitoring programmes, discrete, cool device design)
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What is the breathing technique for pMDIs?
Slow and steady (particles travel at a speed to avoid impaction)
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What is the breathing technique for DPIs?
Deep and forceful (to create turbulence and airflow) or read instructions
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Describe features of the in-check device
Change resistance on device (corresponds to different inhalers). Patient breathes through device. Needs to achieve minimum peak airflow. Check resistance
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What conditions are these patients undergoing treatment for?
COPD, lots of respiratory infections
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Where should the peak inhalation flow be for pMDIs in COPD patients?
Below 90 L/min (improvement with training), recommend spacer if they cannot reach optimum peak inhalation flow
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Where should the peak inhalation flow be for DPIs in COPD patients?
Above 30 L/min (improvement with training), recommend spacer if they cannot reach optimum peak inhalation flow
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What are the most common errors in handling and technique for DPIs
No exhalation before inhalation, no breath hold, incorrect inhaler position (Turbuhaler, Rotahaler)
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What are the most common errors in handling and technique for pMDIs
No exhalation before actuation, no breath hold and inhalation too forceful
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Other cards in this set

Card 2

Front

Describe features of the infant lung (1)

Back

Pre-term/born before due date - 2 years old. At pre-term, lungs not fully developed (main bronchi, no branching). Birth on due date (able to breath better). 10 fold increase in number of alveoli. Some branching. Larger alveoli sacs

Card 3

Front

Describe features of the infant lung (2)

Back

Preview of the front of card 3

Card 4

Front

Describe features of the infant lung (3)

Back

Preview of the front of card 4

Card 5

Front

Describe features of lung development in pre-school children (1)

Back

Preview of the front of card 5
View more cards

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