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Nemcova N, Kosutova P, Kolomaznik M, Mateffy S, Turianikova Z, Calkovska A, Mikolka P. The effect of budesonide delivered by high-frequency oscillatory ventilation on acute inflammatory response in severe lung injury in adult rabbits. Physiol Res 2023; 72:S509-S521. [PMID: 38165755 PMCID: PMC10861260 DOI: 10.33549/physiolres.935232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/15/2023] [Indexed: 02/01/2024] Open
Abstract
The inflammation present in acute respiratory distress syndrome (ARDS) and thereby associated injury to the alveolar-capillary membrane and pulmonary surfactant can potentiate respiratory failure. Even considering the high mortality rate of severe ARDS, glucocorticoids appear to be a reasonable treatment option along with an appropriate route of delivery to the distal lung. This study aimed to investigate the effect of budesonide therapy delivered intratracheally by high-frequency oscillatory ventilation (HFOV) on lung function and inflammation in severe ARDS. Adult New Zealand rabbits with respiratory failure (P/F<13.3 kPa) induced by intratracheal instillation of hydrochloric acid (HCl, 3 ml/kg, pH 1.5) followed by high tidal ventilation (VT 20 ml/kg) to mimic ventilator-induced lung injury (VILI) were treated with intratracheal bolus of budesonide (0.25 mg/kg, Pulmicort) delivered by HFOV (frequency 8 Hz, MAP 1 kPa, deltaP 0.9 kPa). Saline instead of HCl without VILI with HFOV delivered air bolus instead of therapy served as healthy control. All animals were subjected to lung-protective ventilation for 4 h, and respiratory parameters were monitored regularly. Postmortem, lung injury, wet-to-dry weight ratio, leukocyte shifts, and levels of cytokines in plasma and lung were evaluated. Budesonide therapy improved the lung function (P/F ratio, oxygenation index, and compliance), decreased the cytokine levels, reduced lung edema and neutrophils influx into the lung, and improved lung architecture in interstitial congestion, hyaline membrane, and atelectasis formation compared to untreated animals. This study indicates that HFOV delivered budesonide effectively ameliorated respiratory function, and attenuated acid-induced lung injury in a rabbit model of severe ARDS.
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Affiliation(s)
- N Nemcova
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic.
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Montigaud Y, Georges Q, Leclerc L, Clotagatide A, Louf-Durier A, Pourchez J, Prévôt N, Périnel-Ragey S. Impact of gas humidification and nebulizer position under invasive ventilation: preclinical comparative study of regional aerosol deposition. Sci Rep 2023; 13:11056. [PMID: 37422519 PMCID: PMC10329710 DOI: 10.1038/s41598-023-38281-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/06/2023] [Indexed: 07/10/2023] Open
Abstract
Successful aerosol therapy in mechanically ventilated patients depends on multiple factors. Among these, position of nebulizer in ventilator circuit and humidification of inhaled gases can strongly influence the amount of drug deposited in airways. Indeed, the main objective was to preclinically evaluate impact of gas humidification and nebulizer position during invasive mechanical ventilation on whole lung and regional aerosol deposition and losses. Ex vivo porcine respiratory tracts were ventilated in controlled volumetric mode. Two conditions of relative humidity and temperature of inhaled gases were investigated. For each condition, four different positions of vibrating mesh nebulizer were studied: (i) next to the ventilator, (ii) right before humidifier, (iii) 15 cm to the Y-piece adapter and (iv) right after the Y-piece. Aerosol size distribution were calculated using cascade impactor. Nebulized dose, lung regional deposition and losses were assessed by scintigraphy using 99mtechnetium-labeled diethylene-triamine-penta-acetic acid. Mean nebulized dose was 95% ± 6%. For dry conditions, the mean respiratory tract deposited fractions reached 18% (± 4%) next to ventilator and 53% (± 4%) for proximal position. For humidified conditions, it reached 25% (± 3%) prior humidifier, 57% (± 8%) before Y-piece and 43% (± 11%) after this latter. Optimal nebulizer position is proximal before the Y-piece adapter showing a more than two-fold higher lung dose than positions next to the ventilator. Dry conditions are more likely to cause peripheral deposition of aerosols in the lungs. But gas humidification appears hard to interrupt efficiently and safely in clinical use. Considering the impact of optimized positioning, this study argues to maintain humidification.
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Affiliation(s)
- Yoann Montigaud
- Mines Saint-Etienne, Univ Jean Monnet, INSERM, U1059 Sainbiose; Centre CIS, 42023, Saint-Etienne, France
| | - Quentin Georges
- Intensive Care Unit G, CHU Saint-Etienne, 42055, Saint-Etienne, France
| | - Lara Leclerc
- Mines Saint-Etienne, Univ Jean Monnet, INSERM, U1059 Sainbiose; Centre CIS, 42023, Saint-Etienne, France
| | | | | | - Jérémie Pourchez
- Mines Saint-Etienne, Univ Jean Monnet, INSERM, U1059 Sainbiose; Centre CIS, 42023, Saint-Etienne, France
| | - Nathalie Prévôt
- Nuclear Medicine Unit, CHU Saint-Etienne, 42055, Saint-Etienne, France
- Université Jean Monnet, Mines Saint-Etienne, INSERM, U1059 Sainbiose, 42023, Saint-Etienne, France
| | - Sophie Périnel-Ragey
- Intensive Care Unit G, CHU Saint-Etienne, 42055, Saint-Etienne, France.
- Université Jean Monnet, Mines Saint-Etienne, INSERM, U1059 Sainbiose, 42023, Saint-Etienne, France.
- Intensive Care Unit G, Saint Etienne University Hospital, North Hospital, UMR INSERM U1059, Avenue Albert Raymond, 42270, Saint Priest en Jarez, France.
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Lima CA, Campos SL, Bandeira MP, Leite WS, Brandão DC, Fernandes J, Fink JB, Dornelas de Andrade A. Influence of Mechanical Ventilation Modes on the Efficacy of Nebulized Bronchodilators in the Treatment of Intubated Adult Patients with Obstructive Pulmonary Disease. Pharmaceutics 2023; 15:pharmaceutics15051466. [PMID: 37242708 DOI: 10.3390/pharmaceutics15051466] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/03/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Little has been reported in terms of clinical outcomes to confirm the benefits of nebulized bronchodilators during mechanical ventilation (MV). Electrical Impedance Tomography (EIT) could be a valuable method to elucidate this gap. OBJECTIVE The purpose of this study is to evaluate the impact of nebulized bronchodilators during invasive MV with EIT by comparing three ventilation modes on the overall and regional lung ventilation and aeration in critically ill patients with obstructive pulmonary disease. METHOD A blind clinical trial in which eligible patients underwent nebulization with salbutamol sulfate (5 mg/1 mL) and ipratropium bromide (0.5 mg/2 mL) in the ventilation mode they were receiving. EIT evaluation was performed before and after the intervention. A joint and stratified analysis into ventilation mode groups was performed, with p < 0.05. RESULTS Five of nineteen procedures occurred in controlled MV mode, seven in assisted mode and seven in spontaneous mode. In the intra-group analysis, the nebulization increased total ventilation in controlled (p = 0.04 and ⅆ = 2) and spontaneous (p = 0.01 and ⅆ = 1.5) MV modes. There was an increase in the dependent pulmonary region in assisted mode (p = 0.01 and ⅆ = 0.3) and in spontaneous mode (p = 0.02 and ⅆ = 1.6). There was no difference in the intergroup analysis. CONCLUSIONS Nebulized bronchodilators reduce the aeration of non-dependent pulmonary regions and increase overall lung ventilation but there was no difference between the ventilation modes. As a limitation, it is important to note that the muscular effort in PSV and A/C PCV modes influences the impedance variation, and consequently the aeration and ventilation values. Thus, future studies are needed to evaluate this effort as well as the time on ventilator, time in UCI and other variables.
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Affiliation(s)
- Cibelle Andrade Lima
- Physiotherapy Depatment, Universidade Federal do Rio Grande do Norte, Natal 59078-970, RN, Brazil
| | - Shirley Lima Campos
- Physiotherapy Depatment, Universidade Federal de Pernambuco, Recife 50740-560, PE, Brazil
| | | | - Wagner Souza Leite
- Physiotherapy Depatment, Universidade Federal de Pernambuco, Recife 50740-560, PE, Brazil
| | - Daniella Cunha Brandão
- Physiotherapy Depatment, Universidade Federal de Pernambuco, Recife 50740-560, PE, Brazil
| | - Juliana Fernandes
- Physiotherapy Depatment, Universidade Federal de Pernambuco, Recife 50740-560, PE, Brazil
| | - James B Fink
- Department of Cardiopulmonary Science, Division of Respiratory, CA Rush University Medical Center, Chicago, IL 60612, USA
- Aerogen Pharma, San Mateo, CA 94402, USA
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Chartrand L, Ploszay V, Tessier S. Optimal delivery of aerosolized medication to mechanically ventilated pediatric and neonatal patients: A scoping review. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2022; 58:199-203. [PMID: 36545463 PMCID: PMC9757125 DOI: 10.29390/cjrt-2022-044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives Delivering aerosolized medication to patients during mechanical ventilation is a common practice in respiratory therapy for adult, pediatric, and neonatal populations. However, aerosol delivery in pediatric populations is inconsistent and challenging, impacting how the drug is delivered. Some factors that influence drug delivery efficiency are directly under the purview of the clinician or therapist administering the drugs. However, excessive variability exists amongst clinicians and therapists working at the same site and between different sites. This review aims to systematically summarize the literature to identify current practice variations, identify common practices, and provide suggestions to guide future research in this area. In addition, this scoping review aims to identify the available evidence and knowledge gaps in the literature regarding the delivery of aerosolized medication to pediatric populations during mechanical ventilation. More specifically, the question that guided our research was: What are the best strategies for optimizing aerosol delivery of medication to pediatric patients, including neonates, while on mechanical ventilation? Methods A scoping review, using the Joanna Briggs Institute methodology, was conducted until September 2022 in the CINAHL, EMBASE (Ovid), and Medline (Ovid) databases. Our initial search yielded 248 articles. After screening the titles, abstracts, and full text of the articles according to inclusion and exclusion criteria, five articles were analyzed. Results We identified three main topics for discussion: the type of device used for administering aerosolized medication, appropriate mechanical ventilation settings, and optimal placement of the nebulizer delivery system. Conclusion Of the three topics we intended to discuss, we only found enough evidence to suggest using mesh nebulizers to increase aerosol deposition. We found conflicting or outdated results for the other two topics. This demonstrates a significant gap in the literature since aerosol medications are routinely administered to mechanically ventilated neonatal and other pediatric patients.
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Affiliation(s)
- Louise Chartrand
- Department of Respiratory Therapy, University of Manitoba, Winnipeg, MB
| | | | - Sébastien Tessier
- Children’s Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB
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Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, Khilnani GC, Chaudhary D, Singla R, Koul PA, Mahashur AA, Ghoshal AG, Behera D, Christopher DJ, Talwar D, Ganguly D, Paramesh H, Gupta KB, Kumar T M, Motiani PD, Shankar PS, Chawla R, Guleria R, Jindal SK, Luhadia SK, Arora VK, Vijayan VK, Faye A, Jindal A, Murar AK, Jaiswal A, M A, Janmeja AK, Prajapat B, Ravindran C, Bhattacharyya D, D'Souza G, Sehgal IS, Samaria JK, Sarma J, Singh L, Sen MK, Bainara MK, Gupta M, Awad NT, Mishra N, Shah NN, Jain N, Mohapatra PR, Mrigpuri P, Tiwari P, Narasimhan R, Kumar RV, Prasad R, Swarnakar R, Chawla RK, Kumar R, Chakrabarti S, Katiyar S, Mittal S, Spalgais S, Saha S, Kant S, Singh VK, Hadda V, Kumar V, Singh V, Chopra V, B V. Indian Guidelines on Nebulization Therapy. Indian J Tuberc 2022; 69 Suppl 1:S1-S191. [PMID: 36372542 DOI: 10.1016/j.ijtb.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/16/2023]
Abstract
Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.
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Affiliation(s)
- S K Katiyar
- Department of Tuberculosis & Respiratory Diseases, G.S.V.M. Medical College & C.S.J.M. University, Kanpur, Uttar Pradesh, India.
| | - S N Gaur
- Vallabhbhai Patel Chest Institute, University of Delhi, Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater NOIDA, Uttar Pradesh, India
| | - R N Solanki
- Department of Tuberculosis & Chest Diseases, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Raj Kumar
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, National Centre of Allergy, Asthma & Immunology; University of Delhi, Delhi, India
| | - G C Khilnani
- PSRI Institute of Pulmonary, Critical Care, & Sleep Medicine, PSRI Hospital, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhary
- Department of Pulmonary & Critical Care Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rupak Singla
- Department of Tuberculosis & Respiratory Diseases, National Institute of Tuberculosis & Respiratory Diseases (formerly L.R.S. Institute), Delhi, India
| | - Parvaiz A Koul
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Ashok A Mahashur
- Department of Respiratory Medicine, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
| | - A G Ghoshal
- National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
| | - D Behera
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepak Talwar
- Metro Centre for Respiratory Diseases, Noida, Uttar Pradesh, India
| | | | - H Paramesh
- Paediatric Pulmonologist & Environmentalist, Lakeside Hospital & Education Trust, Bengaluru, Karnataka, India
| | - K B Gupta
- Department of Tuberculosis & Respiratory Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India
| | - Mohan Kumar T
- Department of Pulmonary, Critical Care & Sleep Medicine, One Care Medical Centre, Coimbatore, Tamil Nadu, India
| | - P D Motiani
- Department of Pulmonary Diseases, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - P S Shankar
- SCEO, KBN Hospital, Kalaburagi, Karnataka, India
| | - Rajesh Chawla
- Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Department of Pulmonary Medicine & Sleep Disorders, AIIMS, New Delhi, India
| | - S K Jindal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Luhadia
- Department of Tuberculosis and Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - V K Arora
- Indian Journal of Tuberculosis, Santosh University, NCR Delhi, National Institute of TB & Respiratory Diseases Delhi, India; JIPMER, Puducherry, India
| | - V K Vijayan
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, University of Delhi, Delhi, India
| | - Abhishek Faye
- Centre for Lung and Sleep Disorders, Nagpur, Maharashtra, India
| | | | - Amit K Murar
- Respiratory Medicine, Cronus Multi-Specialty Hospital, New Delhi, India
| | - Anand Jaiswal
- Respiratory & Sleep Medicine, Medanta Medicity, Gurugram, Haryana, India
| | - Arunachalam M
- All India Institute of Medical Sciences, New Delhi, India
| | - A K Janmeja
- Department of Respiratory Medicine, Government Medical College, Chandigarh, India
| | - Brijesh Prajapat
- Pulmonary and Critical Care Medicine, Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
| | - C Ravindran
- Department of TB & Chest, Government Medical College, Kozhikode, Kerala, India
| | - Debajyoti Bhattacharyya
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, Army Hospital (Research & Referral), New Delhi, India
| | | | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Centre for Research and Treatment of Allergy, Asthma & Bronchitis, Department of Chest Diseases, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Jogesh Sarma
- Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Lalit Singh
- Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - M K Sen
- Department of Respiratory Medicine, ESIC Medical College, NIT Faridabad, Haryana, India; Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mahendra K Bainara
- Department of Pulmonary Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nilkanth T Awad
- Department of Pulmonary Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, M.K.C.G. Medical College, Berhampur, Orissa, India
| | - Naveed N Shah
- Department of Pulmonary Medicine, Chest Diseases Hospital, Government Medical College, Srinagar, Jammu & Kashmir, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care & Sleep Medicine, PSRI, New Delhi, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Parul Mrigpuri
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pawan Tiwari
- School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - R Narasimhan
- Department of EBUS and Bronchial Thermoplasty Services at Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Vijai Kumar
- Department of Pulmonary Medicine, MediCiti Medical College, Hyderabad, Telangana, India
| | - Rajendra Prasad
- Vallabhbhai Patel Chest Institute, University of Delhi and U.P. Rural Institute of Medical Sciences & Research, Safai, Uttar Pradesh, India
| | - Rajesh Swarnakar
- Department of Respiratory, Critical Care, Sleep Medicine and Interventional Pulmonology, Getwell Hospital & Research Institute, Nagpur, Maharashtra, India
| | - Rakesh K Chawla
- Department of, Respiratory Medicine, Critical Care, Sleep & Interventional Pulmonology, Saroj Super Speciality Hospital, Jaipur Golden Hospital, Rajiv Gandhi Cancer Hospital, Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - S Chakrabarti
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sonam Spalgais
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | | | - Surya Kant
- Department of Respiratory (Pulmonary) Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - V K Singh
- Centre for Visceral Mechanisms, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Virendra Singh
- Mahavir Jaipuria Rajasthan Hospital, Jaipur, Rajasthan, India
| | - Vishal Chopra
- Department of Chest & Tuberculosis, Government Medical College, Patiala, Punjab, India
| | - Visweswaran B
- Interventional Pulmonology, Yashoda Hospitals, Hyderabad, Telangana, India
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The Clinical Practice and Best Aerosol Delivery Location in Intubated and Mechanically Ventilated Patients: A Randomized Clinical Trial. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6671671. [PMID: 33884269 PMCID: PMC8041534 DOI: 10.1155/2021/6671671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 03/18/2021] [Accepted: 03/27/2021] [Indexed: 11/25/2022]
Abstract
This randomized clinical trial (RCT) is aimed at exploring the best nebulizer position for aerosol delivery within the mechanical ventilation (MV) circuitry. This study enrolled 75 intubated and MV patients with respiratory failure and randomly divided them into three groups. The nebulizer position of patients in group A was between the tracheal tube and Y-piece. For group B, the nebulizer was placed at the inspiratory limb near the ventilator water cup (80 cm away from the Y-piece). For group C, the nebulizer was placed between the ventilator inlet and the heated humidifier. An indirect competitive enzyme-linked immunosorbent assay (ELISA) was used to measure salbutamol drug concentrations in serum and urine. The serum and urine salbutamol concentrations of the three groups were the highest in group B, followed by group C, and the lowest in group A. Serum and urine salbutamol concentrations significantly differed among the three groups (P < 0.05). It was found that the drug was statistically significant between group differences for groups B and A (P = 0.001; P = 0.002, respectively) for both serum and urine salbutamol concentrations. There were no significant differences observed among the other groups. It was found that the drug concentrations were the highest when the nebulizer was placed 80 cm away from the Y-piece, while the location between the tracheal tube and the Y-piece with the higher frequency of nebulizer placement was the location with the lowest drug concentration.
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7
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Ke WR, Chang RYK, Kwok PCL, Tang P, Chen L, Chen D, Chan HK. Administration of dry powders during respiratory supports. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:596. [PMID: 33987294 DOI: 10.21037/atm-20-3946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Inhaled drugs are routinely used for the treatment of respiratory-supported patients. To date, pressurized metered dose inhalers and nebulizers are the two platforms routinely employed in the clinical setting. The scarce utilization of the dry powder inhaler (DPI) platform is partly due to the lack of in vivo data that proves optimal delivery and drug efficacy are achievable. Additionally, fitting a DPI in-line to the respiratory circuit is not as straightforward as with the other aerosol delivery platforms. Importantly, there is a common misconception that the warm and humidified inspiratory air in respiratory supports, even for a short exposure, will deteriorate powder formulation compromising its delivery and efficacy. However, some recent studies have dispelled this myth, showing successful delivery of dry powders through the humidified circuit of respiratory supports. Compared with other aerosol delivery devices, the use of DPIs during respiratory supports possesses unique advantages such as rapid delivery and high dose. In this review, we presented in vitro studies showing various setups employing commercial DPIs and effects of ventilator parameters on the aerosol delivery. Inclusion of novel DPIs was also made to illustrate characteristics of an ideal inhaler that would give high lung dose with low powder deposition loss in tracheal tubes and respiratory circuits. Clinical trials are urgently needed to confirm the benefits of administration of dry powders in ventilated patients, thus enabling translation of powder delivery into practice.
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Affiliation(s)
- Wei-Ren Ke
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rachel Yoon Kyung Chang
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Philip Chi Lip Kwok
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Patricia Tang
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lan Chen
- Hangzhou Chance Pharmaceuticals, Hangzhou, China
| | - Donghao Chen
- Hangzhou Chance Pharmaceuticals, Hangzhou, China
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Mac Giolla Eain M, O'Sullivan A, Joyce M, MacLoughlin R. In vitro evaluation of disposable transport ventilators with combination aerosol therapy. BMJ Open Respir Res 2021; 8:8/1/e000739. [PMID: 33771812 PMCID: PMC8006849 DOI: 10.1136/bmjresp-2020-000739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/30/2020] [Accepted: 03/13/2021] [Indexed: 11/17/2022] Open
Abstract
Background The COVID-19 pandemic has highlighted the need for alternative short-term, reliable means to aid in the treatment of patients requiring ventilatory support. Concurrent aerosol drug delivery is often prescribed to such patients. As such, this study examines one such short-term option, the disposable gas-powered transport ventilator to effectively deliver aerosol therapy. Factors such as aerosol generator type, patient breathing pattern, humidification and nebuliser position within the respiratory circuit were also examined. Methods Aerosol drug delivery characterisation was undertaken using two different disposable transport ventilators (DTVs). Two different nebuliser types, a closed circuit vibrating mesh nebuliser (VMN) and an open circuit jet nebuliser (JN), at different locations in a respiratory circuit, proximal and distal to an endotracheal tube (ETT), with and without passive humidification, were evaluated in simulated adult and paediatric patients. Results Placement of a nebuliser proximal to the ETT (VMN: 25.19%–34.15% and JN: 3.14%–8.92%), and the addition of a heat and moisture exchange filter (VMN: 32.37%–40.43% and JN: 5.60%–9.91%) resulted in the largest potential lung dose in the adult patient model. Irrespective of nebuliser position and humidification in the respiratory circuit, use of the VMN resulted in the largest potential lung dose (%). A similar trend was recorded in the paediatric model data, where the largest potential lung dose was recorded with both nebuliser types placed proximal to the ETT (VMN: 8.12%–10.89% and JN: 2.15%–3.82%). However, the addition of a heat and moisture exchange filter had no statistically significant effect on the potential lung dose (%) a paediatric patient would receive (p>>0.05). Conclusions This study demonstrates that transport ventilators, such as DTVs, can be used concurrently with aerosol generators to effectively deliver aerosolised medication in both adult and paediatric patients.
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Affiliation(s)
| | | | - Mary Joyce
- R&D Science and Emerging Technologies, Aerogen Ltd, Galway, Ireland
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9
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Zhang C, Mi J, Wang X, Lv S, Zhang Z, Nie Z, Luo X, Gan R, Zou Y, Chen X, Fan L, Chen Y, Zhao H, Liao G. Knowledge and current practices of ICU nurses regarding aerosol therapy for patients treated with invasive mechanical ventilation: a nationwide cross-sectional study. J Clin Nurs 2021; 30:3429-3438. [PMID: 33440027 DOI: 10.1111/jocn.15639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 11/14/2020] [Accepted: 12/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aerosol therapy is a routine operation for intensive care unit (ICU) nurses; however, evidence of the knowledge and current practices of ICU nurses regarding aerosol therapy for patients with invasive mechanical ventilation is insufficient in China. OBJECTIVE This study aimed to determine the knowledge and current practices of ICU nurses regarding aerosol therapy for patients with invasive mechanical ventilation in China. SETTING A total of 433 hospitals in 92 cities (including 31 capital cities) in 31 provinces in China participated in the study. METHODS A questionnaire was used to investigate the knowledge and current practices of ICU nurses regarding aerosol therapy for patients treated with invasive mechanical ventilation, including 42 questions covering five aspects: sociodemographic information, aerosolization devices, atomised drugs, atomisation operation, and atomisation-related knowledge. Descriptive analyses of the distribution of the sample are reported as percentages and medians. Univariate and multivariate analysis was used to detect the factors of the interviewee's atomisation knowledge and practices scores. A STROBE checklist was used to guide the reporting of the research. RESULTS Of the 1,995 questionnaires that were returned, 1,978 were analysed. Bronchodilators and glucocorticoids were the most frequently administered drugs. Seventy-four percent of the total respondents reported placing a filter on the expiratory limb during aerosol therapy, and 47% of these reported that the filter was changed once a day. Only 13% of the respondents reported always turning the heating humidifier off during aerosol therapy, and 48% never did. Knowledge about the optimal droplet size or atomisation yield was poor. Work experience in the ICU and frequency of atomisation training were the independent influencing factors for atomisation knowledge and practice scores (F=279.653, P<0.001; F=120.556, P<0.001, respectively). CONCLUSIONS The knowledge of ICU nurses about the optimal implementation of aerosol therapy is poor, and the current scientific knowledge about optimal implementation seemed to be applied infrequently. Atomisation-related training should be strengthened, especially for nurses with junior titles and with less work experience. RELEVANCE TO CLINICAL PRACTICE Improving the level of ICU nurses' atomization practice ability is helpful to ensure patient safety. In clinical work, atomization expert consensus can be used to carry out relevant training and standardize atomization operation.
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Affiliation(s)
- Chuanlin Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Jie Mi
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xueqin Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Shunqiao Lv
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Zeju Zhang
- School of Nursing, Chongqing Medical and Pharmaceutical College, Chongqing, PR China
| | - Zhi Nie
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xinyi Luo
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Ruiying Gan
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Yujun Zou
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xiaoya Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Lu Fan
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Yu Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Huanhuan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Guoyu Liao
- Department of Medical Records, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
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10
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Effect of Tiotropium Soft Mist Inhalers on Dynamic Changes in Lung Mechanics of Patients with Chronic Obstructive Pulmonary Disease Receiving Mechanical Ventilation: A Prospective Pilot Study. Pharmaceutics 2020; 13:pharmaceutics13010051. [PMID: 33396552 PMCID: PMC7824634 DOI: 10.3390/pharmaceutics13010051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 02/07/2023] Open
Abstract
The effects of tiotropium bromide soft mist inhalers (SMIs) in patients with chronic obstructive pulmonary disease (COPD) receiving mechanical ventilation remain unexplored. This study investigated the dynamic effects of a tiotropium SMI on lung mechanics and gas exchange in these patients. We analyzed 11 mechanically ventilated and hemodynamically stable patients with COPD who experienced acute exacerbation and were ready to be weaned from the ventilator. Two puffs of tiotropium (2.5 μg/puff) were administered with a T-adaptor connected to the ventilator circuit. Lung mechanics—peak inspiratory pressure, plateau pressure, mean airway pressure, maximum respiratory resistance (Rrs), and gas exchange function—were analyzed. The two-puff tiotropium SMI treatment led to the greatest reduction in Rrs at 6 h, with the Rrs returning to baseline gradually, and significantly improved the PaO2/FiO2 ratio at 24 h. Compared with baseline values, tiotropium SMI had the strongest effect on Rrs between hours 3 and 6 but did not significantly affect hemodynamic parameters. Tiotropium SMI administration in mechanically ventilated patients with COPD achieved the greatest reduction in Rrs at 6 h and significantly improved the PaO2/FiO2 ratio at 24 h. Future studies should investigate whether the bronchodilation effect can be improved with increased dosage or frequency.
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Liu CY, Ko HK, Fink JB, Wan GH, Huang CC, Chen YC, Lin HL. Size Distribution of Colistin Delivery by Different Type Nebulizers and Concentrations During Mechanical Ventilation. Pharmaceutics 2019; 11:pharmaceutics11090459. [PMID: 31491870 PMCID: PMC6781281 DOI: 10.3390/pharmaceutics11090459] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 08/27/2019] [Accepted: 09/03/2019] [Indexed: 02/02/2023] Open
Abstract
Although aerosol delivery through mechanical ventilators has been used to administer various medications, little is known of administration with colistin. This in vitro evaluation aimed to evaluate size distribution of colistin delivery by different types of nebulizers and concentrations during mechanical ventilation. Colistin methanesulfonate (colistin) for injection was dissolved in 6 mL of distilled water to produce a low concentration (L; 156 mg) and a high concentration (H; 312 mg). A dose volume of 6 mL was placed in a vibrating mesh nebulizer (VMN) and a jet nebulizer (JN). The inhaled mass (mean ± SD) of the VMN-L (53.80 ± 14.79 mg) was greater than both the JN-L (19.82 ± 3.34 mg, P = 0.001) and JN-H (31.72 ± 4.48 mg, P = 0.017). The nebulization time of the VMN-L (42.35 ± 2.30 min) was two times longer than the JN-L (21.12 ± 0.8 min) or JN-H (21.65 ± 0.42 min; P < 0.001). The mass median aerodynamic distal to the endotracheal tube was within a similar range at 2.03 to 2.26 μm (P = 0.434), independent of neb or formulation concentration. In conclusion, the VMN-L yields greater inhaled mass than the JN with either concentration. Therefore, a standard nominal dose of colistin results in a higher delivered dose during mechanical ventilation with a VMN compared with a JN and may be considered the preferred device. If JN must be used, multiple doses of low concentration colistin may compensate for poor delivery performance.
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Affiliation(s)
- Ching-Yi Liu
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.
- Division of Respiratory therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
| | - Hsin-Kuo Ko
- Division of Respiratory therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan.
| | | | - Gwo-Hwa Wan
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.
- Department of Respiratory Therapy, Chang Gung University of Science and Technology, Chiayi 61301, Taiwan.
- Department of Obstetrics and Gynaecology, Chang Gung Memorial Hospital-Linko, Taoyuan 33301, Taiwan.
| | - Chung-Chi Huang
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.
- Division of Thoracic Medicine, Chang Gung Memorial Hospital-Linko, Taoyuan 33301, Taiwan.
| | - Yu-Chun Chen
- Division of Respiratory therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
| | - Hui-Ling Lin
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.
- Department of Respiratory Therapy, Chang Gung University of Science and Technology, Chiayi 61301, Taiwan.
- Department of Respiratory Therapy, Chiayi Chang Gung Memorial Hospital, Chiayi 61301, Taiwan.
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Rahmel T, Koniusch A, Schwertner M, Oprea G, Adamzik M, Nowak H. Evaluation of inhaled salbutamol effectiveness under supportive use of electrical impedance tomography in ventilated ICU patients: study protocol for a randomised controlled clinical trial. BMJ Open 2019; 9:e026038. [PMID: 30862635 PMCID: PMC6429886 DOI: 10.1136/bmjopen-2018-026038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The inhalative administration of drugs is a non-invasive application form that is regularly used in the treatment of ventilated patients in critical care setting. However, assessment of effectiveness or distribution of nebulised drugs is one of the lacking cornerstones of modern intensive care monitoring. Electrical impedance tomography (EIT) may provide a promising new monitoring and guiding tool for an adequate optimisation of mechanical ventilation in critically ill patients. EIT may assist in defining mechanical ventilation settings, assess distribution of tidal volume and evaluate associated pathologies at bedside. This study aims to elucidate the extent to which the effectiveness of inhaled salbutamol can be increased by the additional use of EIT for optimisation of respirator settings. METHODS AND ANALYSIS This study is a randomised, open-label, superiority trial conducted on an intensive care unit of a German university hospital, comparing two groups of mechanically ventilated patients with an acute or chronic bronchial airway obstruction according to the effectiveness of inhaled salbutamol with (intervention) or without (control) additional use of EIT for optimising ventilator settings. The primary outcome is change in airway resistance 30 min after salbutamol inhalation. ETHICS AND DISSEMINATION The study has received approval from the Ethics Committee of the Medical Faculty of Ruhr-University Bochum (17-6306). The results will be made available to critical care survivors, their caregivers, the funders, the critical care societies and other researchers by publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER DRKS00014706; Pre-results.
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Affiliation(s)
- Tim Rahmel
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Alexandra Koniusch
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Martin Schwertner
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Günther Oprea
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Michael Adamzik
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Hartmuth Nowak
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
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13
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Zhang Z, Xu P, Fang Q, Ma P, Lin H, Fink JB, Liang Z, Chen R, Ge H. Practice pattern of aerosol therapy among patients undergoing mechanical ventilation in mainland China: A web-based survey involving 447 hospitals. PLoS One 2019; 14:e0221577. [PMID: 31465523 PMCID: PMC6715194 DOI: 10.1371/journal.pone.0221577] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Aerosol therapies are widely used for mechanically ventilated patients. However, the practice pattern of aerosol therapy in mainland China remains unknown. This study aimed to determine the current practice of aerosol therapy in mainland China. METHODS A web-based survey was conducted by the China Union of Respiratory Care (CURC) from August 2018 to January 2019. The survey was disseminated via Email or WeChat to members of CURC. A questionnaire comprising 16 questions related to hospital information and 12 questions related to the practice of aerosol therapy. Latent class analysis was employed to identify the distinct classes of aerosol therapy practice. MAIN RESULTS A total of 693 valid questionnaires were returned by respiratory care practitioners from 447 hospitals. Most of the practitioners used aerosol therapy for both invasive mechanical ventilation (90.8%) and non-invasive mechanical ventilation (91.3%). Practitioners from tertiary care centers were more likely to use aerosol therapy compared with those from non-tertiary care centers (91.9% vs. 85.4%, respectively; p = 0.035). The most commonly used drugs for aerosol therapy were bronchodilators (64.8%) followed by mucolytic agents (44.2%), topical corticosteroids (43.4%) and antibiotics (16.5%). The ultrasonic nebulizer (48.3%) was the most commonly used followed by the jet nebulizer (39.2%), the metered dose inhaler (15.4%) and the vibrating mesh nebulizer (14.6%). Six latent classes were identified via latent class analysis. Class 1 was characterized by the aggressive use of aerosol therapy without a standard protocol, while class 3 was characterized by the absence of aerosol therapy. CONCLUSIONS Substantial heterogeneity among institutions with regard to the use of aerosol therapy was noted. The implementation of aerosol therapy during mechanical ventilation was inconsistent in light of recent practice guidelines. Additional efforts by the CURC to improve the implementation of aerosol therapy in mainland China are warranted.
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Affiliation(s)
- Zhongheng Zhang
- Department of emergency medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Peifeng Xu
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiang Fang
- Department of critical care medicine, First hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Penglin Ma
- Department of Critical Care Medicine, Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Huiling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan City, Taiwan
| | - Jim B. Fink
- Aerogen Pharma Corp., San Mateo, California, United States of America
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Medical Center, Sichuan University, China
| | - Rongchang Chen
- Guangzhou Institute of Respiratory Diseases, Guangzhou, China
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- * E-mail:
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14
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Ehrmann S. Vibrating Mesh Nebulisers – Can Greater Drug Delivery to the Airways and Lungs Improve Respiratory Outcomes? ACTA ACUST UNITED AC 2018. [DOI: 10.17925/erpd.2018.4.1.33] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Aerosols are an increasingly important mode of delivery of drugs, particularly bronchodilators, for the treatment of respiratory diseases, notably asthma and chronic obstructive pulmonary disease. The most common type of nebuliser is the jet nebuliser (JN); they have been in use for more than a century but these devices can be cumbersome to use and may sometimes deliver insufficient amounts of drug. A more recent development in aerosol therapy is the vibrating mesh nebuliser (VMN) which is very user friendly and is more efficient than the JNs due to an extremely low residual volume. Scintigraphy images from studies of volunteer subjects using radio-labelled aerosol treatment show that VMN-generated aerosols deliver more drug to patients in a shorter period of time than JN-generated aerosols. Various bench, animal model and small clinical studies have shown that VMNs are more efficient than JNs in drug delivery, potentially improving clinical outcomes. These studies have included various breathing circuits used in mechanical ventilation (MV), non-invasive ventilation, high-flow nasal cannula systems and devices for spontaneously breathing patients. The efficiency of drug delivery was affected by factors including the position of the nebuliser in the circuit and humidity. Some studies have shown potential substantial savings by hospitals in the cost of MV treatments after switching from metered dose inhalers to VMNs. VMNs have also been shown to be effective for the administration of inhaled antibiotics, corticosteroids and other drugs. Larger studies of the effects of VMNs on patient outcomes are needed but they are likely to be an increasingly important means of administering therapies to a burgeoning population with respiratory disease.
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Michotte JB, Staderini E, Aubriot AS, Jossen E, Dugernier J, Liistro G, Reychler G. Pulmonary Drug Delivery Following Continuous Vibrating Mesh Nebulization and Inspiratory Synchronized Vibrating Mesh Nebulization During Noninvasive Ventilation in Healthy Volunteers. J Aerosol Med Pulm Drug Deliv 2017; 31:33-41. [PMID: 28683216 DOI: 10.1089/jamp.2016.1339] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A breath-synchronized nebulization option that could potentially improve drug delivery during noninvasive positive pressure ventilation (NIPPV) is currently not available on single-limb circuit bilevel ventilators. The aim of this study was to compare urinary excretion of amikacin following aerosol delivery with a vibrating mesh nebulizer coupled to a single-limb circuit bilevel ventilator, using conventional continuous (Conti-Neb) and experimental inspiratory synchronized (Inspi-Neb) nebulization modes. MATERIALS AND METHODS A crossover clinical trial involving 6 noninvasive ventilated healthy volunteers (mean age of 32.3 ± 9.5 y) randomly assigned to both vibrating mesh nebulization modes was conducted: Inspi-Neb delivered aerosol during only the whole inspiratory phase, whereas Conti-Neb delivered aerosol continuously. All subjects inhaled amikacin solution (500 mg/4 mL) during NIPPV using a single-limb bilevel ventilator (inspiratory positive airway pressure: 12 cm H2O, and expiratory positive airway pressure: 5 cm H2O). Pulmonary drug delivery of amikacin following both nebulization modes was compared by urinary excretion of drug for 24 hours post-inhalation. RESULTS The total daily amount of amikacin excreted in the urine was significantly higher with Inspi-Neb (median: 44.72 mg; interquartile range [IQR]: 40.50-65.13) than with Conti-Neb (median: 40.07 mg; IQR: 31.00-43.73), (p = 0.02). The elimination rate constant of amikacin (indirect measure of the depth of drug penetration into the lungs) was significantly higher with Inspi-Neb (median: 0.137; IQR: 0.113-0.146) than with Conti-Neb (median: 0.116; IQR: 0.105-0.130), (p = 0.02). However, the mean pulmonary drug delivery rate, expressed as the ratio between total daily urinary amount of amikacin and nebulization time, was significantly higher with Conti-Neb (2.03 mg/min) than with Inspi-Neb (1.09 mg/min) (p < 0.01). CONCLUSIONS During NIPPV with a single-limb circuit bilevel ventilator, the use of inspiratory synchronized vibrating mesh nebulization may improve pulmonary drug delivery compared with conventional continuous vibrating mesh nebulization.
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Affiliation(s)
- Jean-Bernard Michotte
- 1 Western Switzerland University of Applied Sciences-Haute Ecole de Santé Vaud (HESAV), Filière Physiothérapie, 1011 Lausanne, Switzerland
| | - Enrico Staderini
- 2 Western Switzerland University of Applied Sciences-Haute Ecole d'Ingénierie et de Gestion du Canton de Vaud (HEIG-VD), 1401 Yverdon-les-Bains, Switzerland
| | - Anne-Sophie Aubriot
- 3 Cliniques Universitaires Saint-Luc, Centre de Référence pour la Mucoviscidose, 1200 Brussels, Belgium
| | - Emilie Jossen
- 4 Ligue pulmonaire neuchâteloise, 2034 Peseux, Switzerland
| | - Jonathan Dugernier
- 5 Cliniques Universitaires Saint-Luc, Service des soins intensifs, 1200 Brussels, Belgium
| | - Giuseppe Liistro
- 6 Cliniques Universitaires Saint-Luc, Service de Pneumologie; Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL & Dermatologie, 1200 Brussels, Belgium
| | - Gregory Reychler
- 6 Cliniques Universitaires Saint-Luc, Service de Pneumologie; Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL & Dermatologie, 1200 Brussels, Belgium
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Rello J, Rouby JJ, Sole-Lleonart C, Chastre J, Blot S, Luyt CE, Riera J, Vos MC, Monsel A, Dhanani J, Roberts JA. Key considerations on nebulization of antimicrobial agents to mechanically ventilated patients. Clin Microbiol Infect 2017; 23:640-646. [PMID: 28347790 DOI: 10.1016/j.cmi.2017.03.018] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 11/30/2022]
Abstract
Nebulized antibiotics have an established role in patients with cystic fibrosis or bronchiectasis. Their potential benefit to treat respiratory infections in mechanically ventilated patients is receiving increasing interest. In this consensus statement of the European Society of Clinical Microbiology and Infectious Diseases, the body of evidence of the therapeutic utility of aerosolized antibiotics in mechanically ventilated patients was reviewed and resulted in the following recommendations: Vibrating-mesh nebulizers should be preferred to jet or ultrasonic nebulizers. To decrease turbulence and limit circuit and tracheobronchial deposition, we recommend: (a) the use of specifically designed respiratory circuits avoiding sharp angles and characterized by smooth inner surfaces, (b) the use of specific ventilator settings during nebulization including use of a volume controlled mode using constant inspiratory flow, tidal volume 8 mL/kg, respiratory frequency 12 to 15 bpm, inspiratory:expiratory ratio 50%, inspiratory pause 20% and positive end-expiratory pressure 5 to 10 cm H2O and (c) the administration of a short-acting sedative agent if coordination between the patient and the ventilator is not obtained, to avoid patient's flow triggering and episodes of peak decelerating inspiratory flow. A filter should be inserted on the expiratory limb to protect the ventilator flow device and changed between each nebulization to avoid expiratory flow obstruction. A heat and moisture exchanger and/or conventional heated humidifier should be stopped during the nebulization period to avoid a massive loss of aerosolized particles through trapping and condensation. If these technical requirements are not followed, there is a high risk of treatment failure and adverse events in mechanically ventilated patients receiving nebulized antibiotics for pneumonia.
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Affiliation(s)
- J Rello
- European Study Group for Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain.
| | - J J Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | | | - J Chastre
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - S Blot
- Department of Internal Medicine, Faculty of Medicine & Health Science, Ghent University, European Study Group for Infections in Critically Ill Patients (ESGCIP), Ghent, Belgium
| | - C E Luyt
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - J Riera
- Critical Care Department, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Institut of Research, Barcelona, Spain
| | - M C Vos
- Department of Medical Microbiology and Infectious Diseases, European Study Group of Nosocomial Infections (ESGNI), Rotterdam, The Netherlands
| | - A Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - J Dhanani
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
| | - J A Roberts
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
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Feng B, Tang P, Leung SSY, Dhanani J, Chan HK. A Novel In-Line Delivery System to Administer Dry Powder Mannitol to Mechanically Ventilated Patients. J Aerosol Med Pulm Drug Deliv 2016; 30:100-107. [PMID: 27754730 DOI: 10.1089/jamp.2016.1320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Mechanically ventilated patients commonly suffer from ventilator-associated pneumonia, hypoxemia, and other lower respiratory tract infection as a result of pathogen colonization and poor sputum clearance. Consequently, there is a high rate of morbidity and mortality in these patients. Dry powder mannitol increases sputum clearance, and therefore, we developed a system to administer it to mechanically ventilated patients without disconnection from the ventilator. METHODS The inspiratory line from a ventilator was split by using a three-way valve into two parallel lines where one contains a humidifier for normal breathing cycle and the other line contains a dry powder inhaler (Osmohaler™). The inspiratory air went through the dry powder line and aerosolized the mannitol powder only when its administration to a patient is required. We determined the delivered dose and particle size distributions of emitted aerosols in vitro from 9.5 mm endotracheal and 7.5 mm tracheostomy tubes, with inspiratory airflow of 60, 70, and 80 L/min. RESULTS This novel setup was able to deliver 24.6% ± 3.33% of the 160 mg loaded dose mannitol powder (4 × 40 mg capsules) and 26.7% ± 2.19% of the 320 mg dose (4 × 80 mg capsules) when the endotracheal tube was used. With the shorter tracheostomy tube, the delivery dose increased to 35.6% ± 3.01% and 39.5% ± 2.04% of the 160 and 320 mg doses, respectively. The volume median diameters of the aerosols were in the respirable range with the largest value being 5.17 ± 0.87 μm. CONCLUSIONS This delivery system has been shown to consistently deliver a high respirable dose of mannitol powder. Since this setup does not require disconnection of patients from the ventilator, it is safer for hypoxemic patients and easier to be adapted in a real clinical use.
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Affiliation(s)
- Benny Feng
- 1 Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, Australia
| | - Patricia Tang
- 1 Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, Australia
| | - Sharon Shui Yee Leung
- 1 Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, Australia
| | - Jayesh Dhanani
- 2 Department of Intensive Care, Royal Brisbane Women's Hospital , Herston, Australia .,3 Burns, Trauma and Critical Care Research Centre, University of Queensland , Queensland, Australia
| | - Hak-Kim Chan
- 1 Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, Australia
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Dhanani J, Fraser JF, Chan HK, Rello J, Cohen J, Roberts JA. Fundamentals of aerosol therapy in critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:269. [PMID: 27716346 PMCID: PMC5054555 DOI: 10.1186/s13054-016-1448-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Drug dosing in critically ill patients is challenging due to the altered drug pharmacokinetics–pharmacodynamics associated with systemic therapies. For many drug therapies, there is potential to use the respiratory system as an alternative route for drug delivery. Aerosol drug delivery can provide many advantages over conventional therapy. Given that respiratory diseases are the commonest causes of critical illness, use of aerosol therapy to provide high local drug concentrations with minimal systemic side effects makes this route an attractive option. To date, limited evidence has restricted its wider application. The efficacy of aerosol drug therapy depends on drug-related factors (particle size, molecular weight), device factors, patient-related factors (airway anatomy, inhalation patterns) and mechanical ventilation-related factors (humidification, airway). This review identifies the relevant factors which require attention for optimization of aerosol drug delivery that can achieve better drug concentrations at the target sites and potentially improve clinical outcomes.
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Affiliation(s)
- Jayesh Dhanani
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, 4029, QLD, Australia.
| | - John F Fraser
- Department of Intensive Care Medicine, The Prince Charles Hospital, Brisbane, Australia.,Critical Care Research Group, The University of Queensland, Brisbane, Australia
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Jordi Rello
- Critical Care Department, Hospital Vall d'Hebron, Barcelona, Spain.,CIBERES, Vall d'Hebron Institut of Research, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Jeremy Cohen
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, 4029, QLD, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, 4029, QLD, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Herston, Brisbane, Australia.,School of Pharmacy, The University of Queensland, Brisbane, Australia
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Geiseler J, Kelbel C. [Weaning from mechanical ventilation. Weaning categories and weaning concepts]. Med Klin Intensivmed Notfmed 2016; 111:208-14. [PMID: 27084181 DOI: 10.1007/s00063-016-0147-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Abstract
The international classification of three weaning categories (simple weaning, difficult weaning, prolonged weaning) has been modified in the German weaning guidelines: the group of prolonged weaning has been subclassified into weaning without noninvasive ventilation (NIV), weaning with NIV, if necessary with continuing NIV in the form of home mechanical ventilation, and weaning failure.Strategies to prevent prolonged weaning comprise daily interruption of sedation, daily screening of capability of spontaneous breathing by a spontaneous breathing trial (SBT) and early implementation of NIV instead of continuing invasive mechanical ventilation especially in hypercapnic patients. The comorbidity left heart failure plays a major role in weaning failure and need for re-intubation-in this case early diagnosis and if necessary modification of heart therapy are important.Specialised weaning-centres offer the option for successful weaning for about 50-60 % of patients declared as unweanable by usual intensive care units. A multimodal therapy concept with respiratory therapists, physiotherapists and speech therapy is necessary to reach this goal. In case of weaning failure a professional discharge management to invasive home mechanical ventilation is important. Competent care by physicians in the out-of-hospital area is restricted by the sectoral division of responsibility by the German health care system. Improvement in this area is urgently needed.
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Affiliation(s)
- J Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Klinikum Vest GmbH, Paracelsus-Klinik, Postfach: 101880, Lipper Weg 11, 45770, Marl, Deutschland.
| | - C Kelbel
- Medizinsche Klinik I, Klinik für Pneumologie, Gastroenterologie und Intensivmedizin, Klinik am Park, Lünen, Deutschland.,Medizinische Klinik II, Klinik für Pneumologie, Intensivmedizin und Schlafmedizin, Knappschaftskrankenhaus Dortmund, Klinikum Westfalen, Dortmund, Deutschland
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20
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Michotte JB, Jossen E, Roeseler J, Liistro G, Reychler G. In vitro comparison of five nebulizers during noninvasive ventilation: analysis of inhaled and lost doses. J Aerosol Med Pulm Drug Deliv 2015; 27:430-40. [PMID: 24517084 DOI: 10.1089/jamp.2013.1070] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few studies on performance comparison of nebulizer systems coupled with a single-limb circuit bilevel ventilator are available. Most of these data compared the aerosol drug delivery for only two different systems. Using an adult lung bench model of noninvasive ventilation, we compared inhaled and lost doses of three nebulizer systems coupled with a single-limb circuit bilevel ventilator, as well as the influence of the nebulizer position. METHOD Three vibrating mesh nebulizers (Aeroneb(®) Pro, Aeroneb(®) Solo, and NIVO(®)), one jet nebulizer (Sidestream(®)), and one ultrasonic nebulizer (Servo Ultra Nebulizer 145(®)) coupled with a bilevel ventilator were tested. They were charged with amikacin solution (500 mg/4 mL) and operated at two different positions: before and after the exhalation port (starting from the lung). The inhaled dose, the expiratory wasted dose, and the estimated lost dose were assessed by the residual gravimetric method. RESULTS The doses varied widely among the nebulizer types and position. When the nebulizer was positioned before the exhalation port, the vibrating mesh nebulizer delivered the highest inhaled dose (p<0.001), the jet nebulizer the highest expiratory wasted dose (p<0.001), and the ultrasonic device the highest total lost dose (p<0.001). When the nebulizer was positioned after the exhalation port, the vibrating mesh nebulizers delivered the highest inhaled (p<0.001) and expiratory wasted doses (p<0.001), and the ultrasonic device the highest total lost dose (p<0.001). The most efficient nebulizers were NIVO and Aeroneb Solo when placed before the exhalation port. CONCLUSIONS In a single-limb circuit bilevel ventilator, vibrating mesh nebulizers positioned between the exhalation port and lung model are more efficient for drug delivery compared with jet or ultrasonic nebulizers. In this position, the improved efficiency of vibrating mesh nebulizers was due to an increase in the inhaled dose and a reduction in the exhaled wasted dose compared with placement between the ventilator and the expiratory port. Because of the high total lost dose, the ultrasonic device should not be recommended. Nebulizer placement before the exhalation port increased the inhaled dose and decreased the expiratory wasted dose, except for the jet nebulizer.
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Affiliation(s)
- Jean-Bernard Michotte
- 1 University of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO) , 1011 Lausanne, Switzerland
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Maccari JG, Teixeira C, Gazzana MB, Savi A, Dexheimer-Neto FL, Knorst MM. Inhalation therapy in mechanical ventilation. J Bras Pneumol 2015; 41:467-72. [PMID: 26578139 PMCID: PMC4635094 DOI: 10.1590/s1806-37132015000000035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 06/29/2015] [Indexed: 12/04/2022] Open
Abstract
Patients with obstructive lung disease often require ventilatory support via invasive or noninvasive mechanical ventilation, depending on the severity of the exacerbation. The use of inhaled bronchodilators can significantly reduce airway resistance, contributing to the improvement of respiratory mechanics and patient-ventilator synchrony. Although various studies have been published on this topic, little is known about the effectiveness of the bronchodilators routinely prescribed for patients on mechanical ventilation or about the deposition of those drugs throughout the lungs. The inhaled bronchodilators most commonly used in ICUs are beta adrenergic agonists and anticholinergics. Various factors might influence the effect of bronchodilators, including ventilation mode, position of the spacer in the circuit, tube size, formulation, drug dose, severity of the disease, and patient-ventilator synchrony. Knowledge of the pharmacological properties of bronchodilators and the appropriate techniques for their administration is fundamental to optimizing the treatment of these patients.
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Affiliation(s)
| | - Cassiano Teixeira
- Unidade de Terapia Intensiva Adulto, Hospital Moinhos de Vento, Porto Alegre (RS) Brasil
| | | | - Augusto Savi
- Unidade de Terapia Intensiva Adulto, Hospital Moinhos de Vento, Porto Alegre (RS) Brasil
| | | | - Marli Maria Knorst
- Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil
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Linakis MW, Roberts JK, Lala AC, Spigarelli MG, Medlicott NJ, Reith DM, Ward RM, Sherwin CMT. Challenges Associated with Route of Administration in Neonatal Drug Delivery. Clin Pharmacokinet 2015; 55:185-96. [DOI: 10.1007/s40262-015-0313-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Saraogi A. Improvised arrangement of aerosol delivery to the ventilator dependent patient. Indian J Crit Care Med 2014; 18:409-10. [PMID: 24987249 PMCID: PMC4071694 DOI: 10.4103/0972-5229.133955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
Existing pharmacopeial methods for the in vitro testing of orally inhaled products (OIPs) are simplified representations of clinical reality, as their objective is to provide metrics that are discriminating of product quality. Attempts to correlate measures such as fine particle fraction <5 µm aerodynamic diameter with in vivo measures of lung deposition have therefore been notoriously difficult to achieve. Although particle imaging-based techniques may be helpful to link in vitro to in vivo data as surrogates for clinical responses, a reappraisal of the purposes for laboratory-based testing of OIPs is required. This article provides guidance on approaches that may be helpful to develop clinically appropriate methods to assess OIP performance in the laboratory, with the ultimate goal of developing robust in vitro–in vivo relationships for the major inhaled drug classes.
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Holland A, Smith F, Penny K, McCrossan G, Veitch L, Nicholson C. Metered dose inhalers versus nebulizers for aerosol bronchodilator delivery for adult patients receiving mechanical ventilation in critical care units. Cochrane Database Syst Rev 2013; 2013:CD008863. [PMID: 23740736 PMCID: PMC6516804 DOI: 10.1002/14651858.cd008863.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Nebulizers and metered dose inhalers (MDI) have both been adapted for delivering aerosol bronchodilation to mechanically ventilated patients, but there is incomplete knowledge as to the most effective method of delivery. OBJECTIVES To compare the effectiveness of nebulizers and MDIs for bronchodilator delivery in invasively ventilated, critically ill adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5); Ovid MEDLINE (1950 to Week 19 2012); Ovid EMBASE (1980 to Week 19 2012); CINAHL via EBSCOhost (1982 to Week 19 2012) and reference lists of articles. We searched conference proceedings and reference lists of articles. We also contacted manufacturers and researchers in this field. There were no constraints based on language or publication status. SELECTION CRITERIA Randomized controlled trials (RCTs), including randomized cross-over trials where the order of the intervention was randomized, comparing the nebulizer and MDI for aerosol bronchodilation in mechanically ventilated adult patients in critical care units. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information where required. We collected information about adverse effects from the trials. MAIN RESULTS This review included three trials, two addressing the primary outcome measure of a reduction of airway resistance (measured as a reduction in interrupter and additional airway resistance) with a total of 28 patients (n =10, n =18) and two addressing adverse changes to haemodynamic observations with a total of 36 patients (n =18, n =18). Limitations in data availability and reporting in the included trials precluded meta-analysis and therefore the present review consisted of a descriptive analysis. Risk of bias in the included trials was judged as low or of unknown risk across the majority of items in the 'Risk of bias' tool.Cautious interpretation of the included study results suggests that nebulizers could be a more effective method of bronchodilator administration than MDI in terms of a change in resistance. No apparent changes to haemodynamic observations (measured as an increase in heart rate) were associated with either mode of delivery. Due to missing data issues, meta analyses were not possible. Additionally, small sample sizes and variability between the studies with regards to patient diagnoses, bronchodilator agent and administration technique mean that it would be speculative to infer definitive recommendations based on these results at this time. This is insufficient evidence to determine which is the most effective delivery system between nebuliser and MDI for aerosol bronchodilation in adult patients receiving mechanical ventilation. AUTHORS' CONCLUSIONS Existing randomized controlled trials, including randomized cross-over trials where the order of the intervention was randomized, comparing nebulizer and MDI for aerosol bronchodilation in mechanically ventilated adult patients do not provide sufficient evidence to support either delivery method at this time.
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Affiliation(s)
- Agi Holland
- School of Nursing, Midwifery and Social Care, Faculty of Health, Life & Social Sciences, Edinburgh Napier University, Edinburgh,UK.
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Abstract
Asthma is usually treated with inhaled corticosteroids (ICS) and bronchodilators generated from pressurized metered dose inhalers (pMDI), dry powder inhalers (DPI), or nebulizers. The target areas for ICS and beta 2-agonists in the treatment of asthma are explained. Drug deposition not only depends on particle size, but also on inhalation manoeuvre. Myths regarding inhalation treatments lead to less than optimal use of these delivery systems. We discuss the origin of many of these myths and provide the background and evidence for rejecting them.
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Affiliation(s)
- Bart L Rottier
- Department of Paediatric Pulmonology and Paediatric Allergology, Beatrix Children's Hospital, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, the Netherlands.
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28
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Ehrmann S, Roche-Campo F, Sferrazza Papa GF, Isabey D, Brochard L, Apiou-Sbirlea G. Aerosol therapy during mechanical ventilation: an international survey. Intensive Care Med 2013; 39:1048-56. [DOI: 10.1007/s00134-013-2872-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/31/2013] [Indexed: 11/28/2022]
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Albuterol delivery in an in vitro pediatric ventilator lung model: comparison of jet, ultrasonic, and mesh nebulizers. Pediatr Crit Care Med 2013; 14:e98-102. [PMID: 23287904 DOI: 10.1097/pcc.0b013e3182712783] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the influence of nebulizer types and nebulization modes on bronchodilator delivery in a mechanically ventilated pediatric lung model. DESIGN In vitro, laboratory study. SETTING Research laboratory of a university hospital. INTERVENTIONS Using albuterol as a marker, three nebulizer types (jet nebulizer, ultrasonic nebulizer, and vibrating-mesh nebulizer) were tested in three nebulization modes in a nonhumidified bench model mimicking the ventilatory pattern of a 10-kg infant. The amounts of albuterol deposited on the inspiratory filters (inhaled drug) at the end of the endotracheal tube, on the expiratory filters, and remaining in the nebulizers or in the ventilator circuit were determined. Particle size distribution of the nebulizers was also measured. MEASUREMENTS AND MAIN RESULTS The inhaled drug was 2.8% ± 0.5% for the jet nebulizer, 10.5% ± 2.3% for the ultrasonic nebulizer, and 5.4% ± 2.7% for the vibrating-mesh nebulizer in intermittent nebulization during the inspiratory phase (p < 0.01). The most efficient nebulizer was the vibrating-mesh nebulizer in continuous nebulization (13.3% ± 4.6%, p < 0.01). Depending on the nebulizers, a variable but important part of albuterol was observed as remaining in the nebulizers (jet and ultrasonic nebulizers), or being expired or lost in the ventilator circuit (all nebulizers). Only small particles (range 2.39-2.70 µm) reached the end of the endotracheal tube. CONCLUSIONS Important differences between nebulizer types and nebulization modes were seen for albuterol deposition at the end of the endotracheal tube in an in vitro pediatric ventilator-lung model. New aerosol devices, such as ultrasonic and vibrating-mesh nebulizers, were more efficient than the jet nebulizer.
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Vargas MADO, Teixeira C, Zanchin F, Ghiot A, Pauli K, Schoeller SD. Capacitação dos técnicos de enfermagem para as melhores práticas no uso de broncodilatadores em pacientes mecanicamente ventilados. TEXTO & CONTEXTO ENFERMAGEM 2012. [DOI: 10.1590/s0104-07072012000300003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A inaloterapia de broncodilatadores é uma das principais terapêuticas no tratamento de doenças respiratórias, desde que a administração seja correta para produzir uma absorção e uma ação medicamentosa efetiva. Assim, realizou-se uma pesquisa quantitativa, quase-experimental, com o delineamento pré e pós-teste, cujos objetivos foram avaliar o conhecimento dos técnicos de enfermagem na administração de broncodilatadores inalatórios, em pacientes mecanicamente ventilados, na Unidade de Terapia Intensiva, e capacitá-los para a correta aplicação desses fármacos. Com base no pré-teste, foi realizada a capacitação de 34 técnicos de enfermagem e, após, um pós-teste para a avaliação da técnica de administração dos broncodilatadores. Aplicou-se um questionário. Os resultados sinalizam que nenhum dos entrevistados descreveu, adequadamente, as etapas da nebulização no paciente mecanicamente ventilado no pré-teste. Já no pós-teste, 44,11% responderam adequadamente. Através da análise dos resultados, avaliando os pré e pós-testes, nota-se um aprendizado balizado nas melhores práticas.
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Affiliation(s)
| | - Cassiano Teixeira
- Complexo Hospitalar da Santa Casa de Porto Alegre; Universidade Federal de Ciências da Saúde de Porto Alegre, Brasil
| | | | - Aline Ghiot
- Hospital Pereira Filho Rio Grande do Sul, Brasil
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Ari A, Fink JB, Dhand R. Inhalation therapy in patients receiving mechanical ventilation: an update. J Aerosol Med Pulm Drug Deliv 2012; 25:319-32. [PMID: 22856594 DOI: 10.1089/jamp.2011.0936] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Incremental gains in understanding the influence of various factors on aerosol delivery in concert with technological advancements over the past 2 decades have fueled an ever burgeoning literature on aerosol therapy during mechanical ventilation. In-line use of pressurized metered-dose inhalers (pMDIs) and nebulizers is influenced by a host of factors, some of which are unique to ventilator-supported patients. This article reviews the impact of various factors on aerosol delivery with pMDIs and nebulizers, and elucidates the correlation between in-vitro estimates and in-vivo measurement of aerosol deposition in the lung. Aerosolized bronchodilator therapy with pMDIs and nebulizers is commonly employed in intensive care units (ICUs), and bronchodilators are among the most frequently used therapies in mechanically ventilated patients. The use of inhaled bronchodilators is not restricted to mechanically ventilated patients with chronic obstructive pulmonary disease (COPD) and asthma, as they are routinely employed in other ventilator-dependent patients without confirmed airflow obstruction. The efficacy and safety of bronchodilator therapy has generated a great deal of interest in employing other inhaled therapies, such as surfactant, antibiotics, prostacyclins, diuretics, anticoagulants and mucoactive agents, among others, in attempts to improve outcomes in critically ill ICU patients receiving mechanical ventilation.
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Affiliation(s)
- Arzu Ari
- Georgia State University, Division of Respiratory Therapy, Atlanta, GA, USA
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Dellweg D, Wachtel H, Höhn E, Pieper MP, Barchfeld T, Köhler D, Glaab T. In vitro validation of a Respimat® adapter for delivery of inhaled bronchodilators during mechanical ventilation. J Aerosol Med Pulm Drug Deliv 2011; 24:285-92. [PMID: 21870959 DOI: 10.1089/jamp.2011.0883] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Inhaled bronchodilators are frequently used in patients with chronic obstructive pulmonary disease (COPD). However, there has been no efficient way to administer the long-acting anticholinergic tiotropium to mechanically ventilated patients. The aim of this in vitro study was to compare the fine particle dose (FPD) output of a specifically designed adapter with other accessory devices for the delivery of bronchodilators using the Respimat® (RMT) inhaler by simulating the specific inhalation flow profiles of patients with COPD. METHODS Using characteristic flow profiles from COPD patients being weaned off mechanical ventilation, an in vitro study was performed analyzing the FPD achieved with different accessory devices (connectors, spacers, AeroTrachPlus valved holding chamber), which can be used to deliver drugs from pressurized metered dose inhalers (pMDI) and RMT inhalers to artificial airways. Fenoterol pMDI, tiotropium RMT, and a fixed-dose combination of salbutamol and ipratropium delivered by pMDI or RMT, were used as bronchodilators. Aerosols were collected by a next-generation impactor. RESULTS The RMT inhaler, combined with a new in-line adapter, was superior to other inhaler device connector or spacer combinations in FPD delivery during simulated mechanical ventilation (p<0.01). The outcome with the RMT inhaler/RMT adapter combination during simulation of mechanical ventilation was comparable to the measurements with the RMT/AeroTrachPlus valved holding chamber during simulation of spontaneous breathing. The delivery rates of the RMT adapter were not significantly affected by the administered bronchodilators or by the type of artificial airway (endotracheal or tracheostomy tube) employed. CONCLUSIONS The RMT inhaler combined with the prototype in-line adapter was better than the other accessory device combinations in fine particle deposition of inhaled bronchodilators during mechanical ventilation. Further research is required to determine the clinical relevance of these in vitro findings.
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Affiliation(s)
- Dominic Dellweg
- Hospital Kloster Grafschaft, Department of Respiratory and Critical Care Medicine, Schmallenberg, Germany
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Ari A, Fink JB. Factors affecting bronchodilator delivery in mechanically ventilated adults. Nurs Crit Care 2010; 15:192-203. [DOI: 10.1111/j.1478-5153.2010.00395.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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