Aerosol Medication Aerosol Medication TreatmentsTreatments

Three Primary Indications for Three Primary Indications for AerosolAerosol

Deliver medicationDeliver medication Deliver bland aerosolsDeliver bland aerosols Deliver aerosol to induce sputumDeliver aerosol to induce sputum

Three general reasons for giving Three general reasons for giving aerosol treatments: aerosol treatments:

I. I. To deliver meds SVN , MDI, DPI, SVUSN, Continuous Neb : To deliver meds SVN , MDI, DPI, SVUSN, Continuous Neb : to lower airways ( MMAD of 2 -5 microns ) - such as bronchodilators, to lower airways ( MMAD of 2 -5 microns ) - such as bronchodilators,

anticholinergics, anti asthmaticsanticholinergics, anti asthmatics* allows rapid onset of med* allows rapid onset of med*less toxic and fewer side effects than if given PO or IV*less toxic and fewer side effects than if given PO or IV

to deliver meds to the lung parenchyma - (MMAD of 1 -3 microns ) - to deliver meds to the lung parenchyma - (MMAD of 1 -3 microns ) - such as antibiotics, antifungals )such as antibiotics, antifungals )

to deliver meds to upper airways – (MMAD of > or=5 microns) - such to deliver meds to upper airways – (MMAD of > or=5 microns) - such as racemic epinephrine for upper airway edemaas racemic epinephrine for upper airway edema

* several factors determine overall deposition location* several factors determine overall deposition locationsize of particle - breathing pattern - other physical characteristicssize of particle - breathing pattern - other physical characteristics

General reasons for giving aerosol General reasons for giving aerosol treatmentstreatments

II. II. to deliver cool bland aerosol: to deliver cool bland aerosol: (primarily to the (primarily to the upper airway - MMAD of >/= 5 microns ) use upper airway - MMAD of >/= 5 microns ) use sterile water or normal saline sterile water or normal saline

toto increase expectoration - can also use increase expectoration - can also use hypo and hypertonic saline ( note that systemic hypo and hypertonic saline ( note that systemic hydration - drinking water is the best way )hydration - drinking water is the best way )

to reduce airway swellingto reduce airway swellingpost-op management of airwayspost-op management of airwayscroupcroup

General reasons for giving aerosol General reasons for giving aerosol treatmentstreatments

III. III. to deliver bland aerosol for sputum to deliver bland aerosol for sputum inductioninduction: ( MMAD of 1 - 5 microns ) use : ( MMAD of 1 - 5 microns ) use hypo - hyper or isotonic saline hypo - hyper or isotonic saline

to get C & S (culture and sensitivity )to get C & S (culture and sensitivity )

to get cytologyto get cytology

*per facility policy*per facility policy

Hazards in Performing Aerosol Hazards in Performing Aerosol TreatmentsTreatments

Infection – aerosol particles can cross-Infection – aerosol particles can cross-contaminate the neb, the patient and the contaminate the neb, the patient and the RCP, airborne microbes can cause RCP, airborne microbes can cause nosocomial infections, (common organism- nosocomial infections, (common organism- Pseudomonas aeruginosaPseudomonas aeruginosa) change neb ) change neb setup regularly* and WASH HANDSsetup regularly* and WASH HANDS

HazardsHazards

Bronchospasm – cool and high-density aerosols Bronchospasm – cool and high-density aerosols can cause relative bronchospasm and increased can cause relative bronchospasm and increased airway resistance (especially in patients with airway resistance (especially in patients with preexisting resp. disease) preexisting resp. disease) – Examples of some meds that may lead to Examples of some meds that may lead to

bronchospasm are: acetylcysteine, antibiotics, steroids, bronchospasm are: acetylcysteine, antibiotics, steroids, cromolyn, ribavirin and distilled watercromolyn, ribavirin and distilled water

– Monitor these patients closely and if you suspect Monitor these patients closely and if you suspect bronchospasm, stay with the patient, attempt to calm bronchospasm, stay with the patient, attempt to calm the patient and contact the nurse to call docthe patient and contact the nurse to call doc

HazardsHazards

Overhydration - long term administration Overhydration - long term administration (72 hours or more) with a bland aerosol, it is (72 hours or more) with a bland aerosol, it is more serious in infantsmore serious in infants– Saline may alter electrolytesSaline may alter electrolytes

Airway thermal injury – a problem with Airway thermal injury – a problem with heated aerosols, monitor the temperature heated aerosols, monitor the temperature and do not let the water run dryand do not let the water run dry

HazardsHazards

Airway obstruction from swollen secretions Airway obstruction from swollen secretions – make sure the patient can cough and does – make sure the patient can cough and does cough to get secretions out, if the patient is cough to get secretions out, if the patient is unable to generate a strong enough cough, unable to generate a strong enough cough, you need to suction or assist with another you need to suction or assist with another bronchial hygiene methodbronchial hygiene method

HazardsHazards

Remember additional hazards from the medicationRemember additional hazards from the medication– TachycardiaTachycardia– NervousnessNervousness– TremorsTremors– Thrush from steroidsThrush from steroids– BronchospasmBronchospasm

from steroids,from steroids, mucomysts,mucomysts, antibioticsantibiotics Preservatives in some medications Preservatives in some medications

Drug CalculationsDrug Calculations

Convert from given dose to desired doseConvert from given dose to desired dose Concentrated albuterolConcentrated albuterol 5mg/ mL of concentrated albuterol5mg/ mL of concentrated albuterol Unit dose of albuterol per MD orderUnit dose of albuterol per MD order

5mg5mg 2.5 mg2.5 mg

mL = ?mL = ?

Drug CalculationsDrug Calculations

Lidocaine doseLidocaine dose 0.75 mg/kg?0.75 mg/kg? 210 pound male 210 pound male

patientpatient

Drug CalculationsDrug Calculations

Convert pounds to kilogramsConvert pounds to kilograms 210 lbs divided by 2.2 (conversion factor) 210 lbs divided by 2.2 (conversion factor)

– 210/2.2=95.45 kg210/2.2=95.45 kg

Multiply drug amount by weight in kgMultiply drug amount by weight in kg– 0.75 mg X 95.45 kg = 71.59 mg of medication0.75 mg X 95.45 kg = 71.59 mg of medication

Common Nebulized MedsCommon Nebulized Meds

albuterol 2.5 mg/ 3 mL NS (Proventilalbuterol 2.5 mg/ 3 mL NS (Proventil®®)) XopenexXopenex®® 1.25 mg/ 3 mL NS (levalbuterol) 1.25 mg/ 3 mL NS (levalbuterol)

0.63mg/ 3mL0.63mg/ 3mL 0.32 mg/ 3 mL0.32 mg/ 3 mL

AtroventAtrovent®® 0.5mg/ 2.5 mL 0.5mg/ 2.5 mL (ipratropium (ipratropium bromide)bromide)

DuoNeb® (ipratropium bromide 0.5 mg/albuterol Sulfate 3.0 mg)

Brovana® 15 mcg/2mL (arformoterol)

XopenexXopenex

(Racemic) albuterol is a 50:50 mix of both (Racemic) albuterol is a 50:50 mix of both the (S)- isomer and the (R)-isomer. the (S)- isomer and the (R)-isomer.

XOPENEXXOPENEX®® contains only the single (R)- contains only the single (R)-isomer. The (R)-isomer is known to be isomer. The (R)-isomer is known to be the isomer responsible for the the isomer responsible for the bronchodilation provided by racemic bronchodilation provided by racemic albuterol.albuterol.

Drawing up medicationsDrawing up medications

Drawing Up MedicationsDrawing Up Medications

Use appropriate size syringeUse appropriate size syringe Clean surface of vial with alcohol wipeClean surface of vial with alcohol wipe Invert bottle with rubber stopper down and insert Invert bottle with rubber stopper down and insert

needleneedle Inject sufficient air to replace volume to be Inject sufficient air to replace volume to be

removedremoved Keep tip of needle below surface of liquidKeep tip of needle below surface of liquid Withdraw desired volume of fluid, monitoring for Withdraw desired volume of fluid, monitoring for

bubbles or air pockets -tap syringe?bubbles or air pockets -tap syringe?

Safety !!Safety !!

Do NOT recap the Do NOT recap the needleneedle

Dispose of Dispose of unsheathed needle unsheathed needle appropriatelyappropriately

*Use needleless *Use needleless systems when systems when possiblepossible

Equipment Needed to Give Equipment Needed to Give TreatmentsTreatments

4 TYPES of aerosol treatments4 TYPES of aerosol treatments

1. SVN with meds1. SVN with meds

2. MDI/ DPI with or without spacer device 2. MDI/ DPI with or without spacer device for med deliveryfor med delivery

3. USN / LVN for bland aerosol3. USN / LVN for bland aerosol

4. USN / LVN or SVN for sputum induction4. USN / LVN or SVN for sputum induction

EquipmentEquipment

SVN -small volume nebulizer - gas powered with SVN -small volume nebulizer - gas powered with low flow air or O2 ( uses flowmeter, compressor low flow air or O2 ( uses flowmeter, compressor and sometimes a squeeze bulb ) and sometimes a squeeze bulb )

Uses Bernoulli's principle - SVNs have a jet in Uses Bernoulli's principle - SVNs have a jet in which gas flows thru and as lateral pressure which gas flows thru and as lateral pressure decreases, the med or other liquid is brought up decreases, the med or other liquid is brought up thru a capillary tube, the liquid meets with the gas thru a capillary tube, the liquid meets with the gas and aerosol is produced - particles are baffled to and aerosol is produced - particles are baffled to generate correct MMADgenerate correct MMAD

EquipmentEquipment There are many different types of SVN ( hand-held, used with IPPB There are many different types of SVN ( hand-held, used with IPPB

circuit or MV circuit or MV SVNs used with IPPB or MV (mechanical ventilation) are classified as SVNs used with IPPB or MV (mechanical ventilation) are classified as

either either – mainstreammainstream - the main flow of gas actually passes thru the aerosol - the main flow of gas actually passes thru the aerosol

generator (Pg 267 “White-Clinical book)generator (Pg 267 “White-Clinical book)– sidestreamsidestream - in which the aerosol is injected into the main stream - most - in which the aerosol is injected into the main stream - most

newer nebs can be used as one or the othernewer nebs can be used as one or the other Common hand-held type - uses a T-piece with a Common hand-held type - uses a T-piece with a mouthpiecemouthpiece and a 50 and a 50

cc reservoir ( retains aerosol for increased deposition ) cc reservoir ( retains aerosol for increased deposition ) Can also use a Can also use a mask mask ( aerosol, venti, face tent ) or ( aerosol, venti, face tent ) or adaptor for MVadaptor for MV

SVN-Factors Affecting PerformanceSVN-Factors Affecting Performance

1. Liquid within unit - 4 ml optimal ( SVNs provide more aerosol with this 1. Liquid within unit - 4 ml optimal ( SVNs provide more aerosol with this volume and flows of 6-8 L/m )volume and flows of 6-8 L/m )

2. Gas flow rate - 6-8 L/m clinically useful particles with average of 1 - 5 2. Gas flow rate - 6-8 L/m clinically useful particles with average of 1 - 5 microns ) - microns ) - as flow increases, particle size decreases, but flows above 8 L/m as flow increases, particle size decreases, but flows above 8 L/m decrease the tx time, so pt. gets less med - flows less than 6 L/m take too longdecrease the tx time, so pt. gets less med - flows less than 6 L/m take too long

3. Dead volume -fluid remaining in cup at the pt. in which no more aerosol is 3. Dead volume -fluid remaining in cup at the pt. in which no more aerosol is generated - generated - (.5 -1.0 ml) as dead volume increases, more med stays in cup and (.5 -1.0 ml) as dead volume increases, more med stays in cup and the efficiency decreases - flick sides when device starts to sputter to get as the efficiency decreases - flick sides when device starts to sputter to get as much med to pt. as possible*much med to pt. as possible*

4. Particle size4. Particle size

5. Breathing pattern5. Breathing pattern

SVNSVN

As the fluid level decreases, the diluent evaporates and the As the fluid level decreases, the diluent evaporates and the med concentration increases, esp. towards end of txmed concentration increases, esp. towards end of tx

SVNs only provide about 10 % of the med to the lower SVNs only provide about 10 % of the med to the lower airwaysairways

Different brands available, so choose brand most beneficial Different brands available, so choose brand most beneficial for pt.’s condition and dz processfor pt.’s condition and dz process

During MV- place SVN 18” from pt.During MV- place SVN 18” from pt.Some vents need filters ( Servo)Some vents need filters ( Servo)Finger control type - finger on port nebulizes , finger off port, Finger control type - finger on port nebulizes , finger off port,

no nebulization no nebulization Meds wasted with continuous nebulizationMeds wasted with continuous nebulization

pg 818 Eganpg 818 Egan

Breath Activated NebBreath Activated Neb

Aero-Eclipse II BANAero-Eclipse II BANHelps eliminate wasted Helps eliminate wasted

medicationmedicationLess exposure to Less exposure to

caregiverscaregiversHigher percentage of Higher percentage of

breathable particlesbreathable particlesShorter treatment timeShorter treatment timeReduction of the number Reduction of the number

of treatmentof treatment

insertinsert

Breath Enhanced NebBreath Enhanced Neb(Pari LC Jet plus)(Pari LC Jet plus)

insertedinserted

Breath Enhanced NebulizerBreath Enhanced Nebulizer

insertedinserted

Respiguard IIRespiguard II

For aerosolized For aerosolized Pentamidine delivery. Pentamidine delivery. Includes: Acorn II®, 7' Includes: Acorn II®, 7' kink-resistant supply kink-resistant supply tube, universal anti-tube, universal anti-drool ‘T’, mouthpiece, drool ‘T’, mouthpiece, 6" aerosol tube, 6" aerosol tube, nonported wye, 1-way nonported wye, 1-way valves and expiratory valves and expiratory filter. filter.

PROCEDURE FOR PROCEDURE FOR ADMINISTERING AN AEROSOL TX ADMINISTERING AN AEROSOL TX

WITH MEDWITH MED 1. check the order - make sure dosages are WNL, 1. check the order - make sure dosages are WNL,

check for tx frequency and when last tx was given, check for tx frequency and when last tx was given, check labs ( K+ with cont. neb tx ), diagnostics, check labs ( K+ with cont. neb tx ), diagnostics, meds, H&P, and normal VS KNOW DIAGNOSISmeds, H&P, and normal VS KNOW DIAGNOSIS

2. usual room entry - “ Hi Mrs. Miller, I’m from 2. usual room entry - “ Hi Mrs. Miller, I’m from respiratory and I’m here to give you your breathing respiratory and I’m here to give you your breathing tx” wash hands, Don gloves, check arm ID, get tx” wash hands, Don gloves, check arm ID, get equipment ready check to see when changed out equipment ready check to see when changed out last.last.

ProcedureProcedure 3. check VS to include : Pulse, RR, 3. check VS to include : Pulse, RR,

auscultate and BP - position pt. (full or auscultate and BP - position pt. (full or semi-fowlers - obtain vital capacity, peak semi-fowlers - obtain vital capacity, peak flow, FEV1flow, FEV1

4. get meds ready- measure correct amt., 4. get meds ready- measure correct amt., may be bottle with dropper (USE SYRINGE may be bottle with dropper (USE SYRINGE AND DRAW UP CORRECT AMOUNT) , AND DRAW UP CORRECT AMOUNT) , pre-filled vials- glass or plastic , - check pre-filled vials- glass or plastic , - check med or diluent med or diluent name and check for exp. name and check for exp. datedate, some meds have to be refrigerated, , some meds have to be refrigerated, some meds can be kept at room temp. and some meds can be kept at room temp. and some meds have to be made up by the some meds have to be made up by the pharmacy pharmacy

*some facilities do NOT allow *some facilities do NOT allow blow byblow by

ProcedureProcedure 5. Instruct pt. on breathing pattern - 5. Instruct pt. on breathing pattern -

slow,normal breaths with a moderate deep slow,normal breaths with a moderate deep breath thru mouth q1” and a breath hold of breath thru mouth q1” and a breath hold of 4-10 secs - avoid hyperventilation - 4-10 secs - avoid hyperventilation - encourage diaphragmatic breathing which encourage diaphragmatic breathing which may be helpful may be helpful

6. Turn on flow - 6 -8 l/m - check for 6. Turn on flow - 6 -8 l/m - check for adequate mistadequate mist

7. Apply device (use appropriate device for 7. Apply device (use appropriate device for individual pt. ) mouthpiece best device individual pt. ) mouthpiece best device (including children over 3 ), but... may need (including children over 3 ), but... may need mask or blow-by* mask or blow-by*

Monitor the pt. closely - watch for Monitor the pt. closely - watch for hyperventilation , problems with maskhyperventilation , problems with mask

ProcedureProcedurewatch for side effects of meds - ex. acetylcysteine - watch for side effects of meds - ex. acetylcysteine -

bronchospasm bronchospasm sympathomimetics – tachycardia, hypertension, sympathomimetics – tachycardia, hypertension, tremors, palpitations, N&V and nervousnesstremors, palpitations, N&V and nervousnessallergic reaction to drug -SOB , bronchospasmallergic reaction to drug -SOB , bronchospasm

IF HR INCREASES BY 20 BEATS STOP TX - pt. IF HR INCREASES BY 20 BEATS STOP TX - pt. may already have an increased HR , if so, check may already have an increased HR , if so, check with physician before giving txwith physician before giving tx

8. Check VS midway thru tx- ask pt. how they are 8. Check VS midway thru tx- ask pt. how they are feeling, the length of tx will vary TRY TO USE UP feeling, the length of tx will vary TRY TO USE UP MEDMED

9. Check VS again after tx and spirometry - check 9. Check VS again after tx and spirometry - check hospital policy for cleaning neb and storagehospital policy for cleaning neb and storage

ProcedureProcedure 10. Have pt. cough and expectorate if 10. Have pt. cough and expectorate if

possible - note amt. , color, consistency & possible - note amt. , color, consistency & smell of secretions uhhhh?yucckkkk!smell of secretions uhhhh?yucckkkk!

11. Put room back together and ask it they 11. Put room back together and ask it they need anything – (check with nurse - maybe need anything – (check with nurse - maybe NPO) NPO)

12. CHART - date, time started, type of tx, 12. CHART - date, time started, type of tx, duration, meds & amt., position, duration, meds & amt., position, complications, VS ( 80-85-84 ) include all, complications, VS ( 80-85-84 ) include all, cough effort, secretions, signature and cough effort, secretions, signature and credentialscredentials

The above should be included for all types The above should be included for all types of aerosol txsof aerosol txs

Large Volume NebLarge Volume Neb

Ultrasonic NebulizerUltrasonic Nebulizer

Car Power adapterCar Power adapter Rechargeable Rechargeable

batterybattery PortablePortable Ease of UseEase of Use

MDI MDI

MDIs are small, pressurized canisters with a mouthpiece MDIs are small, pressurized canisters with a mouthpiece that uses pressurized gas propellants - 80 -100 doses that uses pressurized gas propellants - 80 -100 doses (varies with med ) - depression of the canister leads to a (varies with med ) - depression of the canister leads to a measured amt. of propellant carrying the med crystals to measured amt. of propellant carrying the med crystals to the pt.s open airway ( the propellants, ‘CFCs in the past, the pt.s open airway ( the propellants, ‘CFCs in the past, now most use HFAs ( hydrofluoroalkanes)’, high pressure now most use HFAs ( hydrofluoroalkanes)’, high pressure causes rapid evaporation & dissipation while the med is causes rapid evaporation & dissipation while the med is aerosolized aerosolized – can be used inline MV circuit can be used inline MV circuit – if using Atrovent place in mouth to avoid glaucomaif using Atrovent place in mouth to avoid glaucoma

Metered Dose InhalersMetered Dose Inhalers

MDI MDI - the most important aspect for effectiveness is - the most important aspect for effectiveness is patient understanding of proper instruction and being able patient understanding of proper instruction and being able to follow the proper instruction to follow the proper instruction

successful delivery of med depends on :successful delivery of med depends on :a. coordinating the actuation at the appropriate timea. coordinating the actuation at the appropriate timeb. slow inspiratory flowb. slow inspiratory flowc. 4 -10 second breath hold at end inspirationc. 4 -10 second breath hold at end inspiration

use the bronchodilator first -if using steroid gargle use the bronchodilator first -if using steroid gargle after & use spacerafter & use spacer

wait at least one minute between puffs with 3 – 10” wait at least one minute between puffs with 3 – 10” being optimalbeing optimal

Egan pg 808 Box 36-1Egan pg 808 Box 36-1

Optimal Technique for pMDIOptimal Technique for pMDI

Warm the MDI to body temperatureWarm the MDI to body temperature ““Prime” by activating into the airPrime” by activating into the air Assure mouthpiece is clearAssure mouthpiece is clear Open mouth technique*Open mouth technique*

– 2 fingers from lips and mouth opened2 fingers from lips and mouth opened

Closed mouth-lips around mouth pieceClosed mouth-lips around mouth piece Breath out normallyBreath out normally

Optimal Technique for pMDIOptimal Technique for pMDI

Slowly begin to breath in-actuate the MDISlowly begin to breath in-actuate the MDI Continue to breath in to total lung capacityContinue to breath in to total lung capacity Hold breath for up to 10 secondsHold breath for up to 10 seconds Wait at least 1 minute between puffsWait at least 1 minute between puffs Recap and store deviceRecap and store device

– Clean as requiredClean as required– Rinse mouth after some medicationsRinse mouth after some medications– Count puffs?*Count puffs?*

MDIMDI

Breath activated Breath activated MDI’sMDI’s

(Autohaler)(Autohaler)– pirbuterol has a pirbuterol has a

preferential effect on preferential effect on beta-2 adrenergic beta-2 adrenergic

Frequent MDI’sFrequent MDI’s

albuterolalbuterol XopenexXopenex AtroventAtrovent FloventFlovent CombiventCombivent

Brand NameBrand Name Drug NameDrug Name

ProventilProventil® albuterolalbuterol

XopenexXopenex®® levalbuterollevalbuterol

AtroventAtrovent®® Ipratropium Ipratropium bromidebromide

FloventFlovent®® flucticasoneflucticasone

CombiventCombivent®® albuterol & albuterol & ipratropium ipratropium

bromidebromide

DPI (dry powder inhaler)DPI (dry powder inhaler)

DPIsDPIs ( dry powder inhalers )( dry powder inhalers ) - alternate method for - alternate method for certain med delivery - do not use CFCs - DPIs are breath-certain med delivery - do not use CFCs - DPIs are breath-actuated (no need for coordination but must have sufficient actuated (no need for coordination but must have sufficient inspiratory flow) ex. - Spinhaler, Rotohalerinspiratory flow) ex. - Spinhaler, Rotohaler– the device requires a gelatin capsule with powdered med - the the device requires a gelatin capsule with powdered med - the

delivery device opens the capsule and the pt. must inspire at a delivery device opens the capsule and the pt. must inspire at a certain high flow in order to get the med into the airways certain high flow in order to get the med into the airways

– main problems with this delivery main problems with this delivery

sufficient flows required sufficient flows required no reaction to powder no reaction to powder also cannot be used with MV as moisture would also cannot be used with MV as moisture would

clump med clump med

Brand NameBrand Name Drug NameDrug Name

SereventSerevent®® salmeterolsalmeterol

FloventFlovent®® Diskus Diskus fluticasonefluticasone

AdvairAdvair Salmeterol & Salmeterol & fluticasonefluticasone

Pulmocort Pulmocort FlexhalerFlexhaler

budesonidebudesonide

SPACERS AND CHAMBERS FOR SPACERS AND CHAMBERS FOR MDIsMDIs

Used to enhance aerosol delivery - there are many types available Used to enhance aerosol delivery - there are many types available Goals:Goals:

1. to decrease velocity of the propelled aerosol from MDI1. to decrease velocity of the propelled aerosol from MDI2. to decrease inertial impaction2. to decrease inertial impaction3. to decrease oropharyngeal deposition3. to decrease oropharyngeal deposition4. to improve pt. synchronization4. to improve pt. synchronization

Spacers and chambers are partial reservoirs for medicationSpacers and chambers are partial reservoirs for medicationSPACERS DIFFER FROM CHAMBERSSPACERS DIFFER FROM CHAMBERS

spacers still require coordinationspacers still require coordinationchambers have a one-way valve, so no med lost on exp.chambers have a one-way valve, so no med lost on exp.chambers take 2 -3 additional puffschambers take 2 -3 additional puffsthey are also available with maskthey are also available with maskcan be used inline with MVcan be used inline with MVchamber or spacer mouthpiece should be placed chamber or spacer mouthpiece should be placed inin mouth mouth

*some facilities have policies *some facilities have policies against blow byagainst blow by

Medication Delivery in ChildrenMedication Delivery in Children

Not just little people (what dose is right?)Not just little people (what dose is right?) May pose special problemsMay pose special problems

– UncooperativeUncooperative– Crying-quick inspiratory time with prolonged Crying-quick inspiratory time with prolonged

expiratory “cry”expiratory “cry”– Avoid medications in eyesAvoid medications in eyes– Avoid medicating other caregiversAvoid medicating other caregivers– Avoid blow-by*Avoid blow-by*

Medication Delivery in ChildrenMedication Delivery in Children

Most meds labeled for adults and children 6 Most meds labeled for adults and children 6 years of age and olderyears of age and older

Do they need twice as much?Do they need twice as much? Do they need half as much?Do they need half as much?