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Inline MDI's VS Nebulizers with ventilators.
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Junior Member
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I am trying to figure out how to come up with the correct dose of puffs, for a MDI medication treatment, that is equal to the medication solution for a nebulizer treatment. I would like to try, using MDI's with ventilator patients instead of nebulizers or at least cut the number down by half on nebulizer treatments.
 
Posts: 1 | Registered: June 20, 2006Reply With QuoteReport This Post
<RVK>
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Why would you want to do that? MDIs are notoriously difficult to synchronise with the inspiratory cycle, and besides there are too many variables that affect the level of distal drug deposition etc, e.g. size of ETT, tidal volume, secretions, operator variations. As far as I am concerned the MDIs were developed for intubated patients as a response to the pneumatic ventilators interfering with the flow/volume delivery. Better pneumatic nebulizers synchronise with the inspiratory stroke and ventilators subtact the extra flow added by nebulizer from the total volume delivered. Additionally there are newer technologies, specifically Aeroneb Pro, that most of the ventilator companies will sell you to go with your vent (and us nice people at GE build into the ventilator as a standard feature). Not only does it not affect the volumes, it is silent, does not heat up and potentially degrade the medication like ultrasonics, and best of all has the smallest size particles.

Why do you feel that you have to reduce the number of nebulizer treatments?
 
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Picture of GaryMefford
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This is a great question. I have my own preferences as to inhaled med admin on vented patients, and some of my own observations collected over the years.

I appreciate very much both of the posts on this so far and they demonstrate both sides of the coin here. RVK your points are well taken and valid, however many, many departments have begun to embrace MDI as their major method for topical airway med delivery. Those on that side of the coin cite cost savings and decreased potential for VAP as some of their main reasons for taking this route. I have heard both sides on the cost issue. Some have cited savings, others greater cost. If you have to increase your dosing to get a equivalent effect, you wind up going through larger amounts of canisters, or what of the short stay that discharges from the unit never needing another MDI treatment and several canisters still almost full needing to be discarded. There may be some ways around this, but where I have had to use MDIs primarily we chunked them on discharge if the patient did not continue on MDIs. As to decreased VAP the justification here is decreased circuit breaks. That is potentially valid with heated water humidification systems. I do not know what the statistics are, or if anyone has even collected them, but HME type of devices seem to be of extreme popularity lately, and most published MDI techniques generally dictates removal of the HME. Circuit break.

Runner, your goals are good, equal dose response and decrease treatments. I wonder if decreased number of treatments can be achieved. You should expect little difference in duration of effect with good delivery via either method. Another consideration brought out by RVK is that of the variables effecting good delivery. Across an entire staff I have always felt that a med delivery technique of neb given as usually recommended 15 inches back from the Y in the insp limb of the circuit via continuous nebulization would get patients more meds where they could do the most good more consistently. Yes that is a staff ed thing and we should be able to get good MDI technique out of everyone all the time, but reality is... I realize intermittant nebulization is better synchronized and perhaps works better than it used to be, but I believe in an a inspiratory limb charged with a dense cloud of meds at the beginning of inspiration.

Another observation I have made is that frequently it is difficult to observe even subtle changes in airway dynamics following BD delivery via any method, unless there is a significant reactive airway component, or significant secretions clearance is achieved following the med delivery. I have used locked and overlayed loops pre and post treatments and found myself wondering if just being vented is reason enough to justify BD administration. It does seem routine in many facilities. Another of my observations, weak evidence I know if evidence at all, is that my patients seem to produce more secretions following inline neb treatments vs. MDIs.
There was a great piece in Respiratory Care last fall. INHALATION THERAPY WITH MDIS AND DPIS IN MECHANICALLY VENTILATED PATIENTS
RESPIRATORY CARE "¢ OCTOBER 2005 VOL 50 NO 10 1337 by Rajiv Dhand MD

Table 3 and 4 from that article follow. They should be helpful in answering some of your questions Runner.

Table 3. Optimal Technique for Drug Delivery via MDI in
Mechanically Ventilated Patients
1. Review order, identify patient, and assess need for bronchodilator
2. Suction endotracheal tube and airway secretions
3. Shake MDI and warm to hand temperature
4. Place MDI in space chamber adapter in ventilator circuit
5. Remove HME / Do not disconnect humidifier
6. Coordinate MDI actuation with beginning of inspiration
7. Wait at least 15 seconds between actuations; administer total dose
8. Monitor for adverse response
9. Reconnect HME
10. Document clinical outcome
MDI _ metered-dose inhaler
HME _ heat-and-moisture exchanger

Table 4. Bronchodilators Administered via pMDI in Mechanically-Ventilated Patients*
Bronchodilator Formulation
Dose (mcg/puff)
Recommended Dose and Frequency" 
_-adrenergic
Albuterol CFC 100 4–6 puffs every 3–6 h
Albuterol sulfate HFA 100 4–6 puffs every 3–6 h
Anti-cholinergic
Ipratropium bromide CFC 18 4–6 puffs every 3–6 h
Combination
Albuterol sulfate _
Ipratropium bromide
CFC 100/18 4–6 puffs every 3–6 h
pMDI _ pressurized metered-dose inhaler
*Commonly employed bronchodilator aerosols administered via pMDI to mechanicallyventilated
patients in the United States are shown
" The doses indicated are those employed in stable, mechanically-ventilated patients. Higher
doses may be required for patients experiencing episodes of acute bronchoconstriction.
CFC _ chlorofluorocarbon
HFA _ hydrofluoroalkane

Some additional citations recommended to me that might be useful on the subject:
the journal for respiratory care practitioners Feb/march 1996
ajrccm vol156 pp3-101997
ajrccm vol 154 pp382-387 1996
ajrccm vol 152 pp1391-1394, 1995
Critical Care Alert Dec. 1996 discusses # of puffs, interval between puffs, and delivery device
Chest1994; 106:560-71
Chest/107/1/January 1995
Chest/105/1/January 1994

Welcome and thanks Runner for starting this thread. Wonder what some of the other thinkers here are thinking on this???
 
Posts: 147 | Location: Buckeye Az | Registered: January 27, 2006Reply With QuoteReport This Post
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More articles for readings
1) Garner, S S 1; Wiest, D B 1; Bradley, J W 3; Habib, D M 2 Two administration methods for inhaled salbutamol in intubated patients. Archives of Disease in Childhood. 87(1):49-53, July 2002.

Results: There was no difference in percentage change in respiratory mechanics or haemodynamics between the two methods of administration. Mean area under the curve (AUC0–4) was 5.86 for MDI plus spacer versus 4.93 ng/ml × h for SVN.

2) Fink, James B. M.S., R.R.T., F.A.A.R.C. 1; Dhand, Rajiv M.D. 2 Aerosol Therapy in Mechanically Ventilated Patients: Recent Advances and New Techniques. Seminars in Respiratory & Critical Care Medicine. Innovations in Mechanical Ventilation: Neil R. MacIntyre, M.D.. 21(3):183-201, May 2000

Until recently, the consensus of opinion was that the efficiency of aerosol delivery to the lower respiratory tract in mechanically ventilated patients was much lower that that in ambulatory patients. Data suggest that this might be overly pessimistic and that the endotracheal tube may actually facilitate greater aerosol delivery compared with the normal airway when a variety of variables effecting aerosol delivery during mechanical ventilation are optimized.

3)Di Paolo, Ermindo R. PhD; Pannatier, Andre PhD; Cotting, Jacques MD In vitro evaluation of bronchodilator drug delivery by jet nebulization during pediatric mechanical ventilation. Pediatric Critical Care Medicine. 6(4):462-469, July 2005.

Conclusions: In our in vitro pediatric lung model, the quantity of inhaled drug was low. Jet nebulizer brands and nebulization modes significantly affected drug delivery, and in vitro models designed for adults cannot be extrapolated to infants

I have more if you want them. In my opinion bronchodilators are given to way more patients on the vent than need them. Just becasue they had respiratory distress and had to go the vent does not mean they need a bronchodilator. If I am to use a bronchodilator on a vent patient I would prefer to use a MDI and dose to effect.


Light
 
Posts: 104 | Location: Springfield, MO | Registered: March 08, 2004Reply With QuoteReport This Post
VentWorld Director
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Picture of GaryMefford
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Great post, thanks again Light!
 
Posts: 147 | Location: Buckeye Az | Registered: January 27, 2006Reply With QuoteReport This Post
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