1
|
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.
Collapse
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
| |
Collapse
|
2
|
le Noble JLML, Terpoorten FJM, der Snoek MAFV, Foudraine N. Ventilator dysfunction due to unexpected salbutamol crystallisation while using a nebuliser: a practical advice for intensivists. Intensive Care Med Exp 2022; 10:16. [PMID: 35467162 PMCID: PMC9038966 DOI: 10.1186/s40635-022-00441-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/05/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jos L M L le Noble
- Department of Intensive Care, VieCuri Medical Center, Tegelseweg 210, 5912 BL, Venlo, The Netherlands. .,Department of Pharmacology and Toxicology, UM, PO Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Frank J M Terpoorten
- Department of Medical Technology, VieCuri Medical Center, PO Box 1926, 5900 BX, Venlo, The Netherlands
| | | | - Norbert Foudraine
- Department of Intensive Care, VieCuri Medical Center, Tegelseweg 210, 5912 BL, Venlo, The Netherlands
| |
Collapse
|
3
|
Li J, Augustynovich AE, Gurnani PK, Fink JB. In-vitro and in-vivo comparisons of high versus low concentrations of inhaled epoprostenol to adult intubated patients. Respir Res 2021; 22:231. [PMID: 34419068 PMCID: PMC8379597 DOI: 10.1186/s12931-021-01827-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/16/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Inhaled epoprostenol (iEPO) has been shown to reduce pulmonary artery pressure and improve oxygenation. iEPO is mainly delivered via a syringe pump with feed tubing connected to a vibrating mesh nebulizer with high or low formulation concentration delivery. METHODS An in vitro study and a two-period retrospective case-control study were implemented. The in vitro study compared iEPO delivery via invasive ventilation at low concentrations of 7.5, and 15 mcg/mL and high concentration at 30 mcg/mL, to deliver the ordered dose of 30 and 50 ng/kg/min for three clinical scenarios with predicted body weight of 50, 70 and 90 kg. While in the clinical study, adult patients receiving iEPO via invasive ventilation to treat refractory hypoxemia, pulmonary hypertension, or right ventricular failure were included. 80 patients received low concentration iEPO at multiple concentrations (2.5, 7.5, and 15 mcg/mL, depending on the ordered dose) from 2015 to 2017, while 84 patients received high concentration iEPO at 30 mcg/mL from 2018 to 2019. RESULTS In the in vitro study, there were no significant differences in aerosol deposition between high vs low concentrations of iEPO at a dose of 50 ng/kg/min. In the clinical study, age, gender, ethnicity, and indications for iEPO were similar between high and low concentration groups. After 30-120 min of iEPO administration, both delivery strategies significantly improved oxygenation in hypoxemic patients and reduced mean pulmonary arterial pressure (mPAP) for patients with pulmonary hypertension. However, no significant differences of the incremental changes were found between two delivery groups. Compared to low concentration, high concentration delivery group had better adherence to the iEPO weaning protocol (96% vs 71%, p < 0.001), fewer iEPO syringes utilized per patient (5 [3, 10] vs 12 [6, 22], p = 0.001), and shorter duration of invasive ventilation (6 [3, 12] vs 9 [5, 18] days, p = 0.028). Intensive care unit length of stay and mortality were similar between two groups. CONCLUSION Compared to low concentration delivery of iEPO, high concentration iEPO via a vibrating mesh nebulizer maintained clinical benefits and increased clinician compliance with an iEPO weaning protocol, required less medication preparation time, and shortened duration of invasive ventilation.
Collapse
Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA.
| | - Ashley E Augustynovich
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA
| | - Payal K Gurnani
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
| |
Collapse
|
4
|
Ke WR, Chang RYK, Kwok PCL, Tang P, Chen L, Chen D, Chan HK. Administration of dry powders during respiratory supports. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:596. [PMID: 33987294 DOI: 10.21037/atm-20-3946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Inhaled drugs are routinely used for the treatment of respiratory-supported patients. To date, pressurized metered dose inhalers and nebulizers are the two platforms routinely employed in the clinical setting. The scarce utilization of the dry powder inhaler (DPI) platform is partly due to the lack of in vivo data that proves optimal delivery and drug efficacy are achievable. Additionally, fitting a DPI in-line to the respiratory circuit is not as straightforward as with the other aerosol delivery platforms. Importantly, there is a common misconception that the warm and humidified inspiratory air in respiratory supports, even for a short exposure, will deteriorate powder formulation compromising its delivery and efficacy. However, some recent studies have dispelled this myth, showing successful delivery of dry powders through the humidified circuit of respiratory supports. Compared with other aerosol delivery devices, the use of DPIs during respiratory supports possesses unique advantages such as rapid delivery and high dose. In this review, we presented in vitro studies showing various setups employing commercial DPIs and effects of ventilator parameters on the aerosol delivery. Inclusion of novel DPIs was also made to illustrate characteristics of an ideal inhaler that would give high lung dose with low powder deposition loss in tracheal tubes and respiratory circuits. Clinical trials are urgently needed to confirm the benefits of administration of dry powders in ventilated patients, thus enabling translation of powder delivery into practice.
Collapse
Affiliation(s)
- Wei-Ren Ke
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rachel Yoon Kyung Chang
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Philip Chi Lip Kwok
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Patricia Tang
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lan Chen
- Hangzhou Chance Pharmaceuticals, Hangzhou, China
| | - Donghao Chen
- Hangzhou Chance Pharmaceuticals, Hangzhou, China
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
5
|
Patout M, Fresnel E, Lujan M, Rabec C, Carlucci A, Razakamanantsoa L, Kerfourn A, Nunes H, Tandjaoui-Lambiotte Y, Cuvelier A, Muir JF, Lalmoda C, Langevin B, Sayas J, Gonzalez-Bermejo J, Janssens JP. Recommended Approaches to Minimize Aerosol Dispersion of SARS-CoV-2 During Noninvasive Ventilatory Support Can Cause Ventilator Performance Deterioration: A Benchmark Comparative Study. Chest 2021; 160:175-186. [PMID: 33667491 PMCID: PMC7921720 DOI: 10.1016/j.chest.2021.02.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/28/2021] [Accepted: 02/18/2021] [Indexed: 01/07/2023] Open
Abstract
Background SARS-CoV-2 aerosolization during noninvasive positive-pressure ventilation may endanger health care professionals. Various circuit setups have been described to reduce virus aerosolization. However, these setups may alter ventilator performance. Research Question What are the consequences of the various suggested circuit setups on ventilator efficacy during CPAP and noninvasive ventilation (NIV)? Study Design and Methods Eight circuit setups were evaluated on a bench test model that consisted of a three-dimensional printed head and an artificial lung. Setups included a dual-limb circuit with an oronasal mask, a dual-limb circuit with a helmet interface, a single-limb circuit with a passive exhalation valve, three single-limb circuits with custom-made additional leaks, and two single-limb circuits with active exhalation valves. All setups were evaluated during NIV and CPAP. The following variables were recorded: the inspiratory flow preceding triggering of the ventilator, the inspiratory effort required to trigger the ventilator, the triggering delay, the maximal inspiratory pressure delivered by the ventilator, the tidal volume generated to the artificial lung, the total work of breathing, and the pressure-time product needed to trigger the ventilator. Results With NIV, the type of circuit setup had a significant impact on inspiratory flow preceding triggering of the ventilator (P < .0001), the inspiratory effort required to trigger the ventilator (P < .0001), the triggering delay (P < .0001), the maximal inspiratory pressure (P < .0001), the tidal volume (P = .0008), the work of breathing (P < .0001), and the pressure-time product needed to trigger the ventilator (P < .0001). Similar differences and consequences were seen with CPAP as well as with the addition of bacterial filters. Best performance was achieved with a dual-limb circuit with an oronasal mask. Worst performance was achieved with a dual-limb circuit with a helmet interface. Interpretation Ventilator performance is significantly impacted by the circuit setup. A dual-limb circuit with oronasal mask should be used preferentially.
Collapse
Affiliation(s)
- Maxime Patout
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service des Pathologies du Sommeil (Département R3S), F-75013 Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France; Respiratory Department, Avicenne Hospital, AP-HP, Bobigny, France; Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.
| | - Emeline Fresnel
- Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France; Kernel Biomedical, Bois-Guillaume, France
| | - Manuel Lujan
- Pneumology Department, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - Claudio Rabec
- Pulmonary Department and Respiratory Critical Care Unit, University Hospital Dijon, Dijon, France; Fédération ANTADIR, Paris, France
| | - Annalisa Carlucci
- Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, Pavia, Italy; Department of Medicine, University of Insubria Varese, Como, Italy
| | - Léa Razakamanantsoa
- Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
| | - Adrien Kerfourn
- Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France; Kernel Biomedical, Bois-Guillaume, France
| | - Hilario Nunes
- Respiratory Department, Avicenne Hospital, AP-HP, Bobigny, France; INSERM U1272, "Hypoxia and the Lung", Paris 13 University, Bobigny, France
| | - Yacine Tandjaoui-Lambiotte
- INSERM U1272, "Hypoxia and the Lung", Paris 13 University, Bobigny, France; Intensive Care Unit, Avicenne Hospital, AP-HP, Bobigny, France
| | | | - Jean-François Muir
- Normandie University, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France; Fédération ANTADIR, Paris, France
| | - Cristina Lalmoda
- Pneumology Department, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - Bruno Langevin
- Réanimation, Pôle Soins Aigus, Centre Hospitalier Alès, Alès, France
| | - Javier Sayas
- Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jesus Gonzalez-Bermejo
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), F-75013 Paris, France
| | - Jean-Paul Janssens
- Division of Pulmonary Diseases, Geneva University Hospitals (HUG), Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | |
Collapse
|
6
|
Zhang C, Mi J, Wang X, Lv S, Zhang Z, Nie Z, Luo X, Gan R, Zou Y, Chen X, Fan L, Chen Y, Zhao H, Liao G. Knowledge and current practices of ICU nurses regarding aerosol therapy for patients treated with invasive mechanical ventilation: a nationwide cross-sectional study. J Clin Nurs 2021; 30:3429-3438. [PMID: 33440027 DOI: 10.1111/jocn.15639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 11/14/2020] [Accepted: 12/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aerosol therapy is a routine operation for intensive care unit (ICU) nurses; however, evidence of the knowledge and current practices of ICU nurses regarding aerosol therapy for patients with invasive mechanical ventilation is insufficient in China. OBJECTIVE This study aimed to determine the knowledge and current practices of ICU nurses regarding aerosol therapy for patients with invasive mechanical ventilation in China. SETTING A total of 433 hospitals in 92 cities (including 31 capital cities) in 31 provinces in China participated in the study. METHODS A questionnaire was used to investigate the knowledge and current practices of ICU nurses regarding aerosol therapy for patients treated with invasive mechanical ventilation, including 42 questions covering five aspects: sociodemographic information, aerosolization devices, atomised drugs, atomisation operation, and atomisation-related knowledge. Descriptive analyses of the distribution of the sample are reported as percentages and medians. Univariate and multivariate analysis was used to detect the factors of the interviewee's atomisation knowledge and practices scores. A STROBE checklist was used to guide the reporting of the research. RESULTS Of the 1,995 questionnaires that were returned, 1,978 were analysed. Bronchodilators and glucocorticoids were the most frequently administered drugs. Seventy-four percent of the total respondents reported placing a filter on the expiratory limb during aerosol therapy, and 47% of these reported that the filter was changed once a day. Only 13% of the respondents reported always turning the heating humidifier off during aerosol therapy, and 48% never did. Knowledge about the optimal droplet size or atomisation yield was poor. Work experience in the ICU and frequency of atomisation training were the independent influencing factors for atomisation knowledge and practice scores (F=279.653, P<0.001; F=120.556, P<0.001, respectively). CONCLUSIONS The knowledge of ICU nurses about the optimal implementation of aerosol therapy is poor, and the current scientific knowledge about optimal implementation seemed to be applied infrequently. Atomisation-related training should be strengthened, especially for nurses with junior titles and with less work experience. RELEVANCE TO CLINICAL PRACTICE Improving the level of ICU nurses' atomization practice ability is helpful to ensure patient safety. In clinical work, atomization expert consensus can be used to carry out relevant training and standardize atomization operation.
Collapse
Affiliation(s)
- Chuanlin Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Jie Mi
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xueqin Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Shunqiao Lv
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Zeju Zhang
- School of Nursing, Chongqing Medical and Pharmaceutical College, Chongqing, PR China
| | - Zhi Nie
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xinyi Luo
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Ruiying Gan
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Yujun Zou
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xiaoya Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Lu Fan
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Yu Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Huanhuan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Guoyu Liao
- Department of Medical Records, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| |
Collapse
|
7
|
Zannin E, Veneroni C, Dellaca’ R, Mosca F, Gizzi C, Ventura ML. Bacterial-viral filters to limit the spread of aerosolized respiratory pathogens during neonatal respiratory support in a pandemic era. Pediatr Res 2021; 89:1322-1325. [PMID: 32746450 PMCID: PMC7424961 DOI: 10.1038/s41390-020-1102-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/23/2020] [Accepted: 07/17/2020] [Indexed: 11/13/2022]
Affiliation(s)
- Emanuela Zannin
- grid.4643.50000 0004 1937 0327TechRes Lab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Chiara Veneroni
- grid.4643.50000 0004 1937 0327TechRes Lab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Raffaele Dellaca’
- grid.4643.50000 0004 1937 0327TechRes Lab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Fabio Mosca
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Camilla Gizzi
- Neonatal Intensive Care Unit, "San Giovanni Calibita Hospital" Fatebenefratelli - Isola Tiberina, Rome, Italy.
| | | |
Collapse
|
8
|
Nebulized Heparin in Burn Patients with Inhalation Trauma-Safety and Feasibility. J Clin Med 2020; 9:jcm9040894. [PMID: 32218127 PMCID: PMC7230289 DOI: 10.3390/jcm9040894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Pulmonary hypercoagulopathy is intrinsic to inhalation trauma. Nebulized heparin could theoretically be beneficial in patients with inhalation injury, but current data are conflicting. We aimed to investigate the safety, feasibility, and effectiveness of nebulized heparin. Methods: International multicenter, double-blind, placebo-controlled randomized clinical trial in specialized burn care centers. Adult patients with inhalation trauma received nebulizations of unfractionated heparin (25,000 international unit (IU), 5 mL) or placebo (0.9% NaCl, 5 mL) every four hours for 14 days or until extubation. The primary outcome was the number of ventilator-free days at day 28 post-admission. Here, we report on the secondary outcomes related to safety and feasibility. Results: The study was prematurely stopped after inclusion of 13 patients (heparin N = 7, placebo N = 6) due to low recruitment and high costs associated with the trial medication. Therefore, no analyses on effectiveness were performed. In the heparin group, serious respiratory problems occurred due to saturation of the expiratory filter following nebulizations. In total, 129 out of 427 scheduled nebulizations were withheld in the heparin group (in 3 patients) and 45 out of 299 scheduled nebulizations were withheld in the placebo group (in 2 patients). Blood-stained sputum or expected increased bleeding risks were the most frequent reasons to withhold nebulizations. Conclusion: In this prematurely stopped trial, we encountered important safety and feasibility issues related to frequent heparin nebulizations in burn patients with inhalation trauma. This should be taken into account when heparin nebulizations are considered in these patients.
Collapse
|
9
|
Nebulized antibiotics in mechanically ventilated patients: a challenge for translational research from technology to clinical care. Ann Intensive Care 2017; 7:78. [PMID: 28766281 PMCID: PMC5539056 DOI: 10.1186/s13613-017-0301-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/17/2017] [Indexed: 01/20/2023] Open
Abstract
Nebulized antibiotic therapy directly targets airways and lung parenchyma resulting in high local concentrations and potentially lower systemic toxicities. Experimental and clinical studies have provided evidence for elevated lung concentrations and rapid bacterial killing following the administration of nebulized antibiotics during mechanical ventilation. Delivery of high concentrations of antibiotics to infected lung regions is the key to achieving efficient nebulized antibiotic therapy. However, current non-standardized clinical practice, the difficulties with implementing optimal nebulization techniques and the lack of robust clinical data have limited its widespread adoption. The present review summarizes the techniques and clinical constraints for optimal delivery of nebulized antibiotics to lung parenchyma during invasive mechanical ventilation. Pulmonary pharmacokinetics and pharmacodynamics of nebulized antibiotic therapy to treat ventilator-associated pneumonia are discussed and put into perspective. Experimental and clinical pharmacokinetics and pharmacodynamics support the use of nebulized antibiotics. However, its clinical benefits compared to intravenous therapy remain to be proved. Future investigations should focus on continuous improvement of nebulization practices and techniques. Before expanding its clinical use, careful design of large phase III randomized trials implementing adequate therapeutic strategies in targeted populations is required to demonstrate the clinical effectiveness of nebulized antibiotics in terms of patient outcomes and reduction in the emergence of antibiotic resistance.
Collapse
|
10
|
Vargas M, Chiumello D, Sutherasan Y, Ball L, Esquinas AM, Pelosi P, Servillo G. Heat and moisture exchangers (HMEs) and heated humidifiers (HHs) in adult critically ill patients: a systematic review, meta-analysis and meta-regression of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:123. [PMID: 28552074 PMCID: PMC5447307 DOI: 10.1186/s13054-017-1710-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 05/09/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND The aims of this systematic review and meta-analysis of randomized controlled trials are to evaluate the effects of active heated humidifiers (HHs) and moisture exchangers (HMEs) in preventing artificial airway occlusion and pneumonia, and on mortality in adult critically ill patients. In addition, we planned to perform a meta-regression analysis to evaluate the relationship between the incidence of artificial airway occlusion, pneumonia and mortality and clinical features of adult critically ill patients. METHODS Computerized databases were searched for randomized controlled trials (RCTs) comparing HHs and HMEs and reporting artificial airway occlusion, pneumonia and mortality as predefined outcomes. Relative risk (RR), 95% confidence interval for each outcome and I 2 were estimated for each outcome. Furthermore, weighted random-effect meta-regression analysis was performed to test the relationship between the effect size on each considered outcome and covariates. RESULTS Eighteen RCTs and 2442 adult critically ill patients were included in the analysis. The incidence of artificial airway occlusion (RR = 1.853; 95% CI 0.792-4.338), pneumonia (RR = 932; 95% CI 0.730-1.190) and mortality (RR = 1.023; 95% CI 0.878-1.192) were not different in patients treated with HMEs and HHs. However, in the subgroup analyses the incidence of airway occlusion was higher in HMEs compared with HHs with non-heated wire (RR = 3.776; 95% CI 1.560-9.143). According to the meta-regression, the effect size in the treatment group on artificial airway occlusion was influenced by the percentage of patients with pneumonia (β = -0.058; p = 0.027; favors HMEs in studies with high prevalence of pneumonia), and a trend was observed for an effect of the duration of mechanical ventilation (MV) (β = -0.108; p = 0.054; favors HMEs in studies with longer MV time). CONCLUSIONS In this meta-analysis we found no superiority of HMEs and HHs, in terms of artificial airway occlusion, pneumonia and mortality. A trend favoring HMEs was observed in studies including a high percentage of patients with pneumonia diagnosis at admission and those with prolonged MV. However, the choice of humidifiers should be made according to the clinical context, trying to avoid possible complications and reaching the appropriate performance at lower costs.
Collapse
Affiliation(s)
- Maria Vargas
- Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples "Federico II", Naples, Italy.
| | - Davide Chiumello
- Dipartimento di Emergenza - Urgenza, ASST Santi Paolo e Carlo; Dipartimento di Scienze della salute, Università degli Studi di Milano, Milan, Italy
| | - Yuda Sutherasan
- Division of pulmonary and critical care medicine, Faculty of medicine Ramathibodi hospital, Mahidol University, 270 RAMA VI road, Bangkok, 10400, Thailand
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, AOU IRCCS San Martino- IST, University of Genoa, Genoa, Italy
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, AOU IRCCS San Martino- IST, University of Genoa, Genoa, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples "Federico II", Naples, Italy
| |
Collapse
|
11
|
Aerosol therapy in intensive and intermediate care units: prospective observation of 2808 critically ill patients. Intensive Care Med 2015; 42:192-201. [PMID: 26602786 DOI: 10.1007/s00134-015-4114-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/18/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Unlike in the outpatient setting, delivery of aerosols to critically ill patients may be considered complex, particularly in ventilated patients, and benefits remain to be proven. Many factors influence aerosol delivery and recommendations exist, but little is known about knowledge translation into clinical practice. METHODS Two-week cross-sectional study to assess the prevalence of aerosol therapy in 81 intensive and intermediate care units in 22 countries. All aerosols delivered to patients breathing spontaneously, ventilated invasively or noninvasively (NIV) were recorded, and drugs, devices, ventilator settings, circuit set-up, humidification and side effects were noted. RESULTS A total of 9714 aerosols were administered to 678 of the 2808 admitted patients (24 %, CI95 22-26 %), whereas only 271 patients (10 %) were taking inhaled medication before admission. There were large variations among centers, from 0 to 57 %. Among intubated patients 22 % (n = 262) received aerosols, and 50 % (n = 149) of patients undergoing NIV, predominantly (75 %) inbetween NIV sessions. Bronchodilators (n = 7960) and corticosteroids (n = 1233) were the most frequently delivered drugs (88 % overall), predominantly but not exclusively (49 %) administered to patients with chronic airway disease. An anti-infectious drug was aerosolized 509 times (5 % of all aerosols) for nosocomial infections. Jet-nebulizers were the most frequently used device (56 %), followed by metered dose inhalers (23 %). Only 106 (<1 %) mild side effects were observed, despite frequent suboptimal set-ups such as an external gas supply of jet nebulizers for intubated patients. CONCLUSIONS Aerosol therapy concerns every fourth critically ill patient and one-fifth of ventilated patients.
Collapse
|
12
|
Leung SSY, Parumasivam T, Tang P, Chan HK. A Proof-of-Principle Setup for Delivery of Relenza ® (Zanamivir) Inhalation Powder to Intubated Patients. J Aerosol Med Pulm Drug Deliv 2015; 29:30-35. [PMID: 25974393 DOI: 10.1089/jamp.2014.1179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND A fatal incident was reported when a mechanical ventilated patient received nebulization of a reconstituted Relenza® formulation. We propose a delivery system to introduce Relenza and other inhalation dry powders to intubated patients to avoid accidental fatalities in the future. METHODS This is a bench study demonstrating the feasibility of a delivery system to introduce dry powder of Relenza to intubated patients. A dry powder inhaler placed within a delivery chamber was actuated by compressing a ventilation bag to disperse powder into a tracheal tube. The performance of two inhalers, a Diskhaler® and an Osmohaler™, were compared. The effects of the length and size of the tracheal tube on the powder output and sizing of emitted powder were investigated using the more efficient Osmohaler™. RESULTS The efficiency of Osmohaler in delivering Relenza to the distal end [delivered dose=30.2±0.2% and fine particle fraction (FPF)=14.5±1.7%] was significantly higher than the Diskhaler (delivered dose=18.1±4.7% and FPF=3.4±2.1%). While no differences in the delivered dose and FPF were observed between the tracheostomy and endotracheal tubes of the same internal diameter, a larger endotracheal tube (9.0 mm internal diameter) gave a 6% higher FPF compared with the smaller counterpart (7.0 mm internal diameter). CONCLUSION The dry powder delivery system has been demonstrated to be capable of delivering Relenza formulation to the distal end of tracheal tubes with a reasonable delivered dose and FPF. It would be necessary for further investigation into incorporating the proposed powder delivery system within a mechanical ventilator, as well as animal and clinical studies to prove its applicability to deliver zanamivir dry powder to ventilated influenza patients in the intensive care setting.
Collapse
Affiliation(s)
| | | | - Patricia Tang
- Faculty of Pharmacy, The University of Sydney , Sydney, NSW, Australia
| | - Hak-Kim Chan
- Faculty of Pharmacy, The University of Sydney , Sydney, NSW, Australia
| |
Collapse
|