1
|
Stanford G, Morrison L, Brown C. Nebuliser systems for drug delivery in cystic fibrosis. Cochrane Database Syst Rev 2023; 11:CD007639. [PMID: 37942828 PMCID: PMC10633867 DOI: 10.1002/14651858.cd007639.pub3] [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] [Indexed: 11/10/2023]
Abstract
BACKGROUND Nebuliser systems are used to deliver medications to the lungs, to control the symptoms and the progression of lung disease in people with cystic fibrosis (CF). There are many different nebulised-medications prescribed for people with CF and there are many different types of nebuliser systems. Some of these nebulised medications are licenced for, and can be taken via only one type of nebuliser system; some are licensed for, and can be taken via more than one type of nebuliser system. This is an update to a previous systematic review. OBJECTIVES To assess the time efficiency, effectiveness, safety, cost and impact of use (e.g. burden of care, adherence, quality of life (QoL)) of different nebuliser systems, when used with different inhaled medications for people with CF. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books containing conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. We also searched online trial registries. Date of the most recent search: 9 August 2023. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs comparing nebuliser systems, including conventional nebulisers, vibrating mesh technology (VMT) systems, adaptive aerosol delivery (AAD) systems and ultrasonic nebuliser systems. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third review author assessed studies where agreement could not be reached. They assessed the certainty of the evidence using GRADE. MAIN RESULTS The search identified 216 studies with 33 of these (2270 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic saline and other solutions through the different nebuliser systems in children and adults with CF. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. The certainty of the evidence ranged from low to very low. Some conventional nebuliser systems providing higher flows, higher respirable fractions, and smaller particles decrease treatment time, increase deposition (the amount of drug reaching the lung), and may be preferred by people with CF, as compared to other conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Newer nebuliser systems using AAD, or VMT (or both) reduce treatment time compared to conventional systems. Deposition (as a percentage of priming dose) with AAD is greater than with conventional systems. VMT systems may give greater deposition than conventional systems when measuring sputum levels. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved and that individuals prefer AAD or VMT systems, but also that some nebuliser systems using VMT may be subject to increased system failures. There is limited, unclear evidence on the impact of different nebuliser systems on lung function and a lack of data on the impact of different nebuliser systems on our outcomes of quality of life (QoL), adverse effects, respiratory exacerbations and related implications, adherence, satisfaction, cost and device reliability. AUTHORS' CONCLUSIONS Newer technologies e.g. AAD and VMT have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, preference and adherence. Data are lacking for all varieties of medications which are used in CF care, including different inhaled antibiotics or hypertonic saline, with all delivery (nebuliser system) possibilities. Long-term RCTs are needed to evaluate different nebuliser systems to determine patient-focused outcomes (such as QoL and burden of care), safe and effective dosing levels of a wide variety of medications, clinical outcomes (such as hospitalisations and need for antibiotics), and an economic evaluation of their use. There are insufficient data to establish whether one nebuliser system is better than another overall. Clinicians should be aware of the variability in the performance of different nebuliser systems, compatibility with specific nebulised medication, and they must work with their patients to choose the best nebuliser system for each individual. This is likely to be an ongoing process as the needs and circumstances of each individual change over time.
Collapse
Affiliation(s)
- Gemma Stanford
- Department of Adult Cystic Fibrosis, Royal Brompton Hospital, Guys and St Thomas's NHS Foundation Trust, London, UK
| | - Lisa Morrison
- West of Scotland Adult CF Unit, Queen Elizabeth University Hospital (The Southern General Hospital), Glasgow, UK
| | | |
Collapse
|
2
|
Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis. Antibiotics (Basel) 2021; 10:antibiotics10050472. [PMID: 33919035 PMCID: PMC8142975 DOI: 10.3390/antibiotics10050472] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 12/18/2022] Open
Abstract
Lung disease is the main cause of morbidity and mortality in cystic fibrosis (CF). CF patients inhale antibiotics regularly as treatment against persistent bacterial infections. The goal of this study was to investigate the effect of clinical intervention on aerosol therapy during the escalation of care using a bench model of adult CF. Droplet size analysis of selected antibiotics was completed in tandem with the delivered aerosol dose (% of total dose) assessments in simulations of various interventions providing oxygen supplementation or ventilatory support. Results highlight the variability of aerosolised dose delivery. In the homecare setting, the vibrating mesh nebuliser (VMN) delivered significantly more than the jet nebuliser (JN) (16.15 ± 0.86% versus 6.51 ± 2.15%). In the hospital setting, using VMN only, significant variability was seen across clinical interventions. In the emergency department, VMN plus mouthpiece (no supplemental oxygen) was seen to deliver (29.02 ± 1.41%) versus low flow nasal therapy (10 L per minute (LPM) oxygen) (1.81 ± 0.47%) and high flow nasal therapy (50 LPM oxygen) (3.36 ± 0.34%). In the ward/intensive care unit, non-invasive ventilation recorded 19.02 ± 0.28%, versus 22.64 ± 1.88% of the dose delivered during invasive mechanical ventilation. These results will have application in the design of intervention-appropriate aerosol therapy strategies and will be of use to researchers developing new therapeutics for application in cystic fibrosis and beyond.
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Corcoran TE. Measurements of deposited aerosol dose in infants and small children. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:595. [PMID: 33987293 PMCID: PMC8105848 DOI: 10.21037/atm-20-2045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/19/2020] [Indexed: 11/06/2022]
Abstract
Pediatric patients are very dependent on inhaled aerosol medications. There are significant differences in how these aerosols deposit in the lungs of children vs. adults that may affect the efficacy of the therapies. Inefficient aerosol delivery to children, caused by factors such as high mouth and throat deposition during oral inhalation, significant losses within adjunct devices such as masks, and high rates of nasal deposition during cannula delivery, can lead to dosing that is difficult to control. Here we discuss the methods, such as deposition scintigraphy, that are used to assess inhaled dose in vivo and review previous studies where these techniques have been applied to measure dosing in children. This includes studies of nebulizers and metered dose inhalers and delivery through adjuncts such as facemasks and nasal cannulas. We discuss the factors that can lead to inefficient inhaled drug delivery and high levels of mouth and throat deposition in children. Finally, we propose areas of innovation to improve inhaled drug delivery to this population. There is a need for child-specific technologies for inhaled drug delivery. This includes the use of smart devices that can guide pediatric breathing patterns and better engage children during treatments, the use of smaller aerosols which are less likely to deposit in the upper airways after inhalation, and the design of better nasal cannula interfaces for aerosol delivery to infants.
Collapse
Affiliation(s)
- Timothy E Corcoran
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
5
|
Häussermann S, Sommerer K, Scheuch G. Regional Lung Deposition: In Vivo Data. J Aerosol Med Pulm Drug Deliv 2020; 33:291-299. [PMID: 33021414 DOI: 10.1089/jamp.2020.29032.sh] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The method section of this chapter on in vivo regional lung deposition highlights a nonradioactive method to measure regional deposition, which uses a photometer to quantify inhaled and exhaled particles and in that way is able to estimate the lung region from which the particles are exhaled and to what amount. The radioactive methods cover the measurement of clearance of the deposited particles as well as different imaging techniques to determine regional deposition. The result section reviews in vivo trials in human subjects. It also addresses different parameters that influence the regional deposition in the lungs: particle size, inhalation maneuver, carrier gas, disease, and inhalation device. All of these factors can affect regional deposition significantly. By choosing specific values of these parameters, it should be feasible to target different regions of the lungs for the therapy of different diseases.
Collapse
|
6
|
Atag E, Krivec U, Ersu R. Non-invasive Ventilation for Children With Chronic Lung Disease. Front Pediatr 2020; 8:561639. [PMID: 33262959 PMCID: PMC7687222 DOI: 10.3389/fped.2020.561639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/13/2020] [Indexed: 11/24/2022] Open
Abstract
Advances in medical care and supportive care options have contributed to the survival of children with complex disorders, including children with chronic lung disease. By delivering a positive pressure or a volume during the patient's inspiration, NIV is able to reverse nocturnal alveolar hypoventilation in patients who experience hypoventilation during sleep, such as patients with chronic lung disease. Bronchopulmonary dysplasia (BPD) is a common complication of prematurity, and despite significant advances in neonatal care over recent decades its incidence has not diminished. Most affected infants have mild disease and require a short period of oxygen supplementation or respiratory support. However, severely affected infants can become dependent on positive pressure support for a prolonged period. In case of established severe BPD, respiratory support with non-invasive or invasive positive pressure ventilation is required. Patients with cystic fibrosis (CF) and advanced lung disease develop hypoxaemia and hypercapnia during sleep and hypoventilation during sleep usually predates daytime hypercapnia. Hypoxaemia and hypercapnia indicates poor prognosis and prompts referral for lung transplantation. The prevention of respiratory failure during sleep in CF may prolong survival. Long-term oxygen therapy has not been shown to improve survival in people with CF. A Cochrane review on the use NIV in CF concluded that NIV in combination with oxygen therapy improves gas exchange during sleep to a greater extent than oxygen therapy alone in people with moderate to severe CF lung disease. Uncontrolled, non-randomized studies suggest survival benefit with NIV in addition to being an effective bridge to transplantation. Complications of NIV relate mainly to prolonged use of a face or nasal mask which can lead to skin trauma, and neurodevelopmental delay by acting as a physical barrier to social interaction. Another associated risk is pulmonary aspiration caused by vomiting whilst wearing a face mask. Adherence to NIV is one of the major barriers to treatment in children. This article will review the current evidence for indications, adverse effects and long term follow up including adherence to NIV in children with chronic lung disease.
Collapse
Affiliation(s)
- Emine Atag
- Division of Pediatric Pulmonology, Medipol University, Istanbul, Turkey
| | - Uros Krivec
- Division of Pediatric Pulmonology, University Children's Hospital, University Medical Centre, Ljubljana, Slovenia
| | - Refika Ersu
- Division of Pediatric Respirology, Children's Hospital of Ontario, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
7
|
Dentice RL, Elkins MR, Verschuer J, Eberl S, Dwyer G, Bye PTP. Side lying during nebulisation can significantly improve apical deposition in healthy adults and adults with mild cystic fibrosis lung disease: a randomised crossover trial. BMC Pulm Med 2019; 19:128. [PMID: 31311524 PMCID: PMC6636004 DOI: 10.1186/s12890-019-0886-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/25/2019] [Indexed: 11/17/2022] Open
Abstract
Background In people with and without Cystic Fibrosis (CF), does side lying during nebulisation change: the proportion of the dose loaded in the nebuliser that is deposited in the lungs; the uniformity of deposition throughout the lungs; or the apical drug density as a percentage of the drug density in the remaining lung? Do these effects differ depending on the degree of lung disease present? Methods A randomised crossover trial with concealed allocation, intention-to-treat analysis and blinded assessors, involving 39 adults: 13 healthy, 13 with mild CF lung disease (FEV1 > 80%pred), and 13 with more advanced CF lung disease (FEV1 < 80%pred). In random order, 4 mL of nebulised radioaerosol was inhaled in upright sitting and in alternate right and left side lying at 2-min intervals, for 20 min. Results Compared to sitting upright, lung deposition and the uniformity of deposition were not significantly altered by side lying in any of the three groups. In sitting, the density of the deposition was significantly less in the apical regions than in the rest of the lung in all participants. Side lying significantly improved apical deposition in healthy adults (MD, 13%; 95% CI, 7 to 19), and in minimal CF lung disease (MD, 4%; 95% CI, 1 to 7) but not in advanced disease (MD, 4%; 95% CI, − 2 to 9). Conclusion Alternating between right and left side lying during nebulisation significantly improves apical deposition in healthy adults and in adults with mild CF lung disease, without substantial detriment to overall deposition. Trial registration ACTRN12611000674932 (Healthy), ACTRN12611000672954 (CF) Retrospectively registered 4/7/2011. Electronic supplementary material The online version of this article (10.1186/s12890-019-0886-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ruth L Dentice
- Physiotherapy Department, Royal Prince Alfred Hospital, Sydney, Australia.
| | - Mark R Elkins
- Centre for Education & Workforce Development, Sydney Local Health District, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Jordan Verschuer
- Department of Molecular Imaging, Royal Prince Alfred Hospital, Sydney, Australia
| | - Stefan Eberl
- Department of Molecular Imaging, Royal Prince Alfred Hospital, Sydney, Australia
| | - Genevieve Dwyer
- Physiotherapy Program, Western Sydney University, Sydney, Australia.
| | - Peter T P Bye
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| |
Collapse
|
8
|
Bodet-Contentin L, Guillon A, Boulain T, Frat JP, Garot D, Le Pennec D, Vecellio L, Ehrmann S, Giraudeau B, Tavernier E, Dequin PF. Salbutamol Nebulization During Noninvasive Ventilation in Exacerbated Chronic Obstructive Pulmonary Disease Patients: A Randomized Controlled Trial. J Aerosol Med Pulm Drug Deliv 2019; 32:149-155. [DOI: 10.1089/jamp.2018.1484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Antoine Guillon
- Université de Tours, Tours, France
- Médecine Intensive-Réanimation, CHRU Tours, Tours, France
- INSERM, Centre d'Étude des Pathologies Respiratoires, U1100, Tours, France
| | | | | | - Denis Garot
- Médecine Intensive-Réanimation, CHRU Tours, Tours, France
| | - Deborah Le Pennec
- Université de Tours, Tours, France
- INSERM, Centre d'Étude des Pathologies Respiratoires, U1100, Tours, France
| | - Laurent Vecellio
- Université de Tours, Tours, France
- INSERM, Centre d'Étude des Pathologies Respiratoires, U1100, Tours, France
| | - Stephan Ehrmann
- Université de Tours, Tours, France
- Médecine Intensive-Réanimation, CHRU Tours, Tours, France
- INSERM, Centre d'Étude des Pathologies Respiratoires, U1100, Tours, France
| | - Bruno Giraudeau
- Centre d'Investigation Clinique Inserm CIC 1415, Tours, France
| | - Elsa Tavernier
- Centre d'Investigation Clinique Inserm CIC 1415, Tours, France
| | - Pierre-François Dequin
- Université de Tours, Tours, France
- Médecine Intensive-Réanimation, CHRU Tours, Tours, France
- INSERM, Centre d'Étude des Pathologies Respiratoires, U1100, Tours, France
| | | |
Collapse
|
9
|
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
| |
Collapse
|
10
|
Radioaerosol Imaging Predicts the Utility of Aerosolized Antifungal Therapy in Allergic Bronchopulmonary Aspergillosis. Clin Nucl Med 2018; 43:830-831. [PMID: 30199380 DOI: 10.1097/rlu.0000000000002264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 10-year-old girl with a history of complicated cystic fibrosis was hospitalized for pulmonary exacerbation with allergic bronchopulmonary aspergillosis and severe right upper lobe bronchiectasis diagnosed with chest radiograph and CT. She was started on itraconazole during the hospitalization in attempt to decrease her systemic steroid dose, but she had ongoing coughing and wheezing. The possibility was raised that the right upper lobe bronchiectasis may be a nidus for ongoing aspergillosis. Radioaerosol imaging was performed to determine whether the aerosolized antifungals would reach the area of bronchiectasis.
Collapse
|
11
|
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.
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Abstract
BACKGROUND Non-invasive ventilation may be a means to temporarily reverse or slow the progression of respiratory failure in cystic fibrosis by providing ventilatory support and avoiding tracheal intubation. Using non-invasive ventilation, in the appropriate situation or individuals, can improve lung mechanics through increasing airflow and gas exchange and decreasing the work of breathing. Non-invasive ventilation thus acts as an external respiratory muscle. This is an update of a previously published review. OBJECTIVES To compare the effect of non-invasive ventilation versus no non-invasive ventilation in people with cystic fibrosis for airway clearance, during sleep and during exercise. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We searched the reference lists of each trial for additional publications possibly containing other trials.Most recent search: 08 August 2016. SELECTION CRITERIA Randomised controlled trials comparing a form of pressure preset or volume preset non-invasive ventilation to no non-invasive ventilation used for airway clearance or during sleep or exercise in people with acute or chronic respiratory failure in cystic fibrosis. DATA COLLECTION AND ANALYSIS Three reviewers independently assessed trials for inclusion criteria and methodological quality, and extracted data. MAIN RESULTS Ten trials met the inclusion criteria with a total of 191 participants. Seven trials evaluated single treatment sessions, one evaluated a two-week intervention, one evaluated a six-week intervention and one a three-month intervention. It is only possible to blind trials of airway clearance and overnight ventilatory support to the outcome assessors. In most of the trials we judged there was an unclear risk of bias with regards to blinding due to inadequate descriptions. The six-week trial was the only one judged to have a low risk of bias for all other domains. One single intervention trial had a low risk of bias for the randomisation procedure with the remaining trials judged to have an unclear risk of bias. Most trials had a low risk of bias with regard to incomplete outcome data and selective reporting.Six trials (151 participants) evaluated non-invasive ventilation for airway clearance compared with an alternative chest physiotherapy method such as the active cycle of breathing techniques or positive expiratory pressure. Three trials used nasal masks, one used a nasal mask or mouthpiece and one trial used a face mask and in one trial it is unclear. Three of the trials reported on one of the review's primary outcome measures (quality of life). Results for the reviews secondary outcomes showed that airway clearance may be easier with non-invasive ventilation and people with cystic fibrosis may prefer it. We were unable to find any evidence that non-invasive ventilation increases sputum expectoration, but it did improve some lung function parameters.Three trials (27 participants) evaluated non-invasive ventilation for overnight ventilatory support compared to oxygen or room air using nasal masks (two trials) and nasal masks or full face masks (one trial). Trials reported on two of the review's primary outcomes (quality of life and symptoms of sleep-disordered breathing). Results for the reviews secondary outcome measures showed that they measured lung function, gas exchange, adherence to treatment and preference, and nocturnal transcutaneous carbon dioxide. Due to the small numbers of participants and statistical issues, there were discrepancies in the results between the RevMan and the original trial analyses. No clear differences were found between non-invasive ventilation compared with oxygen or room air except for exercise performance, which significantly improved with non-invasive ventilation compared to room air over six weeks.One trial (13 participants) evaluated non-invasive ventilation on exercise capacity (interface used was unclear) and did not reported on any of the review's primary outcomes. The trial found no clear differences between non-invasive ventilation compared to no non-invasive ventilation for any of our outcomes.Three trials reported on adverse effects. One trial, evaluating non-invasive ventilation for airway clearance, reported that a participant withdrew at the start of the trial due to pain on respiratory muscle testing. One trial evaluating non-invasive ventilation for overnight support reported that one participant could not tolerate an increase in inspiratory positive airway pressure. A second trial evaluating non-invasive ventilation in this setting reported that one participant did not tolerate the non-invasive ventilation mask, one participant developed a pneumothorax when breathing room air and two participants experienced aerophagia which resolved when inspiratory positive airway pressure was decreased. AUTHORS' CONCLUSIONS Non-invasive ventilation may be a useful adjunct to other airway clearance techniques, particularly in people with cystic fibrosis who have difficulty expectorating sputum. Non-invasive ventilation, used in addition to oxygen, may improve gas exchange during sleep to a greater extent than oxygen therapy alone in moderate to severe disease. The effect of NIV on exercise is unclear. These benefits of non-invasive ventilation have largely been demonstrated in single treatment sessions with small numbers of participants. The impact of this therapy on pulmonary exacerbations and disease progression remain unclear. There is a need for long-term randomised controlled trials which are adequately powered to determine the clinical effects of non-invasive ventilation in cystic fibrosis airway clearance and exercise.
Collapse
Affiliation(s)
- Fidelma Moran
- Ulster UniversityInstitute of Nursing and Health Research and School of Health SciencesShore RoadNewtownabbeyNorthern IrelandUKBT37 0QB
| | - Judy M Bradley
- Queen's University BelfastThe Wellcome Trust‐Wolfson Northern Ireland Clinical Research Facility U FloorBelfast City HospitalLisburn RoadBelfastNorthern IrelandUKBT9 7AB
| | - Amanda J Piper
- Royal Prince Alfred HospitalDepartment of Respiratory and Sleep MedicineMissenden RdCamperdownNSWAustralia2050
| | | |
Collapse
|
14
|
Walenga RL, Longest PW, Kaviratna A, Hindle M. Aerosol Drug Delivery During Noninvasive Positive Pressure Ventilation: Effects of Intersubject Variability and Excipient Enhanced Growth. J Aerosol Med Pulm Drug Deliv 2017; 30:190-205. [PMID: 28075194 DOI: 10.1089/jamp.2016.1343] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Nebulized aerosol drug delivery during the administration of noninvasive positive pressure ventilation (NPPV) is commonly implemented. While studies have shown improved patient outcomes for this therapeutic approach, aerosol delivery efficiency is reported to be low with high variability in lung-deposited dose. Excipient enhanced growth (EEG) aerosol delivery is a newly proposed technique that may improve drug delivery efficiency and reduce intersubject aerosol delivery variability when coupled with NPPV. MATERIALS AND METHODS A combined approach using in vitro experiments and computational fluid dynamics (CFD) was used to characterize aerosol delivery efficiency during NPPV in two new nasal cavity models that include face mask interfaces. Mesh nebulizer and in-line dry powder inhaler (DPI) sources of conventional and EEG aerosols were both considered. RESULTS Based on validated steady-state CFD predictions, EEG aerosol delivery improved lung penetration fraction (PF) values by factors ranging from 1.3 to 6.4 compared with conventional-sized aerosols. Furthermore, intersubject variability in lung PF was very high for conventional aerosol sizes (relative differences between subjects in the range of 54.5%-134.3%) and was reduced by an order of magnitude with the EEG approach (relative differences between subjects in the range of 5.5%-17.4%). Realistic in vitro experiments of cyclic NPPV demonstrated similar trends in lung delivery to those observed with the steady-state simulations, but with lower lung delivery efficiencies. Reaching the lung delivery efficiencies reported with the steady-state simulations of 80%-90% will require synchronization of aerosol administration during inspiration and reducing the size of the EEG aerosol delivery unit. CONCLUSIONS The EEG approach enabled high-efficiency lung delivery of aerosols administered during NPPV and reduced intersubject aerosol delivery variability by an order of magnitude. Use of an in-line DPI device that connects to the NPPV mask appears to be a convenient method to rapidly administer an EEG aerosol and synchronize the delivery with inspiration.
Collapse
Affiliation(s)
- Ross L Walenga
- 1 Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University , Richmond, Virginia
| | - P Worth Longest
- 1 Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University , Richmond, Virginia.,2 Department of Pharmaceutics, Virginia Commonwealth University , Richmond, Virginia
| | - Anubhav Kaviratna
- 2 Department of Pharmaceutics, Virginia Commonwealth University , Richmond, Virginia
| | - Michael Hindle
- 2 Department of Pharmaceutics, Virginia Commonwealth University , Richmond, Virginia
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
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
| |
Collapse
|
17
|
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]
|
18
|
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]
|
19
|
Aerosol therapy in intensive and intermediate care units: prospective observation of 2808 critically ill patients. Intensive Care Med 2015; 42:192-201. [PMID: 26602786 DOI: 10.1007/s00134-015-4114-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/18/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Unlike in the outpatient setting, delivery of aerosols to critically ill patients may be considered complex, particularly in ventilated patients, and benefits remain to be proven. Many factors influence aerosol delivery and recommendations exist, but little is known about knowledge translation into clinical practice. METHODS Two-week cross-sectional study to assess the prevalence of aerosol therapy in 81 intensive and intermediate care units in 22 countries. All aerosols delivered to patients breathing spontaneously, ventilated invasively or noninvasively (NIV) were recorded, and drugs, devices, ventilator settings, circuit set-up, humidification and side effects were noted. RESULTS A total of 9714 aerosols were administered to 678 of the 2808 admitted patients (24 %, CI95 22-26 %), whereas only 271 patients (10 %) were taking inhaled medication before admission. There were large variations among centers, from 0 to 57 %. Among intubated patients 22 % (n = 262) received aerosols, and 50 % (n = 149) of patients undergoing NIV, predominantly (75 %) inbetween NIV sessions. Bronchodilators (n = 7960) and corticosteroids (n = 1233) were the most frequently delivered drugs (88 % overall), predominantly but not exclusively (49 %) administered to patients with chronic airway disease. An anti-infectious drug was aerosolized 509 times (5 % of all aerosols) for nosocomial infections. Jet-nebulizers were the most frequently used device (56 %), followed by metered dose inhalers (23 %). Only 106 (<1 %) mild side effects were observed, despite frequent suboptimal set-ups such as an external gas supply of jet nebulizers for intubated patients. CONCLUSIONS Aerosol therapy concerns every fourth critically ill patient and one-fifth of ventilated patients.
Collapse
|
20
|
Cheng C, Du L, Yu J, Lu Q, He Y, Ran T. Ciprofloxacin plus erythromycin or ambroxol ameliorates endotracheal tube-associated Pseudomonas aeruginosa biofilms in a rat model. Pathol Res Pract 2015; 211:982-8. [PMID: 26601615 DOI: 10.1016/j.prp.2015.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 09/27/2015] [Accepted: 10/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Pseudomonas aeruginosa is a multi-drug resistant bacterium, with its biofilm-growing mucoid (alginate-producing) strains being particularly resistant. As atomized drug administration is a common practice in pediatric patients, we compared the effect of inhalational therapy with erythromycin plus ciprofloxacin, with that of ambroxol plus ciprofloxacin, against biofilm producing strains of P. aeruginosa. RESULTS Both combined treatment regimens were associated with a significant reduction in bacterial counts in endotracheal (ET) tubes and lungs, as compared to that observed with ambroxol and erythromycin monotherapies (P<0.05). Ciprofloxacin plus ambroxol appeared to have a higher efficacy than ciprofloxacin plus erythromycin, both in lowering bacterial counts (P<0.05) and in disrupting the structural integrity of biofilm. Histopathological changes in the lungs were milder in the two combined treatment groups, as compared to that in groups treated with single drugs. CONCLUSION Erythromycin or ambroxol in combination with ciprofloxacin could eliminate P. aeruginosa biofilms. When combined with ciprofloxacin, ambroxol outperformed erythromycin in eradicating P. aeruginosa biofilm.
Collapse
Affiliation(s)
- Chen Cheng
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Lizhong Du
- The Children's Hospital, Zhejiang University School of Medicine, China
| | - Jialin Yu
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China.
| | - Qi Lu
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Yu He
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Tao Ran
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| |
Collapse
|
21
|
Michotte JB, Jossen E, Roeseler J, Liistro G, Reychler G. In vitro comparison of five nebulizers during noninvasive ventilation: analysis of inhaled and lost doses. J Aerosol Med Pulm Drug Deliv 2015; 27:430-40. [PMID: 24517084 DOI: 10.1089/jamp.2013.1070] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few studies on performance comparison of nebulizer systems coupled with a single-limb circuit bilevel ventilator are available. Most of these data compared the aerosol drug delivery for only two different systems. Using an adult lung bench model of noninvasive ventilation, we compared inhaled and lost doses of three nebulizer systems coupled with a single-limb circuit bilevel ventilator, as well as the influence of the nebulizer position. METHOD Three vibrating mesh nebulizers (Aeroneb(®) Pro, Aeroneb(®) Solo, and NIVO(®)), one jet nebulizer (Sidestream(®)), and one ultrasonic nebulizer (Servo Ultra Nebulizer 145(®)) coupled with a bilevel ventilator were tested. They were charged with amikacin solution (500 mg/4 mL) and operated at two different positions: before and after the exhalation port (starting from the lung). The inhaled dose, the expiratory wasted dose, and the estimated lost dose were assessed by the residual gravimetric method. RESULTS The doses varied widely among the nebulizer types and position. When the nebulizer was positioned before the exhalation port, the vibrating mesh nebulizer delivered the highest inhaled dose (p<0.001), the jet nebulizer the highest expiratory wasted dose (p<0.001), and the ultrasonic device the highest total lost dose (p<0.001). When the nebulizer was positioned after the exhalation port, the vibrating mesh nebulizers delivered the highest inhaled (p<0.001) and expiratory wasted doses (p<0.001), and the ultrasonic device the highest total lost dose (p<0.001). The most efficient nebulizers were NIVO and Aeroneb Solo when placed before the exhalation port. CONCLUSIONS In a single-limb circuit bilevel ventilator, vibrating mesh nebulizers positioned between the exhalation port and lung model are more efficient for drug delivery compared with jet or ultrasonic nebulizers. In this position, the improved efficiency of vibrating mesh nebulizers was due to an increase in the inhaled dose and a reduction in the exhaled wasted dose compared with placement between the ventilator and the expiratory port. Because of the high total lost dose, the ultrasonic device should not be recommended. Nebulizer placement before the exhalation port increased the inhaled dose and decreased the expiratory wasted dose, except for the jet nebulizer.
Collapse
Affiliation(s)
- Jean-Bernard Michotte
- 1 University of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO) , 1011 Lausanne, Switzerland
| | | | | | | | | |
Collapse
|
22
|
|
23
|
Mukker JK, Singh RSP, Derendorf H. Pharmacokinetic and pharmacodynamic implications in inhalable antimicrobial therapy. Adv Drug Deliv Rev 2015; 85:57-64. [PMID: 25770775 DOI: 10.1016/j.addr.2015.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/14/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
Inhaled antimicrobials provide a promising alternative to the systemically delivered drugs for the treatment of acute and chronic lung infections. The delivery of antimicrobials via inhalation route decreases the systemic exposure while increasing the local concentration in the lungs, enabling the use of antimicrobials with severe systemic side effects. The inhalation route of administration has several challenges in pharmacokinetic (PK) and pharmacodynamic (PD) assessments. This review discusses various issues that need to be considered during study, data analysis, and interpretation of PK and PD of inhaled antimicrobials. Advancements overcoming the challenges are also discussed.
Collapse
|
24
|
Dai B, Kang J, Sun LF, Tan W, Zhao HW. Influence of Exhalation Valve and Nebulizer Position on Albuterol Delivery During Noninvasive Positive Pressure Ventilation. J Aerosol Med Pulm Drug Deliv 2014; 27:125-32. [PMID: 23668546 DOI: 10.1089/jamp.2012.1024] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Bing Dai
- Department of Respiratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, 110001, People's Republic of China
| | - Jian Kang
- Department of Respiratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, 110001, People's Republic of China
| | - Long-feng Sun
- Department of Respiratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, 110001, People's Republic of China
| | - Wei Tan
- Department of Respiratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, 110001, People's Republic of China
| | - Hong-wen Zhao
- Department of Respiratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, 110001, People's Republic of China
| |
Collapse
|
25
|
Abstract
BACKGROUND The most serious complications of cystic fibrosis (CF) relate to respiratory insufficiency. Oxygen supplementation therapy has long been a standard of care for individuals with chronic lung diseases associated with hypoxemia. Physicians commonly prescribe oxygen therapy for people with CF when hypoxemia occurs. However, it is unclear if empiric evidence is available to provide indications for this therapy with its financial costs and often profound impact on lifestyle. OBJECTIVES To assess whether oxygen therapy improves the longevity or quality of life of individuals with CF. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Latest search of Group's Trials Register: 15 May 2013. SELECTION CRITERIA Randomized or quasi-randomized controlled trials comparing oxygen, administered at any concentration, by any route, in people with documented CF for any time period. DATA COLLECTION AND ANALYSIS Authors independently assessed the risk of bias for included studies and extracted data. MAIN RESULTS This review includes 11 published studies (172 participants); only one examined long-term oxygen therapy (28 participants). There was no statistically significant improvement in survival, lung, or cardiac health. There was an improvement in regular attendance at school or work in those receiving oxygen therapy at 6 and 12 months. Four studies examined the effect of oxygen supplementation during sleep by polysomnography. Although oxygenation improved, mild hypercapnia was noted. Participants fell asleep quicker and spent a reduced percentage of total sleep time in rapid eye movement sleep, but there were no demonstrable improvements in qualitative sleep parameters. Six studies evaluated oxygen supplementation during exercise. Again, oxygenation improved, but mild hypercapnia resulted. Participants receiving oxygen therapy were able to exercise for a significantly longer duration during exercise. Other exercise parameters were not altered by the use of oxygen. AUTHORS' CONCLUSIONS There are no published data to guide the prescription of chronic oxygen supplementation to people with advanced lung disease due to CF. Short-term oxygen therapy during sleep and exercise improves oxygenation but is associated with modest and probably clinically inconsequential hypercapnia. There are improvements in exercise duration, time to fall asleep and regular attendance at school or work. There is a need for larger, well-designed clinical trials to assess the benefits of long-term oxygen therapy in people with CF administered continuously or during exercise or sleep or both. However, we do not expect any new research to be undertaken in this area any time soon and do not plan to update this review again until any new evidence does become available.
Collapse
|
26
|
Abstract
PURPOSE OF REVIEW The use of noninvasive ventilation (NIV) has become increasingly popular in the pediatric intensive care unit (PICU) over the last decade. This review intends to assess our current knowledge on the utilization of noninvasive support in children, especially focusing on its efficacy and safety profile. RECENT FINDINGS Recent studies endorse the use of this therapy in the pediatric intensive care setting. NIV appears to be associated with a decrease in the intubation rate in children. Children who are responsive to NIV will usually show improvement in their physiologic parameters shortly after the initiation of this therapy and this improvement is often sustained. NIV is proving to be a well-tolerated alternative to endotracheal intubation, in particular in those patients with primary respiratory failure, postsurgical patients or with postextubation respiratory distress. Most studies represent single-center experience and therefore caution must be exerted when attempting to generalize their results. SUMMARY NIV appears to be a well-tolerated alternative for use in the pediatric population. Its use is associated with decreased intubation rates, which may lead to a decrease in the intubation-related complications. More investigation is needed to fully evaluate the ramifications of increased use of this technology in the PICU.
Collapse
|
27
|
Evaluation of lung function and deposition of aerosolized bronchodilators carried by heliox associated with positive expiratory pressure in stable asthmatics: a randomized clinical trial. Respir Med 2013; 107:1178-85. [PMID: 23664767 DOI: 10.1016/j.rmed.2013.03.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/22/2013] [Accepted: 03/26/2013] [Indexed: 11/23/2022]
Abstract
While administration of medical aerosols with heliox and positive airway pressure are both used clinically to improve aerosol delivery, few studies have differentiated their separate roles in treatment of asthmatics. The aim of this randomized, double blinded study is to differentiate the effect of heliox and oxygen with and without positive expiratory pressure (PEP), on delivery of radiotagged inhaled bronchodilators on pulmonary function and deposition in asthmatics. 32 patients between 18 and 65 years of age diagnosed with stable moderate to severe asthma were randomly assigned into four groups: (1) Heliox + PEP (n = 6), (2) Oxygen + PEP (n = 6), (3) Heliox (n = 11) and (4) Oxygen without PEP (n = 9). Each group received 1 mg of fenoterol and 2 mg of ipratropium bromide combined with 25 mCi (955 Mbq) of Technetium-99m and 0.9% saline to a total dose volume of 3 mL placed in a Venticis II nebulizer attached to a closed, valved mask with PEP of 0 or 10 cm H2O. Both gas type and PEP level were blinded to the investigators. Images were acquired with a single-head scintillation camera with the longitudinal and transverse division of the right lung as regions of interest (ROIs). While all groups responded to bronchodilators, only group 1 showed increase in FEV1%predicted and IC compared to the other groups (p < 0.04). When evaluating the ROI in the vertical gradient we observed higher deposition in the middle and lower third in groups 1 (p = 0.02) and 2 (p = 0.01) compared to group 3. In the horizontal gradient, a higher deposition in the central region in groups 1 (p = 0.03) and 2 (p = 0.02) compared to group 3 and intermediate region of group 2 compared to group 3. We conclude that aerosol deposition was higher in groups with PEP independent of gas used, while bronchodilator response with Heliox + PEP improved FEV1 % and IC compared to administration with Oxygen, Oxygen with PEP and Heliox alone. Trial registration NCT01268462.
Collapse
|
28
|
Abstract
BACKGROUND Nebuliser systems are used to deliver medications to control the symptoms and the progression of lung disease in people with cystic fibrosis. Many types of nebuliser systems are available for use with various medications; however, there has been no previous systematic review which has evaluated these systems. OBJECTIVES To evaluate effectiveness, safety, burden of treatment and adherence to nebulised therapy using different nebuliser systems for people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books of conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. Date of the most recent search: 15 Oct 2012. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials comparing nebuliser systems including conventional nebulisers, vibrating mesh technology systems, adaptive aerosol delivery systems and ultrasonic nebuliser systems. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third author assessed studies where agreement could not be reached. MAIN RESULTS The search identified 40 studies with 20 of these (1936 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic sodium chloride and other solutions through the different nebuliser systems. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. Conventional nebuliser systems providing higher flows, higher respirable fractions and smaller particles decrease treatment time, increase deposition and may be preferred by people with CF, as compared to conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Nebulisers using adaptive aerosol delivery or vibrating mesh technology reduce treatment time to a far greater extent. Deposition (as a percentage of priming dose) is greater than conventional with adaptive aerosol delivery. Vibrating mesh technology systems may give greater deposition than conventional when measuring sputum levels, but lower deposition when measuring serum levels or using gamma scintigraphy. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved with systems which use these newer technologies, but also that some nebuliser systems using vibrating mesh technology may be subject to increased failures. AUTHORS' CONCLUSIONS Clinicians should be aware of the variability in the performance of different nebuliser systems. Technologies such as adaptive aerosol delivery and vibrating mesh technology have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, patient preference and adherence. There is a need for long-term randomised controlled trials of these technologies to determine patient-focused outcomes (such as quality of life and burden of care), safe and effective dosing levels of medications and clinical outcomes (such as hospitalisations and need for antibiotics) and an economic evaluation of their use.
Collapse
|
29
|
Abstract
BACKGROUND Non-invasive ventilation may be a means to temporarily reverse or slow the progression of respiratory failure in cystic fibrosis. OBJECTIVES To compare the effect of non-invasive ventilation versus no non-invasive ventilation in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We searched the reference lists of each trial for additional publications possibly containing other trials.Most recent search: 22 February 2013. SELECTION CRITERIA Randomised controlled trials comparing a form of pressure preset or volume preset non-invasive ventilation to no non-invasive ventilation in people with acute or chronic respiratory failure in cystic fibrosis. DATA COLLECTION AND ANALYSIS Three reviewers independently assessed trials for inclusion criteria and methodological quality, and extracted data. MAIN RESULTS Fifteen trials were identified; seven trials met the inclusion criteria with a total of 106 participants. Six trials evaluated single treatment sessions and one evaluated a six-week intervention.Four trials (79 participants) evaluated non-invasive ventilation for airway clearance compared with an alternative chest physiotherapy method and showed that airway clearance may be easier with non-invasive ventilation and people with cystic fibrosis may prefer it. We were unable to find any evidence that NIV increases sputum expectoration, but it did improve some lung function parameters.Three trials (27 participants) evaluated non-invasive ventilation for overnight ventilatory support, measuring lung function, validated quality of life scores and nocturnal transcutaneous carbon dioxide. Due to the small numbers of participants and statistical issues, there were discrepancies in the results between the RevMan and the original trial analyses. No clear differences were found between non-invasive ventilation compared with oxygen or room air except for exercise performance, which significantly improved with non-invasive ventilation compared to room air over six weeks. AUTHORS' CONCLUSIONS Non-invasive ventilation may be a useful adjunct to other airway clearance techniques, particularly in people with cystic fibrosis who have difficulty expectorating sputum. Non-invasive ventilation, used in addition to oxygen, may improve gas exchange during sleep to a greater extent than oxygen therapy alone in moderate to severe disease. These benefits of non-invasive ventilation have largely been demonstrated in single treatment sessions with small numbers of participants. The impact of this therapy on pulmonary exacerbations and disease progression remain unclear. There is a need for long-term randomised controlled trials which are adequately powered to determine the clinical effects of non-invasive ventilation in cystic fibrosis airway clearance and exercise.
Collapse
Affiliation(s)
- Fidelma Moran
- Health and Rehabilitation Sciences Research Institute and School of Health Sciences, University of Ulster, Newtownabbey, UK.
| | | | | |
Collapse
|
30
|
Noninvasive ventilation in pediatric status asthmaticus: sound physiologic rationale but is it really safe, effective, and cost-efficient? Pediatr Crit Care Med 2012; 13:484-5. [PMID: 22766544 DOI: 10.1097/pcc.0b013e31823db1ff] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
31
|
Dhand R. Aerosol therapy in patients receiving noninvasive positive pressure ventilation. J Aerosol Med Pulm Drug Deliv 2011; 25:63-78. [PMID: 22191396 DOI: 10.1089/jamp.2011.0929] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In selected patients, noninvasive positive pressure ventilation (NIPPV) with a facemask is now commonly employed as the first choice for providing mechanical ventilation in the intensive care unit (ICU). Aerosol therapy for treatment of acute or acute-on-chronic respiratory failure in this setting may be delivered by pressurized metered-dose inhaler (pMDI) with a chamber spacer and facemask or nebulizer and facemask. This article reviews the host of factors influencing aerosol delivery with these devices during NIPPV. These factors include (1) the type of ventilator, (2) mode of ventilation, (3) circuit conditions, (4) type of interface, (5) type of aerosol generator, (6) drug-related factors, (7) breathing parameters, and (8) patient-related factors. Despite the impediments to efficient aerosol delivery because of continuous gas flow, high inspiratory flow rates, air leaks, circuit humidity, and patient-ventilator asynchrony, significant therapeutic effects are achieved after inhaled bronchodilator administration to patients with asthma and chronic obstructive pulmonary disease. Similarly to invasive mechanical ventilation, careful attention to the technique of drug administration is required to optimize therapeutic effects of inhaled therapies during NIPPV. Assessment of the patient's ability to tolerate a facemask, the level of respiratory distress, hemodynamic status, and synchronization of aerosol generation with inspiratory airflow are important factors contributing to the success of aerosol delivery during NIPPV. Further research into novel delivery methods, such as the use of NIPPV with nasal cannulae, could enhance the efficiency, ease of use, and reproducibility of inhalation therapy during noninvasive ventilation.
Collapse
Affiliation(s)
- Rajiv Dhand
- Division of Pulmonary, Critical Care, and Environmental Medicine, Department of Internal Medicine, University of Missouri, Columbia, Missouri 65212, USA.
| |
Collapse
|
32
|
|
33
|
Mayordomo-Colunga J, Medina A, Rey C, Concha A, Menéndez S, Arcos ML, Vivanco-Allende A. Non-invasive ventilation in pediatric status asthmaticus: a prospective observational study. Pediatr Pulmonol 2011; 46:949-55. [PMID: 21520437 DOI: 10.1002/ppul.21466] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/23/2011] [Accepted: 02/17/2011] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Non-invasive ventilation (NIV) has been shown to be effective in different causes of respiratory failure in both adult and pediatric patients. However, its role in status asthmaticus (SA) remains unclear. We designed a prospective study to assess the feasibility of NIV in children with SA. STUDY DESIGN Prospective observational study, over a 4.5-year period. PATIENT SELECTION Children with SA unresponsive to conventional therapy with a modified Wood's clinical asthma score (m-WCAS) ≥4 and marked increased work of breathing, were included. METHODOLOGY Patients were placed on pressure support NIV. During NIV therapy, salbutamol was nebulized continuously and ipratropium bromide every 2 hr; methyl-prednisolone was given at a dose of 1-2 mg/kg/6 hr. Clinical variables were measured at baseline and at 1, 6, 12, 24, and 48 hr. RESULTS During the study period, there were 122 PICU admissions due to SA; 72 episodes fulfilled inclusion criteria. Baseline mean values were as follows: m-WCAS of 5.7 points, heart rate (HR) of 166.7 beats/min, respiratory rate (RR) of 49.5 breaths/min and FiO(2) of 45.3%. In the first hour m-WCAS fell 2.3 ± 1.5 points, HR 13.5 ± 14 beats/min, and RR 9.8 ± 10 breaths/min (P < 0.01). After institution of NIV therapy, 5 children required intubation due to increasing respiratory distress. There was one case of massive subcutaneous emphysema, with no other serious adverse effects associated with NIV. CONCLUSIONS These results show that NIV is a feasible therapy in children with SA unresponsive to conventional treatment. Pediatr. Pulmonol. 2011; 46:949-955. © 2011 Wiley-Liss, Inc.
Collapse
Affiliation(s)
- Juan Mayordomo-Colunga
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Asturias, Spain.
| | | | | | | | | | | | | |
Collapse
|
34
|
Gaur PK, Mishra S, Gupta VB, Rathod MS, Purohit S, Savla BA. Targeted drug delivery of Rifampicin to the lungs: formulation, characterization, and stability studies of preformed aerosolized liposome and in situ formed aerosolized liposome. Drug Dev Ind Pharm 2011; 36:638-46. [PMID: 20136485 DOI: 10.3109/03639040903410300] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE This study aimed at the preparation and characterization of preformed and in situ formed liposomes for sustained delivery to the lungs. METHODS Two different liposome formulations were prepared and subjected to characterization of physical parameters and drug release profile (% cumulative drug release and % drug retained). Formulations were then subjected to accelerated stability studies as per ICH guidelines. RESULTS In situ formed liposome showed better sustained release profile than the preformed liposome as it released sufficient amount of drug while retaining considerable amount of drug. Upon subjection to accelerated conditions for 60 days, preformed liposome lost the objective of being controlled release formulation.
Collapse
Affiliation(s)
- Praveen Kumar Gaur
- Department of Pharmaceutics, I.T.S. Paramedical (Pharmacy) College, Muradnagar, Uttar Pradesh, India.
| | | | | | | | | | | |
Collapse
|
35
|
Calvert LD, Jackson JM, White JA, Barry PW, Kinnear WJ, O'Callaghan C. Enhanced delivery of nebulised salbutamol during non-invasive ventilation. J Pharm Pharmacol 2010; 58:1553-7. [PMID: 17132219 DOI: 10.1211/jpp.58.11.0017] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
Non-invasive ventilation (NIV) is used to treat acute respiratory failure. Nebulised drugs can be delivered concurrently with NIV or during breaks from ventilatory support. We hypothesised that the amount of nebulised salbutamol inhaled when delivered via bi-level ventilation would be no different to the amount available directly from the same nebuliser. A standard bi-level ventilation circuit was attached to a lung model simulating adult respiration. Drug delivery was compared when salbutamol (5 mg) was nebulised at different positions in the circuit and separately, with no ventilator. The amount of salbutamol contained in various particle size fractions was also determined. Nebuliser position within the NIV circuit was critically important for drug delivery. Optimal delivery of salbutamol occurred with the expiration port between the facemask and nebuliser (647 ± 67 μg). This was significantly better than nebulisation without the ventilator (424 ± 61 μg; P < 0.01). Delivery when the nebuliser was positioned between the facemask and expiration port was 544 ± 85 μg. The amount of salbutamol contained in particles < 5 μm was significantly increased when the nebuliser was used in conjunction with bi-level ventilation (576 ± 60 μg vs 300 ± 43 μg, P < 0.001). We conclude that nebulised bronchodilator therapy, using a Cirrus jet nebuliser, during bi-level ventilation increases respirable particles likely to be inhaled when the nebuliser is optimally positioned within the circuit.
Collapse
Affiliation(s)
- Lori D Calvert
- Department of Respiratory Medicine, University Hospital Nottingham, Derby Road, Nottingham, UK.
| | | | | | | | | | | |
Collapse
|
36
|
Brandao DC, Lima VM, Filho VG, Silva TS, Campos TF, Dean E, de Andrade AD. Reversal of bronchial obstruction with bi-level positive airway pressure and nebulization in patients with acute asthma. J Asthma 2009; 46:356-61. [PMID: 19484669 DOI: 10.1080/02770900902718829] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Jet nebulization (JN) and non-invasive mechanical ventilation (NIMV) through bi-level pressure is commonly used in emergency and intensive care of patients experiencing an acute exacerbation of asthma. However, a scientific basis for effect of JN coupled with NIMV is unclear. Objective. To evaluate the effect of jet nebulization administered during spontaneous breathing with that of nebulization with NIV at two levels of inspiratory and expiratory pressures resistance in patients experiencing an acute asthmatic episode. Methods. A prospective, randomized controlled study of 36 patients with severe asthma (forced expiratory volume in 1 second [FEV(1)] less than 60% of predicted) selected with a sample of patients who presented to the emergency department. Subjects were randomized into three groups: control group (nebulization with the use of an unpressured mask), experimental group 1 (nebulization and non-invasive positive pressure with inspiratory positive airway pressure [IPAP] = 15 cm H(2)O, and expiratory positive airway pressure [EPAP] = 5 cm H(2)O), and experimental group 2 (nebulization and non-invasive positive pressure with IPAP = 15 cm H(2)O and EPAP = 10 cm H(2)O). Bronchodilators were administered with JN for all groups. Dependent measures were recorded before and after 30 minutes of each intervention and included respiratory rate (RR), heart rate (HR), oxygen saturation (SpO(2)), peak expiratory flow (PEF), forced expiratory volume in 1 second (FEV(1)), forced vital capacity (FVC), and forced expiratory flow between 25 and 75% (FEF(25-75)). Results. The group E2 showed an increase of the peak expiratory flow (PEF), forced vital capacity (FVC), FEV(1) (p < 0.03) and F(25-75%) (p < 0.000) when compared before and 30 minutes after JN+NIMV. In group E1 the PFE (p < 0.000) reached a significant increase after JN+ NIMV. RR decreased before and after treatment in group E1 only (p = 0.04). Conclusion. Nebulization coupled with NIV in patients with acute asthma has the potential to reduce bronchial obstruction and symptoms secondary to augmented PEF compared with nebulization during spontaneous breathing. In reversing bronchial obstruction, this combination appears to be more efficacious when a low pressure delta is used in combination with a high positive pressure at the end of expiration.
Collapse
|
37
|
Hostetler MA. Use of noninvasive positive-pressure ventilation in the emergency department. Emerg Med Clin North Am 2009; 26:929-39, viii. [PMID: 19059092 DOI: 10.1016/j.emc.2008.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
To optimize the successful use of noninvasive positive-pressure ventilation (NPPV) in the emergency department (ED), clinicians must acquire the necessary knowledge, experience, and skill in its proper application. The purpose of this article is to provide a concise but thorough review of the current state of knowledge relating to the proper application of NPPV pertaining to its use in the ED.
Collapse
Affiliation(s)
- Mark A Hostetler
- Department of Pediatrics, The University of Chicago, Pritzker School of Medicine, Chicago, IL 60637, USA.
| |
Collapse
|
38
|
Abstract
BACKGROUND The most serious complications of cystic fibrosis (CF) relate to respiratory insufficiency. Oxygen supplementation therapy has been a standard of care for individuals with chronic lung diseases associated with hypoxemia for decades. Physicians commonly prescribe oxygen therapy for people with CF when hypoxemia occurs. However, it is unclear if empiric evidence is available to provide indications for this therapy with its financial costs and often profound impact on lifestyle. OBJECTIVES To assess whether oxygen therapy improves the longevity or quality of life of individuals with CF. SEARCH STRATEGY We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Most recent search of Group's Trials Register: November 2008. SELECTION CRITERIA Randomized or quasi-randomized controlled trials comparing oxygen, administered at any concentration, by any route, in people with documented CF for any time period. DATA COLLECTION AND ANALYSIS Authors independently assessed study quality and extracted data. MAIN RESULTS Eleven published studies (172 participants) are included in this review, of which only one examined long-term oxygen therapy (28 participants). There was no statistically significant improvement in survival, lung, or cardiac health. There was an improvement in regular attendance at school or work in those receiving oxygen therapy at 6 and 12 months. Four studies examined the effect of oxygen supplementation during sleep by polysomnography. Although oxygenation improved, mild hypercapnia was noted. Participants took less time to fall asleep and spent a reduced percentage of total sleep time in rapid eye movement sleep, but there were no demonstrable improvements in qualitative sleep parameters. Six studies evaluated oxygen supplementation during exercise. Again, oxygenation improved, but mild hypercapnia resulted. Participants receiving oxygen therapy were able to exercise for a significantly longer duration during exercise. Other exercise parameters were not altered by the use of oxygen. AUTHORS' CONCLUSIONS There are no published data to guide the prescription of chronic oxygen supplementation to people with advanced lung disease due to CF. Short-term oxygen therapy during sleep and exercise improves oxygenation but is associated with modest and probably clinically inconsequential hypercapnia. There are improvements in exercise duration, time to fall asleep and regular attendance at school or work. There is a need for larger, well-designed clinical trials to assess the benefits of long-term oxygen therapy in people with CF administered continuously or during exercise or sleep or both.
Collapse
Affiliation(s)
- Heather E Elphick
- Respiratory Unit, Sheffield Children's Hospital, Western Bank, Sheffield, UK, S10 2TH.
| | | |
Collapse
|
39
|
Abstract
BACKGROUND Non-invasive ventilation (NIV) may be a means to temporarily reverse or slow the progression of respiratory failure in cystic fibrosis (CF). OBJECTIVES To compare the effect of NIV versus no NIV in people with CF. SEARCH STRATEGY We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We searched the reference lists of each trial for additional publications possibly containing other trials.Most recent search: June 2008. SELECTION CRITERIA Randomised controlled trials comparing a form of pressure preset or volume preset NIV to no NIV in people with acute or chronic respiratory failure in CF. DATA COLLECTION AND ANALYSIS Three reviewers independently assessed trials for inclusion criteria and methodological quality, and extracted data. MAIN RESULTS Fifteen trials were identified; seven trials met the inclusion criteria with a total of 106 participants. Six trials evaluated single treatment sessions and one evaluated a six-week intervention.Four trials (79 participants) evaluated NIV for airway clearance compared with an alternative chest physiotherapy method and showed that airway clearance may be easier with NIV and people with CF may prefer it. We were unable to find any evidence that NIV increases sputum expectoration, but it did improve some lung function parameters.Three trials (27 participants) evaluated NIV for overnight ventilatory support, measuring lung function, validated quality of life scores and nocturnal transcutaneous carbon dioxide. Due to the small numbers of participants and statistical issues, there were discrepancies in the results between the RevMan and the original trial analyses. No clear differences were found between NIV compared with oxygen or room air except for exercise performance, which significantly improved with NIV compared to room air over six weeks. AUTHORS' CONCLUSIONS Non-invasive ventilation may be a useful adjunct to other airway clearance techniques, particularly in people with CF who have difficulty expectorating sputum. Non-invasive ventilation, used in addition to oxygen, may improve gas exchange during sleep to a greater extent than oxygen therapy alone in moderate to severe disease. These benefits of NIV have largely been demonstrated in single treatment sessions with small numbers of participants. The impact of this therapy on pulmonary exacerbations and disease progression remain unclear. There is a need for long-term randomised controlled trials which are adequately powered to determine the clinical effects of non-invasive ventilation in CF airway clearance and exercise.
Collapse
Affiliation(s)
- Fidelma Moran
- Room 14J07, School of Health Sciences, University of Ulster, Shore Road, Newtownabbey, Northern Ireland, UK, BT37 0QB.
| | | | | |
Collapse
|
40
|
Dhand R, Guntur VP. How best to deliver aerosol medications to mechanically ventilated patients. Clin Chest Med 2008; 29:277-96, vi. [PMID: 18440437 DOI: 10.1016/j.ccm.2008.02.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pressurized metered-dose inhalers (pMDIs) and nebulizers are employed routinely for aerosol delivery to ventilator-supported patients, but the ventilator circuit and artificial airway previously were thought to be major barriers to effective delivery of aerosols to patients receiving mechanical ventilation. In the past two decades, several investigators have shown that careful attention to many factors, such as the position of the patient, the type of aerosol generator and its configuration in the ventilator circuit, aerosol particle size, artificial airway, conditions in the ventilator circuit, and ventilatory parameters, is necessary to optimize aerosol delivery during mechanical ventilation. The best techniques for aerosol delivery during noninvasive positive-pressure ventilation are not well established as yet, and the efficiency of aerosol delivery in this setting is lower than that during invasive mechanical ventilation. The most efficient methods of using the newer hydrofluoroalkane-pMDIs and vibrating mesh nebulizers in ventilator-supported patients also require further evaluation. When optimal techniques of administration are employed, the efficiency of aerosolized drug delivery in mechanically ventilated patients is comparable to that achieved in ambulatory patients.
Collapse
Affiliation(s)
- Rajiv Dhand
- Division of Pulmonary, Critical Care, and Environmental Medicine, University of Missouri, MA-421 Health Sciences Center, 1 Hospital Drive, Columbia, MO 65212, USA.
| | | |
Collapse
|
41
|
Dhand R. Aerosol delivery during mechanical ventilation: from basic techniques to new devices. J Aerosol Med Pulm Drug Deliv 2008; 21:45-60. [PMID: 18518831 DOI: 10.1089/jamp.2007.0663] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pressurized metered-dose inhalers (pMDIs) and nebulizers are routinely employed for aerosol delivery in mechanically ventilated patients. A significant proportion of the aerosol deposits in the ventilator circuit and artificial airway, thereby reducing the inhaled drug mass. Factors influencing aerosol delivery during mechanical ventilation differ from those in spontaneously breathing patients. The English language literature on aerosol delivery during mechanical ventilation was reviewed. Marked variations in the efficiency of drug delivery with pMDIs and nebulizers occur due to differences in the technique of administration. Careful attention to five factors, viz., the aerosol generator, aerosol particle size, conditions in the ventilator circuit, artificial airway, and ventilator parameters, is necessary to optimize aerosol delivery during mechanical ventilation. Factors influencing drug delivery during NPPV are not well understood, and the efficiency of aerosol delivery in this setting is lower than that during invasive mechanical ventilaiton. With an optimal technique of administration the efficiency of aerosol delivery during mechanical ventilation is similar to that achieved during spontaneous breathing. Further research is needed to optimize aerosol delivery during NPPV.
Collapse
Affiliation(s)
- Rajiv Dhand
- Division of Pulmonary, Critical Care, and Environmental Medicine, Department of Internal Medicine, University of Missouri-Columbia, Columbia, MO 65212, USA.
| |
Collapse
|
42
|
Guerin C, Fassier T, Bayle F, Lemasson S, Richard JC. Inhaled bronchodilator administration during mechanical ventilation: how to optimize it, and for which clinical benefit? J Aerosol Med Pulm Drug Deliv 2008; 21:85-96. [PMID: 18518835 DOI: 10.1089/jamp.2007.0630] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Bronchodilators are frequently used in ICU patients, and are the most common medications administered by inhalation during mechanical ventilation. The amount of bronchodilator that deposits at its site of action depends on the amount of drug, inhaled mass, deposited mass, and particle size distribution. Mechanical ventilation challenges both inhaled mass and lung deposition by specific features, such as a ventilatory circuit, an endotracheal tube, and ventilator settings. Comprehensive in vitro studies have shown that an endotracheal tube is not as significant a barrier for the drug to travel as anticipated. Key variables of drug deposition are attachments of the inhalation device in the inspiratory line 10 to 30 cm to the endotracheal tube, use of chamber with metered-dose inhaler, dry air, high tidal volume, low respiratory frequency, and low inspiratory flow, which can increase the drug deposition. In vivo studies showed that a reduction by roughly 15% of the respiratory resistance was achieved with inhaled bronchodilators during invasive mechanical ventilation. The role of ventilatory settings is not as clear in vivo, and primary factors for optimal delivery and physiologic effects were medication dose and device location. Nebulizers and pressurized metered-dose inhalers can equally achieve physiologic end points. The effects of bronchodilators should be carefully evaluated, which can easily be done with the interrupter technique. With the non-invasive ventilation, the data regarding drug delivery and physiologic effects are still limited. With the bilevel ventilators the inhalation device should be located between the leak port and face mask. Further studies should investigate the effects of inhaled bronchodilators on patient outcome and methods to optimize delivery of inhaled bronchodilators during non-invasive ventilation.
Collapse
|
43
|
Abstract
PURPOSE OF REVIEW The aim of this article is to discuss the various factors that influence aerosol delivery in mechanically ventilated patients and clarify optimal techniques for aerosol administration in this patient population. Clinical use of various inhaled therapies in patients receiving invasive and noninvasive mechanical ventilation is also discussed. RECENT FINDINGS With optimal techniques for using pressurized metered-dose inhalers and nebulizers in ventilator circuits, the efficiency of inhaled drug delivery in mechanically ventilated patients is comparable to that in ambulatory patients. Techniques for enhancing inhaled drug delivery during noninvasive positive pressure ventilation are also being investigated. SUMMARY Pressurized metered-dose inhalers of bronchodilator and corticosteroid aerosols are more efficient and convenient to use than nebulizers for routine therapy in ventilated patients. Nebulizers are, however, more versatile and are employed to generate aerosols of bronchodilators, corticosteroids, antibiotics, prostaglandins, surfactant, and mucolytic agents. Factors influencing drug delivery during noninvasive positive pressure ventilation are not fully understood as yet, and further work is needed to enhance drug delivery in this setting. Improvements in drug formulations and the design and efficiency of aerosol generating devices have led to increasing application of inhaled therapies in mechanically ventilated patients.
Collapse
Affiliation(s)
- Rajiv Dhand
- Division of Pulmonary, Critical Care and Environmental Medicine, Department of Internal Medicine, University of Missouri, Columbia, Missouri 65212, USA.
| |
Collapse
|
44
|
Hess DR. The mask for noninvasive ventilation: principles of design and effects on aerosol delivery. ACTA ACUST UNITED AC 2007; 20 Suppl 1:S85-98; discussion S98-9. [PMID: 17411410 DOI: 10.1089/jam.2007.0574] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
There has been much clinical and academic interest in the use of noninvasive positive-pressure ventilation (NPPV) in patients with acute and chronic respiratory failure. The use of NPPV in appropriately selected patients improves survival and decreases the need for endotracheal intubation. The most commonly used interfaces for NPPV are nasal masks or oronasal masks, but nasal pillows, mouthpieces, total face masks, and helmets can also be used. Critical care ventilators, portable volume ventilators, and ventilators designed specifically for NPPV can be used. There are three options for aerosol delivery during NPPV. The patient can be removed from NPPV and the aerosol administered by nebulizer or MDI in the standard manner, the aerosol can be delivered by nebulizer placed in-line between the circuit and the mask, or a spacer chamber can be placed between the circuit and the mask. There is presently no commercially available system designed specifically for aerosol delivery during NPPV with a bilevel (BiPAP) ventilator. However, in vitro and in vivo studies have demonstrated that a significant amount of bronchodilator can be administered by in-line nebulizer or MDI during NPPV. The evidence base for aerosol delivery during NPPV is not nearly as mature as the evidence for aerosol delivery during invasive mechanical ventilation. With NPVV, issues related to the optimal interface, ventilator settings, and aerosol generator (nebulizer versus MDI) are largely unexplored.
Collapse
Affiliation(s)
- Dean R Hess
- Department of Anesthesia, Harvard Medical School, Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
| |
Collapse
|
45
|
Eichinger M, Puderbach M, Fink C, Gahr J, Ley S, Plathow C, Tuengerthal S, Zuna I, Müller FM, Kauczor HU. Contrast-enhanced 3D MRI of lung perfusion in children with cystic fibrosis—initial results. Eur Radiol 2006; 16:2147-52. [PMID: 16673092 DOI: 10.1007/s00330-006-0257-7] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Revised: 02/10/2006] [Accepted: 03/16/2006] [Indexed: 11/24/2022]
Abstract
This paper is a feasibility study of magnetic resonance imaging (MRI) of lung perfusion in children with cystic fibrosis (CF) using contrast-enhanced 3D MRI. Correlation assessment of perfusion changes with structural abnormalities. Eleven CF patients (9 f, 2 m; median age 16 years) were examined at 1.5 T. Morphology: HASTE coronal, transversal (TR/TE/alpha/ST: 600 ms/28 ms/180 degrees /6 mm), breath-hold 18 s. Perfusion: Time-resolved 3D GRE pulse sequence (FLASH, TE/TR/alpha: 0.8/1.9 ms/40 degrees ), parallel imaging (GRAPPA, PAT 2). Twenty-five data sets were acquired after intravenous injection of 0.1 mmol/kg body weight of gadodiamide, 3-5 ml/s. A total of 198 lung segments were analyzed by two radiologists in consensus and scored for morphological and perfusion changes. Statistical analysis was performed by Mantel-Haenszel chi-square test. Results showed that perfusion defects were observed in all patients and present in 80% of upper, and 39% of lower lobes. Normal lung parenchyma showed homogeneous perfusion (86%, P<0.0001). Severe morphological changes led to perfusion defects (97%, P<0.0001). Segments with moderate morphological changes showed normal (53%) or impaired perfusion (47%). In conclusion, pulmonary perfusion is easy to judge in segments with normal parenchyma or severe changes. In moderately damaged segments, MRI of lung perfusion may help to better assess actual functional impairment. Contrast-enhanced 3D MRI of lung perfusion has the potential for early vascular functional assessment and therapy control in CF patients.
Collapse
Affiliation(s)
- Monika Eichinger
- Department of Radiology (E010), Deutsches Krebsforschungszentrum (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Ferkol T, Rosenfeld M, Milla CE. Cystic fibrosis pulmonary exacerbations. J Pediatr 2006; 148:259-64. [PMID: 16492439 DOI: 10.1016/j.jpeds.2005.10.019] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Revised: 09/15/2005] [Accepted: 10/10/2005] [Indexed: 11/24/2022]
Affiliation(s)
- Thomas Ferkol
- Department of Pediatrics, Cell Biology and Physiology, Washington University School of Medicine, St. Louis Children's Hospital, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | | | | |
Collapse
|
47
|
França EET, Dornelas de Andrade AF, Cabral G, Almeida Filho P, Silva KC, Galindo Filho VC, Marinho PEM, Lemos A, Parreira VF. Nebulization associated with bi-level noninvasive ventilation: analysis of pulmonary radioaerosol deposition. Respir Med 2005; 100:721-8. [PMID: 16139491 DOI: 10.1016/j.rmed.2005.07.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2004] [Revised: 04/18/2005] [Accepted: 07/20/2005] [Indexed: 11/18/2022]
Abstract
UNLABELLED Nebulization associated with noninvasive ventilation is used in emergency services and intensive care units. PURPOSES To compare pulmonary radioaerosol deposition during jet nebulization associated to noninvasive ventilation versus spontaneous breathing nebulization; to measure the rate of lung depuration and the correlation between lung deposition, inspiratory flow and tidal volume (V(t)) using scintigraphy. SUBJECTS Thirteen healthy volunteers (with normal spirometry), mean age (23.3+/-1.49) years, body mass index 21.2+/-2.3 kg/m(2). METHODS Nebulization was performed in spontaneous breathing and associated with bi-level noninvasive ventilation (inspiratory pressure=12 cm H(2)O, expiratory pressure=5 cm H(2)O). The radioaerosol used in the nebulization was technetium (Tc99m) with diethylene triamine penta acetic acid, generated over a period of 9 min in a jet nebulizer. Analysis was performed through scintigraphy. Statistical analysis was performed by analysis of variance (for repeated measures), Bonferroni method, Student's t-test and Person's correlation. RESULTS There was a decrease in radioaerosol lung deposition with nebulization associated to noninvasive ventilation (mean counts in spontaneous breathing 200,510+11,012 and mean counts in noninvasive ventilation 106,093+2811 (P<0.001). During spontaneous breathing nebulization there was a significant correlation between V(t) and radioaerosol deposition (r=0.565, P<0.05), also between inspiratory flow and radioaerosol deposition in the lungs (r=0.141, P<0.05). However, there was no correlation between V(t) and pulmonary deposition of radioaerosol in bi-level noninvasive ventilation nebulization (r=0.082). CONCLUSION During nebulization with noninvasive ventilation in healthy volunteers, there was an increase in V(t) associated to a higher inspiratory flow rate, without resulting in a significant increase in pulmonary radioaerosol deposition.
Collapse
Affiliation(s)
- Eduardo E T França
- Departamento de Fisioterapia, Universidade Federal de Pernambuco, Campus da UFPE, Av. Pro. Moraes Rego, Cidade Universitária Recife, Pernambuco, CEP 50670-901, Brazil
| | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Itti E, Fauroux B, Pigeot J, Isabey D, Clement A, Evangelista E, Harf A, Meignan M. Quantitative lung perfusion scan as a predictor of aerosol distribution heterogeneity and disease severity in children with cystic fibrosis. Nucl Med Commun 2004; 25:563-9. [PMID: 15167515 DOI: 10.1097/01.mnm.0000126508.96340.1d] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The assessment of lung ventilation by radionuclide imaging has proved useful for the optimization of aerosol therapy in children with cystic fibrosis. Further analysis of lung perfusion may provide additional information. METHODS Quantitative analysis of regional lung aerosol distribution (Tc phytates) and perfusion (Tc macroaggregates) homogeneity was performed in 18 children with cystic fibrosis, using the third and fourth spatial moments (skew and Kurtosis) of count distribution. Patients were chosen from a prospective study whose goal was to compare the efficacy of two nebulization methods of a radiolabelled aerosol: one session involved a nebulizer activated by patient inspiratory flow (control session), whereas the other involved a nebulizer powered by a pressure support device (PS session). RESULTS Quantitative regional distribution of perfusion was similar to aerosol distribution, although skew and Kurtosis were lower, indicating better homogeneity. Perfusion skew was inversely correlated with pulmonary volumes and Shwachman score, even more significantly than ventilation skew. Using receiver operating characteristic curve analysis, a perfusion skew threshold of 0.67 was predictive of disease severity (FEV1 > or =60% or FEV1 <60%) with 86% sensitivity and 91% specificity. Furthermore, same skew threshold allowed the identification of patients who were 'PS responders' (greater amount of radioactivity deposited after the PS session) or 'PS non-responders' with 80% sensitivity and 77% specificity. CONCLUSION Quantification of regional lung perfusion is easy to perform and heterogeneity of the distribution is closely correlated to disease severity. Moreover, perfusion skew can identify patients who are likely to benefit from pressure support (to optimize aerosol therapy) and may be helpful for orienting potential non-responders towards alternative therapies.
Collapse
Affiliation(s)
- Emmanuel Itti
- Department of Nuclear Medicine, H. Mondor Hospital, Assistance Publique - Hôpitaux de Paris, Paris XII University, Créteil, France.
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Griese M, Ramakers J, Krasselt A, Starosta V, Van Koningsbruggen S, Fischer R, Ratjen F, Müllinger B, Huber RM, Maier K, Rietschel E, Scheuch G. Improvement of alveolar glutathione and lung function but not oxidative state in cystic fibrosis. Am J Respir Crit Care Med 2004; 169:822-8. [PMID: 14726422 DOI: 10.1164/rccm.200308-1104oc] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic neutrophilic inflammation leads to oxidative damage, which may play an important role in the pathogenesis of cystic fibrosis lung disease. Bronchoalveolar lavage levels of the antioxidant glutathione are diminished in patients with cystic fibrosis. Here we evaluated the effects of glutathione aerosol on lower airway glutathione levels, lung function, and oxidative status. Pulmonary deposition of a radiolabeled monodisperse aerosol generated with a Pari LC Star nebulizer (Allergy Asthma Technology, Morton Grove, IL) connected to an AKITA inhalation device (Inamed, Gauting, Germany) was determined in six patients. In 17 additional patients bronchoalveolar lavage fluid was assessed before and after 14 days of inhalation with thrice-daily doses of 300 or 450 mg of glutathione. Intrathoracic deposition was 86.3 +/- 1.4% of the emitted dose. Glutathione concentration in lavage 1 hour postinhalation was increased three- to fourfold and was still almost doubled 12 hours postinhalation. FEV(1) transiently dropped after inhalation but increased compared with pretreatment values after 14 days (p < 0.001). This improvement was not related to the lavage content of oxidized proteins and lipids, which did not change with treatment. These results show that, using a new inhalation device with high efficacy, glutathione treatment of the lower airways is feasible. Reversion of markers of oxidative injury may need longer treatment, higher doses, or different types of antioxidants.
Collapse
Affiliation(s)
- Matthias Griese
- Department of Pediatric Ludwig -Maximilians-University, Munich, Germany.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Chatmongkolchart S, Schettino GPP, Dillman C, Kacmarek RM, Hess DR. In vitro evaluation of aerosol bronchodilator delivery during noninvasive positive pressure ventilation: effect of ventilator settings and nebulizer position. Crit Care Med 2002; 30:2515-9. [PMID: 12441763 DOI: 10.1097/00003246-200211000-00018] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Respiratory failure due to exacerbation of obstructive lung disease has been successfully treated with noninvasive positive pressure ventilation (NPPV). However, there have been no reports of factors affecting aerosol delivery during NPPV. Our objective was to determine the effect of ventilator settings and nebulizer position on albuterol delivery during NPPV. DESIGN Bench model study. SETTING University laboratory. SUBJECTS None. INTERVENTIONS A Respironics BiPAP S/T-D30 with a standard circuit was attached to a lung model simulating spontaneous breathing. Inspiratory/expiratory pressures of 10/5, 15/5, 20/5, 15/10, 20/10, and 25/10 cm H2O were tested at respiratory rates of 10 and 20/min. A nebulizer was filled with 5 mg of albuterol in 4 mL of solution, driven with 8 L/min oxygen, and placed at either a proximal (ventilator outlet) or distal (between leak port and lung model connection) position. Albuterol delivery was estimated by measuring the amount of the albuterol collected on a filter placed at the inlet of the lung model. MEASUREMENT AND MAIN RESULTS Albuterol delivery varied from 5.2 +/- 0.4% to 24.5 +/- 1.3% of the nominal dose and was significantly affected by the position of the nebulizer, respiratory rate, and BiPAP settings (p <.001 in each case). The greatest albuterol delivery was observed with the nebulizer operating at the distal position and a respiratory rate of 20/min. At this respiratory rate and nebulizer placement, albuterol delivery increased with increasing inspiratory pressure levels and decreased as expiratory pressure levels were increased. Nebulizer flow did not affect function of the ventilator. CONCLUSIONS At optimum nebulizer position (between the leak port and patient connection) and ventilator settings (high inspiratory pressure and low expiratory pressure), as much as 25% of the nominal albuterol dose may be delivered during NPPV.
Collapse
|