Fugitive Aerosol Therapy Emissions during Mechanical Ventilation: In Vitro Assessment of the Effect of Tidal Volume and Use of Protective Filters

O’Toole, Ciarraí; McGrath, James A.; Joyce, Mary; Bennett, Gavin; Byrne, Miriam A.; MacLoughlin, Ronan

doi:10.4209/aaqr.2020.04.0176

Cited by 8 publications

(9 citation statements)

References 28 publications

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“…This study highlights the importance of nebuliser selection as a deciding factor to reduce the risks associated with aerosol therapy during mechanical ventilation. While remaining cognisant of the risks associated with nebuliser selection on the transmission of infection to healthcare workers during drug administration, such as the lack of exhalation limb filtration [26][27][28][29][30], the recommended use of vibrating mesh nebulisers has now been validated.…”

Section: Discussionmentioning

confidence: 99%

Nebuliser Type Influences Both Patient-Derived Bioaerosol Emissions and Ventilation Parameters during Mechanical Ventilation

et al. 2021

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COVID-19 may lead to serious respiratory complications which may necessitate ventilatory support. There is concern surrounding potential release of patient-derived bioaerosol during nebuliser drug refill, which could impact the health of caregivers. Consequently, mesh nebulisers have been recommended by various clinical practice guidelines. Currently, there is a lack of empirical data describing the potential for release of patient-derived bioaerosol during drug refill. This study examined the release of simulated patient-derived bioaerosol, and the effect on positive end expiratory pressure during nebuliser refill during mechanical ventilation of a simulated patient. During jet nebuliser refill, the positive end expiratory pressure decreased from 4.5 to 0 cm H2O. No loss in pressure was noted during vibrating mesh nebuliser refill. A median particle number concentration of 710 particles cm−3 above ambient was detected when refilling the jet nebuliser in comparison to no increase above ambient detected when using the vibrating mesh nebuliser. The jet nebuliser with the endotracheal tube clamped resulted in 60 particles cm−3 above ambient levels. This study confirms that choice of nebuliser impacts both the potential for patient-derived bioaerosol release and the ability to maintain ventilator circuit pressures and validates the recommended use of mesh nebulisers during mechanical ventilation.

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Section: Discussionmentioning

confidence: 99%

Nebuliser Type Influences Both Patient-Derived Bioaerosol Emissions and Ventilation Parameters during Mechanical Ventilation

et al. 2021

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“…Furthermore, the authors noted that up to 45% of the nominal dose placed in the nebulizer could escape. More recently, O'Toole et al [17] suggested that during mechanical ventilation, both tidal volume and filter use have significant influence on the levels of medical aerosol emissions. Using a bag-valve mask, studies by both Hui et al [18] and Chan et al [19] recorded significant exposure risk from bioaerosols to caregivers at distances of up to 0.8 m from a simulated manually ventilated patient.…”

Section: Introductionmentioning

confidence: 99%

“…A 2013 survey by Ehrmann et al [20] found that only 65% of physicians made use of filters during mechanical ventilation, with as many as 28% never changing the filter. Recent reviews and studies point to the importance of filter use and closed-circuit nebulizers and systems, especially in times such as during the COVID-19 pandemic [17,21,22].…”

Section: Introductionmentioning

confidence: 99%

An in vitro investigation into the release of fugitive medical aerosols into the environment during manual ventilation

Eain

Joyce

O’Sullivan

et al. 2021

Journal of Hospital Infection

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Background: During manual resuscitation, nebulizer therapy may be used to deliver therapeutics to patients in respiratory distress. However, the devices used to generate and deliver these medical aerosols have the potential to release these therapeutics into the local environment and expose caregivers to unwanted medical aerosols. Aim: To quantify the levels of fugitive medical aerosol released into the environment during aerosol drug delivery using a manual resuscitation bag with and without filtration. Methods: Time-varying fugitive aerosol concentrations were measured using an aerodynamic particle sizer placed at a position designed to mimic a caregiver. Two nebulizer types were assessed, a vibrating mesh nebulizer and a jet nebulizer. The aerosol dose delivered to the simulated patient lung was also quantified. Findings: Filtration of the exhalation port of the manual resuscitation bag was seen to reduce fugitive medical aerosols to ambient levels for both nebulizer types. The vibrating mesh nebulizer delivered the greatest quantity of aerosol to the simulated adult patient (18.44 AE 1.03% versus 3.64 AE 0.26% with a jet nebulizer). Conclusions: The results highlight the potential for exposure to fugitive medical aerosols released during the delivery of aerosol therapy with a manual resuscitation bag and also the potential for significant variation in patient lung dose depending on nebulizer type.

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“…Furthermore, and to ensure safe volumes and pressures are delivered to the patient’s lung on each breath, air leak is minimal, with cuffed endotracheal tubes creating a complete seal within the trachea. This again not only facilitates increased aerosol delivery, but also reduces fugitive medical aerosol emissions to the local environment, and, cognizant of COVID−19, the risk of patient derived transmission of infectious disease [ 55 , 56 ].…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis

et al. 2021

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Lung disease is the main cause of morbidity and mortality in cystic fibrosis (CF). CF patients inhale antibiotics regularly as treatment against persistent bacterial infections. The goal of this study was to investigate the effect of clinical intervention on aerosol therapy during the escalation of care using a bench model of adult CF. Droplet size analysis of selected antibiotics was completed in tandem with the delivered aerosol dose (% of total dose) assessments in simulations of various interventions providing oxygen supplementation or ventilatory support. Results highlight the variability of aerosolised dose delivery. In the homecare setting, the vibrating mesh nebuliser (VMN) delivered significantly more than the jet nebuliser (JN) (16.15 ± 0.86% versus 6.51 ± 2.15%). In the hospital setting, using VMN only, significant variability was seen across clinical interventions. In the emergency department, VMN plus mouthpiece (no supplemental oxygen) was seen to deliver (29.02 ± 1.41%) versus low flow nasal therapy (10 L per minute (LPM) oxygen) (1.81 ± 0.47%) and high flow nasal therapy (50 LPM oxygen) (3.36 ± 0.34%). In the ward/intensive care unit, non-invasive ventilation recorded 19.02 ± 0.28%, versus 22.64 ± 1.88% of the dose delivered during invasive mechanical ventilation. These results will have application in the design of intervention-appropriate aerosol therapy strategies and will be of use to researchers developing new therapeutics for application in cystic fibrosis and beyond.

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Fugitive Aerosol Therapy Emissions during Mechanical Ventilation: In Vitro Assessment of the Effect of Tidal Volume and Use of Protective Filters

Cited by 8 publications

References 28 publications

Nebuliser Type Influences Both Patient-Derived Bioaerosol Emissions and Ventilation Parameters during Mechanical Ventilation

Nebuliser Type Influences Both Patient-Derived Bioaerosol Emissions and Ventilation Parameters during Mechanical Ventilation

An in vitro investigation into the release of fugitive medical aerosols into the environment during manual ventilation

Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis

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