KELAINAN PARU YANG MEMBUTUHKAN PENANGANAN

FISIOTERAPI DADA DAN TERAPI INHALASI

Respiratory Diseases

Respiratory Care

Respiratory-Care Graduates Address the Changing Job Market

Respiratory Diseases

Pulmonary emphysema

Chronic bronchitis

Asthma

Bronchiectasis

Post tuberculosis

Respiratory care

Respiratory Care

Oxygen therapy

Inhallation therapy

Chest physiotherapyMechanical ventilation/

non invasive

Breathing retraining

Airway managementNutrition and diet

Respiratory Care

Physician

Respiratory care practitioner

Family

Rationale For Pulmonary Care

Variety of Physiologic Clinical Manifestation

Chronic Lung Disease

Pulmonary Care

•Increase airways resistance•Hyperinflation

•Decreased lung and chest wall compliance•Disadvantaged respiratory muscles

•Decreased exercise capacity and endurance•Arterial desaturation during exercise

•Reduced oxygen consumption

INHALATION THERAPY

MINIMUM SYSTEMICSIDE EFFECT

RAPID ONSET OF ACTION

1st LINE DRUG DELIVERY SYSTEM INOBTRUCTIVE PULMONERY DISEASES

INHALATION THERAPY

PHARMACOKINETICS PROPERTIES OF THE DRUG

INHALATION THERAPY

• SLOW ABSORPTION FROM THE LUNG• LOW ORAL BIOAVAILABILITY

• RAPID SYSTEMIC CLEARANCE

WIDER THERAPEUTIC INDEX

THE FACTORS CONTRIBUTE TO VARIATIONIN DOSAGE COMPATIBILITY

• ROUTE OF ADMINISTRATION• THE KIND OF INHALATION DEVICE

• AGE OF THE PATIENT• SEVERITY OF THE DISEASE

• INDIVIDUAL VARIATION IN PARTICLE DISTRIBUTION

• PATIENT COMPLIANCE

Particle deposition in the airways

Particle deposition in the airways

CHARACTERISTICS OF PARTICLE DEPOSITION

>10 µm(Trachea,

large bronchi)

1-5 µmLower airways

< 0.5 µm

To be exhaled

Particle deposition in the airwaysParticle deposition in the airways

•

•

•Gravity

( < 2 mm & alveoli)

Inertial movement ( 2 mm)

Brownian movement

Device factors affecting drug deliveryDevice factors affecting drug delivery

in aerosol therapyin aerosol therapy

Device factorsmetered dose inhaler (MDI)

Lung

Oropharynx

Exhaled

Drug deposition

80%

10%

(Newman, 1985)

Device factorsDevice factors• Particle size generated by device:

0.5-10 µm

• characteristics of particle disposition:

– > 10 µm : trachea, large bronchi

– 1-5 µm : lower airways

– < 0.5 µm : to be exhaled

Device factorsmetered dose inhaler (MDI)

• Most popular aerosol device

• initial particle size: 45 MMAD evaporation 2.8-5.5 µm

• 30-50% of the patients cannot coordinate actuation and inhalation

• CFCs are banned now

• attachment of a spacer could be helpful

Device factorsspacer

Advantages:

• enhances lung delivery

• obviates the need of hand-lung coordination (allows a delay of 5-7 seconds after actuation)

• reduces oropharyngeal deposition of large drug particles

Device factorsBreath-actuated MDI

• does not need hand-lung coordination

• requires forceful inspiratory flow to activate drug release

• still utilizes propellants

• not better than MDI if used properly

• may startle children

Device factorsjet nebulizer

• particle size depends on gas flow rate (5-12 l/min particle size: 4-8 MMAD)

• does not need hand-lung coordination or patients’ cooperation

• lung deposition: 10%

• lost in the apparatus: 60-80%

Device factorsjet nebulizer

• equally effective to MDI+spacer

• more expensive

• bulky

• cumbersome

• noisy

Device factorsdry powder inhaler (DPI)

0

20

40

60

80

100

MDI DPI

Device

Upper

Lung

(Timsina,1994)

Mean % deposition of SCG

Device factorsdry powder inhaler (DPI)

• Contains micronized active drugs (ideal particle size of 0.5-8 µm)

• does not need hand-lung coordination

• requires deep and forceful inspiration

• lower airway deposition: 30%

• mouth rinsing after use of steroid DPI

Patient factors affecting drug deliveryPatient factors affecting drug delivery

in aerosol therapyin aerosol therapy

Patient factorsPatient factors• When is a bronchodilating effect

obtained?

• The effect of inspiratory flow rate

• controllable factors (not always):

– speed and depth of breathing

– breath holding

– hand-lung coordination for inhaler

Patient factorsPatient factors• Uncontrollable factors:

– bronchoconstriction– edema– mucus hypersecretion– parenchymal defect

• Impact of bronchial narrowing:

velocity central airway deposition

Which device for which patients?Which device for which patients?

Which device for which patients?

• Metered-dose inhaler (MDI):

– most adults

– children > 7 years old

• MDI+ spacer

– the elderly or disabled

– children from 3-7 years old

Which device for which patients?

• dry powder inhalation (DPI):

– > 7 years old

• nebulizer:

– severe asthma

– any age

How to improve drug delivery How to improve drug delivery

in aerosol therapyin aerosol therapy

How to improve aerosol drug delivery?• select a suitable device for an

individual patient

• an MDI requires shaking prior to use

• a complete exhalation is needed before drug inhalation

• use spacer with an MDI, if needed

How to improve aerosol drug delivery?

• in an asthma attack, MDI / DPI should be used immediately before broncho-spasm becomes more severe

• for multiple inhaler users: use the bronchodilator first

• breath deeply and slowly (3-5 seconds)

How to improve aerosol drug delivery?

• hold breath for 10 seconds

• repeat administration after 1 minute

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