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Nebulizing: Mouthpiece vs mask


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Is anyone aware of any studies that show using the mouthpiece or mask results in a higher concentration of nebulized medication reaching the lungs? At work it was standard to use the mask unless the patient could not tolerate having a mask on their face. But I was told today that by using the mouthpiece you'll make the nebulizer treatment a "more active process", resulting in the patient taking deeper, more controlled breaths. Just wanted to see if there is some factual basis to either approach and what others tend to use and why.

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Not aware of any studies, but I can throw an observation at ya.

Okay, so I typed up this nice long schpiel showing off my vast genius...then went to the Google monster to see if my assumptions were correct.

I'll just refer you to Google now 'cause what I typed was stupid.


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When considering the deposition of aerosol particles in the airways, assuming the correct size for the specified generation you wish to penetrate, three mechanisms should be considered:

1) Brownian motion and subsequent diffusion

2) Gravitational effects

3) Movement bias and inertial impaction

Unfortunately, having a patient wear a mask and allow them to talk during nebulised aerosol therapy is counterproductive and makes an already inefficient mechanism of delivery even more difficult. The optimal breathing pattern is a slow, deep inhalation followed by an inspiratory hold and exhalation. This minimises inertial impaction in the upper airways and optomises the role of Brownian motion and gravitational settling in order to ensure penetration of the lower airways occurs. Unfortunately, this is not likely to occur in a sick patient who is already tachypneic. However, having somebody talk with a mask only compounds the issue. While you interview them, they will be taking short breaths with an irregular breathing pattern. Also, when the mouth is closed, particles experience inertial impaction on the mask and the patient's face. Ideally, we would like to coach the sick person in a proper breather pattern using a mouthpiece and optimise the three mechanisms as discussed above.

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Admittedly, I have no actual scientific basis, but per department policies, administration of nebulized Albuterol for EMT-B personnel is the mouthpiece. Mask administration is currently restricted to the Paramedics.

As for not allowing the patient to talk? During any episode where Albuterol has to be administered, most patients wouldn't want to talk.

Edited for content

Edited by Richard B the EMT
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There is a good guide for respiratory delivery devices which is used as a reference for nurses working in the ED.


Page 13 describes the SVN and the mouthpiece.

The mouthpiece is definitely the preferred method and there are studies which are listed at the end of this guide.

There are also many types of nebulizers and the newer ones used in the ED are primarily designed for a mouthpiece.

The mask is sometimes more convenient for Paramedics because it can provide oxygen as well as a little medication and frees up their hands.

But, the mask can also present some complications. Lack of attention to the positioning of the mask for the patient who is not able to move it themselves can cause injury to the eye. The medications are also not good to get into the eye nor is the infectious droplets coughed up from the lungs. The patients who do use a mask regularly are at some time treated for eye infections chronically.

Some patients and providers are also just too lax or lazy to use the mouthpiece. For some it is the convenience of the Paramedic or Nurse so they can talk to get the paperwork done and move on. This does the patient a disservice who may actually need to concentrate on breathing better with the aide of the SVN. The hard core COPDer patients often know the difference and will request the mouthpiece and will only nod to yes/no questions. If they don't they may already be well beyond the help of an SVN.

I think the EMTs should be honored to have the responsibility of giving a tx with a mouthpiece since there does require a little more technique and coaching rather than just slinging a neb on someone's face with a mask.

There is also a difference between charting you "gave" the medication and the patient actually receiving the best possible dose of the medication through the correct delivery method and technique. It is like saying blowby is best for a child (older then infant) or that if they scream they get more medication into their lungs which is also not true.

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Typically the mouthpiece is preferred, however the patient must maintain a good 'bite/seal' on mouthpiece to have it more effective than the mask. Patients can hold their own nebs to free your hands, as long as you monitor them maintaining the seal.

The mask should be utilized if the patient cannot hold the mouthpiece, and you cannot assist.

Of course, if the patient is not having adequate inspiratory effort, then bag the med in or identify if CPAP would be better.

Many options available with different lines of thinking. Do what's best for the patient in the situation you are presented.

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