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Ari A, Hoops JA, Koyuncu A, Fink JB. Dos and don'ts to optimize transnasal aerosol drug delivery in clinical practice. Expert Opin Drug Deliv 2024:1-12. [PMID: 39104360 DOI: 10.1080/17425247.2024.2388838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/10/2024] [Accepted: 08/01/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Transnasal aerosol drug delivery has become widely accepted for treating acutely ill infants, children, and adults. More recently aerosol administration to wider populations receiving high and low-flow nasal oxygen has become common practice. AREAS COVERED Skepticism of insufficient aerosol delivery to the lungs has been tempered by multiple in vitro explorations of variables to optimize delivery efficiency. Additionally, clinical studies demonstrated comparable clinical responses to orally inhaled aerosols. This paper provides essential clinical guidance on how to improve transnasal aerosol delivery based on device-, settings-, and drug-related optimization to serve as a resource for educational initiatives and quality enhancement endeavors at healthcare institutions. EXPERT OPINION Transnasal aerosol delivery is proliferating worldwide, but indiscriminate use of excessive-high flows, poor selection and placement of aerosol devices and circuits can greatly reduce aerosol delivery and efficacy, potentially compromising treatment to acute and critically ill patients. Attention to these details can improve inhaled dose by an order of magnitude, making the difference between effective treatment and the progression to more invasive ventilatory support, with greater inherent risk and cost. These revelations have prompted specific recommendations for optimal delivery, driving advancements in aerosol generators, formulations, and future device designs to administer aerosols and maximize treatment effectiveness.
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Affiliation(s)
- Arzu Ari
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Jordan A Hoops
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Ayfer Koyuncu
- Bioengineering Division, College of Engineering, Hacettepe University, Ankara, Turkey
| | - James B Fink
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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Galazzi A, Petrei M, Palese A. Tools used to assess comfort among patients undergoing high flow nasal cannula: A scoping review. Intensive Crit Care Nurs 2024; 83:103719. [PMID: 38718552 DOI: 10.1016/j.iccn.2024.103719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/11/2024] [Accepted: 04/30/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE The aims were twofold: (a) to map tools documented in the literature to evaluate comfort among patients undergoing high flow nasal cannula (HFNC) treatment; and (b) to assess if the retrieved tools have been validated for this purpose. METHODS A scoping review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). In July 2023, PubMed, Scopus, CINAHL and Cochrane Library were consulted. Studies assessing comfort in adult, paediatric, and neonatal patients undergoing HFNC were included. RESULTS Seventy-four articles were included, among which nine (12.2 %) investigated comfort as the primary aim. Twenty-five different tools were found, classifiable into 14 types, mostly unidimensional and originating from those measuring pain. The most widely used was the Visual Analogic Scale (n = 27, 35.6 %) followed by the Numerical Rating Scale (n = 11, 14.5 %) and less defined generic tools (n = 10, 13.2 %) with different metrics (e.g. 0-5, 0-10, 0-100). Only the General Comfort Questionnaire and the Comfort Scale were specifically validated for the assessment of comfort among adults and children, respectively. CONCLUSION Although the comfort of patients undergoing HFNC is widely investigated in the literature, there is a scarcity of tools specifically validated in this field. Those used have been validated mainly to assess pain, suggesting the need to inform patients to prevent confusion while measuring comfort during HFNC and to develop more research in the field. IMPLICATIONS FOR CLINICAL PRACTICE Comfort assessment is an important aspect of nursing care. Given the lack of validation studies in the field, efforts in research are recommended.
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Affiliation(s)
| | - Matteo Petrei
- Department of Medicine, University of Udine, Udine, Italy
| | - Alvisa Palese
- Department of Medicine, University of Udine, Udine, Italy
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3
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Feng Z, Han Z, Wang Y, Guo H, Liu J. Comparison of the Application of Vibrating Mesh Nebulizer and Jet Nebulizer in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis. Int J Chron Obstruct Pulmon Dis 2024; 19:829-839. [PMID: 38562440 PMCID: PMC10984201 DOI: 10.2147/copd.s452191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/24/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To comparison of the application of Vibrating Mesh Nebulizer and Jet Nebulizer in chronic obstructive pulmonary disease (COPD). Research Methods This systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statements. The primary outcome measures analyzed included: The amount of inhaler in the urine sample at 30 minutes after inhalation therapy (USAL0.5), The total amount of inhaler in urine sample within 24 hours (USAL24), Aerosol emitted, Forced expiratory volume in 1 second (FEV1), Forced vital capacity (FVC). Results Ten studies were included with a total of 314 study participants, including 157 subjects in the VMN group and 157 subjects in the JN group. The data analysis results of USAL0.5, MD (1.88 [95% CI, 0.95 to 2.81], P = 0.000), showed a statistically significant difference. USAL24, MD (1.61 [95% CI, 1.14 to 2.09], P = 0.000), showed a statistically significant difference. The results of aerosol emitted showed a statistically significant difference in MD (3.44 [95% CI, 2.84 to 4.04], P = 0.000). The results of FEV1 showed MD (0.05 [95% CI, -0.24 to 0.35], P=0.716), the results were not statistically significant. The results of FVC showed MD (0.11 [95% CI, -0.18 to 0.41], P=0.459), the results were not statistically significant. It suggests that VMN is better than JN and provides higher aerosols, but there is no difference in improving lung function between them. Conclusion VMN is significantly better than JN in terms of drug delivery and utilization in the treatment of patients with COPD. However, in the future use of nebulizers, it is important to select a matching nebulizer based on a combination of factors such as mechanism of action of the nebulizer, disease type and comorbidities, ventilation strategies and modes, drug formulations, as well as cost-effectiveness, in order to achieve the ideal treatment of COPD.
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Affiliation(s)
- Zhouzhou Feng
- The First Clinical Medical College of Lanzhou University, Lanzhou City, People’s Republic of China
| | - Zhengcai Han
- The First Clinical Medical College of Lanzhou University, Lanzhou City, People’s Republic of China
| | - Yaqin Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou City, People’s Republic of China
| | - Hong Guo
- The First Clinical Medical College of Lanzhou University, Lanzhou City, People’s Republic of China
| | - Jian Liu
- The First Clinical Medical College of Lanzhou University, Lanzhou City, People’s Republic of China
- Gansu Maternal and Child Health Hospital/Gansu Central Hospital, Lanzhou City, People’s Republic of China
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Le Pape S, Thille AW, Frat JP. Nebulization With Vibrating Mesh Through High-Flow Nasal Cannula: Why Is It Better? Respir Care 2024; 69:269-271. [PMID: 38267226 PMCID: PMC10898464 DOI: 10.4187/respcare.11811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Sylvain Le Pape
- CHU de Poitiers, Médecine Intensive Réanimation Université de Poitiers, INSERM, CIC-1402, IS-ALIVE Poitiers, France
| | - Arnaud W Thille
- CHU de Poitiers, Médecine Intensive Réanimation Université de Poitiers, INSERM, CIC-1402, IS-ALIVE Poitiers, France
| | - Jean-Pierre Frat
- CHU de Poitiers, Médecine Intensive Réanimation Université de Poitiers, INSERM, CIC-1402, IS-ALIVE Poitiers, France
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5
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Arunsurat I, Rittayamai N, Chuaychoo B, Tangchityongsiva S, Promsarn S, Yuenyong S, Chow CW, Brochard L. Bronchodilator Efficacy of High-Flow Nasal Cannula in COPD: Vibrating Mesh Nebulizer Versus Jet Nebulizer. Respir Care 2024; 69:157-165. [PMID: 37607815 PMCID: PMC10898469 DOI: 10.4187/respcare.11139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/10/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Jet nebulizers are commonly used for bronchodilator therapy in COPD. High-flow nasal cannula with vibrating mesh nebulizer (HFNC-VMN) is a recently developed system; however, few studies have compared the efficacy of bronchodilator administration via HFNC-VMN to jet nebulizer in stable COPD. This study aimed to compare the effect of salbutamol administered via HFNC-VMN versus jet nebulizer on airway and lung function in subjects with stable COPD. METHODS This randomized non-inferiority crossover physiologic study enrolled subjects with stable COPD. Salbutamol was nebulized via HFNC-VMN or jet nebulizer in random order with a 4-h washout period between crossover sequences. Spirometry, lung volume, and impulse oscillometry were performed at baseline and after each intervention. The primary outcome was change in FEV1 from baseline. Secondary outcomes included changes in other respiratory-related parameters and nebulization time compared between the 2 devices. RESULTS Seventeen subjects were enrolled. HFNC-VMN and jet nebulizer both significantly improved FEV1 from baseline (P = .005 and P = .002, respectively). The difference between respiratory resistance at 5 Hz and 20 Hz significantly decreased after HFNC-VMN compared to baseline (P = .02), while no significant change was observed after jet nebulizer (P = .056). Area of reactance and resonant frequency of reactance were both significantly decreased (P = .035 and P = .03, respectively), and respiratory reactance at 5 Hz significantly increased (P = .02) in the HFNC-VMN group compared to baseline indicating improved lung mechanics, with no significant changes with the jet nebulizer. HFNC-VMN had a shorter nebulization time (6 [5-9] min vs 20 [16-22] min, respectively, P < .001). CONCLUSIONS Bronchodilator therapy via HFNC-VMN was not inferior to jet nebulizer for subjects with stable COPD and can significantly improve airway oscillometry mechanics and decrease nebulization time compared to jet nebulizer.
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Affiliation(s)
- Itthiphat Arunsurat
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nuttapol Rittayamai
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Benjamas Chuaychoo
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suwat Tangchityongsiva
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Simaporn Promsarn
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Somruthai Yuenyong
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chung-Wai Chow
- Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada; and Toronto Lung Transplant Programme, Multi-Organ Transplant Unit, University Health Network, Toronto, Ontario, Canada
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Moon J, McPeck M, Jayakumaran J, Smaldone GC. Enhanced Aerosol Delivery During High-Flow Nasal Cannula Therapy. Respir Care 2023; 68:1221-1228. [PMID: 37253612 PMCID: PMC10468167 DOI: 10.4187/respcare.10644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Aerosolized drug delivery via high-flow nasal cannula (HFNC) decreases as gas flow is increased. To improve aerosol delivery, breath-enhanced jet nebulizer may increase aerosol output. This study tested that hypothesis and compared breath-enhanced jet nebulizer to vibrating mesh nebulizer technology. METHODS First, in an isolated circuit, breath-enhanced jet nebulizer and vibrating mesh nebulizer aerosol outputs were measured during simulated HFNC by using infused saline solution at rates of 5-60 mL/h. Limits were defined when nebulizer filling was detected. The devices were then tested by using 99mTc/saline solution to measure maximum rates of aerosol production. After the output experiments, drug delivery was measured in vitro by using a model that consisted of an HFNC circuit interfaced to a realistic 3-dimensional printed head. The 99mTc/saline solution was infused at rates of 5 to 60 mL/h for the breath-enhanced jet nebulizer and 5 to 20 mL/h for the vibrating mesh nebulizer with HFNC gas flows of 10 to 60 L/min. Aerosol delivery to the trachea was measured by using a shielded ratemeter, which defined the rate of drug delivery (µg NaCl/min). RESULTS With increasing gas flow, breath-enhanced jet nebulizer output increased to a maximum of 50 mL/h, the vibrating mesh nebulizer maximum was 12 mL/h. At HFNC gas flow of 60 L/min, breath-enhanced jet nebulizer delivered 3.16 to 316.8 µg NaCl/min, the vibrating mesh nebulizer delivered 23.5 to 61.7 µg NaCl/min. For infusion pump flows of 5 to 12 mL/h, the rate of drug delivery was independent of nebulizer type (P = .19) and dependent on infusion pump flow (P < .001) and gas flow (P < .001). CONCLUSIONS Increasing gas flow increased breath-enhanced jet nebulizer output, which demonstrated the effects of breath enhancement. At 60 L/min, breath enhanced jet nebulizer delivered up to 5 times more aerosol compared with conventional vibrating mesh nebulizer technology. Breath-enhanced jet nebulizer delivered a wide range of dose rates at all high flows. In patients who are critically ill, breath-enhanced jet nebulizer technology may allow titration of bedside dosing based on clinical response by simple adjustment of the infusion rate.
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Affiliation(s)
- Jane Moon
- Pulmonary, Critical Care and Sleep Medicine Division, Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York.
| | - Michael McPeck
- Pulmonary, Critical Care and Sleep Medicine Division, Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Jeyanthan Jayakumaran
- Pulmonary, Critical Care and Sleep Medicine Division, Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Gerald C Smaldone
- Pulmonary, Critical Care and Sleep Medicine Division, Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
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7
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Li J, Liu K, Lyu S, Jing G, Dai B, Dhand R, Lin HL, Pelosi P, Berlinski A, Rello J, Torres A, Luyt CE, Michotte JB, Lu Q, Reychler G, Vecellio L, de Andrade AD, Rouby JJ, Fink JB, Ehrmann S. Aerosol therapy in adult critically ill patients: a consensus statement regarding aerosol administration strategies during various modes of respiratory support. Ann Intensive Care 2023; 13:63. [PMID: 37436585 DOI: 10.1186/s13613-023-01147-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 05/31/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Clinical practice of aerosol delivery in conjunction with respiratory support devices for critically ill adult patients remains a topic of controversy due to the complexity of the clinical scenarios and limited clinical evidence. OBJECTIVES To reach a consensus for guiding the clinical practice of aerosol delivery in patients receiving respiratory support (invasive and noninvasive) and identifying areas for future research. METHODS A modified Delphi method was adopted to achieve a consensus on technical aspects of aerosol delivery for adult critically ill patients receiving various forms of respiratory support, including mechanical ventilation, noninvasive ventilation, and high-flow nasal cannula. A thorough search and review of the literature were conducted, and 17 international participants with considerable research involvement and publications on aerosol therapy, comprised a multi-professional panel that evaluated the evidence, reviewed, revised, and voted on recommendations to establish this consensus. RESULTS We present a comprehensive document with 20 statements, reviewing the evidence, efficacy, and safety of delivering inhaled agents to adults needing respiratory support, and providing guidance for healthcare workers. Most recommendations were based on in-vitro or experimental studies (low-level evidence), emphasizing the need for randomized clinical trials. The panel reached a consensus after 3 rounds anonymous questionnaires and 2 online meetings. CONCLUSIONS We offer a multinational expert consensus that provides guidance on the optimal aerosol delivery techniques for patients receiving respiratory support in various real-world clinical scenarios.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA.
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shan Lyu
- Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Guoqiang Jing
- Department of Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Paolo Pelosi
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Ariel Berlinski
- Pulmonary and Sleep Medicine Division, Department of Pediatrics, University of Arkansas for Medical Sciences, and Pediatric Aerosol Research Laboratory at Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Clinical Research in the ICU, Anaesthesia Department, CHU Nimes, Université de Nimes-Montpellier, Nimes, France
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, University of Barcelona, IDIBAPS CIBERES, Icrea, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, and INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Jean-Bernard Michotte
- School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts of Western Switzerland, Lausanne, Switzerland
| | - Qin Lu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, and Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Gregory Reychler
- Secteur de Kinésithérapie et Ergothérapie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Service de Pneumologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL and Dermatologie, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Jean-Jacques Rouby
- Research Department DMU DREAM and Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Sorbonne University of Paris, Paris, France
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA
- Chief Science Officer, Aerogen Pharma Corp, San Mateo, CA, USA
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, and INSERM, Centre d'étude des Pathologies Respiratoires, U1100, Université de Tours, Tours, France
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Colaianni-Alfonso N, MacLoughlin R, Espada A, Saa Y, Techera M, Toledo A, Montiel G, Castro-Sayat M. Delivery of Aerosolized Bronchodilators by High-Flow Nasal Cannula During COPD Exacerbation. Respir Care 2023; 68:721-726. [PMID: 37041023 PMCID: PMC10209003 DOI: 10.4187/respcare.10614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND Bronchodilator delivery via a high-flow nasal cannula (HFNC) has generated interest in recent years. The efficacy of in-line vibrating mesh nebulizers with an HFNC during COPD exacerbation is limited. The aim of this study was to evaluate the clinical response of subjects with COPD exacerbation who require bronchodilator therapy (anticholinergic and β-agonist) by using a vibrating mesh nebulizer in line with an HFNC. METHODS This was a prospective single-center study performed in a respiratory intermediate care unit that enrolled patients with a diagnosis of COPD exacerbation who required noninvasive ventilation on admission. All the subjects underwent noninvasive ventilation breaks with an HFNC. After clinical stability, pulmonary function tests were performed to assess changes in FEV1 and clinical parameters before and after bronchodilation by using a vibrating mesh nebulizer in line with an HFNC. RESULTS Forty-six patients with COPD exacerbation were admitted. Five patients who did not use noninvasive ventilation and 10 patients who did not receive bronchodilator treatment with a vibrating mesh nebulizer were excluded. Thirty-one were selected, but 1 subject was secondarily excluded due to loss of data. Finally, 30 subjects were included. The primary outcome was spirometric changes in FEV1. The mean ± SD FEV1 before receiving bronchodilator treatment by using a vibrating mesh nebulizer in line with an HFNC was 0.74 ± 0.10 L, and, after receiving treatment, the mean ± SD FEV1 changed to 0.88 ± 0.12 L (P < .001). Similarly, the mean ± SD FVC increased from 1.75 ± 0.54 L to 2.13 ± 0.63 L (P < .001). Considerable differences were observed in breathing frequency and heart rate after receiving bronchodilator treatment. No relevant changes were observed in the Borg scale or Sp O2 after treatment. The mean clinical stability recorded was 4 d. CONCLUSIONS In subjects with COPD exacerbation, bronchodilator treatment by using a vibrating mesh nebulizer in line with an HFNC showed a mild but significant improvement in FEV1 and FVC. In addition, a decrease in breathing frequency was observed, suggesting a reduction in dynamic hyperinflation.
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Affiliation(s)
- Nicolás Colaianni-Alfonso
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Ronan MacLoughlin
- Dr Research and Development, Science and Emerging Technologies, Aerogen Ltd, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
| | - Ariel Espada
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Yasmine Saa
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mariano Techera
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ada Toledo
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Guillermo Montiel
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mauro Castro-Sayat
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
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9
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Hess DR. Respiratory Care Management of COPD Exacerbations. Respir Care 2023; 68:821-837. [PMID: 37225653 PMCID: PMC10208989 DOI: 10.4187/respcare.11069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
A COPD exacerbation is characterized by an increase in symptoms such as dyspnea, cough, and sputum production that worsens over a period of 2 weeks. Exacerbations are common. Respiratory therapists and physicians in an acute care setting often treat these patients. Targeted O2 therapy improves outcomes and should be titrated to an SpO2 of 88-92%. Arterial blood gases remain the standard approach to assessing gas exchange in patients with COPD exacerbation. The limitations of arterial blood gas surrogates (pulse oximetry, capnography, transcutaneous monitoring, peripheral venous blood gases) should be appreciated so that they can be used wisely. Inhaled short-acting bronchodilators can be provided by nebulizer (jet or mesh), pressurized metered-dose inhaler (pMDI), pMDI with spacer or valved holding chamber, soft mist inhaler, or dry powder inhaler. The available evidence for the use of heliox for COPD exacerbation is weak. Noninvasive ventilation (NIV) is standard therapy for patients who present with COPD exacerbation and is supported by clinical practice guidelines. Robust high-level evidence with patient important outcomes is lacking for the use of high-flow nasal cannula in patients with COPD exacerbation. Management of auto-PEEP is the priority in mechanically ventilated patients with COPD. This is achieved by reducing airway resistance and decreasing minute ventilation. Trigger asynchrony and cycle asynchrony are addressed to improve patient-ventilator interaction. Patients with COPD should be extubated to NIV. Additional high-level evidence is needed before widespread use of extracorporeal CO2 removal. Care coordination can improve the effectiveness of care for patients with COPD exacerbation. Evidence-based practices improve outcomes in patients with COPD exacerbation.
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Affiliation(s)
- Dean R Hess
- Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts; and Northeastern University, Boston, Massachusetts.
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10
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Calabrese C, Annunziata A, Mariniello DF, Allocca V, Imitazione P, Cauteruccio R, Simioli F, Fiorentino G. Aerosol delivery through high-flow nasal therapy: Technical issues and clinical benefits. Front Med (Lausanne) 2023; 9:1098427. [PMID: 36743674 PMCID: PMC9889634 DOI: 10.3389/fmed.2022.1098427] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/26/2022] [Indexed: 01/20/2023] Open
Abstract
High-flow nasal cannula (HFNC) therapy is an oxygen delivery method particularly used in patients affected by hypoxemic respiratory failure. In comparison with the conventional "low flow" oxygen delivery systems, it showed several important clinical benefits. The possibility to nebulize drugs via HFNC represents a desirable medical practice because it allows the administration of inhaled drugs, mostly bronchodilators, without the interruption or modification of the concomitant oxygen therapy. HFNC, by itself has shown to exert a small but significant bronchodilator effect and improves muco-ciliary clearance; thus, the nebulization of bronchodilators through the HFNC circuit may potentially increase their pharmacological activity. Several technical issues have been observed which include the type of the nebulizer that should be used, its position within the HFNC circuit, and the optimal gas flow rates to ensure an efficient drug delivery to the lungs both in "quiet" and "distressed" breathing patterns. The aim of this review has been to summarize the scientific evidence coming from "in vitro" studies and to discuss the results of "in vivo" studies performed in adult subjects, mainly affected by obstructive lung diseases. Most studies seem to indicate the vibrating mesh nebulizer as the most efficient type of nebulizer and suggest to place it preferentially upstream from the humidifier chamber. In a quite breathing patterns, the inhaled dose seems to increase with lower flow rates while in a "distressed" breathing pattern, the aerosol delivery is higher when gas flow was set below the patient's inspiratory flow, with a plateau effect seen when the gas flow reaches approximately 50% of the inspiratory flow. Although several studies have demonstrated that the percentage of the loaded dose nebulized via HFNC reaching the lungs is small, the bronchodilator effect of albuterol seems not to be impaired when compared to the conventional inhaled delivery methods. This is probably attributed to its pharmacological activity. Prospective and well-designed studies in different cohort of patients are needed to standardize and demonstrate the efficacy of the procedure.
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Affiliation(s)
- Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy,*Correspondence: Cecilia Calabrese,
| | - Anna Annunziata
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | | | - Valentino Allocca
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Pasquale Imitazione
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | - Rosa Cauteruccio
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | - Francesca Simioli
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | - Giuseppe Fiorentino
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
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11
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Dhanani J, Taniguchi LU, Ranzani OT. Optimising aerosolized therapies in critically ill patients. Intensive Care Med 2022; 48:1418-1421. [PMID: 35804200 DOI: 10.1007/s00134-022-06800-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Jayesh Dhanani
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Leandro U Taniguchi
- Emergency Medicine Discipline, Clinical Hospital, University of São Paulo, São Paulo, Brazil.,Syrian-Lebanese Institute of Teaching and Research, São Paulo, Brazil
| | - Otavio T Ranzani
- Barcelona Institute for Global Health, ISGlobal, Universitat Pompeu Fabra (UPF), CIBER Epidemiología Y Salud Pública (CIBERESP), Barcelona, Spain.,Pulmonary Division, Heart Institute, Faculty of Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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12
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Frat JP, Le Pape S, Coudroy R, Thille AW. Noninvasive Oxygenation in Patients with Acute Respiratory Failure: Current Perspectives. Int J Gen Med 2022; 15:3121-3132. [PMID: 35418775 PMCID: PMC9000535 DOI: 10.2147/ijgm.s294906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/22/2022] [Indexed: 01/16/2023] Open
Abstract
Purpose of Review High-flow nasal oxygen and noninvasive ventilation are two alternative strategies to standard oxygen in the management of acute respiratory failure. Discussion Although high-flow nasal oxygen has gained major popularity in ICUs due to its simplicity of application, good comfort for patients, efficiency in improving oxygenation and promising results in patients with acute hypoxemic respiratory failure, further large clinical trials are needed to confirm its superiority over standard oxygen. Non-invasive ventilation may have deleterious effects, especially in patients exerting strong inspiratory efforts, and no current recommendations support its use in this setting. Protective non-invasive ventilation using higher levels of positive-end expiratory pressure, more prolonged sessions and other interfaces such as the helmet may have beneficial physiological effects leading to it being proposed as alternative to high-flow nasal oxygen in acute hypoxemic respiratory failure. By contrast, non-invasive ventilation is the first-line strategy of oxygenation in patients with acute exacerbation of chronic lung disease, while high-flow nasal oxygen could be an alternative to non-invasive ventilation after partial reversal of respiratory acidosis. Questions remain about the target populations and non-invasive oxygen strategy representing the best alternative to standard oxygen in acute hypoxemic respiratory failure. As concerns acute on-chronic-respiratory failure, the place of high-flow nasal oxygen remains to be evaluated.
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Affiliation(s)
- Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- Centre d’Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Sylvain Le Pape
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- Centre d’Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Arnaud W Thille
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- Centre d’Investigation Clinique 1402 ALIVE, INSERM, Université de Poitiers, Poitiers, France
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13
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Kumar N, Kandrakonda PK, Ahmed S. Modified T-piece jet nebulizer with high-flow nasal cannula in a severe COVID-19 patient with intensive care unit delirium. Lung India 2021; 38:588-589. [PMID: 34747747 PMCID: PMC8614614 DOI: 10.4103/lungindia.lungindia_399_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Neeraj Kumar
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
| | | | - Sarfaraz Ahmed
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
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14
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Beuvon C, Coudroy R, Bardin J, Marjanovic N, Rault C, Bironneau V, Drouot X, Robert R, Thille AW, Frat JP. β Agonist Delivery by High-Flow Nasal Cannula During COPD Exacerbation: A Prospective Physiological Study. Respir Care 2021; 67:9-15. [PMID: 34702767 DOI: 10.4187/respcare.09242] [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: 11/05/2022]
Abstract
BACKGROUND Whereas high-flow nasal cannula (HFNC) oxygen therapy is increasingly used in patients with exacerbation of COPD, the effectiveness of β 2 agonist nebulization through HFNC has been poorly assessed. We hypothesized that salbutamol vibrating-mesh nebulization through HFNC improves pulmonary function tests in subjects with COPD. METHODS We conducted a physiological crossover study including subjects admitted to the ICU for severe exacerbation of COPD. After subject improvement allowing a 3-h washout period without bronchodilator, pulmonary function tests were performed while breathing through HFNC alone and after salbutamol vibrating-mesh nebulization through HFNC. The primary end point consisted in the changes in FEV1 before and after salbutamol nebulization. Secondary end points included the changes in FVC, peak expiratory flow (PEF), airway resistance, and clinical parameters. RESULTS Among the 15 subjects included, mean (SD) FEV1 significantly increased after salbutamol nebulization from 931 mL (383) to 1,019 (432), mean difference +87 mL (95% CI 30-145) (P = .006). Similarly, FVC and PEF significantly increased, +174 mL (95% CI 66-282) (P = .004) and +0.3 L/min (95% CI 0-0.6) (P = .037), respectively. Airway resistances and breathing frequency did not significantly differ, whereas heart rate significantly increased after nebulization. CONCLUSIONS In subjects with severe exacerbation of COPD, salbutamol vibrating-mesh nebulization through HFNC induced a significant bronchodilator effect with volume and flow improvement.
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Affiliation(s)
- Clément Beuvon
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France and Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
| | - Rémi Coudroy
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France and Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
| | - Justine Bardin
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France and Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
| | - Nicolas Marjanovic
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France and Service d'accueil des Urgences, CHU de Poitiers, Poitiers, France
| | - Christophe Rault
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France and Service de Neurophysiologie, CHU de Poitiers, Poitiers, France
| | - Vanessa Bironneau
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France; and Service de Pneumologie, CHU de Poitiers, Poitiers, France
| | - Xavier Drouot
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France and Service de Neurophysiologie, CHU de Poitiers, Poitiers, France
| | - René Robert
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France and Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
| | - Arnaud W Thille
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France and Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
| | - Jean-Pierre Frat
- INSERM CIC-1402, ALIVE Research Group, University of Poitiers, Poitiers, France and Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
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15
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Li J, Williams L, Fink JB. The Impact of High-Flow Nasal Cannula Device, Nebulizer Type, and Placement on Trans-Nasal Aerosol Drug Delivery: An In Vitro Study. Respir Care 2021; 67:1-8. [PMID: 34670859 DOI: 10.4187/respcare.09133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aerosol delivery via high-flow nasal cannula (HFNC) has been increasingly used in recent years. However, the effects of different HFNC devices, nebulizer types, and placement on aerosol deposition remain largely unknown. METHODS An adult manikin with anatomically correct upper airway was used with a collection filter placed between the manikin's trachea and a breathing simulator, composed of a dual-chamber model lung driven by a critical care ventilator. Three HFNC device configurations were compared, with vibrating mesh nebulizer and small-volume nebulizer placed at the humidifier (inlet for Optiflow and outlet for Airvo 2) and proximal to the nasal cannula at gas flows of 10, 20, 40 and 60 L/min, in quiet and distressed breathing patterns. Albuterol (2.5 mg) was nebulized for each condition (no. = 3). The drug was eluted from the collection filter and assayed with ultraviolet spectrophotometry (276 nm). RESULTS At all settings, except when a nebulizer was placed proximal to the nasal cannula with the Optiflow and when the HFNC flow was set at 60 L/min, the vibrating mesh nebulizer generated a higher inhaled dose than did the small-volume nebulizer (all P < .05). With the exception of distressed breathing at an HFNC flow of 10 L/min, the inhaled dose with the vibrating mesh nebulizer placed at the humidifier was greater than with the vibrating mesh nebulizer placed proximal to the nasal cannula (all P < .05), Optiflow provided a higher inhaled dose than did Airvo 2 with either AirSpiral or 900PT501 circuits with the vibrating mesh nebulizer placed at the humidifier (all P < .05). CONCLUSIONS During transnasal aerosol delivery, the vibrating mesh nebulizer generated a higher inhaled dose than did the small-volume nebulizer when the nebulizer was placed at the humidifier. With the vibrating mesh nebulizer placed at the humidifier and an HFNC flow > 10 L/min, the inhaled dose was higher than with the vibrating mesh nebulizer placed proximal to the nasal cannula, and the inhaled dose was higher with Optiflow than with Airvo 2.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois.
| | - Lucas Williams
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois
- Aerogen Pharma Corp, San Mateo, California
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16
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Bronchodilator Delivery via High-Flow Nasal Cannula: A Randomized Controlled Trial to Compare the Effects of Gas Flows. Pharmaceutics 2021; 13:pharmaceutics13101655. [PMID: 34683948 PMCID: PMC8539308 DOI: 10.3390/pharmaceutics13101655] [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: 08/15/2021] [Revised: 09/13/2021] [Accepted: 09/26/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Aerosol delivery via high-flow nasal cannula (HFNC) has attracted increasing clinical interest. In vitro studies report that the ratio of HFNC gas flow to patient inspiratory flow (GF:IF) is a key factor in the efficiency of trans-nasal aerosol delivery. (2) Methods: In a randomized controlled trial, patients with a history of COPD or asthma and documented positive responses to inhaled bronchodilators in an outpatient pulmonary function laboratory were recruited. Subjects were randomized to receive inhalation at gas flow ratio settings of: GF:IF = 0.5, GF:IF = 1.0, or GF = 50 L/min. Subjects were assigned to inhale saline (control) followed by salbutamol via HFNC with cumulative doses of 0.5 mg, 1.5 mg, 3.5 mg, and 7.5 mg. Spirometry was performed at baseline and 10-12 min after each inhalation. (3) Results: 75 subjects (49 asthma and 26 COPD) demonstrating bronchodilator response were enrolled. Per the robust ATS/ERS criteria no difference was observed between flows, however using the criteria of post-bronchodilator forced expiratory volume in the first second (FEV1) reaching the screening post-bronchodilator FEV1 with salbutamol, a higher percentage of subjects receiving GF:IF = 0.5 met the criteria at a cumulative dose of 1.5 mg than those receiving GF:IF = 1.0, and GF = 50 L/min (64% vs. 29% vs. 27%, respectively, p = 0.011). Similarly at 3.5 mg (88% vs. 54% vs. 46%, respectively, p = 0.005). The effective dose at GF:IF = 0.5 was 1.5 mg while for GF = 50 L/min it was 3.5 mg. (4) Conclusions: During salbutamol delivery via HFNC, cumulative doses of 1.5 mg to 3.5 mg resulted in effective bronchodilation. Applying the robust ATS/ERS criteria no difference was observed between the flows, however using the more sensitive criteria of subjects reaching post screening FEV1 to salbutamol via HFNC, a higher number of subjects responded to the doses of 0.5 mg and 1.5 mg when HFNC gas flow was set at 50% of patient peak inspiratory flow.
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17
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Li J, Tu M, Yang L, Jing G, Fink JB, Burtin C, Andrade ADD, Gong L, Xie L, Ehrmann S. Worldwide Clinical Practice of High-Flow Nasal Cannula and Concomitant Aerosol Therapy in the Adult ICU Setting. Respir Care 2021; 66:1416-1424. [PMID: 33824172 PMCID: PMC9993868 DOI: 10.4187/respcare.08996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND High-flow nasal cannula (HFNC) oxygen therapy has been broadly used. However, no consensus has been achieved on the practical implementation of HFNC and how to provide aerosol delivery during HFNC therapy in adult patients. METHODS An online anonymous questionnaire survey endorsed by 4 academic societies from America, Europe, mainland China, and Taiwan was administered from May to December 2019. Clinicians who had worked in adult ICUs for > 1 year and had used HFNC to treat patients within 30 days were included. RESULTS A total of 2,279 participants clicked on the survey link, 1,358 respondents completed the HFNC section of the questionnaire, whereas 1,014 completed the whole survey. Postextubation hypoxemia and moderate hypoxemia were major indications for HFNC. The initial flow was mainly set at 40-50 L/min. Aerosol delivery via HFNC was used by 24% of the participants (248/1,014), 30% (74/248) of whom reported reducing flow during aerosol delivery. For the patients who required aerosol treatment during HFNC therapy, 40% of the participants (403/1,014) reported placing a nebulizer with a mask or mouthpiece while pursuing HFNC whereas 33% (331/1,014) discontinued HFNC to use conventional aerosol devices. A vibrating mesh nebulizer was the most commonly used nebulizer (40%) and was mainly placed at the inlet of the humidifier. CONCLUSIONS The clinical utilization of HFNC was variable, as were indications, flow settings, and criteria for adjustment. Many practices associated with concomitant aerosol therapy were not consistent with available evidence for optimal use. More efforts are warranted to close the knowledge gap.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois.
| | - Meilien Tu
- Department of Respiratory Care, Chang Gung University of Science and Technology, Taiwan
| | - Lei Yang
- Hongli Hospital, Xinxiang, Henan, China
| | - Guoqiang Jing
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois
- Aerogen Pharma Corp, San Mateo, California
| | - Chris Burtin
- Universiteit Hasselt - Campus Diepenbeek, Hasselt, Belgium
| | | | - Lingyue Gong
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois
| | - Lixin Xie
- Department of Respiratory and Critical Care Medicine, People's Liberation Army General Hospital, Beijing, China.
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC Institut National de la Santé et de la Recherche Médicale 1415, CRICS-TriggerSEP F-CRIN Research Network, Tours, France
- Institut National de la Santé et de la Recherche Médicale, Centre d'étude des pathologies respiratoires, U1100, Université de Tours, Tours, France
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18
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Ari A. A path to successful patient outcomes through aerosol drug delivery to children: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:593. [PMID: 33987291 PMCID: PMC8105845 DOI: 10.21037/atm-20-1682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/03/2020] [Indexed: 11/06/2022]
Abstract
Although using aerosolized medications is a mainstay of treatment in children with asthma and other respiratory diseases, there are many issues in terms of device and interface selection, delivery technique and dosing, as well as patient and parental education that have not changed for half a century. Also, due to many aerosol devices and interfaces available on the market and the broad range of patient characteristics and requirements, providing effective aerosol therapy to children becomes a challenge. While aerosol delivery devices are equally effective, if they are age-appropriate and used correctly, the majority of aerosol devices require multiple steps to be used efficiently. Unfortunately, many children with pulmonary diseases have problems with the correct delivery technique and do not gain therapeutic benefits from therapy that result in poor disease management and increased healthcare costs. Therefore, the purpose of this paper is to review the current knowledge on aerosol delivery devices used in children and guide clinicians on the optimum device- and interface-selection, delivery technique, and dosing in this patient population. Strategies on how to deliver aerosolized medications in crying and distressed children and how to educate parents on aerosol therapy and promote patient adherence to prescribed medications are also provided. Future directions of aerosol therapy in children should focus on these issues and implement policies and clinical practices that highlight the potential solutions to these problems.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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19
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Li J, Fink JB. Narrative review of practical aspects of aerosol delivery via high-flow nasal cannula. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:590. [PMID: 33987288 DOI: 10.21037/atm-20-7383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Using high-flow nasal cannula (HFNC) as a "vehicle" to administer aerosolized medication has attracted clinicians' interest in recent years. In this paper, we summarize the current evidence to answer the common questions raised by clinicians about this new aerosol delivery route and best practices of administration. Benefits of trans-nasal aerosol delivery include increased comfort, ability to speak, eat, and drink for patients while meeting a range of oxygen requirements, particularly for those who need to inhale aerosolized medication for long periods. Aerosol administration via HFNC has been shown to be well tolerated by children and adults, with comparable or better delivery efficacy than other interfaces, ranging from 2-20%. In vitro and in vivo scintigraphy studies among pediatric and adult populations reported that the inhaled dose delivered via a vibrating mesh nebulizer is 2 to 3 fold greater than that via a jet nebulizer. For adults, placement of nebulizer at the inlet of humidifier increases inhaled dose while reducing rainout obstructing nasal prongs. When HFNC gas flow is set below patient inspiratory flow, aerosol deposition is higher than when the gas flow exceeds patient inspiratory flow; thus, if tolerated, titrating down HFNC gas flow during trans-nasal aerosol delivery, with close monitoring and the use of unit dose with high concentration are recommended. Trans-nasal pulmonary aerosol delivery has not been shown to increase bioaerosols generated by patients, but gas flow may disperse aerosols. Placement of a surgical or procedure mask over HFNC might reduce aerosol dispersion.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
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20
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Szychowiak P, Gensburger S, Bocar T, Landel C, Philippe M, Le Pennec D, Cabrera M, Mordier L, Vecellio L, Reminiac F, Heuze-Vourc'h N, Ehrmann S. Pressurized Metered Dose Inhaler Aerosol Delivery Within Nasal High-Flow Circuits: A Bench Study. J Aerosol Med Pulm Drug Deliv 2021; 34:303-310. [PMID: 33761286 DOI: 10.1089/jamp.2020.1643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: Obstructive patients may benefit from nasal high-flow (NHF) therapy, but the use of pressurized metered-dose inhalers (pMDIs) has not been evaluated in this situation. Methods: Using an adult circuit and medium-sized cannula, we have tested different NHF rates, pMDI positions, breathing patterns, spacers, and spacer orientation. First, we evaluated albuterol delivery at the nasal cannula outlet. The second set of experiments made use of a nasopharyngeal cast to estimate the mass of albuterol potentially reaching the lungs. Albuterol was caught on filters placed at the cannula outlet and downstream of the nasal cast, and albuterol was quantified by spectrophotometry. Results: The highest amounts of albuterol delivered at the cannula outlet were observed with a 30 L/min flow rate (vs. 45 and 60 L/min) and placing the device close to the nasal cannula (in comparison with a position on the dry side of the humidification chamber). The use of a spacer was associated with higher delivery. The highest albuterol delivery was observed placing the spacer close to the nasal cannula, oriented for aerosol delivery following the gas flow and a 30 L/min NHF rate. Using this optimal setting, activating the pMDI at the beginning of inspiration (compared to expiration) increased albuterol delivery downstream of the nasopharyngeal cast. Whether in a quiet- or distress-breathing pattern, our measurements showed an amount of albuterol potentially delivered to the lungs exceeding 10% of the actuated dose in optimal conditions. Conclusions: The use of pMDIs is feasible to deliver albuterol within a NHF circuit. Using a spacer placed just upstream from the nasal cannulas, a low NHF rate and activating the pMDI at the beginning of inspiration was associated with drug delivery susceptible to induce bronchodilation, which will require to be tested in the clinical setting.
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Affiliation(s)
- Piotr Szychowiak
- Service de Médecine Intensive Réanimation, CHRU de Tours, Tours, France
| | - Samuel Gensburger
- Service de Médecine Intensive Réanimation, CHRU de Tours, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France
| | - Thomas Bocar
- Service de Médecine Intensive Réanimation, CHRU de Tours, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France
| | - Cassandre Landel
- INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France
| | - Marion Philippe
- INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France
| | - Deborah Le Pennec
- INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France
| | - Maria Cabrera
- INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France
| | - Lydiane Mordier
- INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France
| | - Laurent Vecellio
- INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France
| | - François Reminiac
- INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France.,Service de Médecine Intensive Réanimation, INSERM CIC 1415, Réseau CRICS-TRIGGERSEP, FCRIN endorsed network, CHRU de Tours, Tours, France
| | - Nathalie Heuze-Vourc'h
- INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France
| | - Stephan Ehrmann
- INSERM, Centre d'Étude des Pathologies Respiratoires (CEPR) UMR 1100, Université de Tours, Tours, France.,Service de Médecine Intensive Réanimation, INSERM CIC 1415, Réseau CRICS-TRIGGERSEP, FCRIN endorsed network, CHRU de Tours, Tours, France
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Dubus JC, Becquemin MH, Vecellio L, Chaumuzeau JP, Reychler G. [Good practice for aerosol therapy by nebulization in 2020]. Rev Mal Respir 2020; 38:171-176. [PMID: 33288396 DOI: 10.1016/j.rmr.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/21/2020] [Indexed: 11/16/2022]
Abstract
Nebulization is a drug delivery mode whose prescription and application remain uncertain. A guide to good practice has been proposed by the work group on aerosol therapy of the French Society for Respiratory Diseases, so-called GAT. The previous recommendations date from 2007. In addition to an update of data on nebulization, these expert recommendations aim to be of real help to the prescriber.
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Affiliation(s)
- J-C Dubus
- Pneumologie et allergologie pédiatrique, CHU Timone-Enfants, et Aix Marseille Université, IRD, MEPHI, IHU-Méditerranée Infection, Marseille, France.
| | - M-H Becquemin
- Hôpitaux universitaires Pitié-Salpétrière-Charles Foix, AP-HP, Paris, France
| | - L Vecellio
- Inserm, centre d'étude des pathologies respiratoires (CEPR), UMR 1100, université de Tours, Tours, France
| | | | - G Reychler
- Service de pneumologie, université catholique de Louvain, cliniques universitaires Saint-Luc, et institut de recherche expérimentale et clinique, Bruxelles, Belgique
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22
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Papalampidou A, Bibaki E, Boutlas S, Pantazopoulos I, Athanasiou N, Moylan M, Vlachakos V, Grigoropoulos V, Eleftheriou K, Daniil Z, Gourgoulianis K, Kalomenidis I, Zakynthinos S, Ischaki E. Nasal high-flow oxygen versus noninvasive ventilation in acute exacerbation of COPD: protocol for a randomised noninferiority clinical trial. ERJ Open Res 2020; 6:00114-2020. [PMID: 33123554 PMCID: PMC7569159 DOI: 10.1183/23120541.00114-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Noninvasive ventilation (NIV) is considered as the first-line treatment for acute exacerbation of COPD (AECOPD) complicated by respiratory acidosis. Recent studies demonstrate a role of nasal high-flow oxygen (NHF) in AECOPD as an alternative treatment in patients intolerant to NIV or with contraindications to it. Aim The study aimed to evaluate whether NHF respiratory support is noninferior compared to NIV in respect to treatment failure, defined as need for intubation or change to alternative treatment group, in patients with AECOPD and mild-to-moderate acute or acute-on-chronic hypercapnic respiratory failure. Methods We designed a multicentre, prospective, randomised trial on patients with AECOPD, who have pH<7.35 but >7.25 and PaCO2 >45 mmHg, in whom NIV is indicated as a first-line treatment. According to power analysis, 498 participants will be required for establishing noninferiority of NHF compared to NIV. Patients will be randomly assigned to receive NIV or NHF. Treatment will be adjusted to maintain SpO2 between 88%–92% for both groups. Arterial blood gases, respiratory variables, comfort, dyspnoea score and any pulmonary or extrapulmonary complications will be assessed at baseline, before treatment initiation, and at 1, 2, 4, 6, 12, 24, 48 h, then once daily from day 3 to patient discharge, intubation or death. Conclusion Given the increasing number of studies demonstrating the physiological effects of NHF in COPD patients, we hypothesise that NHF respiratory support will be noninferior to NIV in patients with AECOPD and mild-to-moderate acute or acute on chronic hypercapnic respiratory failure. Nasal high-flow oxygen could be an effective alternative to NIV respiratory support for patients with mild-to-moderate #AECOPD, especially for those who do not tolerate or have contraindications for NIVhttps://bit.ly/3bgxDYx
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Affiliation(s)
- Athanasia Papalampidou
- First Dept of Critical Care Medicine and Pulmonary Services, Medical School of Athens, Evangelismos Hospital, Athens, Greece.,Both authors contributed equally to this manuscript
| | - Eleni Bibaki
- Respiratory Dept, Venizelio General Hospital, Athens, Greece.,Both authors contributed equally to this manuscript
| | - Stylianos Boutlas
- Dept of Respiratory Medicine, School of Medicine, University of Thessaly, Larissa, Greece
| | | | | | - Melanie Moylan
- Dept of Epidemiology and Biostatistics, Auckland University of Technology, Auckland, New Zealand
| | - Vasileios Vlachakos
- First Dept of Critical Care Medicine and Pulmonary Services, Medical School of Athens, Evangelismos Hospital, Athens, Greece
| | - Vasileios Grigoropoulos
- First Dept of Critical Care Medicine and Pulmonary Services, Medical School of Athens, Evangelismos Hospital, Athens, Greece
| | - Konstantinos Eleftheriou
- First Dept of Critical Care Medicine and Pulmonary Services, Medical School of Athens, Evangelismos Hospital, Athens, Greece
| | - Zoe Daniil
- Dept of Respiratory Medicine, School of Medicine, University of Thessaly, Larissa, Greece
| | | | - Ioannis Kalomenidis
- First Dept of Critical Care Medicine and Pulmonary Services, Medical School of Athens, Evangelismos Hospital, Athens, Greece
| | - Spyros Zakynthinos
- First Dept of Critical Care Medicine and Pulmonary Services, Medical School of Athens, Evangelismos Hospital, Athens, Greece
| | - Eleni Ischaki
- First Dept of Critical Care Medicine and Pulmonary Services, Medical School of Athens, Evangelismos Hospital, Athens, Greece
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Li J, Fink JB, MacLoughlin R, Dhand R. A narrative review on trans-nasal pulmonary aerosol delivery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:506. [PMID: 32807226 PMCID: PMC7430014 DOI: 10.1186/s13054-020-03206-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/27/2020] [Indexed: 01/21/2023]
Abstract
The use of trans-nasal pulmonary aerosol delivery via high-flow nasal cannula (HFNC) has expanded in recent years. However, various factors influencing aerosol delivery in this setting have not been precisely defined, and no consensus has emerged regarding the optimal techniques for aerosol delivery with HFNC. Based on a comprehensive literature search, we reviewed studies that assessed trans-nasal pulmonary aerosol delivery with HFNC by in vitro experiments, and in vivo, by radiolabeled, pharmacokinetic and pharmacodynamic studies. In these investigations, the type of nebulizer employed and its placement, carrier gas, the relationship between gas flow and patient’s inspiratory flow, aerosol delivery strategies (intermittent unit dose vs continuous administration by infusion pump), and open vs closed mouth breathing influenced aerosol delivery. The objective of this review was to provide rational recommendations for optimizing aerosol delivery with HFNC in various clinical settings.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
| | | | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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24
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Acute respiratory failure: nonintubation assist methods for the acutely deteriorating patient. Curr Opin Crit Care 2020; 25:591-596. [PMID: 31567516 DOI: 10.1097/mcc.0000000000000670] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Noninvasive ventilation is strongly recommended in acute hypercapnic respiratory failure, whereas high-flow nasal oxygen therapy could be an alternative in de novo respiratory failure. RECENT FINDINGS High-flow nasal oxygen may improve the outcome of patients de novo respiratory failure as compared with standard oxygen. Its success within 2 h after initiation is well predicted by a ROX index (ratio of SpO2/FiO2 to respiratory rate) greater than 4.88, as failure when less than 3.85 at 12 h after initiation. However, the superiority of high-flow nasal oxygen to standard oxygen has not been confirmed in immunocompromised patients. Although noninvasive ventilation may be deleterious through barotrauma in patients with de novo respiratory failure, its use seems to be an optimal strategy for preoxygenation before intubation in preventing severe hypoxemia in most hypoxemic patients. In mild hypoxemic patient, high-flow nasal oxygen may be more efficient than bag-valve mask in preventing severe adverse events. After anesthetic induction further positive-pressure ventilation can better secure intubation procedure than absence of ventilation. SUMMARY Despite the growing use of high-flow nasal oxygen, new studies are needed to confirm its superiority to standard oxygen in de novo respiratory failure and others causes of acute respiratory failure in place of standard oxygen.
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25
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Li J, Wu W, Fink JB. In vitro comparison between inspiration synchronized and continuous vibrating mesh nebulizer during trans-nasal aerosol delivery. Intensive Care Med Exp 2020; 8:6. [PMID: 32006290 PMCID: PMC6994578 DOI: 10.1186/s40635-020-0293-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/14/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Compared to continuous vibrating mesh nebulizer (VMN), inspiration synchronized VMN has shown increased inhaled dose during noninvasive ventilation; however, its use during aerosol delivery via high-flow nasal cannula (HFNC) is still unknown. METHODS An adult manikin was connected to a dual-chamber model lung, which was driven by a critical care ventilator to simulate spontaneous breathing. A HFNC system was utilized with temperature at 37 ° C while gas flow at 5, 10, 20, 40, and 60 L/min. Inspiration synchronized and continuous aerosol generation were compared at different positions (at the inlet of humidifier vs close to patient). One milliliter of albuterol (2.5 mg/mL) was used in each run (n = 3). Collection filter was placed at the trachea and was removed after each run. Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). RESULTS When nebulizer was placed close to patient, inhaled dose was higher with inspiration synchronized than continuous aerosol generation at all gas flows (p = 0.05) except at 5 L/min. When placed at the inlet of humidifier, compared to continuous, inspiration synchronized aerosol generated higher inhaled dose with gas flow set below 50% of patient inspiratory flow [23.9 (20.6, 28.3)% vs 18.1 (16.7, 19.6)%, p < 0.001], but lower inhaled dose with gas flow set above 50% of patient inspiratory flow [3.5 (2.2, 9.3)% vs 9.9 (8.2, 16.4)%, p = 0.001]. Regardless of breathing pattern, continuous aerosol delivered greater inhaled dose with nebulizer placed at humidifier than close to patient at all gas flows except at 5 L/min. CONCLUSION When the HFNC gas flow was set higher than 50% of patient inspiratory flow, no significant advantage was found in inspiration synchronized over continuous aerosol. However, inspiration synchronized aerosol generated 30% more inhaled dose than continuous with gas flow set below 50% of patient inspiratory flow, regardless of nebulizer placement. Continuous nebulizer needs to be placed at the inlet of humidifier.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.
| | - Wei Wu
- Department of Critical Care Medicine, Shanghai Zhongshan Hospital, Fu Dan University, Shanghai, China
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
- Aerogen Pharma Corp, San Mateo, CA, USA
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26
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Pantazopoulos I, Daniil Z, Moylan M, Gourgoulianis K, Chalkias A, Zakynthinos S, Ischaki E. Nasal High Flow Use in COPD Patients with Hypercapnic Respiratory Failure: Treatment Algorithm & Review of the Literature. COPD 2020; 17:101-111. [PMID: 31965868 DOI: 10.1080/15412555.2020.1715361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Nasal high flow (NHF) therapy has recently gained attention as a new respiratory support system and is increasingly being utilized in every day clinical practice. Recent studies suggest that it may also be effective in patients with hypercapnia and suggest NHF as a possible alternative for patients who cannot tolerate standard noninvasive ventilation. The present review discusses the mechanisms of action that make NHF potentially suitable for chronic obstructive pulmonary disease (COPD) patients and evaluates the current evidence of NHF use for treatment of stable hypercapnic COPD patients as well as acute hypercapnic exacerbation of COPD. An algorithm is also proposed for the clinical application of NHF in patients with acute hypercapnic exacerbation of COPD, based on current literature.
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Affiliation(s)
- Ioannis Pantazopoulos
- Department of Emergency Medicine, University of Thessaly, School of Medicine, General Hospital of Larisa, Thessaly, Greece
| | - Zoi Daniil
- Department of Respiratory Medicine, University of Thessaly, School of Medicine, General Hospital of Larisa, Thessaly, Greece
| | - Melanie Moylan
- Department of Biostatistics and Epidemiology, Auckland University of Technology, Auckland, New Zealand
| | - Konstantinos Gourgoulianis
- Department of Emergency Medicine, University of Thessaly, School of Medicine, General Hospital of Larisa, Thessaly, Greece
| | - Athanasios Chalkias
- Department of Anesthesiology, University of Thessaly, School of Medicine, General Hospital of Larisa, Thessaly, Greece
| | - Spyros Zakynthinos
- First Department of Critical Care Medicine & Pulmonary Services, Medical School, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - Eleni Ischaki
- First Department of Critical Care Medicine & Pulmonary Services, Medical School, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
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Alalwan MA, Fink JB, Ari A. In vitro evaluation of aerosol drug delivery with and without high flow nasal cannula in children. Pediatr Pulmonol 2019; 54:1968-1973. [PMID: 31468741 DOI: 10.1002/ppul.24501] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 08/14/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To quantify aerosol delivery with or without a high flow nasal cannula (HFNC) in place using pressurized metered-dose inhaler (pMDI) and jet nebulizer (JN) with facemask in a simulated spontaneously breathing pediatric lung model. METHODS An upper airway model of a 9-month-old infant (Sophia Anatomical Infant Nose-Throat) with an absolute filter distal to the trachea was connected to a breathing simulator to simulate pediatric parameters (tidal volume = 100 mL, respiratory rate = 30 breaths/min, and I:E ratio = 1:1.4). Oxygen at 3 L/min was administered through an infant HFNC (Fisher & Paykel Healthcare Ltd, Auckland, New Zealand) attached to the nares of the model. Albuterol sulfate (2.5 mg/3 mL) was delivered with JN attached to an aerosol facemask and powered by air at 8 L/min. Ventolin Hydrofluoroalkane (HFA) (360 μg) was administered using pMDI connected to a valved holding chamber (VHC) with a facemask. Aerosol was administered to the model with and without HFNC in the nares (n = 3). Drug was eluted from the filter and quantified using spectrophotometry. Independent t tests were performed for data analysis (P < .05). RESULTS Aerosol deposition was greater without HFNC (6.05% ± 1.53% and 39.54% ± 8.98% for JN and pMDI/VHC, respectively) than with HFNC using JN (2.91% ± 0.23%; P = .024) and pMDI/VHC (6.04% ± 0.28%; P = .003). Delivery efficiency of pMDI/VHC was greater than JN with or without nasal cannula in place (P = .0001 and .003, respectively). CONCLUSION Aerosol administered via facemask over HFNC was less efficient than removing HFNC during administration. When delivering medical aerosol by facemask, the benefit of increased aerosol delivery must be weighed against the changes in oxygen delivery and risk of lung derecruitment when nasal prongs are removed.
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Affiliation(s)
- Mahmood A Alalwan
- Department of Respiratory Therapy, Inaya Medical College, Riyadh, Saudi Arabia
| | - James B Fink
- Department of Respiratory Care, Texas State University, Round Rock, Texas
| | - Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, Texas
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28
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Dugernier J, Reychler G, Vecellio L, Ehrmann S. Nasal High-Flow Nebulization for Lung Drug Delivery: Theoretical, Experimental, and Clinical Application. J Aerosol Med Pulm Drug Deliv 2019; 32:341-351. [DOI: 10.1089/jamp.2019.1524] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Jonathan Dugernier
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Soins Intensifs, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Médecine Physique, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Grégory Reychler
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Service de pneumologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Laurent Vecellio
- Centre d'études des pathologies respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Stephan Ehrmann
- Centre d'études des pathologies respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
- Médecine intensive réanimation, Centre d'investigation clinique CIC INSERM 1415, CHRU de Tours, Tours, France
- CRICS-TriggerSep Research Network
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Ari A. Effect of nebulizer type, delivery interface, and flow rate on aerosol drug delivery to spontaneously breathing pediatric and infant lung models. Pediatr Pulmonol 2019; 54:1735-1741. [PMID: 31313534 DOI: 10.1002/ppul.24449] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/08/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Different types of nebulizers, interfaces, and flow rates are used to deliver aerosolized medications to children. The purpose of this study was to determine the effect of nebulizer type, delivery interface, and flow rate on aerosol drug delivery to spontaneously breathing pediatric and infant lung models. METHODOLOGY A teaching mannequin was attached to a sinusoidal pump via a collecting filter at the bronchi to simulate a spontaneously breathing child (Vt: 250 mL, RR: 20 bpm and Ti: 1 second) and infant (Vt = 100 mL, RR = 30 bpm, Ti: 0.7 seconds). Albuterol sulfate was nebulized with jet (Misty Max 10; Cardinal Health) and mesh (Aerogen Solo; Aerogen) nebulizers using a low-flow nasal cannula (LFNC; Hudson), a high-flow nasal cannula (HFNC; Fisher & Paykel), face mask (FM; Hudson), and mouthpiece (MP; Cardinal Health). While all interfaces were used in the pediatric study, only LFNC, HFNC, and FM were tested in the infant study. The mesh nebulizer was tested at 2, 4, and 6 L/min with LFNC, 4 and 6 L/min with HFNC, and 6 L/min with FM and MP. The jet nebulizer was operated at 6 and 8 L/min with FM and 6 L/min with LFNC, HFNC, and MP (n = 5). The drug was eluted from the filter and analyzed by spectrophotometry. Factorial analysis of variance and post hoc comparisons were used for data analysis. P < .05 was considered statistically significant. RESULTS Delivery efficiency of mesh nebulizers is two to fourfold more than jet nebulizers used with HFNC, FM, and MP. No statistical difference was found between jet and mesh nebulizers used with LFNC in infants (P = .643) and pediatrics (P = .255). Aerosol delivery with MP was the best compared to other interfaces used in pediatrics (P < .05). As the second-best interface in aerosol drug delivery, the delivery efficiency of FM was greater than HFNC (P = .0001) and LFNC (P = .0001). Increasing flow rate with LFNC and HFNC decreased aerosol delivery with the mesh nebulizer in both infants and pediatrics. CONCLUSION The type of nebulizer, delivery interface, and flow rate used in the treatment of children affect aerosol drug delivery.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, College of Health Professions, Texas State University, Round Rock, Texas
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Abstract
The 2014 American Academy of Pediatrics bronchiolitis guidelines do not adequately serve the needs and clinical realities of front-line clinicians caring for undifferentiated wheezing infants and children. This article describes the clinical challenges of evaluating and managing a heterogeneous disease syndrome presenting as undifferentiated patients to the emergency department. Although the 2014 American Academy of Pediatrics bronchiolitis guidelines and the multiple international guidelines that they closely mirror have made a good faith attempt to provide clinicians with the best evidence-based recommendations possible, they have all failed to address practical, front-line clinical challenges. The therapeutic nihilism of the guidelines and the dissonance between many of the recommendations and frontline realities have had wide-ranging consequences. Nevertheless, newer evidence of therapeutic options is emerging and forecasts hope for more therapeutically optimistic recommendations with the next revision of the guidelines.
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Li J, Zhao M, Hadeer M, Luo J, Fink JB. Dose Response to Transnasal Pulmonary Administration of Bronchodilator Aerosols via Nasal High-Flow Therapy in Adults with Stable Chronic Obstructive Pulmonary Disease and Asthma. Respiration 2019; 98:401-409. [PMID: 31473748 DOI: 10.1159/000501564] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/17/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There has been increasing interest in transnasal pulmonary aerosol administration, but the dose-response relationship has not been reported. OBJECTIVES To determine the accumulative bronchodilator dose at which patients with stable mild-to-moderate asthma and chronic obstructive pulmonary disease (COPD) achieve similar spirometry responses before and after bronchodilator tests using albuterol via a metered dose inhaler with a valved holding chamber (MDI + VHC). METHOD Adult patients who met ATS/ERS criteria for bronchodilator responses in pulmonary function laboratory were recruited and consented to participate. After a washout period, patients received escalating doubling dosages (0.5, 1, 2, and 4 mg) of albuterol in a total volume of 2 mL delivered by vibrating mesh nebulizer via a nasal cannula at 37°C with a flow rate of 15-20 L/min using a Venturi air entrainment device. Spirometry was measured at baseline and after each dose. Titration was stopped when an additional forced expiratory volume in 1 second (FEV1) improvement was <5%. RESULTS 42 patients (16 males) with stable mild-to-moderate asthma (n = 29) and COPD (n = 13) were enrolled. FEV1 increment after a cumulative dose of 1.5 mg of albuterol via nasal cannula at 15-20 L/min was similar to 4 actuations of MDI + VHC (0.34 ± 0.18 vs. 0.34 ± 0.12 L, p = 0.878). Using ATS/ERS criteria of the bronchodilator test, 33.3% (14/42) and 69% (29/42) of patients responded to 0.5 and 1.5 mg of albuterol, respectively. CONCLUSIONS With a nasal cannula at 15-20 L/min, transnasal pulmonary delivery of 1.5 mg albuterol resulted in similar bronchodilator response as 4 actuations of MDI + VHC.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA,
| | - Minghua Zhao
- Division of Pulmonary Function Test Laboratory, Department of Respiratory Care, People's Hospital of the Xinjiang Autonomous Region, Urumqi, China
| | - Maierbati Hadeer
- Division of Pulmonary Function Test Laboratory, Department of Respiratory Care, People's Hospital of the Xinjiang Autonomous Region, Urumqi, China
| | - Jian Luo
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, China
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA.,Aerogen Pharma Corporation, San Mateo, California, USA
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Alcoforado L, Ari A, Barcelar JDM, Brandão SCS, Fink JB, de Andrade AD. Impact of Gas Flow and Humidity on Trans-Nasal Aerosol Deposition via Nasal Cannula in Adults: A Randomized Cross-Over Study. Pharmaceutics 2019; 11:pharmaceutics11070320. [PMID: 31284680 PMCID: PMC6680424 DOI: 10.3390/pharmaceutics11070320] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Trans-nasal pulmonary aerosol delivery using high flow nasal cannula (HFNC) devices is described with the administration of high gas flows exceeding patient inspiratory flow (HF) and with lower flows (LF). The aim of this pilot clinical trial was to compare deposition and distribution of radiolabeled aerosol via nasal cannula in healthy adults across three rates of gas flow delivered with active heated humidification, and to further identify the impact of aerosol administration without heated humidity. Methods: Twenty-three (23) healthy adults (16F) were randomized to receive aerosol with active heated humidification or unheated oxygen at gas flows of 10 L/min (n = 8), 30 L/min (n = 7), or 50 L/min (n = 8). Diethylenetriaminepentaacetic acid labeled with 1 millicurie (37 MBq) of Technetium-99m (DTPA-Tc99m) was mixed with NaCl to a fill volume of 1 mL, and administered via mesh nebulizer placed at the inlet of the humidifier. Radioactivity counts were performed using a gamma camera and the regions of interest (ROIs) were delimited with counts from the lungs, upper airways, stomach, nebulizer, circuit, and expiratory filter. A mass balance was calculated and each compartment was expressed as a percentage of the total. Results: Lung deposition (mean ± SD) with heated humidified gas was greater at 10 L/min than 30 L/min or 50 L/min (17.2 ± 6.8%, 5.71 ± 2.04%, and 3.46 ± 1.24%, respectively; p = 0.0001). Using unheated carrier gas, a lung dose of aerosol was similar to the active heated humidification condition at 10 L/min, but greater at 30 and 50 L/min (p = 0.011). Administered gas flow and lung deposition were negatively correlated (r = −0.880, p < 0.001). Conclusions: Both flow and active heated humidity inversely impact aerosol delivery through HFNC. Nevertheless, aerosol administration across the range of commonly used flows can provide measurable levels of lung deposition in healthy adult subjects (NCT 02519465).
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Affiliation(s)
- Luciana Alcoforado
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife 50740-560, PE, Brazil
| | - Arzu Ari
- Department of Respiratory Therapy, Texas State University, Round Rock, TX 78665, USA
| | | | | | - James B Fink
- Department of Respiratory Therapy, Texas State University, Round Rock, TX 78665, USA
- Aerogen Pharma Corp, San Mateo, CA 94402, USA
| | - Armele Dornelas de Andrade
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife 50740-560, PE, Brazil.
- Avenida Jornalista Aníbal Fernandes, SN-Cidade Universitária, CEP, Recife 50740-560, PE, Brazil.
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Li J, Luo J, Chen Y, Xie L, Fink JB. Effects of flow rate on transnasal pulmonary aerosol delivery of bronchodilators via high-flow nasal cannula for patients with COPD and asthma: protocol for a randomised controlled trial. BMJ Open 2019; 9:e028584. [PMID: 31239304 PMCID: PMC6597746 DOI: 10.1136/bmjopen-2018-028584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Both in vitro and in vivo radiolabelled studies on nebulisation via high-flow nasal cannula showed that inhaled dose decreases as the administered gas flow increases. In our previous in vitro study, we investigated the effects of the ratio of gas flow to subject's peak inspiratory flow (GF:IF) on the aerosol deposition, which increased as the GF:IF decreased, with an optimal GF:IF between 0.1 and 0.5 producing a stable 'lung' deposition in both quiet and distressed breathing. Thus, we aim to validate our in vitro findings in subjects with reversible airflow limitations by assessing their response to inhaled bronchodilator. METHODS AND ANALYSIS This is a single-centre, randomised controlled trial. Subjects with chronic obstructive pulmonary disease or asthma with positive response to 400μg albuterol via metered dose inhaler and valved holding chamber will be enrolled and consented. After a washout period (1-3 days), subjects will be randomly assigned to inhale albuterol with one of three gas flows: 50 L/min, GF:IF=1.0 and GF:IF=0.5. In each arm, subjects will inhale 2 mL saline, followed by escalating doubling doses (0.5, 1, 2 and 4 mg) of albuterol in a fill volume of 2 mL, delivered by a vibrating mesh nebuliser via heated nasal cannula set up at 37°C. An interval of 30 min between each dose of albuterol, with spirometry measured at baseline and after each inhalation. Titration will be terminated if forced expiratory volume in 1 s improvement is <5%, or adverse event is observed. ETHICS AND DISSEMINATION This trial has been approved by the Ethic Committee of People's Liberation Army General Hospital, Beijing, China (no. S2018-200-01). The results will be disseminated through peer-reviewed journals, national and international conferences. TRIAL REGISTRATION NUMBER NCT03739359; Pre-results.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois, USA
| | - Jian Luo
- Department of Pulmonary and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Yibing Chen
- Department of Respiratory and Critical Care Medicine, Pulmonary Function Test Lab, General Hospital of People’s Liberation Army, Beijing, China
| | - Lixing Xie
- Department of Respiratory and Critical Care Medicine, Pulmonary Function Test Lab, General Hospital of People’s Liberation Army, Beijing, China
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois, USA
- Aerogen Pharma Corp, San Mateo, California, USA
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Li J, Harnois LJ, Markos B, Roberts KM, Homoud SA, Liu J, Mirza S, Vines D. Epoprostenol Delivered via High Flow Nasal Cannula for ICU Subjects with Severe Hypoxemia Comorbid with Pulmonary Hypertension or Right Heart Dysfunction. Pharmaceutics 2019; 11:pharmaceutics11060281. [PMID: 31207936 PMCID: PMC6631264 DOI: 10.3390/pharmaceutics11060281] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 12/20/2022] Open
Abstract
Inhaled epoprostenol (iEPO) has been utilized to improve oxygenation in mechanically ventilated subjects with severe hypoxemia, but the evidence for iEPO via high-flow nasal cannula (HFNC) is rare. Following approval by the institutional review board, this retrospective cohort study evaluated subjects who received iEPO via HFNC for more than 30 min to treat severe hypoxemia comorbid with pulmonary hypertension or right heart dysfunction between July 2015 and April 2018. A total of 11 subjects were enrolled in the study of whom 4 were male (36.4%), age 57.5 ± 22.1 years, and APACHE II score at ICU admission was 18.5 ± 5.7. Ten subjects had more than three chronic heart or lung comorbidities; seven of them used home oxygen. After inhaling epoprostenol, subjects' SpO2/FIO2 ratio improved from 107.5 ± 26.3 to 125.5 ± 31.6 (p = 0.026) within 30-60 min. Five subjects (45.5%) had SpO2/FIO2 improvement >20%, which was considered as a positive response. Heart rate, blood pressure, and respiratory rate were not significantly different. Seven subjects did not require intubation, and seven subjects were discharged home. This retrospective study demonstrated the feasibility of iEPO via HFNC in improving oxygenation. Careful titration of flow while evaluating subjects' response may help identify responders and avoid delaying other interventions. This study supports the need for a larger prospective randomized control trial to further evaluate the efficacy of iEPO via HFNC in improving outcomes.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Lauren J Harnois
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Bethelhem Markos
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Keith M Roberts
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Salma Al Homoud
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Jing Liu
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Sara Mirza
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - David Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
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The Ratio of Nasal Cannula Gas Flow to Patient Inspiratory Flow on Trans-nasal Pulmonary Aerosol Delivery for Adults: An in Vitro Study. Pharmaceutics 2019; 11:pharmaceutics11050225. [PMID: 31083346 PMCID: PMC6571744 DOI: 10.3390/pharmaceutics11050225] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/08/2019] [Accepted: 05/08/2019] [Indexed: 11/17/2022] Open
Abstract
Trans-nasal aerosol deposition during distressed breathing is higher than quiet breathing, and decreases as administered gas flow increases. We hypothesize that inhaled dose is related to the ratio of gas flow to patient inspiratory flow (GF:IF). An adult manikin (Laerdal) with a collecting filter placed at trachea was connected to a dual-chamber model lung, which was driven by a ventilator to simulate quiet and distressed breathing with different inspiratory flows. Gas flow was set at 5, 10, 20, 40 and 60 L/min. Albuterol (2.5mg in 1 mL) was nebulized by vibrating mesh nebulizer at the inlet of humidifier at 37 °C for each condition (n = 3). Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). GF:IF was the primary predictor of inhaled dose (p < 0.001). When the ratio was < 1.0, the inhaled dose was higher than ratio > 1.0 (21.8 ± 3.8% vs. 9.0 ± 3.7%, p < 0.001), and the inhaled dose was similar between quiet and distressed breathing (22.3 ± 5.0% vs. 21.3 ± 2.7%, p = 0.379). During trans-nasal aerosol delivery, GF:IF primarily affected the inhaled dose. Compared to the ratio above 1.0, the ratio below 1.0 produced a higher and more-consistent inhaled dose.
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