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Li J, Liu K, Lyu S, Jing G, Dai B, Dhand R, Lin HL, Pelosi P, Berlinski A, Rello J, Torres A, Luyt CE, Michotte JB, Lu Q, Reychler G, Vecellio L, de Andrade AD, Rouby JJ, Fink JB, Ehrmann S. Aerosol therapy in adult critically ill patients: a consensus statement regarding aerosol administration strategies during various modes of respiratory support. Ann Intensive Care 2023; 13:63. [PMID: 37436585 DOI: 10.1186/s13613-023-01147-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 05/31/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Clinical practice of aerosol delivery in conjunction with respiratory support devices for critically ill adult patients remains a topic of controversy due to the complexity of the clinical scenarios and limited clinical evidence. OBJECTIVES To reach a consensus for guiding the clinical practice of aerosol delivery in patients receiving respiratory support (invasive and noninvasive) and identifying areas for future research. METHODS A modified Delphi method was adopted to achieve a consensus on technical aspects of aerosol delivery for adult critically ill patients receiving various forms of respiratory support, including mechanical ventilation, noninvasive ventilation, and high-flow nasal cannula. A thorough search and review of the literature were conducted, and 17 international participants with considerable research involvement and publications on aerosol therapy, comprised a multi-professional panel that evaluated the evidence, reviewed, revised, and voted on recommendations to establish this consensus. RESULTS We present a comprehensive document with 20 statements, reviewing the evidence, efficacy, and safety of delivering inhaled agents to adults needing respiratory support, and providing guidance for healthcare workers. Most recommendations were based on in-vitro or experimental studies (low-level evidence), emphasizing the need for randomized clinical trials. The panel reached a consensus after 3 rounds anonymous questionnaires and 2 online meetings. CONCLUSIONS We offer a multinational expert consensus that provides guidance on the optimal aerosol delivery techniques for patients receiving respiratory support in various real-world clinical scenarios.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA.
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shan Lyu
- Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Guoqiang Jing
- Department of Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Paolo Pelosi
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Ariel Berlinski
- Pulmonary and Sleep Medicine Division, Department of Pediatrics, University of Arkansas for Medical Sciences, and Pediatric Aerosol Research Laboratory at Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Clinical Research in the ICU, Anaesthesia Department, CHU Nimes, Université de Nimes-Montpellier, Nimes, France
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, University of Barcelona, IDIBAPS CIBERES, Icrea, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, and INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Jean-Bernard Michotte
- School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts of Western Switzerland, Lausanne, Switzerland
| | - Qin Lu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, and Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Gregory Reychler
- Secteur de Kinésithérapie et Ergothérapie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Service de Pneumologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL and Dermatologie, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Jean-Jacques Rouby
- Research Department DMU DREAM and Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Sorbonne University of Paris, Paris, France
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA
- Chief Science Officer, Aerogen Pharma Corp, San Mateo, CA, USA
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, and INSERM, Centre d'étude des Pathologies Respiratoires, U1100, Université de Tours, Tours, France
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2
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Dhanani J, Taniguchi LU, Ranzani OT. Optimising aerosolized therapies in critically ill patients. Intensive Care Med 2022; 48:1418-1421. [PMID: 35804200 DOI: 10.1007/s00134-022-06800-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Jayesh Dhanani
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Leandro U Taniguchi
- Emergency Medicine Discipline, Clinical Hospital, University of São Paulo, São Paulo, Brazil.,Syrian-Lebanese Institute of Teaching and Research, São Paulo, Brazil
| | - Otavio T Ranzani
- Barcelona Institute for Global Health, ISGlobal, Universitat Pompeu Fabra (UPF), CIBER Epidemiología Y Salud Pública (CIBERESP), Barcelona, Spain.,Pulmonary Division, Heart Institute, Faculty of Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Boules ME, Laz NI, Elberry AA, Hussein RRS, Abdelrahim MEA. Effect of pressures and type of ventilation on aerosol delivery to chronic obstructive pulmonary disease patients. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2022; 11:57. [PMID: 35441078 PMCID: PMC9010937 DOI: 10.1186/s43088-022-00234-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Continuous Positive Airway Pressure (CPAP), BiPhasic Positive Airway Pressure (BiPAP), and high flow nasal cannula (HFNC) show some evidence to have efficacy in COVID-19 patients. Delivery during noninvasive mechanical ventilation (NIV) or HFNC gives faster and more enhanced clinical effects than when aerosols are given without assisted breath. The present work aimed to compare the effect of BiPhasic Positive Airway Pressure (BiPAP) mode at two different pressures; low BiPAP (Inspiratory Positive Airway Pressure (IPAP)/Expiratory Positive Airway Pressure (EPAP) of 10/5 cm water) and high BiPAP (IPAP/EPAP of 20/5 cm water), with HFNC system on pulmonary and systemic drug delivery of salbutamol. On the first day of the experiment, all patients received 2500 μg salbutamol using Aerogen Solo vibrating mesh nebulizer. Urine samples 30 min post-dose and cumulative urinary salbutamol during the next 24 h were collected on the next day. On the third day, the ex-vivo filter was inserted before the patient to collect the delivered dose to the patient of the 2500 μg salbutamol. Salbutamol was quantified using high-performance liquid chromatography (HPLC). Results Low-pressure BiPAP showed the highest amount delivered to the lung after 30 min followed by HFNC then high-pressure BiPAP. But the significant difference was only observed between low and high-pressure BiPAP modes (p = 0.012). Low-pressure BiPAP showed the highest delivered systemic delivery amount followed by HFNC then high-pressure BiPAP. Low-pressure BiPAP was significantly higher than HFNC (p = 0.017) and high-pressure BiPAP (p = 0.008). No significant difference was reported between HFNC and high-pressure BiPAP. The ex-vivo filter was the greatest in the case of low-pressure BiPAP followed by HFNC then high-pressure BiPAP. Low-pressure BiPAP was significantly higher than HFNC (p = 0.033) and high-pressure BiPAP (p = 0.008). Also, no significant difference was found between HFNC and high-pressure BiPAP. Conclusions Our results of pulmonary, systemic, and ex-vivo drug delivery were found to be consistent. The low BiPAP delivered the highest amount followed by the HFNC then the high BiPAP with the least amount. However, no significant difference was found between HFNC and high BiPAP.
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Seif SM, Ma E, Rabea H, Saeed H, Abdelrahim MEA. Aerosol delivery of inhalation devices with different add-on connections to invasively ventilated COPD subjects: An in-vivo study. Eur J Pharm Sci 2021; 167:105988. [PMID: 34492291 DOI: 10.1016/j.ejps.2021.105988] [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: 05/20/2021] [Revised: 08/06/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022]
Abstract
Aerosol delivery to mechanically ventilated patients requires add-on connections to place the inhalation device within the ventilation circuit. The study aimed to evaluate the performance of Combihaler in dual limb invasive mechanical ventilation (IMV). A ventilator with a humidified dual limb circuit was adjusted to volume-controlled mode to imitate the adult breathing parameters. 24 (12 females) intubated chronic obstructive pulmonary disease (COPD) subjects had undergone the study. All patients were prescribed inhaled salbutamol dose delivered by either a metered-dose inhaler (pMDI) or vibrating mesh nebulizer (VMN). Each subject received salbutamol in four different inhalation device/connection conditions; pMDI+VMN+Combihaler, VMN+Combihaler, VMN+T-piece, and pMDI+T-piece. They were individually placed in the inspiratory limb at Y-piece. 5mg salbutamol was delivered by VMN with and without 2 pMDI puffs of salbutamol (100 µg), and 500µg was delivered by pMDI+T-piece. After aerosol delivery, two urine samples were collected from the patient; 30 min post-inhalation (USAL0.5) and cumulatively 24 h post-inhalation (USAL24) as indexes of lung deposition and systemic absorption, respectively. For the ex-vivo study, a collecting filter was placed before an endotracheal tube (ETT) to collect the delivered inhalable dose. In-vitro aerodynamic characteristics were also investigated. pMDI+VMN+Combihaler delivered more salbutamol to the lung and the ex-vivo filter than VMN+T-piece (p˂0.05, p≤0.01, respectively). VMN delivered a higher salbutamol amount to the lung, systemically, and the ex-vivo filter than pMDI+T-piece (p˂0.001). pMDI+VMN+Combihaler and VMN+Combihaler delivered aerosols with a less mass median aerodynamic diameter (MMAD) and higher fine particle fraction (FPF) compared to VMN+T-piece (p≤0.01 for MMAD, p˂0.01 for FPF) and pMDI+T-piece (p˂0.01 for both MMAD and FPF). Results of the study showed that pMDI+VMN+ Combihaler delivered more salbutamol than VMN+T-piece in IMV and demonstrate that 5 puffs (500-µg) of salbutamol with pMDI+T-piece has a lower aerosol delivering power at the level of USAL0.5, USAL24, and the ex-vivo inhalable dose than 5 mg nebulized salbutamol by VMNs in IMV.
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Affiliation(s)
- Salah M Seif
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Elnady Ma
- Chest Diseases Department, Kasr Al Einy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hoda Rabea
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt.
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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5
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Performance of different add-on devices in dual limb non-invasive mechanically ventilated circuit. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2021.102897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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6
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Ari A, Fink JB. Delivered dose with jet and mesh nebulisers during spontaneous breathing, noninvasive ventilation and mechanical ventilation using adult lung models. ERJ Open Res 2021; 7:00027-2021. [PMID: 34262965 PMCID: PMC8273293 DOI: 10.1183/23120541.00027-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/20/2021] [Indexed: 11/05/2022] Open
Abstract
What is the delivered dose with jet and mesh nebulisers during spontaneous breathing (SB), noninvasive ventilation (NIV), and mechanical ventilation (MV) using an adult lung model with exhaled humidity (EH)? The delivery of salbutamol sulfate (2.5 mg per 3 mL) with jet (Mistymax10) and mesh nebulisers (Aerogen Solo) was compared during SB, NIV, and MV using breathing parameters (tidal volume 450 mL, respiratory rate 20 breaths per min, inspiratory:expiratory ratio 1:3) with three lung models simulating exhaled humidity. A manikin was attached to a sinusoidal pump via a filter at the bronchi to simulate an adult with SB. A ventilator (V60) was attached via a facemask to a manikin with a filter at the bronchi connected to a test lung to simulate an adult receiving NIV. A ventilator-dependent adult was simulated through a ventilator (Servo-i) operated with a heated humidifier (Fisher & Paykel) attached to an endotracheal tube (ETT) with a heated-wire circuit. The ETT was inserted into a filter (Respirgard II). A heated humidifier was placed between the filter and test lung to simulate exhaled humidity (35±2°C, 100% relative humidity). Nebulisers were placed at the Y-piece of the inspiratory limb during MV and positioned between the facemask and the leak-port during NIV. A mouthpiece was used during SB. The delivered dose was collected in an absolute filter that was attached to the bronchi of the mannequin during each aerosol treatment and measured with spectrophotometry. Drug delivery during MV was significantly greater than during NIV and SB with a mesh nebuliser (p=0.0001) but not with a jet nebuliser (p=0.384). Delivery efficiency of the mesh nebuliser was greater than the jet nebuliser during MV (p=0.0001), NIV (p=0.0001), and SB (p=0.0001). Aerosol deposition obtained with a mesh nebuliser was greater and differed between MV, NIV, and SB, while deposition was low with a jet nebuliser and similar between the modes of ventilation tested.
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Affiliation(s)
- Arzu Ari
- Dept of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - James B Fink
- Dept of Respiratory Care, Texas State University, Round Rock, TX, USA
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7
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Tan W, Dai B, Lu CL, Hou HJ, Zhao HW, Wang W, Kang J. The Effect of Different Interfaces on the Aerosol Delivery with Vibrating Mesh Nebulizer During Noninvasive Positive Pressure Ventilation. J Aerosol Med Pulm Drug Deliv 2021; 34:366-373. [PMID: 33848443 DOI: 10.1089/jamp.2020.1623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The effect of different interfaces on the aerosol delivery with vibrating mesh nebulizer during noninvasive positive pressure ventilation (NIV) is not clear. Materials and Methods: Noninvasive ventilator and four interfaces were connected to IngMar ASL 5000 lung simulator. Meanwhile, the vibrating mesh nebulizer was connected to a ventilator circuit to simulate the nebulization during noninvasive ventilation. The nebulizer position was placed at proximal position (near the mask) and distal position (15 cm away from the mask); the inspiratory positive airway pressure (IPAP) and the expiratory positive airway pressure (EPAP) were set to 16/4, 16/8, 20/4, and 20/8 cmH2O, respectively. The aerosol was collected through a disposable filter placed between the simulated lung and the mask, after which the aerosol delivery was calculated. Meanwhile, we recorded the inspiratory tidal volume and the mean inspiratory flow. Results: The aerosol delivery varied between 1.7% ± 0.0% and 21.1% ± 1.1%. Only when EPAP was set to 4 cmH2O, the statistical difference in aerosol delivery was observed between the two types of interface, and between different leak port locations (p < 0.01; p = 0.04, respectively). When IPAP/EPAP was set to 16/4 and 20/4 cmH2O, respectively, at different nebulizer positions, there was a statistical difference between the interface with the same type but different leak port locations and between the interface with same leak port location but different inner volumes (all p < 0.01). Also, there was a correlation between the aerosol delivery and interface volume (p < 0.01, R2 = 0.55; p < 0.01, R2 = 0.51, respectively), and between aerosol delivery and the intentional leak of interfaces (p < 0.01, R2 = 0.59; p < 0.01, R2 = 0.48, respectively). When EPAP was set to 4 and 8 cmH2O, respectively, the aerosol delivery of nebulizer distal position was significantly higher than that of proximal position (12.2% ± 5.0% vs. 9.1% ± 4.1%, p < 0.05; 2.5% ± 0. 5% vs. 2.1% ± 0.3%, p < 0.01, respectively). Conclusion: Interfaces have a significant effect on aerosol delivery during NIV. The interfaces with different inner volumes, intentional leak, and leak port location may all have an effect on aerosol delivery. The addition of a 15 cm tube between the nebulizer and the mask significantly increases the aerosol delivery.
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Affiliation(s)
- Wei Tan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Chang-Ling Lu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Hai-Jia Hou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Hong-Wen Zhao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Wei Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Jian Kang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
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Avdeev SN, Nuralieva GS, Soe AK, Gainitdinova VV, Fink JB. Comparison of Vibrating Mesh and Jet Nebulizers During Noninvasive Ventilation in Acute Exacerbation of Chronic Obstructive Pulmonary Disease. J Aerosol Med Pulm Drug Deliv 2021; 34:358-365. [PMID: 33848441 DOI: 10.1089/jamp.2020.1665] [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] [Indexed: 11/12/2022] Open
Abstract
Background: Advances in aerosol technology have improved drug delivery efficiency during noninvasive ventilation (NIV). Clinical evaluation of the efficacy of aerosol therapy during NIV in the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) is very limited. The aim of our study was to compare the efficacy of bronchodilators administered through a vibrating mesh nebulizer (VMN) and jet nebulizer (JN) during NIV in patients with acute exacerbation of COPD. Methods: Prospective randomized cross-over study included 30 patients treated with NIV for acute exacerbation of COPD in an acute care hospital. Patients were consented and enrolled after stabilization of acute exacerbation (3-5 days after admission). Subjects were randomly assigned into two treatment arms receiving salbutamol (2.5 mg): with VMN (Aerogen Solo) and JN (Sidestream) positioned between the leak port and the nonvented oronasal mask during bilevel ventilation with a single-limb circuit. Measurements (clinical data, pulmonary function tests [PFTs], and arterial blood gases) were performed at baseline, 1, and 2 hours after treatment. Results: All measured PFT parameters significantly increased in both groups, but numerically results were better after inhalation with VMN than with JN: for forced expiratory volume in 1 second (FEV1) (mean increase from baseline to 120 minutes-165 ± 64 mL vs. 116 ± 46 mL, p = 0.001) and for forced vital capacity (FVC) (mean increase-394 ± 154 mL vs. 123 ± 57 mL, p < 0.001). There was also a statistically significant reduction in respiratory rate and in Borg dyspnea score after therapy with VMN in comparison with the conventional JN. In both groups, there were improvements in PaCO2, but with VMN these changes were significantly higher. Conclusion: Bronchodilator administration in patients with acute exacerbation of COPD during NIV with VMN resulted in clinically significant improvements in FVC and in Borg dyspnea score. Additional studies required to determine the impact on clinical outcomes.
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Affiliation(s)
- Sergey N Avdeev
- Sechenov First Moscow State Medical University, Healthcare Ministry of Russia, Moscow, Russia.,Federal Pulmonology Research Institute, Moscow, Federal Medical and Biological Agency of Russia, Moscow, Russia
| | - Galia S Nuralieva
- Sechenov First Moscow State Medical University, Healthcare Ministry of Russia, Moscow, Russia.,Federal Pulmonology Research Institute, Moscow, Federal Medical and Biological Agency of Russia, Moscow, Russia
| | - Aung Kyaw Soe
- Federal Pulmonology Research Institute, Moscow, Federal Medical and Biological Agency of Russia, Moscow, Russia
| | - Viliya V Gainitdinova
- Sechenov First Moscow State Medical University, Healthcare Ministry of Russia, Moscow, Russia
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA.,Aerogen Pharma Corp., San Mateo, California, USA
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Saeed H, Harb HS, Madney YM, Abdelrahim MEA. Aerosol delivery via noninvasive ventilation: role of models and bioanalysis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:589. [PMID: 33987287 DOI: 10.21037/atm-20-1261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Non-invasive ventilation (NIV) is external support for respiration to assist breathing in case of respiratory failure (either hypercapnic or hypoxemic) without patient intubation. Nowadays, medicated aerosols are normally delivered to mechanically ventilated patients by nebulizers and pressurized metered-dose inhaler (pMDI) attached to adapter or spacer that fit into the ventilated circuit. Studies with obstructive lung disease patients have shown that aerosol delivery during mechanical ventilation is possible and of benefit. There are several models for investigating the aerosol delivery and deposition during mechanical ventilation such as in vitro, in vivo, and ex vivo models, these models depend on the technique used for quantitative or qualitative measurement of the deposited aerosol. In vitro models could be used for calculating the total emitted doses from different aerosol-generating devices or for aerodynamic characterization of the deposited inhaled medications. In vivo models dependents of extracting drugs from biological samples for measuring its concentration and bioavailability (pharmacokinetic model) or be dependent on the imaging technique of the radioactive aerosol. Applying different methods to predict aerosol efficiency before starting NIV and to quantify aerosol delivery during NIV are promising approaches that guide clinicians to avoid treatment failure before and during patient therapy.
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Affiliation(s)
- Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hadeer S Harb
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Yasmin M Madney
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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Alharbi AS, Yousef AA, Alharbi SA, Al-Shamrani A, Alqwaiee MM, Almeziny M, Said YS, Alshehri SA, Alotaibi FN, Mosalli R, Alawam KA, Alsaadi MM. Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus. Ann Thorac Med 2021; 16:188-218. [PMID: 34012486 PMCID: PMC8109687 DOI: 10.4103/atm.atm_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022] Open
Abstract
The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.
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Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahd Hospital of the University, Khobar, Saudi Arabia
| | - Saleh A. Alharbi
- Department of Pediatrics, Umm Al-Qura University, Mecca, Saudi Arabia
- Department of Pediatrics, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mansour M. Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mohammed Almeziny
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Yazan S. Said
- Department of Pediatrics, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Saleh Ali Alshehri
- Department of Emergency, Pediatric Emergency Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Faisal N. Alotaibi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura University, Makkah, Saudi Arabia
- Department of Pediatrics, International Medical Center, Jeddah, Saudi Arabia
| | - Khaled Ali Alawam
- Department of Respiratory Therapy Sciences, Inaya Medical College, Riyadh, Saudi Arabia
| | - Muslim M. Alsaadi
- Department of Pediatrics, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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Seif SM, Elnady MA, Rabea H, Saeed H, Abdelrahim ME. Effect of different connection adapters on aerosol delivery in invasive ventilation setting; an in-vitro study. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2020.102177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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12
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Harb HS, Saeed H, Madney YM, Abdelrahman MA, Osama H, Esquinas AM, Abdelrahim ME. Update efficacy of aerosol therapy with noninvasive ventilator approach (non-invasive ventilation and nasal high flow). J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2020.101922] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Lyu S, Li J, Yang L, Du X, Liu X, Chuan L, Jing G, Wang Z, Shu W, Ye C, Dong Q, Duan J, Fink JB, Gao Z, Liang Z. The utilization of aerosol therapy in mechanical ventilation patients: a prospective multicenter observational cohort study and a review of the current evidence. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1071. [PMID: 33145290 PMCID: PMC7575997 DOI: 10.21037/atm-20-1313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background Aerosol delivery via mechanical ventilation has been reported to vary significantly among different intensive care units (ICU). The optimal technique for using each aerosol generator may need to be updated with the available evidence. Methods A 2-week prospective multicenter observational cohort study was implemented to record aerosol delivery for mechanically ventilated adult patients in Chinese ICUs. Our data included the type of aerosol device and its placement, ventilator type, humidification, and aerosolized medication administered. A guide for the optimal technique for aerosol delivery during mechanical ventilation was summarized after a thorough literature review. Results A total of 160 patients (105 males) from 28 ICUs were enrolled, of whom 125 (78.1%) received aerosol therapy via invasive ventilation. Among these 125 patients, 53 received ventilator-integrated jet nebulizer, with 64% (34/53) of them placed the nebulizer close to Y piece in the inspiratory limb. Further, 56 patients used continuous nebulizers, with 84% (47/56) of them placed the nebulizer close to the Y piece in the inspiratory limb. Of the 35 patients who received aerosol therapy via noninvasive ventilation, 30 received single limb ventilators and continuous nebulizers, with 70% (21/30) of them placed between the mask and exhalation port. Only 36% (58/160) of the patients received aerosol treatments consistent with optimal practice. Conclusions Aerosol delivery via mechanical ventilation varied between ICUs, and only 36% of the patients received aerosol treatments consistent with optimal practice. ICU clinicians should be educated on the best practices for aerosol therapy, and quality improvement projects aim to improve the quality and outcome of patients with the optimal technique for aerosol delivery during mechanical ventilation are warranted.
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Affiliation(s)
- Shan Lyu
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - Limin Yang
- Department of Respiratory Care, Zhejiang University School of Medical Sir Run Run Shaw Hospital, Hangzhou, China
| | - Xiaoliang Du
- Department of Neurosurgical, Tongji Medical College of Huazhong University of Science and Technology Tongji Hospital, Wuhan, China
| | - Xiaoyi Liu
- Department of Critical Care Medicine, Dazhou Central Hospital, Dazhou, China
| | - Libo Chuan
- Intensive Care Unit, the First People's Hospital of Yunnan Province, Kunming, China
| | - Guoqiang Jing
- Department of Respiratory and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Zhenyan Wang
- Department of Critical Care Medicine, Peking University International Hospital, Beijing, China
| | - Weiwei Shu
- Department of Critical Care Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Chunjuan Ye
- Department of Surgical Intensive Care Unit, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qionglan Dong
- Department of Critical Care Medicine, the Third People's Hospital of Mianyang, Mianyang, China
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - 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
| | - Zhancheng Gao
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Medical Center, Sichuan University, Chengdu, China
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Pantazopoulos I, Daniil Z, Moylan M, Gourgoulianis K, Chalkias A, Zakynthinos S, Ischaki E. Nasal High Flow Use in COPD Patients with Hypercapnic Respiratory Failure: Treatment Algorithm & Review of the Literature. COPD 2020; 17:101-111. [PMID: 31965868 DOI: 10.1080/15412555.2020.1715361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Nasal high flow (NHF) therapy has recently gained attention as a new respiratory support system and is increasingly being utilized in every day clinical practice. Recent studies suggest that it may also be effective in patients with hypercapnia and suggest NHF as a possible alternative for patients who cannot tolerate standard noninvasive ventilation. The present review discusses the mechanisms of action that make NHF potentially suitable for chronic obstructive pulmonary disease (COPD) patients and evaluates the current evidence of NHF use for treatment of stable hypercapnic COPD patients as well as acute hypercapnic exacerbation of COPD. An algorithm is also proposed for the clinical application of NHF in patients with acute hypercapnic exacerbation of COPD, based on current literature.
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Affiliation(s)
- Ioannis Pantazopoulos
- Department of Emergency Medicine, University of Thessaly, School of Medicine, General Hospital of Larisa, Thessaly, Greece
| | - Zoi Daniil
- Department of Respiratory Medicine, University of Thessaly, School of Medicine, General Hospital of Larisa, Thessaly, Greece
| | - Melanie Moylan
- Department of Biostatistics and Epidemiology, Auckland University of Technology, Auckland, New Zealand
| | - Konstantinos Gourgoulianis
- Department of Emergency Medicine, University of Thessaly, School of Medicine, General Hospital of Larisa, Thessaly, Greece
| | - Athanasios Chalkias
- Department of Anesthesiology, University of Thessaly, School of Medicine, General Hospital of Larisa, Thessaly, Greece
| | - Spyros Zakynthinos
- First Department of Critical Care Medicine & Pulmonary Services, Medical School, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - Eleni Ischaki
- First Department of Critical Care Medicine & Pulmonary Services, Medical School, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
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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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Blais CM, Davis BE, Graham BL, Cockcroft DW. Respiratory Duty Cycles in Individuals With and Without Airway Hyperresponsiveness. Chest 2019; 157:356-362. [PMID: 31542451 DOI: 10.1016/j.chest.2019.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/17/2019] [Accepted: 09/08/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The respiratory duty cycle (Ti/Ttot) can influence bronchoprovocation test results and nebulized drug delivery. The Ti/Ttot has not yet been examined in individuals with airway hyperresponsiveness (AHR) in typical bronchoprovocation test conditions. This study investigated the mean Ti/Ttot in participants with and without AHR and whether the Ti/Ttot changes with increasing bronchoconstriction. METHODS Fifteen participants with AHR and fifteen participants without AHR completed this randomized crossover study. An ultrasonic spirometer was used for continuous measurement of the Ti/Ttot as participants inhaled room air or aerosolized solution. Each participant completed two methacholine challenges, one using a continuous-output vibrating mesh nebulizer/ultrasonic spirometer and one with the nebulizer only. Prior to each methacholine challenge, participants inhaled room air and aerosolized saline through the nebulizer/spirometer setup to record baseline Ti/Ttot data. RESULTS The mean Ti/Ttot findings [95% CIs] during room air inhalation were 0.392 [0.378-0.406] and 0.447 [0.426-0.468] in participants with and without AHR, respectively (P < .001). The mean Ti/Ttot during saline inhalation were 0.389 [0.373-0.405] and 0.424 [0.398-0.450] in participants with and without AHR (P = .040). The Ti/Ttot showed a nonsignificant downward trend with progressive methacholine-induced bronchoconstriction. CONCLUSIONS The mean Ti/Ttot in participants with AHR closely resembles the assumed Ti/Ttot of 0.40 recommended for standard use when calculating methacholine challenge results. Since the Ti/Ttot did not change significantly over the course of a methacholine challenge, the same Ti/Ttot can be used to calculate the dose of methacholine inhaled, regardless of the level of bronchoconstriction. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03505489; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Christianne M Blais
- Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Beth E Davis
- Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Brian L Graham
- Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Donald W Cockcroft
- Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.
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Chang KH, Moon SH, Oh JY, Yoon YS, Gu N, Lim CY, Park BJ, Nam KC. Comparison of Salbutamol Delivery Efficiency for Jet versus Mesh Nebulizer Using Mice. Pharmaceutics 2019; 11:pharmaceutics11040192. [PMID: 31010218 PMCID: PMC6523426 DOI: 10.3390/pharmaceutics11040192] [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: 02/12/2019] [Revised: 04/11/2019] [Accepted: 04/17/2019] [Indexed: 11/16/2022] Open
Abstract
Recent reports using a breathing simulator system have suggested that mesh nebulizers provide more effective medication delivery than jet nebulizers. In this study, the performances of jet and mesh nebulizers were evaluated by comparing their aerosol drug delivery efficiencies in mice. We compared four home nebulizers: two jet nebulizers (PARI BOY SX with red and blue nozzles), a static mesh nebulizer (NE-U22), and a vibrating mesh nebulizer (NE-SM1). After mice were exposed to salbutamol aerosol, the levels of salbutamol in serum and lung were estimated by ELISA. The residual volume of salbutamol was the largest at 34.6% in PARI BOY SX, while the values for NE-U22 and NE-SM1 mesh nebulizers were each less than 1%. The salbutamol delivery efficiencies of NE-U22 and NE-SM1 were higher than that of PARI BOY SX, as the total delivered amounts of lung and serum were 39.9% and 141.7% as compared to PARI BOY SX, respectively. The delivery efficiency of the mesh nebulizer was better than that of the jet nebulizer. Although the jet nebulizer can generate smaller aerosol particles than the mesh nebulizer used in this study, the output rate of the jet nebulizer is low, resulting in lower salbutamol delivery efficiency. Therefore, clinical validation of the drug delivery efficiency according to nebulizer type is necessary to avoid overdose and reduced drug wastage.
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Affiliation(s)
- Kyung Hwa Chang
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Sang-Hyub Moon
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Jin Young Oh
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Young-Soon Yoon
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Namyi Gu
- Department of Clinical Pharmacology and Therapeutics, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Chi-Yeon Lim
- Department of Biostatistics, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Bong Joo Park
- Department of Electrical Biological Physics and Institute of Biomaterials, Kwangwoon University, Seoul 01897, Korea.
| | - Ki Chang Nam
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea.
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Reychler G, Michotte JB. Development challenges and opportunities in aerosol drug delivery systems in non-invasive ventilation in adults. Expert Opin Drug Deliv 2019; 16:153-162. [DOI: 10.1080/17425247.2019.1572111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Gregory Reychler
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL & Dermatologie, Université Catholique de Louvain, Bruxelles, Belgium
- Service de Pneumologie, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Jean-Bernard Michotte
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL & Dermatologie, Université Catholique de Louvain, Bruxelles, Belgium
- Filière Physiothérapie, School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
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Aerosol Delivery to a Critically Ill Patient: A Big Issue Easily Solved by Developing Guidelines. Pulm Ther 2018; 4:125-133. [PMID: 32026391 PMCID: PMC6967039 DOI: 10.1007/s41030-018-0060-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Indexed: 11/26/2022] Open
Abstract
Nowadays, therapeutic aerosols are commonly delivered to mechanically ventilated patients by nebulizers and pressurized metered dose inhaler attached to an adapter or a spacer. Studies with asthmatics and chronic obstructive pulmonary disease patients have confirmed that aerosol delivery during mechanical ventilation is feasible. They have also reported that the inhaled drugs administered during mechanical ventilation provide greater and faster clinical outcomes than when delivering during spontaneous unassisted breathing. Researchers studied factors that would affect aerosol delivery during mechanical ventilation. Even with the tremendous amount of publications in this area, there have still been no recommendations or guidelines released to help respiratory therapists in their decision as to when to deliver aerosol to ventilated patients. Mostly, respiratory therapists read the literature and decide accordingly what to do and which device to use for their patients. This puts the patients at risk of receiving a sub-therapeutic or toxic dose of the inhaled aerosol. Some studies raise an alarm of physician decision upon reading any released publication related to aerosol delivery in mechanical ventilation without a trusted recommendation and guidelines. This increases the need for the development of recommendations and guidelines, by a trusted board or society, for aerosol delivery to such critically ill patients. To summarize, inhaled drugs administered to critically ill patients is of benefit compared to taking the patient off the ventilator and delivering during spontaneous unassisted breathing. However, dependable guidelines are needed to optimize aerosol delivery.
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Inhalation Techniques Used in Patients with Respiratory Failure Treated with Noninvasive Mechanical Ventilation. Can Respir J 2018; 2018:8959370. [PMID: 29973963 PMCID: PMC6008820 DOI: 10.1155/2018/8959370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/02/2018] [Indexed: 11/18/2022] Open
Abstract
The administration of aerosolized medication is a basic therapy for patients with numerous respiratory tract diseases, including obstructive airway diseases (OADs), cystic fibrosis (CF), and infectious airway diseases. The management and care for patients requiring mechanical ventilation remains one of the greatest challenges for medical practitioners, both in intensive care units (ICUs) and pulmonology wards. Aerosol therapy is often necessary for patients receiving noninvasive ventilation (NIV), which may be stopped for the time of drug delivery and administered through a metered-dose inhaler or nebulizer in the traditional way. However, in most severe cases, this may result in rapid deterioration of the patient's clinical condition. Unfortunately, only limited number of original well-planned studies addressed this problem. Due to inconsistent information coming from small studies, there is a need for more precise data coming from large prospective real life studies on inhalation techniques in patients receiving NIV.
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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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Peng Y, Dai B, Hu CX, Su J, Tan W, Zhao HW, Kang J. Which Nebulizer Position Should Be Avoided? An Extended Study of Aerosol Delivery and Ventilator Performance during Noninvasive Positive Pressure Ventilation. Respiration 2017; 95:145-153. [DOI: 10.1159/000481868] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/26/2017] [Indexed: 11/19/2022] Open
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Harb HS, Elberry AA, Rabea H, Fathy M, Abdelrahim ME. Is Combihaler usable for aerosol delivery in single limb non-invasive mechanical ventilation? J Drug Deliv Sci Technol 2017. [DOI: 10.1016/j.jddst.2017.05.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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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25
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ElHansy MHE, Boules ME, El Essawy AFM, Al-Kholy MB, Abdelrahman MM, Said ASA, Hussein RRS, Abdelrahim ME. Inhaled salbutamol dose delivered by jet nebulizer, vibrating mesh nebulizer and metered dose inhaler with spacer during invasive mechanical ventilation. Pulm Pharmacol Ther 2017. [PMID: 28627376 DOI: 10.1016/j.pupt.2017.06.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patient receiving invasive mechanical ventilation (IMV) may benefit from medical aerosol, but guidance on dosing with different aerosol devices is limited to in-vitro studies. The study was designed to compare aerosol delivery with five different types of aerosol generators during IMV. METHOD In randomized design, 60 (30 female) mechanically ventilated chronic obstructive pulmonary disease (COPD) patients were assigned to one of 5 groups. Groups 1-4 received 5000 μg salbutamol using Aerogen Pro (PRO), Aerogen Solo (SOLO), NIVO vibrating mesh and jet nebulizers (JN), respectively, while group 5 received 800 μg (8 puffs) of salbutamol via metered dose inhaler with AeroChamber-MV (MDI-AC). All devices were place in the inspiratory limb of ventilator downstream from humidifier which was switched off while delivery. Patients received the inhaled dose on day 1 and provided urine 30 post dosing. They also recived the same inhaled dose with a filter before the endotracheal tube on day 2. Amount of salbutamol excreted in urine 30 min post inhalation and the amount deposited on the filter from all the COPD patients were determined as indeces of pulmonary deposition and systemic absorption, respectively. RESULTS No significant difference was found between the 3 vibrating mesh nebulizers (VMNs). The in-vivo and ex-vivo testing showed that all the VMNs resulted in better aerosol delivery compared to JN (p < 0.01). However, MDI-AC resulted in better aerosol delivery to VMNs but must be accompanied with careful attention and proper delivery of MDI-AC doses by healthcare provider. CONCLUSIONS VMNs can be exchanged with each other, with no dose adjustment. However, dose adjustment is a must when replacing VMNs by JN or MDI-AC. This similarity and difference between the 5 aerosol delivery methods suggest that for IMV patients, aerosol delivery methods should be chosen or substituted with care.
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Affiliation(s)
- Muhammad H E ElHansy
- Clinical Pharmacy Department, Teaching Hospital of Faculty of Medicine, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Marina E Boules
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | | | | | - Maha M Abdelrahman
- Analytical Chemistry Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Amira S A Said
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Raghda R S Hussein
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed E Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt; Clinical Pharmacy Department, Faculty of Pharmacy, Ahram Canadian University, Giza, Egypt.
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Saeed H, Mohsen M, Fink JB, Dailey P, Salah Eldin A, Abdelrahman MM, Elberry AA, Rabea H, Hussein RR, Abdelrahim ME. Fill volume, humidification and heat effects on aerosol delivery and fugitive emissions during noninvasive ventilation. J Drug Deliv Sci Technol 2017. [DOI: 10.1016/j.jddst.2017.04.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
In the later half of the 20th century, nebulized therapy was in decline, but in the 21st century the prospects for the expanded use of nebulized therapy within respiratory medicine look bright. The advent of mesh nebulizers, which combine the universal applicability of the nebulizer in the treatment of all respiratory patients with the convenience of portable inhaler use, is ideally timed to capitalize on the forecast of increased numbers of patients who will require nebulized therapy in the future. This special report will highlight some of the opportunities that the development of mesh nebulizers presents in the field of respiratory medicine.
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Clinical outcome associated with the use of different inhalation method with and without humidification in asthmatic mechanically ventilated patients. Pulm Pharmacol Ther 2017; 45:40-46. [PMID: 28435031 DOI: 10.1016/j.pupt.2017.04.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/27/2017] [Accepted: 04/19/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Inhaled-medication delivered during mechanical-ventilation is affected by type of aerosol-generator and humidity-condition. Despite many in-vitro studies related to aerosol-delivery to mechanically-ventilated patients, little has been reported on clinical effects of these variables. The aim of this study was to determine effect of humidification and type of aerosol-generator on clinical status of mechanically ventilated asthmatics. METHOD 72 (36 females) asthmatic subjects receiving invasive mechanical ventilation were enrolled and assigned randomly to 6 treatment groups of 12 (6 females) subjects each received, as possible, all inhaled medication using their assigned aerosol generator and humidity condition during delivery. Aerosol-generators were placed immediately after humidifier within inspiratory limb of mechanical ventilation circuit. First group used vibrating-mesh-nebulizer (Aerogen Solo; VMN) with humidification; Second used VMN without humidification; Third used metered-dose-inhaler with AeroChamber Vent (MDI-AV) with humidification; Forth used MDI-AV without humidification; Fifth used Oxycare jet-nebulizer (JN) with humidification; Sixth used JN without humidification. Measured parameters included clinical-parameters reflected patient response (CP) and endpoint parameters e.g. length-of-stay in the intensive-care-unit (ICU-days) and mechanical-ventilation days (MV-days). RESULTS There was no significant difference between studied subjects in the 6 groups in baseline of CP. VMN resulted in trend to shorter ICU-days (∼1.42days) compared to MDI-AV (p = 0.39) and relatively but not significantly shorter ICU-days (∼0.75days) compared JN. Aerosol-delivery with or without humidification did not have any significant effect on any of parameters studied with very light insignificant tendency of delivery at humid condition to decrease MV-days and ICU-days. No significant effect was found of changing humidity during aerosol-delivery to ventilated-patient. CONCLUSIONS VMN to deliver aerosol in ventilated patient resulted in trend to decreased ICU-days compared to JN and MDI-AV. Aerosol-delivery with or without humidification did not have any significant effect on any of parameters studied. However, we recommend increasing the number of patients studied to corroborate this finding.
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Hassan A, Salah Eldin R, Abdelrahman MM, Abdelrahim ME. In-vitro/in-vivo comparison of inhaled salbutamol dose delivered by jet nebulizer, vibrating mesh nebulizer and metered dose inhaler with spacer during non-invasive ventilation. Exp Lung Res 2017; 43:19-28. [PMID: 28394653 DOI: 10.1080/01902148.2017.1282993] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patients receiving noninvasive ventilation (NIV) may benefit from medical aerosol, but most guidance on dosing with different aerosol devices is limited to in-vitro studies. The study was designed to in-vitro, ex-vivo, and in-vivo compare aerosol delivery during bilevel NIV with three types of aerosol generators: metered dose inhaler with AeroChamber-MV spacer (AC), Aerogen Pro vibrating mesh nebulizer (PRO), and Sidestream jet nebulizer (SIDE). MATERIALS AND METHOD A bilevel ventilator with dry single limb circuit and fixed expiratory port was set in spontaneous mode with initial inspiratory and expiratory pressures of 20 and 5 cmH20, 1:3 inspiratory-expiratory ratio, and 15 breaths.min-1. Aerosol generators were placed proximal to facial mask of NIV chronic obstructive pulmonary disease (COPD) patients. 1 mL salbutamol nebulizer solution (5 mg/mL) was nebulized using PRO and SIDE. 12MDI doses, containing 100μg salbutamol each, were delivered using AC. In-vitro aerosol fate and aerodynamic droplet characteristics, in-vivo amount of salbutamol excreted 30 mins and pooled up to 24 h post inhalation in urine from 12 COPD patients (as indices of pulmonary deposition and systemic absorption, respectively) and amount of salbutamol deposited on ex-vivo filters (expected inhalable amount) was determined. RESULTS The in-vitro, in-vivo and ex-vivo testing showed that PRO had better aerosol delivery compared to SIDE (p < 0.01). However, with smaller nominal dose MDI with AC resulted in similar aerosol delivery to PRO suggesting better aerosol delivery stress on careful attention and proper delivery by health care provider. CONCLUSIONS These similarities and differences between the three aerosol generators tested suggest that aerosol delivery methods should be carefully chosen or substituted in non-invasive ventilated patients.
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Affiliation(s)
- Ahmed Hassan
- a Hospital Pharmacy Department , Beba General Hospital , Beni-suef , Egypt
| | - Randa Salah Eldin
- b Respiratory Department , Faculty of Medicine, Beni-suef University , Beni-suef , Egypt
| | - Maha M Abdelrahman
- c Analytical Chemistry Department , Faculty of Pharmacy, Beni-suef University , Beni-suef , Egypt
| | - Mohamed E Abdelrahim
- d Clinical Pharmacy Department , Faculty of Pharmacy, Beni-suef University , Beni-suef , Egypt.,e Clinical Pharmacy Department , Faculty of Pharmacy, Ahram Canadian University , Giza , Egypt
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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: 62] [Impact Index Per Article: 7.8] [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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Yano T, Yonaha T, Hidaka K, Nagahama M, Koshida T, Matsuoka H, Taniguchi M, Tsuneyoshi I. A case of severe acute exacerbation of Yokkaichi asthma treated with a vibrating mesh nebulizer. Respir Med Case Rep 2016; 19:83-5. [PMID: 27547723 PMCID: PMC4982920 DOI: 10.1016/j.rmcr.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 08/02/2016] [Accepted: 08/02/2016] [Indexed: 11/27/2022] Open
Abstract
Yokkaichi asthma was one of the most common environmental pollution diseases in Japan in the 1960s and 1970s. The problem of air pollution in Yokkaichi was solved in the 1970s. However, mortality and life expectancy were still affected by the late effects of air pollution in patients with Yokkaichi asthma even in the 2000s. In this case report, we described the experience of successful treatment of a patient with severe asthmatic status due to Yokkaichi asthma. A 40s-year-old man, who was officially certified as a patient with Yokkaichi asthma from his infancy, was admitted to hospital due to acute exacerbation of asthma. Mechanical ventilation, intravenous administration of aminophylline and dexamethasone, enteral administration of montelukast, and a transdermal patch of tulobuterol were started. However, because of the lack of improvement in clinical status, inhalation of procaterol using vibrating mesh nebulizer systems was started. Inhalation of procaterol was used three times a day. After using the vibrating mesh nebulizer, respiratory system compliance and hypercapnia rapidly improved. Bilateral expiratory wheezing was diminished. Weaning from mechanical ventilation was initiated, and on the eighth day of mechanical ventilation, the patient was extubated. Although intractable respiratory failure with decreased respiratory system compliance resulting from the late effects of air pollution and a long-time asthmatic inflammatory condition was observed, the use of a vibrating mesh nebulizer for the inhaled administration of procaterol was useful to relieve severe bronchospasm due to Yokkaichi asthma.
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Affiliation(s)
- Takeshi Yano
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Miyazaki, Miyazaki 889-1692, Japan
| | - Tetsu Yonaha
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Miyazaki, Miyazaki 889-1692, Japan
| | - Koutaro Hidaka
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Miyazaki, Miyazaki 889-1692, Japan
| | - Masumi Nagahama
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Miyazaki, Miyazaki 889-1692, Japan
| | - Tomohiro Koshida
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Miyazaki, Miyazaki 889-1692, Japan
| | - Hiroshi Matsuoka
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Miyazaki, Miyazaki 889-1692, Japan
| | - Masahiko Taniguchi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Miyazaki, Miyazaki 889-1692, Japan
| | - Isao Tsuneyoshi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Miyazaki, Miyazaki 889-1692, Japan
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Michotte JB, Staderini E, Le Pennec D, Dugernier J, Rusu R, Roeseler J, Vecellio L, Liistro G, Reychler G. In Vitro Comparison of a Vibrating Mesh Nebulizer Operating in Inspiratory Synchronized and Continuous Nebulization Modes During Noninvasive Ventilation. J Aerosol Med Pulm Drug Deliv 2016; 29:328-36. [PMID: 27310926 DOI: 10.1089/jamp.2015.1243] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Backround: Coupling nebulization with noninvasive ventilation (NIV) has been shown to be effective in patients with respiratory diseases. However, a breath-synchronized nebulization option that could potentially improve drug delivery by limiting drug loss during exhalation is currently not available on bilevel ventilators. The aim of this in vitro study was to compare aerosol delivery of amikacin 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. METHODS Using an adult lung bench model of NIV, we tested a vibrating mesh device coupled with a bilevel ventilator in both nebulization modes. Inspi-Neb delivered aerosol only during the whole inspiratory phase, whereas Conti-Neb delivered aerosol continuously. The nebulizer was charged with amikacin solution (250 mg/3 mL) and placed at two different positions: between the lung and exhalation port and between the ventilator and exhalation port. Inhaled, expiratory wasted and circuit lost doses were assessed by residual gravimetric method. Particle size distribution of aerosol delivered at the outlet of the ventilator circuit during both nebulization modes was measured by laser diffraction method. RESULTS Regardless of the nebulizer position, Inspi-Neb produced higher inhaled dose (p < 0.01; +6.3% to +16.8% of the nominal dose), lower expiratory wasted dose (p < 0.05; -2.7% to -42.6% of the nominal dose), and greater respirable dose (p < 0.01; +8.4% to +15.2% of the nominal dose) than Conti-Neb. The highest respirable dose was found with the nebulizer placed between the lung and exhalation port (48.7% ± 0.3% of the nominal dose). CONCLUSIONS During simulated NIV with a single-limb circuit bilevel ventilator, the use of inspiratory synchronized vibrating mesh nebulization improves respirable dose and reduces drug loss of amikacin compared with 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 , Filière Physiothérapie, Switzerland .,6 Cliniques Universitaires Saint-Luc, Service de Pneumologie; Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC) , Pôle de Pneumologie, ORL & Dermatologie, Belgium
| | - Enrico Staderini
- 2 Western Switzerland University of Applied Sciences-Haute Ecole d'Ingénierie et de Gestion du Canton de Vaud , Switzerland
| | - Deborah Le Pennec
- 3 Centre d'Etude des Pathologies Respiratoires, INSERM, UMR 1100, Equipe "aérosolthérapie et biomédicaments à visée respiratoire," Université de Tours , Faculté de Médecine, France
| | - Jonathan Dugernier
- 4 Cliniques Universitaires Saint-Luc , Service des soins intensifs, Belgium
| | - Rares Rusu
- 2 Western Switzerland University of Applied Sciences-Haute Ecole d'Ingénierie et de Gestion du Canton de Vaud , Switzerland
| | - Jean Roeseler
- 4 Cliniques Universitaires Saint-Luc , Service des soins intensifs, Belgium
| | - Laurent Vecellio
- 3 Centre d'Etude des Pathologies Respiratoires, INSERM, UMR 1100, Equipe "aérosolthérapie et biomédicaments à visée respiratoire," Université de Tours , Faculté de Médecine, France .,5 Aerodrug, DTF, Faculty of Medicine, Tours University , France
| | - 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, Belgium
| | - Grégory 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, Belgium
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Ari A, Fink JB. Differential Medical Aerosol Device and Interface Selection in Patients during Spontaneous, Conventional Mechanical and Noninvasive Ventilation. J Aerosol Med Pulm Drug Deliv 2016; 29:95-106. [DOI: 10.1089/jamp.2015.1266] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Arzu Ari
- Division of Respiratory Therapy, Georgia State University, Atlanta, Georgia
| | - James B. Fink
- Division of Respiratory Therapy, Georgia State University, Atlanta, Georgia
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Réminiac F, Bodet-Contentin L, Vecellio L, Dequin PF, Ehrmann S. Aérosolthérapie au cours de l’assistance respiratoire non invasive. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1158-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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35
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Inhaled Drug Delivery for Children on Long-term Mechanical Ventilation. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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36
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In-Vitro Characterization of the Aerosolized Dose During Non-Invasive Automatic Continuous Positive Airway Pressure Ventilation. Pulm Ther 2015. [DOI: 10.1007/s41030-015-0010-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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37
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Schulzke SM, Deshmukh M, Nathan EA, Doherty DA, Patole SK. Nebulized pentoxifylline for reducing the duration of oxygen supplementation in extremely preterm neonates. J Pediatr 2015; 166:1158-1162.e2. [PMID: 25748566 DOI: 10.1016/j.jpeds.2015.01.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/15/2014] [Accepted: 01/22/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of nebulized pentoxifylline for reducing the duration of oxygen supplementation in extremely preterm neonates at high risk of bronchopulmonary dysplasia (BPD). STUDY DESIGN Single-center, randomized, double-blind, placebo-controlled trial was conducted. Infants of 23(0) to 27(6) weeks' gestational age requiring mechanical ventilation or ≥30% supplemental oxygen on continuous positive airway pressure at 72-168 hours were randomized to receive 20 mg/kg (1 mL/kg) nebulized pentoxifylline or an equal volume of normal saline placebo every 6 hours for 10 consecutive days via a vibrating mesh nebulizer. The primary outcome was the duration of oxygen supplementation at 40 weeks' postmenstrual age. We used Cox proportional hazards regression modeling to analyze outcomes. RESULTS All infants had adequate data for analysis of the primary outcome. Intention-to-treat analysis revealed no differences in duration of oxygen supplementation at 40 weeks' postmenstrual age between pentoxifylline (n=41) and placebo (n=40) groups (median 2262 vs 2160 hours, adjusted hazard ratio: 1.14, 95% CI 0.72-1.80, P=.63). There was no difference in mortality and further secondary outcomes. No adverse effects were noted. CONCLUSIONS Nebulized pentoxifylline is safe but did not reduce the duration of oxygen supplementation in extremely preterm infants at high risk of BPD. Dose-ranging studies and large, well-designed clinical trials are required to determine whether the use of nebulized or systemic pentoxifylline as a prophylactic therapy offers small but relevant benefits for prevention of BPD. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12611000145909.
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Affiliation(s)
- Sven M Schulzke
- Centre for Neonatal Research and Education, The University of Western Australia, Crawley, Australia; University Children's Hospital Basel (UKBB), Basel, Switzerland.
| | - Mangesh Deshmukh
- Centre for Neonatal Research and Education, The University of Western Australia, Crawley, Australia; Neonatal Clinical Care Unit, King Edward Memorial Hospital for Women, Subiaco, Australia
| | | | | | - Sanjay K Patole
- Centre for Neonatal Research and Education, The University of Western Australia, Crawley, Australia; Neonatal Clinical Care Unit, King Edward Memorial Hospital for Women, Subiaco, Australia
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