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Administering medicated aerosols to pediatric patients is as easy as 1, 2, 3.

The best way to give a medicated aerosol therapy to a pediatric patient is a controversial topic. Arguments for and against specific medications, techniques, and devices have echoed through the hallowed halls of the inpatient hospital facility and in respiratory therapy department meetings for decades.

I received a call from a colleague who asked my advice on this important topic, so I decided to look into who was saying what in the literature about this procedure, one of the most frequently ordered treatments in the pediatric population.

The literature in the last 10 years has been more specific on how not to give aerosol therapy to young pediatric patients and babies than it has been instructive on how we should give therapy. This reticence may be the offspring of the change that is occurring in our profession, in part due to the relentless pursuit of perfection in developing the ultimate nebulizer, aerosol generator and face mask by our industry research and development colleagues.

In training consultant-level respiratory therapists at the baccalaureate level, I expect my students and graduates to follow the sage advice of my mentors John G. Byers, Jr., MD, FCCP, and Joe DiPietro, RRT, who said that we should be confident that we are" ... the right person to give the right treatment to the right patient at the right time."

Confidence arises from a scholarly approach to our studies, experience, good mentors and hard work to achieve praxis, where our colleagues think and state that we know what we are doing, but we ourselves know that we know. I consider this the teaching mission of my program, and a really good place to begin this conversation.

RTs are the most qualified team member to apply and modify the key physical principles of our science, especially concerning the physical nature of the gas or solutions we use, optimal aerosol particle size, airway deposition effected by inertial impaction, sedimentation, diffusion and aging of the aerosol.

Likewise, these independent variables are relentless in working against us in our quest to achieve the goal of right sizing a medication particle, placing it at the targeted conducting airways where it can do the most good in regards to a specific ailment, and keeping the desired therapeutic effect for a period of time.

Let's use a three-step model that may be helpful when we take stock of what we are trying to do when we determine the therapeutic objective and think about what we are trying to achieve when we are ordered to deliver a medication via aerosol to a baby.

First, why are you giving this particular medicine by aerosol? Is there an alternative technique to give the medication, and, outside of the orders, what process led you to think your way to this branch of the algorithm? There is a wide array of medications available to a respiratory therapist. In my view, this is a truly spectacular point when one recalls that not long ago the available tools in the respiratory therapist's medicine toolbox were a few catecholamine beta2 adrenergics, mucolytics with as many hazards as indices, an off-label inhaled steroid or two, salines of varietal tonicity, sterile water as diluent, lots of ethanol, a few mucokinetic agents, and many more creative "cocktails" compounded by the wizened pharmacist.

I am sure my list is incomplete, but that was about the extent, in toto, of our list of available medications.

The respiratory therapy student must now remember many different sub-groups of bronchodilators, and the ranks of anti-inflammatory and long-acting beta agonist medicines continue to swell. The therapist must determine if the medicine ordered is appropriate for the problem and then decide, in concert with members the multidisciplinary team, if the planned delivery device will yield a predicted outcome.


I recently read a brilliant opinion piece on our professional list-serv on how to deliver alphal agonists (primary topical vasoconstrictors) targeted at the upper airways in a croupy baby. Because coaching was not determined to be plausible in that wee patient, the therapist used an "old school" atomizer to deliver the medicine in a short time, with the anticipated outcome of diminution of stridor, improved air exchange and visually reduced work of the child's breathing.

This therapist worked within departmental and patient safety guidelines, and used a creative approach to get the right medicine (with a right-sized particle) to the target. The therapist controlled the delivery of therapy while monitoring vitals signs for outcome and side effect. Well-meaning but misguided experts may recommend procedures or use terminology that could render aerosol therapy less effective. A recent publication encouraged patient families to add saline to treatments as "saline leads to an increase in the amount of the medication that is nebulized."

Appropriate teaching and reinforcement is critical to home infection control and maintenance of proper technique after discharge to home. Departmental leaders, especially those in the critical role of in-house clinical educator and preceptor, should brainstorm their existing treatment approaches within the ranks of the staff, and poll the physicians and other stakeholders to see if the most cost-effective methods are covered by policy and available to improve the care of clientele. Even if policy remains unchanged, voices have been heard, the options have been explored, and new answers to old problems have emerged and have been documented for further investigation.

Second, consider if the technical method of aerosol delivery is age appropriate and suited to the patient in each particular case. The time-tested technique of blow-by nebulizer therapy has suffered a fatal blow from the slings and arrows of the foremost experts and researchers in aerosol medicine. So, supported by the literature, we can put any policies and procedures suggesting blow-by aerosol therapy for babies into the respiratory therapy dumpster.

Medicated aerosol nebulizer therapy with a mouthpiece, using deep inhalation and sustained breath holding, can be demonstrated by very small children. Many of the available face masks, especially the critter masks and cute devices that make treatments fun for the patient, may enhance patient motivation and provide a fair to marginal amount of medication deposition. However, getting a small baby to hold still while you administer aerosol therapy continues to be an art versus a science.

Many therapists are adept at metered dose inhaler therapy using a snug-fitting, appropriately sized face mask and holding chambers in children less than 3 years old, and then provide family education to as many caregivers as possible to allow for effective therapy when they are back at home.

Fink and associates, using images of tagged aerosols within the pediatric lung, found equally appropriate amounts of deposited particles when they used either a snug fitting face mask or an aerosol therapy cube or mini-therapy tent for medicated aerosol therapy. Amirov and Newhouse wrote that skilled administration of the therapy, along with an optimal mask design that addressed the variables of appropriate mask fit, the volume of dead space, contour, flexibility, transparency, weight and cost were all critical to providing effective medicated aerosol therapy.

The third thing to be addressed is the overall effectiveness of the delivery system for aerosol therapy. This includes how the therapist accesses and receives orders, and the administrative paper chase that flows from a patient's initial presentation to the time they receive their first respiratory therapy treatment.

I did this analysis in my department and found that there was a very significant lag in time from patient presentation to medicated aerosol treatment, in particular related to a perceived hierarchy that literally left our patients breathless. A lot of communication, collaboration and teamwork, sprinkled with collegiality, backed by a strong physician champion who encouraged medical staff buy-in helped me to repair most of these fixable problems. However, you can see that many hands touch this recipe, and some days it seemed that the patient was lost in the shuffle.

When you evaluate the efficacy of therapy, consider all of these steps and seek the counsel of your colleague CRTs and RRTs who deal with this 12 hours a day, every day, as they know exactly what's broken and who needs fixing.

Optimizing the delivery of medicated aerosol therapy in pediatrics is more than the logistical issues of unit-dose medications, metered dose inhalers, nebulizers and spacers. A team approach will make your department the strongest link in the hands-on chain of patient care delivery.

Douglas Masini, EdD, RPFT, RRT-NPS, AE-C, FAARC


Douglas Masini is the Department Head/Chair of the Respiratory Therapy Program at Armstrong Atlantic State University in Savannah, GA. He can be reached at
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Author:Masini, Douglas
Publication:FOCUS: Journal for Respiratory Care & Sleep Medicine
Date:Mar 1, 2010
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