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Inhaled nebulised adrenaline delivery in children and adults: A simulation study
Natalie V Anderson1, William F Ditcham2, Barry Clements3
1School of Population Health, Curtin University, Perth, Australia; Perioperative Medicine Team, The Kids Research Institute Australia, Nedlands, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, Australia; Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Australia.
Insights
Inhaled adrenaline delivery varied significantly by device in children. Endotracheal tubes (ETT) delivered the most adrenaline, while facemasks delivered the least, impacting emergency treatment efficacy.
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Care
- Pharmacokinetics
Background:
- Urgent administration of inhaled adrenaline is critical for pediatric respiratory emergencies like asthma and croup.
- Current dosing and administration guidelines may not fully account for variable delivery efficiencies.
Purpose of the Study:
- To quantify adrenaline delivery via nebulizer using different interfaces (facemask, Laryngeal Mask Airway [LMA], Endotracheal tube [ETT]) in a simulated pediatric setting.
- To inform improved emergency dosing and administration guidelines for inhaled adrenaline in children.
Main Methods:
- Adrenaline was nebulized using jet or vibrating-mesh devices for simulated pediatric weights (3-75 kg).
- Delivery efficiency was measured using facemask, LMA, and ETT, with inhaled doses collected on filters.
- Adrenaline concentrations were quantified using liquid chromatography.
Main Results:
- Endotracheal tubes (ETT) delivered significantly more adrenaline (12-32%) compared to Laryngeal Mask Airways (LMA) (8-15%) and facemasks (2-10%).
- LMA delivery was approximately four times higher than facemask delivery in infants and young children.
- ETT delivery was approximately two times higher than LMA delivery.
Conclusions:
- Delivery efficiency of nebulized adrenaline varies substantially based on the airway interface used in children.
- Endotracheal tubes offer the highest delivery, while facemasks offer the lowest, necessitating guideline review.
- Further research is needed to optimize LMA and facemask delivery for improved pediatric treatment outcomes.
Objective:
Sometimes, there is an urgent need to administer inhaled adrenaline to children, awake, sedated or anaesthetised to treat asthma, bronchospasm, croup, and suspected laryngeal/pharyngeal oedema or stridor, which can become severe or even life-threatening. To better inform emergency dosing and administration guidelines, we aimed to quantify the amount of adrenaline delivered for inhalation from a nebuliser, in a simulated experimental delivery set-up for spontaneously breathing children and adults, either via an anaesthetic face mask, a Laryngeal Mask Airway (LMA) or an Endotracheal tube (ETT).
Methods:
Adrenaline was delivered using a jet or vibrating-mesh nebuliser as per standard hospital protocols for each patient's weight: 3, 12, 30 and 75 kg, using age and weight-appropriate LMA, ETT or facemask, and collected on a filter to represent the inhaled dose. Adrenaline was rinsed from the filter and stored at 4 degrees Celsius until quantified using liquid chromatography.
Results:
The facemask delivered a smaller inhaled mass percentage (2-10%) compared to an LMA (8-15%) with any patient weight (p < 0.001), and an ETT (12-32%) delivered 2 times more than an LMA (p < 0.001).
Conclusion:
The dose delivered using an LMA was approximately four times that of the facemask for infants and young children, and ETT was two times more than LMA. Future research should consider improving the delivery efficiency of nebulised adrenaline via LMA for children of all sizes in appropriate circumstances and investigate improving drug delivery to children via facemask, as well as the safety and efficacy of higher-dosage regimens.
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