Expert consensus on nebulization therapy in pre-hospital and in-hospital emergency care

Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand

OBJECTIVE

This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults.

DATA SOURCES

We conducted a search on PubMed for nebulized budesonide treatment.

SELECTED STUDIES

Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies.

RESULTS

Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings.

CONCLUSION

Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Prophylactic antibiotics for preventing ventilator-associated pneumonia: a pairwise and Bayesian network meta-analysis

BACKGROUND

The role of prophylactic antibiotics in preventing ventilator-associated pneumonia (VAP) in patients undergoing invasive mechanical ventilation (IMV) remains unclear. This network meta-analysis compared the efficacy and safety of antibiotic prophylaxis in preventing VAP in an IMV population in intensive-care units (ICUs).

METHODS

We searched the PubMed, Web of Science, Embase, and Cochrane Library databases from inception to December 2021, to identify relevant studies assessing the impact of prophylactic antibiotics on the incidence of VAP, the mortality, and the duration of ICU stays and hospitalization to perform a meta-analysis.

RESULTS

Thirteen studies (2144 patients) were included, 12 of which were selected for the primary analysis, which revealed that treatment with prophylactic antibiotics resulted in a lower VAP rate compared with control groups [risk ratio (RR) = 0.62]. Bayesian network meta-analysis indicated that aerosolized tobramycin and intravenous ampicillin-sulbactam presented the greatest likelihood being the most efficient regimen for reducing VAP.

CONCLUSIONS

Antibiotic prophylaxis may reduce the incidence of VAP, but not the mortality, for adult patients undergoing IMV in ICUs. Tobramycin via nebulization and ampicillin-sulbactam via intravenous administration presented the greatest likelihood of being the most efficient regimen for preventing VAP. However, well-designed randomized studies are warranted before definite recommendations can be made.

Does Good Nebulization Therapy in the Emergency Room Reduce the Need for Hospitalization in Asthmatic Children?

INTRODUCTION

Asthma is a chronic inflammatory disorder characterized by obstruction, hyperresponsiveness, and inflammatory changes in the airways. The overall prevalence of asthma in Saudi Arabian children ranges from 8% to 25%. Studies have shown that children who did not respond adequately to treatment in the emergency room (ER) were admitted to hospital for additional treatment which increased the cost and risk of hospital-acquired infections. The quality of nebulization therapy is influenced by several factors such as the position, dose, oxygen flow rate, and duration of treatment.  Objectives: In this study, we aimed to explore factors that affect nebulization therapy in ER and to assess the relation between nebulization technique in ER and hospital admission for asthmatic children, and these aims were achieved over the period from December 2021 to May 2023.

METHODOLOGY

An observational cross-sectional study was conducted in Maternity and Children Hospital (MCH) in Medina at the ER over the period from December 2021 to May 2023 for all children admitted to ER with asthma exacerbation. The sample size used to include patients in the study is 289 calculated using the Openepi website. Data were collected by observation and using medical records of the patients and analyzed using Statistical Package for Social Sciences (SPSS) version 26.0 (IBM Corp., Armonk, NY, USA).

RESULTS

The total number of the sample was 289 children ages between two to 14 years. Sixty-four percent (n=185) reported as their gender as male while 36% (n = 104) as female. The median age of the children was four years old (interquartile range [IQR] = 4), and their median weight was 15 kg (IQR = 8.15). Also, more than 83% of the patients has mild asthma, while 16.3% of the sample were diagnosed with moderate to severe asthma. Besides, 92.4% of the sample was discharged from a hospital, and 76.5% received an appropriate dose of nebulization.

DISCUSSION

After reviewing the results of the statistical analysis, the main findings were that the severity of asthma exacerbation was the most important factor influencing the outcome. It was found that 0.4% of patients with mild asthma were admitted to the hospital, compared to 44.7% of patients with moderate to severe asthma.

CONCLUSION

Our study assessed whether effective nebulization therapy in the ER will reduce the need for hospitalization in asthmatic children and the results indicate that the severity of asthma exacerbation was the most significant factor impacting hospital admission in asthmatic patients and influenced other factors of nebulization therapy. However, the other factors, such as the patient position, oxygen flow rate, and the dose of medications did not show any clinically significant impact on hospitalization rates.

[Can mesh nebulizers improve prehospital aerosol therapy? An in vitro study on simulated prehospital emergency patients suffering from respiratory distress]

BACKGROUND

Nebulizers used to treat prehospital emergency patients should provide a high output efficiency to achieve a fast onset of therapeutic drug effects while remaining unaffected by the presence of supplementary oxygen flow or the patient's breathing pattern. On the other hand, nebulizer performance is directly influenced by differences in device design, gas flow and patients' breathing patterns. Several studies from emergency departments were able to demonstrate an improvement in patient outcome when using a mesh nebulizer instead of a jet nebulizer. Data or bench studies regarding prehospital care are non-existent.

OBJECTIVE

The aim of the present in vitro study was to evaluate which type of aerosol generator would best address the requirements of a prehospital adult emergency patient suffering from respiratory distress.

MATERIAL AND METHODS

We evaluated the performance of a jet nebulizer (Cirrus™ 2, Intersurgical®) and two mesh nebulizers (Aerogen Solo® with USB controller, Aerogen Limited and M‑Neb® mobile, NEBU-TEC International med. Produkte Eike Kern GmbH) with the possibility of portable operation in an in vitro model of a spontaneously breathing adult emergency patient. One physiological and three pathological breathing patterns (distressed breathing pattern as well as stable and acute exacerbated chronic obstructive pulmonary disease) were simulated. Nebulizer output and salbutamol lung deposition were measured at different oxygen flow rates using a face mask as the delivery interface.

RESULTS

The mesh nebulizers produced a significantly higher aerosol output when compared to the jet nebulizer. The M‑Neb® mobile was able to significantly exceed the output of the Aerogen Solo®. Oxygen flow had the largest influence on the output of the jet nebulizer but hardly affected the mesh nebulizers. After a nebulization time of 10 min the M‑Neb® mobile also achieved the highest total salbutamol lung deposition (P < 0.001). Aerosol drug deposition was therefore mainly determined by the nebulizer's drug output per unit time. The deposition could not be improved using a spacer but was strongly influenced by the simulated emergency patients' breathing pattern.

CONCLUSION

The use of mesh nebulizers might have the potential to improve the aerosol therapy of prehospital emergency patients. In general, mesh nebulizers seem to be superior to jet nebulizers regarding aerosol output per unit time and total lung deposition. The present data suggest that aerosol output and drug deposition to the collection filter in this simulated setting are closely connected and crucial for total salbutamol deposition, as the deposition could not be improved by adding a spacer. Aerosol drug deposition in simulated emergency patients' lungs is therefore mainly determined by the nebulizer's drug output per unit time. The level of oxygen flow used had the largest influence on the output of the jet nebulizer but hardly affected the output of the tested mesh nebulizers. Mesh nebulizers could therefore enable a demand-adapted oxygen therapy due to their consistent performance despite the presence of oxygen flow. A high respiratory rate was associated with a high drug deposition, which is clinically desirable in the treatment of patients in respiratory distress; however, drug underdosing must also be expected in the treatment of bradypneic patients. Further clinical studies must prove whether our findings also apply to the treatment of real prehospital emergency patients.

Perceptions and Attitudes of Patients and Their Family Caregivers on Nebulization Therapy for COPD

Purpose

The aim of the survey was to evaluate attitudes and perceptions toward nebulization therapy for the management of chronic obstructive pulmonary disease (COPD) in Indian population.

Patients and methods

A cross-sectional, multicenter, quantitative survey was conducted from July to August 2019 among 103 COPD patients [>40 years, either gender, belonging to socio-economic class (SEC) A or SEC B] and their family caregivers. One-on-one interviews were conducted telephonically via an online survey platform (KoBo data collection tool) using a structured questionnaire. Patients receiving home nebulization were included, and the usage of nebulizers, satisfaction, and benefits and concerns with nebulizers were assessed.

Results

Overall, 47% patients were on handheld inhalers + nebulizer, 54% used nebulizer for >8 weeks, and 27% used nebulizers daily for home maintenance. Majority of the patients (77%) were satisfied with nebulization therapy. Around 70% family caregivers opined that the quality of life of COPD patients improved post-nebulization therapy. The benefits of nebulizers perceived by patients were easier breathing (89%), feeling of well-being (86%), and ease of use (86%), while family caregivers reported reduced hospitalization (76%) and easier breathing (75%). Among those with prior experience with inhalers, 72% felt nebulizers gave long-term relief, while 65% perceived having immediate relief compared to inhaler. Overall, 61% opined that benefits with nebulizers outweighed the inconvenience associated with its use. Key concerns regarding nebulizers cited by patients were time-consuming procedure (50%), feeling of dependency (49%), and social embarrassment (48%), while family caregivers highlighted social embarrassment (45%) and multiple daily use (45%) as major concerns. Majority of the patients (73%) were compliant with their recommended frequency of the nebulizer.

Conclusion

This first-of-its-kind survey highlights that the majority of patients and family caregivers were satisfied with nebulizers and reported improvements in symptoms and reduced hospitalizations with nebulizer therapy. The patients preferred nebulized therapy to inhalers.

[Nebulization of emergency medications in the south German rescue service]

BACKGROUND

In German emergency rescue services, inhalation treatment is routinely carried out by qualified health personnel. Standard operating procedures (SOP) for nebulization are neither uniform throughout Germany nor available in all federal states. Standardized recommendations with respect to which nebulizer type should be used are missing. The aerosol output as well as the drug deposition rates of jet and mesh nebulizers, however, differ considerably. Mesh devices can achieve a threefold higher lung deposition. Their use in emergency departments has also been shown to be associated with a better patient outcome when compared to jet nebulizers.

OBJECTIVE

This survey was designed to evaluate the type of nebulizer used in the south German rescue services. Special attention was paid to the influence of existing SOP on the decision to perform nebulization during emergency treatment.

MATERIAL AND METHODS

A total of 4800 emergency paramedics working in Baden-Württemberg, Bavaria and Rhineland-Palatinate received a questionnaire with a total of 17 questions on the implementation of drug nebulization in the daily practice.

RESULTS

Despite the existence of more efficient nebulizer types, the jet nebulizer was by far the most frequently used nebulizer in the south German rescue services. The deposition rates of both the jet and mesh nebulizers were considerably overestimated by most respondents; however, 77.5% of all respondents could not give any information about the deposition rates of the mesh nebulizer. Only two thirds of all respondents carried out nebulization treatment on the basis of SOP. The implementation of SOP, however, was pivotal to the application of nebulization during emergencies. If SOP were in place,76.9% of the responders used aerosol treatment compared to 23.1% when there were none. The perceived safety when using nebulization during emergencies was also significantly higher (p = 0.013) when SOP were implemented.

CONCLUSION

The exclusive use of mesh nebulizers could standardize the treatment of emergency patients in the south German rescue services. The use of mesh devices might possibly improve patient outcomes, even if clinical studies are still lacking. Nebulizer treatment differs between the federal states. A comprehensive implementation of SOP for nebulization treatment might support this process and could increase the application frequency and the perceived safety of nebulization during emergencies. A better training of paramedic personnel could improve the knowledge of aerosols as a treatment option for emergency patients and help to classify the advantages and disadvantages of the different aerosol generators available.

The future of dry powder inhaled therapy: Promising or Discouraging for systemic disorders?

Dry powder inhalation therapy has been shown to be an effective method for treating respiratory diseases like asthma, Chronic Obstructive Pulmonary Diseases and Cystic Fibrosis. It has also been widely accepted and used in clinical practices. Such success has led to great interest in inhaled therapy on treating systemic diseases in the past two decades. The current coronavirus (COVID-19) pandemic also has increased such interest and is triggering more potential applications of dry powder inhalation therapy in vaccines and antivirus drugs. Would the inhaled dry powder therapy on systemic disorders be as encouraging as expected? This paper reviews the marketed and in-development dry powder inhaler (DPI) products on the treatment of systemic diseases, their status in clinical trials, as well as the potential for COVID-19 treatment. The advancements and unmet problems on DPI systems are also summarized. With countless attempts behind and more challenges ahead, it is believed that the dry powder inhaled therapy for the treatment of systemic disorders still holds great potential and promise.

Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus

The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.

Nebulised surface-active hybrid nanoparticles of voriconazole for pulmonary Aspergillosis demonstrate clathrin-mediated cellular uptake, improved antifungal efficacy and lung retention

BACKGROUND

Incidence of pulmonary aspergillosis is rising worldwide, owing to an increased population of immunocompromised patients. Notable potential of the pulmonary route has been witnessed in antifungal delivery due to distinct advantages of direct lung targeting and first-pass evasion. The current research reports biomimetic surface-active lipid-polymer hybrid (LPH) nanoparticles (NPs) of voriconazole, employing lung-specific lipid, i.e., dipalmitoylphosphatidylcholine and natural biodegradable polymer, i.e., chitosan, to augment its pulmonary deposition and retention, following nebulization.

RESULTS

The developed nanosystem exhibited a particle size in the range of 228-255 nm and drug entrapment of 45-54.8%. Nebulized microdroplet characterization of NPs dispersion revealed a mean diameter of  ≤ 5 μm, corroborating its deep lung deposition potential as determined by next-generation impactor studies. Biophysical interaction of LPH NPs with lipid-monolayers indicated their surface-active potential and ease of intercalation into the pulmonary surfactant membrane at the air-lung interface. Cellular viability and uptake studies demonstrated their cytocompatibility and time-and concentration-dependent uptake in lung-epithelial A549 and Calu-3 cells with clathrin-mediated internalization. Transepithelial electrical resistance experiments established their ability to penetrate tight airway Calu-3 monolayers. Antifungal studies on laboratory strains and clinical isolates depicted their superior efficacy against Aspergillus species. Pharmacokinetic studies revealed nearly 5-, 4- and threefolds enhancement in lung AUC, Tmax, and MRT values, construing significant drug access and retention in lungs.

CONCLUSIONS

Nebulized LPH NPs were observed as a promising solution to provide effective and safe therapy for the management of pulmonary aspergillosis infection with improved patient compliance and avoidance of systemic side-effects.