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Galazzi A, Petrei M, Palese A. Tools used to assess comfort among patients undergoing high flow nasal cannula: A scoping review. Intensive Crit Care Nurs 2024; 83:103719. [PMID: 38718552 DOI: 10.1016/j.iccn.2024.103719] [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: 02/21/2024] [Revised: 04/11/2024] [Accepted: 04/30/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE The aims were twofold: (a) to map tools documented in the literature to evaluate comfort among patients undergoing high flow nasal cannula (HFNC) treatment; and (b) to assess if the retrieved tools have been validated for this purpose. METHODS A scoping review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). In July 2023, PubMed, Scopus, CINAHL and Cochrane Library were consulted. Studies assessing comfort in adult, paediatric, and neonatal patients undergoing HFNC were included. RESULTS Seventy-four articles were included, among which nine (12.2 %) investigated comfort as the primary aim. Twenty-five different tools were found, classifiable into 14 types, mostly unidimensional and originating from those measuring pain. The most widely used was the Visual Analogic Scale (n = 27, 35.6 %) followed by the Numerical Rating Scale (n = 11, 14.5 %) and less defined generic tools (n = 10, 13.2 %) with different metrics (e.g. 0-5, 0-10, 0-100). Only the General Comfort Questionnaire and the Comfort Scale were specifically validated for the assessment of comfort among adults and children, respectively. CONCLUSION Although the comfort of patients undergoing HFNC is widely investigated in the literature, there is a scarcity of tools specifically validated in this field. Those used have been validated mainly to assess pain, suggesting the need to inform patients to prevent confusion while measuring comfort during HFNC and to develop more research in the field. IMPLICATIONS FOR CLINICAL PRACTICE Comfort assessment is an important aspect of nursing care. Given the lack of validation studies in the field, efforts in research are recommended.
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Affiliation(s)
| | - Matteo Petrei
- Department of Medicine, University of Udine, Udine, Italy
| | - Alvisa Palese
- Department of Medicine, University of Udine, Udine, Italy
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2
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Ari A, Hoops JA, Koyuncu A, Fink JB. Dos and don'ts to optimize transnasal aerosol drug delivery in clinical practice. Expert Opin Drug Deliv 2024; 21:1103-1114. [PMID: 39104360 DOI: 10.1080/17425247.2024.2388838] [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: 03/05/2024] [Revised: 07/10/2024] [Accepted: 08/01/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Transnasal aerosol drug delivery has become widely accepted for treating acutely ill infants, children, and adults. More recently aerosol administration to wider populations receiving high and low-flow nasal oxygen has become common practice. AREAS COVERED Skepticism of insufficient aerosol delivery to the lungs has been tempered by multiple in vitro explorations of variables to optimize delivery efficiency. Additionally, clinical studies demonstrated comparable clinical responses to orally inhaled aerosols. This paper provides essential clinical guidance on how to improve transnasal aerosol delivery based on device-, settings-, and drug-related optimization to serve as a resource for educational initiatives and quality enhancement endeavors at healthcare institutions. EXPERT OPINION Transnasal aerosol delivery is proliferating worldwide, but indiscriminate use of excessive-high flows, poor selection and placement of aerosol devices and circuits can greatly reduce aerosol delivery and efficacy, potentially compromising treatment to acute and critically ill patients. Attention to these details can improve inhaled dose by an order of magnitude, making the difference between effective treatment and the progression to more invasive ventilatory support, with greater inherent risk and cost. These revelations have prompted specific recommendations for optimal delivery, driving advancements in aerosol generators, formulations, and future device designs to administer aerosols and maximize treatment effectiveness.
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Affiliation(s)
- Arzu Ari
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Jordan A Hoops
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Ayfer Koyuncu
- Bioengineering Division, College of Engineering, Hacettepe University, Ankara, Turkey
| | - James B Fink
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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3
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Ari A, Raghavan N, Diaz M, Rubin BK, Fink JB. Individualized aerosol medicine: Integrating device into the patient. Paediatr Respir Rev 2024; 49:14-23. [PMID: 37739833 DOI: 10.1016/j.prrv.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 09/24/2023]
Abstract
Pulmonary drug delivery is complex due to several challenges including disease-, patient-, and clinicians-related factors. Although many inhaled medications are available in aerosol medicine, delivering aerosolized medications to patients requires effective disease management. There is a large gap in the knowledge of clinicians who select and provide instructions for the correct use of aerosol devices. Since improper device selection, incorrect inhaler technique, and poor patient adherence to prescribed medications may result in inadequate disease control, individualized aerosol medicine is essential for effective disease management and control. The components of individualized aerosol medicine include: (1) Selecting the right device, (2) Selecting the right interface, (3) Educating the patient effectively, and (4) Increasing patient adherence to therapy. This paper reviews each of these components and provides recommendations to integrate the device and interface into the patient for better clinical outcomes.
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Affiliation(s)
- Arzu Ari
- Texas State University, Department of Respiratory Care, USA.
| | | | - Martha Diaz
- Latin American Board of Certification in Respiratory Therapy, Colombia
| | - Bruce K Rubin
- Virginia Commonwealth University School of Medicine, USA.
| | - James B Fink
- Texas State University, Department of Respiratory Care, USA; Aerogen Pharma, USA.
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Wang R, Leime CO, Gao W, MacLoughlin R. Aerosol delivery in models of pediatric high flow nasal oxygen and mechanical ventilation. Pediatr Pulmonol 2023; 58:878-886. [PMID: 36478520 DOI: 10.1002/ppul.26270] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Aerosol drug delivery during high flow nasal oxygen (HFNO) and invasive mechanical ventilation (IMV) are key respiratory care strategies available for the treatment of pediatric patients. We aimed to quantify the impact of different HFNO and IMV set-ups on tracheal drug delivery via a vibrating mesh nebuliser (VMN). METHODS Percent tracheal dose via VMN was quantified during HFNO therapy and IMV in a benchtop model of a 9-month-old infant. Under HFNO, 3 cannula sizes were used at 3 flow rate settings with the VMN placed at the dry side of the humidifier. Under IMV, tracheal dose when VMN was placed at the dry side of the humidifier, 15 cm from the wye and between the wye and endotracheal tube (ETT) was assessed. Salbutamol at 2.5 mg/2.5 ml (1 mg/ml) was used for each test (N = 5). The impact of VMN refill on circuit pressure under HFNO and IMV was also assessed. RESULTS Tracheal dose was highest during HFNO with the largest cannula size (OPT318) set to the lowest flow rate setting of 2 L/min (liter per minute) (5.80 ± 0.17%). Increasing flow rate reduced tracheal drug delivery for all cannulas. For IMV, VMN on the dry side of the humidifier and between the wye and ETT gave optimal drug delivery (4.49 ± 0.14% vs. 4.43 ± 0.26% respectively). VMN refill did not impact circuit pressure for either HFNO therapy or IMV. CONCLUSIONS Gas flow rate and cannula size during HFNO and VMN position during IMV has a significant effect on tracheal drug delivery in a pediatric setting.
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Affiliation(s)
- Ran Wang
- Research and Development, Science & Emerging Technologies, Aerogen Limited, Galway Business Park, Galway, Ireland
| | - Ciaran O Leime
- Research and Development, Science & Emerging Technologies, Aerogen Limited, Galway Business Park, Galway, Ireland
| | - Weiwei Gao
- Neonatology Department, Guangdong Women and Children Hospital, Guangdong Neonatal ICU Medical Quality Control Center, Guangdong, China
| | - Ronan MacLoughlin
- Research and Development, Science & Emerging Technologies, Aerogen Limited, Galway Business Park, Galway, Ireland.,School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
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5
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Valencia-Ramos J, Ochoa Sangrador C, García M, Oyagüez P, Arnaez J. Impact of different nebulisation systems on patient comfort in bronchiolitis: a randomised controlled cross-over trial. Arch Dis Child 2022; 107:1122-1127. [PMID: 36162958 DOI: 10.1136/archdischild-2021-323161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 08/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To test the hypothesis that greater comfort is achieved using a nebuliser integrated into a high-flow nasal cannula (nebulisation system integrated in high-flow nasal cannula (NHF)) than using a jet nebuliser (JN), and to explore differences in analgesia requirement and the possibility of feeding during nebulisation. DESIGN Randomised cross-over trial. SETTING Paediatric intensive care unit. PATIENTS Children aged <24 months diagnosed with bronchiolitis between November 2016 and May 2017. INTERVENTIONS Nebulisations using NHF and JN. MAIN OUTCOME MEASURES COMFORT-Behaviour Scale (CBS) and Numerical Rating Comfort Scale (NRSc) were used to measure comfort, and Numerical Rating Satisfaction Scale (NRSs) was used to assess satisfaction before, during and after nebulisation. Other variables included feeding, analgesia, need for being held and respiratory and heart rates. RESULTS Thirty-three children with 233 nebulisations were included in the study. The median age was 3.0 (IQR 2-9) months. Comfort and satisfaction were greater with NHF than with JN. The median staff-recorded CBS, NRSc and NRSs scores for NHF versus JN were 13 (IQR 9-15) vs 17 (IQR 13-23), 8 (IQR 7-0) vs 7 (IQR 4-8), and 4 (IQR 3-4) vs 2 (IQR 2-3), respectively; and caregiver-recorded scores were 12 (IQR 10-15) vs 19 (IQR 13-24), 9 (IQR 7-10) vs 4 (IQR 1-6), and 4 (IQR 3-4) vs 2 (IQR 1-3), respectively (p<0.001). Children who received NHF had lower cardiac and respiratory rates, needed to be held less often during therapy and required less analgesia (p<0.001). CONCLUSION Nebulisation through NHF appears to be a better alternative to JN in terms of comfort and satisfaction as well as making feeding possible during nebulisation.
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Affiliation(s)
- Juan Valencia-Ramos
- Paediatric Intensive Care Unit, Complejo Asistencial Universitario de Burgos, Burgos, Spain .,Ciencias de la Salud, University of Burgos, Burgos, Spain
| | | | - María García
- Paediatric Intensive Care Unit, Complejo Asistencial Universitario de Burgos, Burgos, Spain
| | - Pablo Oyagüez
- Paediatric Intensive Care Unit, Complejo Asistencial Universitario de Burgos, Burgos, Spain
| | - Juan Arnaez
- Neonatology, Complejo Asistencial Universitario de Burgos, Burgos, Spain.,Fundación NeNe, Burgos, Spain
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6
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Nolasco S, Manti S, Leonardi S, Vancheri C, Spicuzza L. High-Flow Nasal Cannula Oxygen Therapy: Physiological Mechanisms and Clinical Applications in Children. Front Med (Lausanne) 2022; 9:920549. [PMID: 35721052 PMCID: PMC9203852 DOI: 10.3389/fmed.2022.920549] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
High-flow nasal cannula (HFNC) oxygen therapy has rapidly become a popular modality of respiratory support in pediatric care. This is undoubtedly due to its ease of use and safety, which allows it to be used in a wide variety of settings, ranging from pediatric intensive care to patients' homes. HFNC devices make it possible to regulate gas flow and temperature, as well as allowing some nebulized drugs to be administered, features very useful in children, in which the balance between therapeutic effectiveness and adherence to treatment is pivotal. Although the physiological effects of HFNC are still under investigation, their mechanisms of action include delivery of fixed concentration of oxygen, generation of positive end-expiratory pressure, reduction of the work of breathing and clearance of the nasopharyngeal dead space, while providing optimal gas conditioning. Nevertheless, current evidence supports the use of HFNC mainly in moderate-to-severe bronchiolitis, whereas for asthma exacerbations and breath sleeping disorders there is a lack of randomized controlled trials comparing HFNC to continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV), which are essentials for the identification of response and non-response predictors. In this regard, the development of clinical guidelines for HFNC, including flow settings, indications, and contraindications is urgently needed.
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Affiliation(s)
- Santi Nolasco
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- *Correspondence: Santi Nolasco
| | - Sara Manti
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Salvatore Leonardi
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Carlo Vancheri
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Lucia Spicuzza
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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7
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Kumar N, Kandrakonda PK, Ahmed S. Modified T-piece jet nebulizer with high-flow nasal cannula in a severe COVID-19 patient with intensive care unit delirium. Lung India 2021; 38:588-589. [PMID: 34747747 PMCID: PMC8614614 DOI: 10.4103/lungindia.lungindia_399_21] [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: 11/04/2022] Open
Affiliation(s)
- Neeraj Kumar
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
| | | | - Sarfaraz Ahmed
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
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8
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Li J, Fink JB. Narrative review of practical aspects of aerosol delivery via high-flow nasal cannula. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:590. [PMID: 33987288 DOI: 10.21037/atm-20-7383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Using high-flow nasal cannula (HFNC) as a "vehicle" to administer aerosolized medication has attracted clinicians' interest in recent years. In this paper, we summarize the current evidence to answer the common questions raised by clinicians about this new aerosol delivery route and best practices of administration. Benefits of trans-nasal aerosol delivery include increased comfort, ability to speak, eat, and drink for patients while meeting a range of oxygen requirements, particularly for those who need to inhale aerosolized medication for long periods. Aerosol administration via HFNC has been shown to be well tolerated by children and adults, with comparable or better delivery efficacy than other interfaces, ranging from 2-20%. In vitro and in vivo scintigraphy studies among pediatric and adult populations reported that the inhaled dose delivered via a vibrating mesh nebulizer is 2 to 3 fold greater than that via a jet nebulizer. For adults, placement of nebulizer at the inlet of humidifier increases inhaled dose while reducing rainout obstructing nasal prongs. When HFNC gas flow is set below patient inspiratory flow, aerosol deposition is higher than when the gas flow exceeds patient inspiratory flow; thus, if tolerated, titrating down HFNC gas flow during trans-nasal aerosol delivery, with close monitoring and the use of unit dose with high concentration are recommended. Trans-nasal pulmonary aerosol delivery has not been shown to increase bioaerosols generated by patients, but gas flow may disperse aerosols. Placement of a surgical or procedure mask over HFNC might reduce aerosol dispersion.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
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9
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Moody GB, Ari A. Quantifying continuous nebulization via high flow nasal cannula and large volume nebulizer in a pediatric model. Pediatr Pulmonol 2020; 55:2596-2602. [PMID: 32681768 DOI: 10.1002/ppul.24967] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Use of high flow nasal cannula (HFNC) to deliver aerosolized medications to children has gained considerable interest. However, data on continuous albuterol delivery (CAD) via HFNC are lacking. This study quantified CAD via HFNC/vibrating mesh nebulizer (VMN) and large-volume jet nebulizer (LVN) with face mask (FM) in a pediatric model. Aerosol delivery with two HFNC cannula designs were also compared. METHODS A pediatric manikin was connected to a lung simulator (Vt = 150 mL, RR = 28 breaths/minute, I:E 1:2.4) via collecting filter at the carina. XL Pediatric and SML Adult HFNC designs were tested to determine optimal cannula design for CAD. VMN was placed Before humidifier (37°C), albuterol (5 mg/mL) was nebulized at 3, 6, and 12 L/minute (n = 3). To compare HFNC/VMN with LVN and FM, albuterol (15 mg/hour) was aerosolized for 3 hours/device (n = 3). LVN was connected to FM and filled with 9 mL of albuterol (5 mg/mL) and 66 mL of normal saline to deliver 25 mL/hour at 13 L/minute. VMN was connected to the infusion pump to deliver 7.5 mL/hr of albuterol (2 mg/mL). Drug eluted from filters was assayed with UV spectrophotometry (276 nm). RESULTS Optimal aerosol delivery occurred at 3 L/minute (12.6% ± 0.5%) with SML Adult HFNC (P = .04). When used for CAD, inhaled drug delivery with HFNC/VMN (2.2 mg/hr ± 0.1, 14.8% ± 0.7%) was significantly greater than LVN and FM (0.48 ± 0.09 mg/hour, 3.2% ± 0.6%) (P = .001). CONCLUSIONS Administration of CAD via HFNC/VMN led to a greater than fourfold increase in drug delivery compared to LVN with FM. Optimal aerosol delivery occurred at 3 L/minute with SML Adult HFNC.
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Affiliation(s)
- Gerald B Moody
- Department of Respiratory Care, Children's Health-Children's Medical Center, Dallas, Texas
| | - Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, Texas
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10
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Li J, Fink JB, MacLoughlin R, Dhand R. A narrative review on trans-nasal pulmonary aerosol delivery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:506. [PMID: 32807226 PMCID: PMC7430014 DOI: 10.1186/s13054-020-03206-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/27/2020] [Indexed: 01/21/2023]
Abstract
The use of trans-nasal pulmonary aerosol delivery via high-flow nasal cannula (HFNC) has expanded in recent years. However, various factors influencing aerosol delivery in this setting have not been precisely defined, and no consensus has emerged regarding the optimal techniques for aerosol delivery with HFNC. Based on a comprehensive literature search, we reviewed studies that assessed trans-nasal pulmonary aerosol delivery with HFNC by in vitro experiments, and in vivo, by radiolabeled, pharmacokinetic and pharmacodynamic studies. In these investigations, the type of nebulizer employed and its placement, carrier gas, the relationship between gas flow and patient’s inspiratory flow, aerosol delivery strategies (intermittent unit dose vs continuous administration by infusion pump), and open vs closed mouth breathing influenced aerosol delivery. The objective of this review was to provide rational recommendations for optimizing aerosol delivery with HFNC in various clinical settings.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
| | | | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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Variation in Practice Related to the Use of High Flow Nasal Cannula in Critically Ill Children. Pediatr Crit Care Med 2020; 21:e228-e235. [PMID: 32106187 DOI: 10.1097/pcc.0000000000002258] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine current management of critically ill children and gather views regarding high flow nasal cannula therapy and to evaluate research priorities for a large prospective randomized controlled trial of noninvasive respiratory support in children. DESIGN Multinational cross-sectional questionnaire survey conducted in 2018. SETTING The sample included pediatric intensive care physicians in North and South America, Asia, Europe, and Australia/New Zealand. MEASUREMENT Questions consisted of: 1) characteristics of intensivists and hospital, 2) practice of high flow nasal cannula, 3) supportive treatment, and 4) research of high flow nasal cannula. INTERVENTIONS None. MAIN RESULTS We collected data from 1,031 respondents; 919 (North America, 215; Australia/New Zealand, 34; Asia, 203; South America, 186; Europe, 281) were analyzed. Sixty-nine percent of the respondents used high flow nasal cannula in non-PICU settings in their institutions. For a case of bronchiolitis/pneumonia infant, 2 L/kg/min of initial flow rate was the most commonly used. For a scenario of pneumonia with 30 kg weight, more than 60% of the respondents initiated flow based on patient body weight; while, 18% applied a fixed flow rate. Noninvasive ventilation was considered as a next step in more than 85% of respondents when the patient is failing with high flow nasal cannula. Significant practice variations were observed in clinical practice markers used, flow weaning strategy, and supportive practices. Views comparing high flow nasal cannula to continuous positive airway pressure also noticeably varied across the respondents. CONCLUSIONS Significant practice variations including views of high flow nasal cannula compared to continuous positive airway pressure was found among pediatric intensive care physicians. To expedite establishment and standardization of high flow nasal cannula practice, research aimed at understanding the heterogeneity found in this study should be undertaken.
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12
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Madney YM, Laz NI, Elberry AA, Rabea H, Abdelrahim ME. The influence of changing interfaces on aerosol delivery within high flow oxygen setting in adults: An in-vitro study. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2019.101365] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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13
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Li J, Wei W, Fink JB. In vitro comparison of unit dose vs infusion pump administration of albuterol via high-flow nasal cannula in toddlers. Pediatr Pulmonol 2020; 55:322-329. [PMID: 31782914 DOI: 10.1002/ppul.24589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/10/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Transnasal pulmonary aerosol delivery using high-flow nasal cannula (HFNC) devices has become a popular route of aerosol administration in toddlers. Clinically, albuterol is administered using an infusion pump or unit doses. However, little evidence is available to compare the two administration strategies. METHODS A toddler manikin (15 kg) with appropriate anatomic airway was connected with collecting filter to a simulator of distressed breathing. HFNC device with mesh nebulizer placed at the inlet of a humidifier at 37°C, with the gas flow set at 25 and 3.75 L/min. Five milligrams of albuterol was delivered in all experiments. With infusion pump administration, albuterol concentrations of 5 and 1 mg/mL were delivered at 4 and 20 mL/hr for 15 minutes. With unit dose administration, 1 mL (5 mg/mL) and 2 mL (2.5 mg/mL) of albuterol were nebulized. Additional tests with mouth open and nebulizers via mask were using 5 mg/1 mL for mesh nebulizer and 5 mg/3 mL for jet nebulizer (n = 3). The drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). RESULTS The inhaled dose was higher with unit dose than infusion pump administration with gas flows of 25 L/min (2.66 ± 0.38 vs 1.16 ± 0.28%; P = .004) and 3.75 L/min (10.51 ± 1.29 vs 8.58 ± 0.68%; P = .025). During unit dose administration, compared with closed-mouth breathing, open-mouth breathing generated a higher inhaled dose at 3.75 L/min and lower inhaled dose at 25 L/min. Compared to the nebulizers via mask with both open and closed-mouth breathing, nebulization via HFNC at 3.75 L/min generated greater inhaled dose, while HFNC at 25 L/min generated lower inhaled dose. CONCLUSIONS During transnasal aerosol delivery, the inhaled dose was higher with medication administrated using unit dose than using an infusion pump.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois
| | - Wu Wei
- Department of Critical Care Medicine, Shanghai Zhongshan Hospital, Fu Dan University, Shanghai, China
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois.,Aerogen Pharma Corp, San Mateo, California
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14
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Li J, Wu W, Fink JB. In vitro comparison between inspiration synchronized and continuous vibrating mesh nebulizer during trans-nasal aerosol delivery. Intensive Care Med Exp 2020; 8:6. [PMID: 32006290 PMCID: PMC6994578 DOI: 10.1186/s40635-020-0293-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/14/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Compared to continuous vibrating mesh nebulizer (VMN), inspiration synchronized VMN has shown increased inhaled dose during noninvasive ventilation; however, its use during aerosol delivery via high-flow nasal cannula (HFNC) is still unknown. METHODS An adult manikin was connected to a dual-chamber model lung, which was driven by a critical care ventilator to simulate spontaneous breathing. A HFNC system was utilized with temperature at 37 ° C while gas flow at 5, 10, 20, 40, and 60 L/min. Inspiration synchronized and continuous aerosol generation were compared at different positions (at the inlet of humidifier vs close to patient). One milliliter of albuterol (2.5 mg/mL) was used in each run (n = 3). Collection filter was placed at the trachea and was removed after each run. Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). RESULTS When nebulizer was placed close to patient, inhaled dose was higher with inspiration synchronized than continuous aerosol generation at all gas flows (p = 0.05) except at 5 L/min. When placed at the inlet of humidifier, compared to continuous, inspiration synchronized aerosol generated higher inhaled dose with gas flow set below 50% of patient inspiratory flow [23.9 (20.6, 28.3)% vs 18.1 (16.7, 19.6)%, p < 0.001], but lower inhaled dose with gas flow set above 50% of patient inspiratory flow [3.5 (2.2, 9.3)% vs 9.9 (8.2, 16.4)%, p = 0.001]. Regardless of breathing pattern, continuous aerosol delivered greater inhaled dose with nebulizer placed at humidifier than close to patient at all gas flows except at 5 L/min. CONCLUSION When the HFNC gas flow was set higher than 50% of patient inspiratory flow, no significant advantage was found in inspiration synchronized over continuous aerosol. However, inspiration synchronized aerosol generated 30% more inhaled dose than continuous with gas flow set below 50% of patient inspiratory flow, regardless of nebulizer placement. Continuous nebulizer needs to be placed at the inlet of humidifier.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.
| | - Wei Wu
- Department of Critical Care Medicine, Shanghai Zhongshan Hospital, Fu Dan University, Shanghai, China
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
- Aerogen Pharma Corp, San Mateo, CA, USA
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15
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Dugernier J, Reychler G, Vecellio L, Ehrmann S. Nasal High-Flow Nebulization for Lung Drug Delivery: Theoretical, Experimental, and Clinical Application. J Aerosol Med Pulm Drug Deliv 2019; 32:341-351. [DOI: 10.1089/jamp.2019.1524] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Jonathan Dugernier
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Soins Intensifs, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Médecine Physique, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Grégory Reychler
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Service de pneumologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Laurent Vecellio
- Centre d'études des pathologies respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Stephan Ehrmann
- Centre d'études des pathologies respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
- Médecine intensive réanimation, Centre d'investigation clinique CIC INSERM 1415, CHRU de Tours, Tours, France
- CRICS-TriggerSep Research Network
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16
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Abstract
The 2014 American Academy of Pediatrics bronchiolitis guidelines do not adequately serve the needs and clinical realities of front-line clinicians caring for undifferentiated wheezing infants and children. This article describes the clinical challenges of evaluating and managing a heterogeneous disease syndrome presenting as undifferentiated patients to the emergency department. Although the 2014 American Academy of Pediatrics bronchiolitis guidelines and the multiple international guidelines that they closely mirror have made a good faith attempt to provide clinicians with the best evidence-based recommendations possible, they have all failed to address practical, front-line clinical challenges. The therapeutic nihilism of the guidelines and the dissonance between many of the recommendations and frontline realities have had wide-ranging consequences. Nevertheless, newer evidence of therapeutic options is emerging and forecasts hope for more therapeutically optimistic recommendations with the next revision of the guidelines.
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17
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Baker K, Greaves T, Fraser JF. How to use humidified high-flow nasal cannula in breathless adults in the emergency department. Emerg Med Australas 2019; 31:863-868. [PMID: 31389171 DOI: 10.1111/1742-6723.13372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Kylie Baker
- Emergency Department, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Tanya Greaves
- Emergency Department, Ipswich Hospital, Ipswich, Queensland, Australia
| | - John F Fraser
- The University of Queensland and Adult Intensive Care Service, Prince Charles Hospital, Brisbane, Queensland, Australia.,St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
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18
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Li J, Gong L, Ari A, Fink JB. Decrease the flow setting to improve trans-nasal pulmonary aerosol delivery via "high-flow nasal cannula" to infants and toddlers. Pediatr Pulmonol 2019; 54:914-921. [PMID: 30920155 DOI: 10.1002/ppul.24274] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/16/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Trans-nasal pulmonary aerosol delivery for infants and toddlers has recently gained popularity, however, the reported lung deposition is low. We aimed to investigate the influential factors to improve the delivery. METHODS Anatomic airway manikins simulating infant (5 kg) and toddler (15 kg) with collecting filter connected the trachea and breath simulator, were set to represent quiet and distressed breathing. Nasal cannula flow was set at 0.125, 0.25, 0.5, 1, and 2 L/kg/min. A mesh nebulizer (Aerogen) was placed at the inlet of humidifier (Fisher & Paykel) and proximal to patient. Albuterol (5 mg in 1 mL) was nebulized for each condition (n = 3). Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). RESULTS Inhaled dose was higher with nebulizer placed at the inlet of humidifier than proximal to patient in all settings, except the infant model at low gas flow settings (0.125 and 0.25 L/kg/min). When nebulizer was placed at the inlet of humidifier, inhaled dose was higher when gas flow was below patient's inspiratory flow than when gas flow exceeded patient's inspiratory flow (8.77 ± 3.84 vs 2.16 ± 1.29%, P < 0.001); aerosol deposition increased as gas flow decreased, with greatest deposition at gas flow of 0.25 L/kg/min (11.29 ± 2.15%). A multiple linear regression identified gas flow as the primary predictor of aerosol delivery. CONCLUSIONS Trans-nasal pulmonary aerosol delivery was significantly improved when gas flow was below patient's inspiratory flow, aerosol deposition increased with decreased nasal cannula flow, with greatest deposition at 0.25 L/kg/min.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - Lingyue Gong
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - Arzu Ari
- Department of Respiratory Care, College of Health Professions, Texas State University, Round Rock, Texas
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
- Aerogen Pharma Corp, San Mateo, California
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19
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The Ratio of Nasal Cannula Gas Flow to Patient Inspiratory Flow on Trans-nasal Pulmonary Aerosol Delivery for Adults: An in Vitro Study. Pharmaceutics 2019; 11:pharmaceutics11050225. [PMID: 31083346 PMCID: PMC6571744 DOI: 10.3390/pharmaceutics11050225] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/08/2019] [Accepted: 05/08/2019] [Indexed: 11/17/2022] Open
Abstract
Trans-nasal aerosol deposition during distressed breathing is higher than quiet breathing, and decreases as administered gas flow increases. We hypothesize that inhaled dose is related to the ratio of gas flow to patient inspiratory flow (GF:IF). An adult manikin (Laerdal) with a collecting filter placed at trachea was connected to a dual-chamber model lung, which was driven by a ventilator to simulate quiet and distressed breathing with different inspiratory flows. Gas flow was set at 5, 10, 20, 40 and 60 L/min. Albuterol (2.5mg in 1 mL) was nebulized by vibrating mesh nebulizer at the inlet of humidifier at 37 °C for each condition (n = 3). Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). GF:IF was the primary predictor of inhaled dose (p < 0.001). When the ratio was < 1.0, the inhaled dose was higher than ratio > 1.0 (21.8 ± 3.8% vs. 9.0 ± 3.7%, p < 0.001), and the inhaled dose was similar between quiet and distressed breathing (22.3 ± 5.0% vs. 21.3 ± 2.7%, p = 0.379). During trans-nasal aerosol delivery, GF:IF primarily affected the inhaled dose. Compared to the ratio above 1.0, the ratio below 1.0 produced a higher and more-consistent inhaled dose.
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20
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Valencia-Ramos J, Arnaez J, Benito JM, Mirás A, Ochoa C, Beltrán S. A comparative in vitro study of standard facemask jet nebulization and high-flow nebulization in bronchiolitis. Exp Lung Res 2019; 45:13-21. [PMID: 31007091 DOI: 10.1080/01902148.2019.1599084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Aim of Study: The use of a nebulizer paired with high-flow nasal cannulas (HFNC) has been proposed for drug delivery in bronchiolitis. Particle size nebulized is a relevant factor determining the efficacy of the nebulization. We replicated in vitro the theoretical parameters most widely used in bronchiolitis and we compared the size of the droplet nebulized with a standard nebulizer and a nebulizer integrated into HFNC. Materials and Methods: We used laser diffraction to analyze the particle size nebulized (volume median diameter Dv50). The standard system was a jet nebulizer connected to a facemask with a flow rate of 8 L/min (JN). Three designs were used as nebulizers integrated into HFNC: a vibrating mesh nebulizer set 1) before (HFNC-BH) and 2) after (HFNC-AH) the humidifier, and 3) a jet nebulizer connected before the nasal cannula (HFNC-BNC). HFNC was used with neonatal (3-8 L/min) and infant cannulas (8-15 L/min). Results: Droplet size was similar among the three drugs studied. A lower particle size was obtained when using the nebulization system integrated into HFNC compared to the standard nebulizer, regardless of the flow rate and the nasal cannula used when the position of the nebulizer was before the nasal cannula (p < 0.05): 6.89 µm (JN), 2.49 µm (HFNC-BNC 3 L/min), 2.59 µm (HFNC-BNC 5 L/min), 2.44 µm (HFNC-BNC 8 L/min), 3.22 µm (HFNC-BNC 10 L/min), 3.23 µm (HFNC-BNC 13 L/min), 3.16 µm (HFNC-BNC 15 L/min). The particle size was lower in HFNC-BF compared to the HFNC-AH using neonatal nasal cannula (3-8 L/min) (p < 0.05). Conclusion: The use of a nebulizer integrated with HFNC has shown promising results in an experimental scenario of bronchiolitis. The particle size achieved with the nebulizer placed before the humidifier is equivalent to the one obtained via conventional nebulization, and it is even smaller when the integrated nebulizer is placed before the nasal cannulas.
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Affiliation(s)
- Juan Valencia-Ramos
- a Paediatric Intensive Care Unit , Hospital Universitario de Burgos , Burgos , Spain
| | - Juan Arnaez
- b Department of Neonatology , Hospital Universitario de Burgos , Burgos , Spain
| | - José Manuel Benito
- c Chemical Engineering Division, Department of Biotechnology and Food Science , Universidad de Burgos , Burgos , Spain
| | - Alicia Mirás
- a Paediatric Intensive Care Unit , Hospital Universitario de Burgos , Burgos , Spain
| | - Carlos Ochoa
- d Department of Investigation Unit , Hospital Virgen de la Concha, Escuela Universitaria de Enfermería de Zamora , Zamora , Spain
| | - Sagrario Beltrán
- c Chemical Engineering Division, Department of Biotechnology and Food Science , Universidad de Burgos , Burgos , Spain
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21
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Bennett G, Joyce M, Fernández EF, MacLoughlin R. Comparison of aerosol delivery across combinations of drug delivery interfaces with and without concurrent high-flow nasal therapy. Intensive Care Med Exp 2019; 7:20. [PMID: 30945044 PMCID: PMC6447636 DOI: 10.1186/s40635-019-0245-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current clinical practice during high-flow nasal therapy (HFNT) involves utilization of a nasal cannula to provide humidification, with a facemask placed over the cannula to deliver aerosol. Few studies have compared aerosol delivery across various delivery interfaces during HFNT. The objective of this study was to address this gap in the literature and evaluate aerosol delivery using two nebulizer types across different drug delivery interfaces, nasal cannula, facemask, and mouthpiece, during simulated adult HFNT. METHODS A facemask or mouthpiece and/or a nasal cannula were positioned on an anatomically correct adult head model. The head model was connected to a breathing simulator via a collection filter. Both healthy breathing pattern and distressed breathing patterns were utilized. Aerosol dose was determined by quantifying the mass of drug captured on a filter positioned distal to the trachea. RESULTS During simulated healthy breathing, a significantly greater aerosol dose was observed when the vibrating mesh nebulizer (VMN) was integrated with HFNT alone, supplying aerosol and humidified air simultaneously (2.88 ± 0.15%), as opposed to using with a facemask (0.33 ± 0.07%, 1.62 ± 0.46%, and 1.07 ± 0.25% at 0 L/min (LPM), 2LPM, and 6LPM, respectively) or mouthpiece (0.56 ± 0.13%, 2.16 ± 0.06%, and 1.82 ± 0.41% at 0LPM, 2LPM, and 6LPM). In addition, aerosol delivery was also significantly greater when the VMN was integrated into simulated HFNT (2.88 ± 0.15%), in comparison with using the jet nebulizer (JN) with a facemask (0.82 ± 0.16%) or a mouthpiece (0.86 ± 0.11%). During simulated distressed breathing, a significantly greater aerosol dose was observed when the VMN was integrated with HFNT, supplying aerosol and humidified air simultaneously (6.81 ± 0.45%), compared with using a facemask (0.86 ± 0.04%, 2.96 ± 0.26%, and 4.23 ± 0.93% at 0LPM, 2LPM, and 6LPM) or mouthpiece (0.73 ± 0.37%, 0.97 ± 0.20%, and 3.11 ± 0.53% at 0LPM, 2LPM, and 6LPM, respectively). Aerosol delivery was also greater when the VMN was integrated into HFNT (6.81 ± 0.45%), in comparison with using the JN with a facemask (5.72 ± 0.71%) or a mouthpiece (0.69 ± 0.53%). Furthermore, across all drug delivery interfaces, and in line with previous reports, aerosol delivery was greater during simulated distressed breathing, in comparison with simulated healthy adult breathing. CONCLUSIONS This article will be of considerable benefit in enhancing the understanding of aerosol delivery during HFNT, an increasingly adopted therapeutic intervention by healthcare professionals.
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Affiliation(s)
- Gavin Bennett
- Aerogen Limited, IDA Business Park, Dangan, Galway, Ireland
| | - Mary Joyce
- Aerogen Limited, IDA Business Park, Dangan, Galway, Ireland
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Observational study of newborn infant parasympathetic evaluation as a comfort system in awake patients admitted to a pediatric intensive care unit. J Clin Monit Comput 2019; 33:749-755. [PMID: 30721390 PMCID: PMC7088066 DOI: 10.1007/s10877-019-00268-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/25/2019] [Indexed: 11/27/2022]
Abstract
To compare the newborn infant parasympathetic evaluation system (NIPE) scores with a validated clinical scale using two different nebulizers in children with bronchiolitis admitted to a PICU. Comfort was evaluated using the COMFORT-behavior scale (CBS) before (T1), during (T2) and after (T3) each nebulization. In order to compare NIPE and CBS values during the whole T1 to T3 period, the variable Dif-CBS was defined as the difference between maximal and minimal CBS scores, and Dif-NIPE as the difference between 75th and 25th percentile NIPE values. Analyses were carried out, firstly for the total of nebulizations and secondly comparing two different nebulization systems: a jet nebulizer (JN) and a nebulizer integrated in high flow nasal cannulas (NHF). 84 nebulizations were recorded on 14 patients with a median [25th–75th percentile] age of 6 months (3.1–9.5). A Dif-CBS of 4 points (2–7), as well as changes in CBS scores between T1 and T2, defined the nebulization as a discomfort stimulus. The NIPE system, represented as the Dif-NIPE, showed a median variation of 9 points (7–10), and was poorly correlated to Dif-CBS [rs 0.162 (P = 0.142)]. Discomfort during nebulization, assessed by CBS was greater with the JN system compared to NHF: 17 (13–22) vs 13 (9–15) (P = 0.001). NIPE monitoring detected no significant differences between both nebulization systems (P = 0.706). NIPE monitoring showed a variation in comfort during nebulization in the patient with bronchiolitis, though correlation with CBS was poor. Further research is required before NIPE can be suggested as a comfort monitoring system for the awake infant.
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