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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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Harb HS, Saeed H, Madney YM, Abdelrahman MA, Osama H, Esquinas AM, Abdelrahim ME. Update efficacy of aerosol therapy with noninvasive ventilator approach (non-invasive ventilation and nasal high flow). J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2020.101922] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Luyt CE, Hékimian G, Bréchot N, Chastre J. Aerosol Therapy for Pneumonia in the Intensive Care Unit. Clin Chest Med 2019; 39:823-836. [PMID: 30390752 DOI: 10.1016/j.ccm.2018.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Antibiotic aerosolization in patients with ventilator-associated pneumonia (VAP) allows very high concentrations of antimicrobial agents in the respiratory secretions, far more than those achievable using the intravenous route. However, data in critically ill patients with pneumonia are limited. Administration of aerosolized antibiotics might increase the likelihood of clinical resolution, but no significant improvements in important outcomes have been consistently documented. Thus, aerosolized antibiotics should be restricted to the treatment of extensively resistant gram-negative pneumonia. In these cases, the use of a vibrating-mesh nebulizer seems to be more efficient, but specific settings and conditions are required to improve lung delivery.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Guillaume Hékimian
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Nicolas Bréchot
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Jean Chastre
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France; Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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4
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Michotte JB, Staderini E, Aubriot AS, Jossen E, Dugernier J, Liistro G, Reychler G. Pulmonary Drug Delivery Following Continuous Vibrating Mesh Nebulization and Inspiratory Synchronized Vibrating Mesh Nebulization During Noninvasive Ventilation in Healthy Volunteers. J Aerosol Med Pulm Drug Deliv 2017; 31:33-41. [PMID: 28683216 DOI: 10.1089/jamp.2016.1339] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A breath-synchronized nebulization option that could potentially improve drug delivery during noninvasive positive pressure ventilation (NIPPV) is currently not available on single-limb circuit bilevel ventilators. The aim of this study was to compare urinary excretion of amikacin following aerosol delivery with a vibrating mesh nebulizer coupled to a single-limb circuit bilevel ventilator, using conventional continuous (Conti-Neb) and experimental inspiratory synchronized (Inspi-Neb) nebulization modes. MATERIALS AND METHODS A crossover clinical trial involving 6 noninvasive ventilated healthy volunteers (mean age of 32.3 ± 9.5 y) randomly assigned to both vibrating mesh nebulization modes was conducted: Inspi-Neb delivered aerosol during only the whole inspiratory phase, whereas Conti-Neb delivered aerosol continuously. All subjects inhaled amikacin solution (500 mg/4 mL) during NIPPV using a single-limb bilevel ventilator (inspiratory positive airway pressure: 12 cm H2O, and expiratory positive airway pressure: 5 cm H2O). Pulmonary drug delivery of amikacin following both nebulization modes was compared by urinary excretion of drug for 24 hours post-inhalation. RESULTS The total daily amount of amikacin excreted in the urine was significantly higher with Inspi-Neb (median: 44.72 mg; interquartile range [IQR]: 40.50-65.13) than with Conti-Neb (median: 40.07 mg; IQR: 31.00-43.73), (p = 0.02). The elimination rate constant of amikacin (indirect measure of the depth of drug penetration into the lungs) was significantly higher with Inspi-Neb (median: 0.137; IQR: 0.113-0.146) than with Conti-Neb (median: 0.116; IQR: 0.105-0.130), (p = 0.02). However, the mean pulmonary drug delivery rate, expressed as the ratio between total daily urinary amount of amikacin and nebulization time, was significantly higher with Conti-Neb (2.03 mg/min) than with Inspi-Neb (1.09 mg/min) (p < 0.01). CONCLUSIONS During NIPPV with a single-limb circuit bilevel ventilator, the use of inspiratory synchronized vibrating mesh nebulization may improve pulmonary drug delivery compared with conventional continuous vibrating mesh nebulization.
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Affiliation(s)
- Jean-Bernard Michotte
- 1 Western Switzerland University of Applied Sciences-Haute Ecole de Santé Vaud (HESAV), Filière Physiothérapie, 1011 Lausanne, Switzerland
| | - Enrico Staderini
- 2 Western Switzerland University of Applied Sciences-Haute Ecole d'Ingénierie et de Gestion du Canton de Vaud (HEIG-VD), 1401 Yverdon-les-Bains, Switzerland
| | - Anne-Sophie Aubriot
- 3 Cliniques Universitaires Saint-Luc, Centre de Référence pour la Mucoviscidose, 1200 Brussels, Belgium
| | - Emilie Jossen
- 4 Ligue pulmonaire neuchâteloise, 2034 Peseux, Switzerland
| | - Jonathan Dugernier
- 5 Cliniques Universitaires Saint-Luc, Service des soins intensifs, 1200 Brussels, Belgium
| | - Giuseppe Liistro
- 6 Cliniques Universitaires Saint-Luc, Service de Pneumologie; Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL & Dermatologie, 1200 Brussels, Belgium
| | - Gregory Reychler
- 6 Cliniques Universitaires Saint-Luc, Service de Pneumologie; Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL & Dermatologie, 1200 Brussels, Belgium
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Enuh HA, Enuh CU, Ezedunukwe IR, Diaz KT, Nfonoyim J. Aerosolised antibiotics for the management of healthcare-associated pneumonia (HCAP) and ventilator-associated pneumonia (VAP). Hippokratia 2017. [DOI: 10.1002/14651858.cd011617.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Hill A Enuh
- Richmond University Medical Center; Department of Internal Medicine; Staten Island New York USA
| | - Collins U Enuh
- University of Abuja Teaching Hospital; Department of Anaesthesiology; Gwagwalda FCT Abuja Abuja Nigeria 234
| | | | - Keith T Diaz
- Richmond University Medical Center; Department of Pulmonary Critical Care; 355 Bard Avenue Staten Island New York USA 10310
| | - Jay Nfonoyim
- Richmond University Medical Center; Department of Pulmonary Critical Care; 355 Bard Avenue Staten Island New York USA 10310
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Abdelrahim MEA. Effects of Heat and Humidification on Aerosol Delivery during Auto-CPAP noninvasive Ventilation. ACTA ACUST UNITED AC 2017. [DOI: 10.17352/aprc.000017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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7
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Feng B, Tang P, Leung SSY, Dhanani J, Chan HK. A Novel In-Line Delivery System to Administer Dry Powder Mannitol to Mechanically Ventilated Patients. J Aerosol Med Pulm Drug Deliv 2016; 30:100-107. [PMID: 27754730 DOI: 10.1089/jamp.2016.1320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Mechanically ventilated patients commonly suffer from ventilator-associated pneumonia, hypoxemia, and other lower respiratory tract infection as a result of pathogen colonization and poor sputum clearance. Consequently, there is a high rate of morbidity and mortality in these patients. Dry powder mannitol increases sputum clearance, and therefore, we developed a system to administer it to mechanically ventilated patients without disconnection from the ventilator. METHODS The inspiratory line from a ventilator was split by using a three-way valve into two parallel lines where one contains a humidifier for normal breathing cycle and the other line contains a dry powder inhaler (Osmohaler™). The inspiratory air went through the dry powder line and aerosolized the mannitol powder only when its administration to a patient is required. We determined the delivered dose and particle size distributions of emitted aerosols in vitro from 9.5 mm endotracheal and 7.5 mm tracheostomy tubes, with inspiratory airflow of 60, 70, and 80 L/min. RESULTS This novel setup was able to deliver 24.6% ± 3.33% of the 160 mg loaded dose mannitol powder (4 × 40 mg capsules) and 26.7% ± 2.19% of the 320 mg dose (4 × 80 mg capsules) when the endotracheal tube was used. With the shorter tracheostomy tube, the delivery dose increased to 35.6% ± 3.01% and 39.5% ± 2.04% of the 160 and 320 mg doses, respectively. The volume median diameters of the aerosols were in the respirable range with the largest value being 5.17 ± 0.87 μm. CONCLUSIONS This delivery system has been shown to consistently deliver a high respirable dose of mannitol powder. Since this setup does not require disconnection of patients from the ventilator, it is safer for hypoxemic patients and easier to be adapted in a real clinical use.
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Affiliation(s)
- Benny Feng
- 1 Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, Australia
| | - Patricia Tang
- 1 Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, Australia
| | - Sharon Shui Yee Leung
- 1 Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, Australia
| | - Jayesh Dhanani
- 2 Department of Intensive Care, Royal Brisbane Women's Hospital , Herston, Australia .,3 Burns, Trauma and Critical Care Research Centre, University of Queensland , Queensland, Australia
| | - Hak-Kim Chan
- 1 Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney , Sydney, Australia
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Michotte JB, Staderini E, Le Pennec D, Dugernier J, Rusu R, Roeseler J, Vecellio L, Liistro G, Reychler G. In Vitro Comparison of a Vibrating Mesh Nebulizer Operating in Inspiratory Synchronized and Continuous Nebulization Modes During Noninvasive Ventilation. J Aerosol Med Pulm Drug Deliv 2016; 29:328-36. [PMID: 27310926 DOI: 10.1089/jamp.2015.1243] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Backround: Coupling nebulization with noninvasive ventilation (NIV) has been shown to be effective in patients with respiratory diseases. However, a breath-synchronized nebulization option that could potentially improve drug delivery by limiting drug loss during exhalation is currently not available on bilevel ventilators. The aim of this in vitro study was to compare aerosol delivery of amikacin with a vibrating mesh nebulizer coupled to a single-limb circuit bilevel ventilator, using conventional continuous (Conti-Neb) and experimental inspiratory synchronized (Inspi-Neb) nebulization modes. METHODS Using an adult lung bench model of NIV, we tested a vibrating mesh device coupled with a bilevel ventilator in both nebulization modes. Inspi-Neb delivered aerosol only during the whole inspiratory phase, whereas Conti-Neb delivered aerosol continuously. The nebulizer was charged with amikacin solution (250 mg/3 mL) and placed at two different positions: between the lung and exhalation port and between the ventilator and exhalation port. Inhaled, expiratory wasted and circuit lost doses were assessed by residual gravimetric method. Particle size distribution of aerosol delivered at the outlet of the ventilator circuit during both nebulization modes was measured by laser diffraction method. RESULTS Regardless of the nebulizer position, Inspi-Neb produced higher inhaled dose (p < 0.01; +6.3% to +16.8% of the nominal dose), lower expiratory wasted dose (p < 0.05; -2.7% to -42.6% of the nominal dose), and greater respirable dose (p < 0.01; +8.4% to +15.2% of the nominal dose) than Conti-Neb. The highest respirable dose was found with the nebulizer placed between the lung and exhalation port (48.7% ± 0.3% of the nominal dose). CONCLUSIONS During simulated NIV with a single-limb circuit bilevel ventilator, the use of inspiratory synchronized vibrating mesh nebulization improves respirable dose and reduces drug loss of amikacin compared with continuous vibrating mesh nebulization.
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Affiliation(s)
- Jean-Bernard Michotte
- 1 Western Switzerland University of Applied Sciences-Haute Ecole de Santé Vaud , Filière Physiothérapie, Switzerland .,6 Cliniques Universitaires Saint-Luc, Service de Pneumologie; Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC) , Pôle de Pneumologie, ORL & Dermatologie, Belgium
| | - Enrico Staderini
- 2 Western Switzerland University of Applied Sciences-Haute Ecole d'Ingénierie et de Gestion du Canton de Vaud , Switzerland
| | - Deborah Le Pennec
- 3 Centre d'Etude des Pathologies Respiratoires, INSERM, UMR 1100, Equipe "aérosolthérapie et biomédicaments à visée respiratoire," Université de Tours , Faculté de Médecine, France
| | - Jonathan Dugernier
- 4 Cliniques Universitaires Saint-Luc , Service des soins intensifs, Belgium
| | - Rares Rusu
- 2 Western Switzerland University of Applied Sciences-Haute Ecole d'Ingénierie et de Gestion du Canton de Vaud , Switzerland
| | - Jean Roeseler
- 4 Cliniques Universitaires Saint-Luc , Service des soins intensifs, Belgium
| | - Laurent Vecellio
- 3 Centre d'Etude des Pathologies Respiratoires, INSERM, UMR 1100, Equipe "aérosolthérapie et biomédicaments à visée respiratoire," Université de Tours , Faculté de Médecine, France .,5 Aerodrug, DTF, Faculty of Medicine, Tours University , France
| | - Giuseppe Liistro
- 6 Cliniques Universitaires Saint-Luc, Service de Pneumologie; Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC) , Pôle de Pneumologie, ORL & Dermatologie, Belgium
| | - Grégory Reychler
- 6 Cliniques Universitaires Saint-Luc, Service de Pneumologie; Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC) , Pôle de Pneumologie, ORL & Dermatologie, Belgium
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Bassetti M, Welte T, Wunderink RG. Treatment of Gram-negative pneumonia in the critical care setting: is the beta-lactam antibiotic backbone broken beyond repair? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:19. [PMID: 26821535 PMCID: PMC4731981 DOI: 10.1186/s13054-016-1197-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Beta-lactam antibiotics form the backbone of treatment for Gram-negative pneumonia in mechanically ventilated patients in the intensive care unit. However, this beta-lactam antibiotic backbone is increasingly under pressure from emerging resistance across all geographical regions, and health-care professionals in many countries are rapidly running out of effective treatment options. Even in regions that currently have only low levels of resistance, the effects of globalization are likely to increase local pressures on the beta-lactam antibiotic backbone in the near future. Therefore, clinicians are increasingly faced with a difficult balancing act: the need to prescribe adequate and appropriate antibiotic therapy while reducing the emergence of resistance and the overuse of antibiotics. In this review, we explore the burden of Gram-negative pneumonia in the critical care setting and the pressure that antibiotic resistance places on current empiric therapy regimens (and the beta-lactam antibiotic backbone) in this patient population. New treatment approaches, such as systemic and inhaled antibiotic alternatives, are on the horizon and are likely to help tackle the rising levels of beta-lactam antibiotic resistance. In the meantime, it is imperative that the beta-lactam antibiotic backbone of currently available antibiotics be supported through stringent antibiotic stewardship programs.
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Affiliation(s)
- Matteo Bassetti
- Santa Maria Misericordia University Hospital, Piazzale S. Maria Misericordia 15, 33100, Udine, Italy.
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Richard G Wunderink
- Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Arkes 14-015, Chicago, IL, 60611, USA
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Michotte JB, Jossen E, Roeseler J, Liistro G, Reychler G. In vitro comparison of five nebulizers during noninvasive ventilation: analysis of inhaled and lost doses. J Aerosol Med Pulm Drug Deliv 2015; 27:430-40. [PMID: 24517084 DOI: 10.1089/jamp.2013.1070] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few studies on performance comparison of nebulizer systems coupled with a single-limb circuit bilevel ventilator are available. Most of these data compared the aerosol drug delivery for only two different systems. Using an adult lung bench model of noninvasive ventilation, we compared inhaled and lost doses of three nebulizer systems coupled with a single-limb circuit bilevel ventilator, as well as the influence of the nebulizer position. METHOD Three vibrating mesh nebulizers (Aeroneb(®) Pro, Aeroneb(®) Solo, and NIVO(®)), one jet nebulizer (Sidestream(®)), and one ultrasonic nebulizer (Servo Ultra Nebulizer 145(®)) coupled with a bilevel ventilator were tested. They were charged with amikacin solution (500 mg/4 mL) and operated at two different positions: before and after the exhalation port (starting from the lung). The inhaled dose, the expiratory wasted dose, and the estimated lost dose were assessed by the residual gravimetric method. RESULTS The doses varied widely among the nebulizer types and position. When the nebulizer was positioned before the exhalation port, the vibrating mesh nebulizer delivered the highest inhaled dose (p<0.001), the jet nebulizer the highest expiratory wasted dose (p<0.001), and the ultrasonic device the highest total lost dose (p<0.001). When the nebulizer was positioned after the exhalation port, the vibrating mesh nebulizers delivered the highest inhaled (p<0.001) and expiratory wasted doses (p<0.001), and the ultrasonic device the highest total lost dose (p<0.001). The most efficient nebulizers were NIVO and Aeroneb Solo when placed before the exhalation port. CONCLUSIONS In a single-limb circuit bilevel ventilator, vibrating mesh nebulizers positioned between the exhalation port and lung model are more efficient for drug delivery compared with jet or ultrasonic nebulizers. In this position, the improved efficiency of vibrating mesh nebulizers was due to an increase in the inhaled dose and a reduction in the exhaled wasted dose compared with placement between the ventilator and the expiratory port. Because of the high total lost dose, the ultrasonic device should not be recommended. Nebulizer placement before the exhalation port increased the inhaled dose and decreased the expiratory wasted dose, except for the jet nebulizer.
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Affiliation(s)
- Jean-Bernard Michotte
- 1 University of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO) , 1011 Lausanne, Switzerland
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Boukhettala N, Porée T, Diot P, Vecellio L. In vitro performance of spacers for aerosol delivery during adult mechanical ventilation. J Aerosol Med Pulm Drug Deliv 2014; 28:130-6. [PMID: 25050644 DOI: 10.1089/jamp.2013.1091] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND During mechanical ventilation, different aerosol generators are employed with various interfaces. The objective of this study was to evaluate the performance of a range of spacers, including a new device called Combihaler® designed for connection with both nebulizers and pressurized Metered-Dose Inhalers (pMDIs). METHODS To assess the spacers, we used a ventilator and the Dual Adult Training and Test Lung (model 5600i, Michigan Instruments). Ventilation parameters were measured with and without spacers in volume-controlled and pressure-controlled mode. A filter was placed at the end of the endotracheal tube to measure aerosol delivery. Amikacin (1 g/8 mL) and salbutamol (5 mg/5 mL) were nebulized with an Aeroneb Solo® connected to its T-adapter or the Combihaler® spacer. Salbutamol (100 μg/actuation with 10 actuations) and beclomethasone (250 μg/actuation with 10 actuations) were delivered with a pMDI connected to a Minispacer®, an ACE® spacer, or a Combihaler® spacer. Drug delivery measurements were performed in volume-controlled mode in dry and humidified conditions. Drug deposits on the filter were assayed. RESULTS The use of spacers and the T-adapter did not change the ventilation parameters (p>0.9). Aerosol delivery of salbutamol and Amikacin by nebulization increased up to three-fold with the Combihaler® compared with the T-adapter in humidified and nonhumidified conditions (p<0.05). Aerosol delivery of salbutamol and beclometasone by pMDI increased up to three-fold with the Combihaler® and the ACE® spacer compared with the Minispacer® in humidified and nonhumidified conditions (p<0.05). Aerosol delivery by pMDIs and vibrating mesh nebulizers using either a T-adapter or spacers was reduced by up to 62.5% in a humidified circuit compared with a nonhumidified circuit. CONCLUSION Aerosol delivery via pMDIs and vibrating mesh nebulizers is greater with large spacers (Combihaler® and ACE®) than with smaller spacers (Minispacer®) or a T-adapter, in both humidified and nonhumidified conditions. In humidified conditions, the aerosol delivery decreased with all spacers.
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Affiliation(s)
- Nabile Boukhettala
- 1 Centre d'Etude des Pathologies Respiratoires INSERM, Université François Rabelais de Tours , F-37032 Tours, France
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Holland A, Smith F, Penny K, McCrossan G, Veitch L, Nicholson C. Metered dose inhalers versus nebulizers for aerosol bronchodilator delivery for adult patients receiving mechanical ventilation in critical care units. Cochrane Database Syst Rev 2013; 2013:CD008863. [PMID: 23740736 PMCID: PMC6516804 DOI: 10.1002/14651858.cd008863.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Nebulizers and metered dose inhalers (MDI) have both been adapted for delivering aerosol bronchodilation to mechanically ventilated patients, but there is incomplete knowledge as to the most effective method of delivery. OBJECTIVES To compare the effectiveness of nebulizers and MDIs for bronchodilator delivery in invasively ventilated, critically ill adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5); Ovid MEDLINE (1950 to Week 19 2012); Ovid EMBASE (1980 to Week 19 2012); CINAHL via EBSCOhost (1982 to Week 19 2012) and reference lists of articles. We searched conference proceedings and reference lists of articles. We also contacted manufacturers and researchers in this field. There were no constraints based on language or publication status. SELECTION CRITERIA Randomized controlled trials (RCTs), including randomized cross-over trials where the order of the intervention was randomized, comparing the nebulizer and MDI for aerosol bronchodilation in mechanically ventilated adult patients in critical care units. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information where required. We collected information about adverse effects from the trials. MAIN RESULTS This review included three trials, two addressing the primary outcome measure of a reduction of airway resistance (measured as a reduction in interrupter and additional airway resistance) with a total of 28 patients (n =10, n =18) and two addressing adverse changes to haemodynamic observations with a total of 36 patients (n =18, n =18). Limitations in data availability and reporting in the included trials precluded meta-analysis and therefore the present review consisted of a descriptive analysis. Risk of bias in the included trials was judged as low or of unknown risk across the majority of items in the 'Risk of bias' tool.Cautious interpretation of the included study results suggests that nebulizers could be a more effective method of bronchodilator administration than MDI in terms of a change in resistance. No apparent changes to haemodynamic observations (measured as an increase in heart rate) were associated with either mode of delivery. Due to missing data issues, meta analyses were not possible. Additionally, small sample sizes and variability between the studies with regards to patient diagnoses, bronchodilator agent and administration technique mean that it would be speculative to infer definitive recommendations based on these results at this time. This is insufficient evidence to determine which is the most effective delivery system between nebuliser and MDI for aerosol bronchodilation in adult patients receiving mechanical ventilation. AUTHORS' CONCLUSIONS Existing randomized controlled trials, including randomized cross-over trials where the order of the intervention was randomized, comparing nebulizer and MDI for aerosol bronchodilation in mechanically ventilated adult patients do not provide sufficient evidence to support either delivery method at this time.
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Affiliation(s)
- Agi Holland
- School of Nursing, Midwifery and Social Care, Faculty of Health, Life & Social Sciences, Edinburgh Napier University, Edinburgh,UK.
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Abstract
This review summarizes recent clinical data examining the use of aerosolized antimicrobial therapy for the treatment of respiratory tract infections in mechanically ventilated patients in the intensive care unit. Aerosolized antibiotics provide high concentrations of drug in the lung without the systemic toxicity associated with the intravenous antibiotics. First introduced in the 1960s as a treatment of tracheobronchitis and bronchopneumonia caused by Pseudomonas aeruginosa, now, more than 40 years later, there is a resurgence of interest in using this mode of delivery as a primary therapy for ventilator-associated tracheobronchitis and an adjunctive therapy for ventilator-associated pneumonia.
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Affiliation(s)
- Lucy B Palmer
- Pulmonary, Critical Care and Sleep Division, SUNY at Stony Brook, NY 11794-8172, USA.
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14
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Rogers L, Reibman J. Pharmacologic approaches to life-threatening asthma. Ther Adv Respir Dis 2011; 5:397-408. [PMID: 21490118 DOI: 10.1177/1753465811398721] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Following a peak in asthma mortality in the late 1980s and early 1990s, we have been fortunate to see a substantial decrease in asthma deaths in recent years. Although most asthma deaths occur outside the hospital, near-fatal events are commonplace, with anywhere from 2-20% of patients with acute asthma admitted to intensive care, and 2-4% intubated for respiratory failure. Standard therapies for acute severe and near-fatal asthma include administration of systemic corticosteroids, and frequent or continuous inhaled beta agonists. Controversy remains regarding the optimal therapy of those who fail to respond to these initial treatments, those who remain at risk of acute respiratory failure, and patients requiring mechanical ventilation. There remain significant gaps in our knowledge regarding relative benefits of intravenous versus oral corticosteroids, intermittent versus continuous beta agonists, and the role of various adjunctive treatments including intravenous magnesium, systemic beta agonists, aminophylline, and helium-oxygen mixtures. Using models and radiolabeled aerosols, there is a greater understanding regarding effective administration of inhaled beta-agonists in ventilated patients. There is limited available evidence for treatment of near-fatal asthma, a fact reflected by the significant variability in asthma critical care practice. Much of the data guiding treatment in this setting has been generalized from studies of acute asthma in the ED and from general populations of hospitalized patients with acute asthma. This review will focus on pharmacologic approaches to life-threatening asthma by reviewing current guideline recommendations, reviewing the scientific basis of the guidelines, and highlighting gaps in our knowledge in treatment of refractory acute or near-fatal asthma.
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Affiliation(s)
- Linda Rogers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA.
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15
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Abstract
PURPOSE OF REVIEW This review will summarize recent clinical data examining the efficacy of aerosolized antimicrobial therapy in treating respiratory tract infections in mechanically ventilated patients in the ICU. RECENT FINDINGS Aerosolized antibiotics provide high levels of drug in the lung and reduce the systemic toxicity associated with intravenous antibiotics. First introduced in the 1970s as a form of prophylaxis for ventilator-associated pneumonia (VAP), now, more than 30 years later, there is a resurgence of interest in using this mode of delivery as primary or adjunctive treatment for ventilator-associated tracheobronchitis (VAT) or VAP. Increasingly resistant organisms are colonizing and infecting critically ill patients, and direct delivery of antibiotic to the lung is being re-evaluated as a means to treat these highly resistant organisms that may not respond to systemic therapy. There are new data emerging that suggest these agents may effectively treat these pathogens when used in targeted, time limited protocols. SUMMARY Aerosolized antibiotic therapy may provide an efficacious means of treating respiratory tract infection when targeted at mechanically ventilated patients with proximal airway infection, VAT (with or without VAP) and with highly resistant organisms.
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Abstract
PURPOSE OF REVIEW This review summarizes the recent data on antibiotic aerosolization to treat ventilator-associated pneumonia. RECENT FINDINGS Most studies on antibiotic aerosolization have been case reports or descriptive studies. The results of a recent randomized, placebo-controlled trial indicated that adjunctive use of nebulized antibiotic with intravenous antibiotics to treat purulent tracheobronchitis was associated with a better outcome than placebo aerosolization. A randomized study, so far published only as an abstract, showed that amikacin aerosolized with a vibrating-mesh nebulizer--a new-generation device--was well distributed in the lung parenchyma and might lead to less intravenous antibiotic use. Several thorough reviews on nebulization devices, techniques and drawbacks have been published recently. SUMMARY Despite recent promising findings, the widespread use of aerosolized antibiotics to treat ventilator-associated pneumonia cannot be recommended. It should be restricted to the treatment of multidrug-resistant Gram-negative ventilator-associated pneumonia.
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17
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Dhand R, Sohal H. Pulmonary Drug Delivery System for inhalation therapy in mechanically ventilated patients. Expert Rev Med Devices 2009; 5:9-18. [PMID: 18095891 DOI: 10.1586/17434440.5.1.9] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Pulmonary Drug Delivery System (PDDS) Clinical represents a newer generation of electronic nebulizers that employ a vibrating mesh or aperture plate to generate an aerosol. The PDDS Clinical is designed for aerosol therapy in patients receiving mechanical ventilation. The components of the device include a control module that is connected to the nebulizer/reservoir unit by a cable. The nebulizer contains Aerogen's OnQ aerosol generator. A pressure sensor monitors the pressure in the inspiratory limb of the ventilator circuit and provides feedback to the control module. Based on the feedback from the pressure sensor, aerosol generation occurs only during a specific part of the respiratory cycle. In bench models, the PDDS Clinical has high efficiency for aerosol delivery both on and off the ventilator, with a lower respiratory tract delivery of 50-70% of the nominal dose. Currently, the PDDS Clinical is being evaluated for the treatment of ventilator-associated pneumonia with aerosolized amikacin, an aminoglycoside antibiotic. Preliminary studies in patients with ventilator-associated pneumonia found that the administration of amikacin via PDDS reduced the need for concomitant intravenous antibiotics; however, more definitive clinical studies are needed. The PDDS Clinical delivers a high percentage of the nominal dose to the lower respiratory tract, and is well suited for inhalation therapy in mechanically ventilated patients.
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Affiliation(s)
- Rajiv Dhand
- Division of Pulmonary, Critical Care, and Environmental Medicine, MA-421 Health Sciences Center, University of Missouri-Columbia, Columbia, MO 65212, USA.
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Selting K, Waldrep JC, Reinero C, Branson K, Gustafson D, Kim DY, Henry C, Owen N, Madsen R, Dhand R. Feasibility and Safety of Targeted Cisplatin Delivery to a Select Lung Lobe in Dogs via the AeroProbe® Intracorporeal Nebulization Catheter. J Aerosol Med Pulm Drug Deliv 2008; 21:255-68. [DOI: 10.1089/jamp.2008.0684] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kim Selting
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, Missouri
| | - J. Clifford Waldrep
- Internal Medicine, Division Pulmonary, Critical Care, and Environmental Medicine, University of Missouri, Columbia
- Harry S. Truman Memorial Veteran's Hospital, Columbia, Missouri
| | - Carol Reinero
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, Missouri
| | - Keith Branson
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, Missouri
| | | | - Dae Young Kim
- Division of Pathobiology, University of Missouri, Columbia, Missouri
| | - Carolyn Henry
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, Missouri
- Division of Hematology/Oncology, University of Missouri, Columbia, Missouri
| | - Nellie Owen
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, Missouri
| | - Richard Madsen
- Division of Biostatistics, University of Missouri, Columbia, Missouri
| | - Rajiv Dhand
- Internal Medicine, Division Pulmonary, Critical Care, and Environmental Medicine, University of Missouri, Columbia
- Harry S. Truman Memorial Veteran's Hospital, Columbia, Missouri
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Dhand R. Aerosol delivery during mechanical ventilation: from basic techniques to new devices. J Aerosol Med Pulm Drug Deliv 2008; 21:45-60. [PMID: 18518831 DOI: 10.1089/jamp.2007.0663] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pressurized metered-dose inhalers (pMDIs) and nebulizers are routinely employed for aerosol delivery in mechanically ventilated patients. A significant proportion of the aerosol deposits in the ventilator circuit and artificial airway, thereby reducing the inhaled drug mass. Factors influencing aerosol delivery during mechanical ventilation differ from those in spontaneously breathing patients. The English language literature on aerosol delivery during mechanical ventilation was reviewed. Marked variations in the efficiency of drug delivery with pMDIs and nebulizers occur due to differences in the technique of administration. Careful attention to five factors, viz., the aerosol generator, aerosol particle size, conditions in the ventilator circuit, artificial airway, and ventilator parameters, is necessary to optimize aerosol delivery during mechanical ventilation. Factors influencing drug delivery during NPPV are not well understood, and the efficiency of aerosol delivery in this setting is lower than that during invasive mechanical ventilaiton. With an optimal technique of administration the efficiency of aerosol delivery during mechanical ventilation is similar to that achieved during spontaneous breathing. Further research is needed to optimize aerosol delivery during NPPV.
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Affiliation(s)
- Rajiv Dhand
- Division of Pulmonary, Critical Care, and Environmental Medicine, Department of Internal Medicine, University of Missouri-Columbia, Columbia, MO 65212, USA.
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20
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Möller W, Meyer G, Kreyling WG. Advances in lung imaging techniques for the treatment of respiratory disease. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.ddstr.2008.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Comparison of lung tissue concentrations of nebulized ceftazidime in ventilated piglets: ultrasonic versus vibrating plate nebulizers. Intensive Care Med 2008; 34:1718-23. [PMID: 18542922 DOI: 10.1007/s00134-008-1126-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Accepted: 04/06/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To compare the efficiency of an Aeroneb Pro vibrating plate and an Atomisor MegaHertz ultrasonic nebulizer for providing ceftazidime distal lung deposition. DESIGN In vitro experiments. One gram of cetazidime was nebulized in respiratory circuits and mass median aerodynamic diameter of particles generated by ultrasonic and vibrating plate nebulizers was compared using a laser velocimeter. In vivo experiments. Lung tissue concentrations and extrapulmonary depositions were measured in ten anesthetized ventilated piglets with healthy lungs that received 1 g of ceftazidime by nebulization with either an ultrasonic (n = 5), or a vibrating plate (n = 5) nebulizer. SETTING A two-bed Experimental Intensive Care Unit of a University School of Medicine. INTERVENTION Following sacrifice, 5 subpleural specimens were sampled in dependent and nondependent lung regions for measuring ceftazidime lung tissue concentrations by high-performance liquid chromatography. MEASUREMENTS AND RESULTS Mass median aerodynamic diameters generated by both nebulizers were similar with more than 95% of the particles between 0.5 and 5 microm. Lung tissue concentrations were 553 +/- 123 [95% confidence interval: 514-638] microg g(-1) using ultrasonic nebulizer, and 452 +/- 172 [95% confidence interval: 376-528] microg g(-1) using vibrating plate nebulizers (NS). Extrapulmonary depositions were, respectively, of 38 +/- 5% (ultrasonic) and 34 +/- 4% (vibrating plate) (NS). CONCLUSIONS Vibrating plate nebulizer is comparable to ultrasonic nebulizers for ceftazidime nebulization. It may represent a new attractive technology for inhaled antibiotic therapy.
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