How Should Aerosols Be Delivered During Invasive Mechanical Ventilation?

Abstract

The delivery of aerosols to mechanically ventilated patients presents unique challenges and differs from inhaled drug delivery in spontaneously breathing patients in several respects. Successful aerosol delivery during invasive mechanical ventilation requires careful consideration of a host of factors that influence the amount of drug inhaled by the patient. Pressurized metered-dose inhalers and nebulizers (jet, ultrasonic, and vibrating mesh) are the most commonly used aerosol delivery devices in these patients, although other delivery devices, such as dry powder inhalers, soft mist inhalers, and intratracheal nebulizing catheters, could also be adapted for in-line use. Bronchodilators, inhaled corticosteroids, antibiotics, pulmonary surfactant, mucolytics, biologicals, genes, prostanoids, and other agents are administered by inhalation during mechanical ventilation for a variety of indications. The goals of inhalation therapy during mechanical ventilation could be best achieved by (1) assuring drug delivery; (2) optimizing drug deposition in the lung; (3) providing consistent dosing; (4) avoiding inappropriate therapies; (5) achieving reproducible dosing; (6) employing clinically feasible methods; (7) enhancing the safety of inhaled drugs; and (8) controlling costs of aerosol therapy. The techniques of administration of aerosols with various delivery devices during mechanical ventilation are well known, but there continues to be significant variation in clinical practice and guidelines are needed to provide best practices for a wide range of clinical settings encountered in mechanically ventilated patients.

Effect of On-Demand vs Routine Nebulization of Acetylcysteine With Salbutamol on Ventilator-Free Days in Intensive Care Unit Patients Receiving Invasive Ventilation

“…To our knowledge, no previous studies have addressed whether on-demand nebulization is as effective as routine nebulization in a general population of ICU patients receiving invasive ventilation. 9 A noninferiority design was chosen because routine nebulization could be considered standard of care (at least in the Netherlands) and because it was hypothesized that a strategy in which nebulization needed strict indications would reduce the number of nebulization-related adverse effects, while not or only slightly affecting duration of ventilation. A patient-centered primary end point of ventilatorfree days and alive at day 28 was chosen because pulmonary complications may affect duration of invasive ventilation as well as mortality.…”

Optimal Connection for Tiotropium SMI Delivery through Mechanical Ventilation: An In Vitro Study

“…Manual resuscitators can be used for aerosol delivery to achieve spontaneous breathing in tracheostomized children [15,16]. This method of drug administration could be employed when doses of bronchodilators need to be rapidly administered to a patient with an artificial airway [17]. Ari reported that, in both tracheostomy and endotracheal tube spontaneous breathing models, manual resuscitation bag provides ventilation with prolonged inflation breaths producing 3-fold greater albuterol delivery dose than through T-adapter or Tr.-collar [18].…”

Aerosol Delivery Devices for Obstructive Lung Diseases

“…Nebulizers are commonly used with critically ill patients. 94 Detailed reviews have been published elsewhere related to nebulizer use during invasive ventilation, 113,114 noninvasive ventilation, 114,115 with high-flow nasal cannula, 115 and with tracheostomy. 116…”