Inhalation Therapy in Mechanically Ventilated Patients.ppt

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1. Inhalation therapy in MVInhalation therapy in MV

2. Therapeutic Use of pMDIs During
Mechanical Ventilation

3. Indications of inhalation therapyIndications of inhalation therapy
IInhaled beta agonist and anticholinergic nhaled beta agonist and anticholinergic
bronchodilators for bronchodilators for
•chronic obstructive lung diseaseschronic obstructive lung diseases
• (eg, asthma, COPD, bronchiectasis, (eg, asthma, COPD, bronchiectasis,
bronchiolitis)bronchiolitis)
Inhaled glucocorticoids Inhaled glucocorticoids
•asthma, eosinophilic bronchitis, and COPDasthma, eosinophilic bronchitis, and COPD
Inhaled antibiotics Inhaled antibiotics
•prevention of Pneumocystis pneumonia prevention of Pneumocystis pneumonia
and treatment of respiratory syncytial and treatment of respiratory syncytial
virus, cystic fibrosis, and bronchiectasisvirus, cystic fibrosis, and bronchiectasis

4. Indications of inhalation therapyIndications of inhalation therapy
Airway secretion modifying agents Airway secretion modifying agents
•cystic fibrosiscystic fibrosis
Inhaled pulmonary vasodilators Inhaled pulmonary vasodilators
pulmonary hypertension pulmonary hypertension
Aerosol delivery of drugs Aerosol delivery of drugs (eg, opiates) (eg, opiates)
may be used to treat some may be used to treat some
nonrespiratory diseases
 
nonrespiratory diseases
 

5. Factors affecting aerosol delivery Factors affecting aerosol delivery
during mechanical ventilationduring mechanical ventilation
NebulizerNebulizer
Position of nebulizerPosition of nebulizer
placement in the circuitplacement in the circuit
Type of nebulizer and fill volumeType of nebulizer and fill volume
Treatment timeTreatment time
Duty cycle (I:E ratio)Duty cycle (I:E ratio)
Ventilator brandVentilator brand

6. Factors affecting aerosol delivery Factors affecting aerosol delivery
during mechanical ventilationduring mechanical ventilation
MDIMDI
•Type of actuatorType of actuator
•Timing of actuationTiming of actuation
Nebulizer and MDINebulizer and MDI
•Endotracheal tube sizeEndotracheal tube size
•Humidification of the inspired gasHumidification of the inspired gas

8. Continuous or intermittentContinuous or intermittent
Several studies have established the Several studies have established the
safety of Continuous nebulization , safety of Continuous nebulization ,
even when high doses (eg, 20 mg/hr even when high doses (eg, 20 mg/hr
of
 
of
 
albuterol) are used Continuous ) are used Continuous
nebulization may be most beneficial nebulization may be most beneficial
in patients with the most severe in patients with the most severe
pulmonary dysfunctionpulmonary dysfunction

9. Pressurized Metered-Dose Inhalers
•The MDI canister contains
Pressurized mixture of propellants,
Surfactants
Preservatives
Flavoring agents
Active drug, the latter comprising
approximately 1% of thetotal contents.

10. Use of pMDIs in
Ventilator Circuits

11. Factors affect MDI therapy in MV
The MDI itself
The type of adapter/actuator employed
Type of ventilator, ventilator settings,
circuit conditions
The type of drug employed
The condition of the patient could
impact drug delivery

12. Factors affect MDI therapy in MV

13. Effect of the pMDI Actuator
• Types of adapters
Elbow adapters,
In-line devices that may be uni-
directional or bi-directional
Chamber or reservoir adapters

14. Types of adaptersTypes of adapters

15. MDIMDI
•Employing a chamber spacer with
a pMDI in a ventilator circuit
results in 4–6-fold greater aerosol
drug delivery,
•compared with either an elbow
adapter or a uni-directionalin-line
spacer.

16. Chamber adapterChamber adapter
•A chamber spacer connected at
15 cm from the ETT provides
efficient aerosol delivery in
mechanically ventilated patients
• with significant bronchodilation
with MDI.
•

17. Inspiratory AirflowSynchronization
of Actuation With
The actuation of a pMDI in a ventilator
circuit must be synchronized with the
precise onset of inspiratory airflow
from the ventilator .

18. Synchronization of Actuation With
Inspiratory Airflow
•Time the pMDI actuation with
expansion of the ventilator tubing
at the onset of a ventilator breath;
to mprove MDI delivery
• .

19. Ventilatory Parameters
1) A tidal volume of 500 mL or more (in
an adult)
2) A longer inspiratory time
3) Inspiratory flow
4) longer inspiratory cycleinspiratory cycle
improves aerosol delivery

20. HumidificationHumidification
Humidification of inhaled gas Humidification of inhaled gas
decreases aerosol deposition by decreases aerosol deposition by
approximately 40 % due approximately 40 % due to increased to increased
particle drug deposition in the particle drug deposition in the
ventilator circuit.ventilator circuit.
increased dosage of medication is increased dosage of medication is
often requireoften required to achieve a therapeutic d to achieve a therapeutic
effect in mechanically ventilatedeffect in mechanically ventilated  

21. Heat and Humidity in the
Ventilator Circuit
•Although circuit humidity reduces
drug delivery, bypassing the
humidifier is not recommended for
routine inhalation therapy in
ventilator-supported patients

22. Valved T-adaptor for nebulization Valved T-adaptor for nebulization
during mechanical ventilationduring mechanical ventilation

24. Endotracheal Tube Size
•In adult mechanical ventilation the
type of aerosol generator and the
ventilator
•parameters have a greater influence
on aerosol deposition within the
ETT than the diameter of the ETT
per se.

25. PharmacodynamicPharmacodynamic
•
It was found that administration
of albuterol with an MDI and
spacer produced peak serum
levels in mechanically ventilated
patients that were similar to those
in healthy control subjects,

27. Technique for using MDIs in MV adult Technique for using MDIs in MV adult
patientspatients
Shake the MDI vigorouslyShake the MDI vigorously
Place canister in the actuator of a Place canister in the actuator of a
cylindrical spacer situated in the cylindrical spacer situated in the
inspiratory limb inspiratory limb of ventilator circuit of ventilator circuit
Actuate the MDI once only with the Actuate the MDI once only with the onset onset
of inspiration by the ventilatorof inspiration by the ventilator
Repeat actuations after Repeat actuations after 20 to 30 20 to 30 seconds seconds
u ntil the total dose is deliveredu ntil the total dose is delivered

28. continuous or intermittentcontinuous or intermittent
For patients with severe asthma For patients with severe asthma
exacerbations (exacerbations (eg, dyspnea at rest, eg, dyspnea at rest,
accessory muscle use, retractions, accessory muscle use, retractions,
forced expiratory volume in one forced expiratory volume in one
second or peak expiratory flow <40 second or peak expiratory flow <40
percent predicted), percent predicted), beta agonists are beta agonists are
often administered continuously often administered continuously
rather than intermittentlyrather than intermittently

29. MDI with a chamberMDI with a chamber

30. MDI with special adaptor can it workMDI with special adaptor can it work

31. Helium-oxygen mixturesHelium-oxygen mixtures
Helium-oxygen mixtures affect aerosol Helium-oxygen mixtures affect aerosol
deposition, and in vitro modeling has deposition, and in vitro modeling has
reported a reported a 5050 % increase in deposition of
 
% increase in deposition of
 
albuterol 
from an MDI during mechanical
 
from an MDI during mechanical
ventilation when heliox was used as the ventilation when heliox was used as the
driving gas driving gas
However, heliox can interfere with the However, heliox can interfere with the
functioning of flow sensors and oxygen functioning of flow sensors and oxygen
levels when delivered through some levels when delivered through some
ventilators ventilators

32. HMEHME
The use of a heat and moisture exchanger The use of a heat and moisture exchanger
(HME) in the ventilator circuit can (HME) in the ventilator circuit can filter out filter out
the aerosol when an MDI (or nebulizer) is the aerosol when an MDI (or nebulizer) is
used. used.
Commercially available devices can be used Commercially available devices can be used
to bypass the HME when a MDI is used to bypass the HME when a MDI is used
AlternativelyAlternatively, the HME must be removed , the HME must be removed
from the circuit when the aerosol is from the circuit when the aerosol is
delivered.delivered.

33. Humid-Flo® HMEHumid-Flo® HME

34. Duration of Bronchodilator Response
•. In stable mechanically ventilated
patients with COPD, th bronchodilator
effect of albuterol is sustained for 2–3
hours
• Mechanically ventilated patients
may require an every-3-to-4-hour
dosing schedule with albuterol to
sustain a bronchodilator response.

36. Nebulizer
   Delivery
Nebulizer
   Delivery
Aerosol delivery by nebulizer is affected by using Aerosol delivery by nebulizer is affected by using ::
Large tidal volume Large tidal volume
End-inspiratory pause, End-inspiratory pause,
Slow inspiratory flow (but these factors do not affect Slow inspiratory flow (but these factors do not affect
MDI delivery)MDI delivery)
Nebulizer performance can be optimized by Nebulizer performance can be optimized by placing placing
the nebulizer 30 cm from the endotracheal tube, the nebulizer 30 cm from the endotracheal tube,
rather than at the Y-piece, because the inspiratory rather than at the Y-piece, because the inspiratory
ventilator tubing acts as a spacerventilator tubing acts as a spacer..

37. Factors optimize Nebulizer
   Delivery
Factors optimize Nebulizer
   Delivery
Operating the nebulizer only during inspiration Operating the nebulizer only during inspiration
Using breath-actuated nebulizer (increase Using breath-actuated nebulizer (increase
five-fold)five-fold). .
Bypassing the humidifier increase delivered Bypassing the humidifier increase delivered
dose a factor four dose a factor four ..

38. Aerosol delivery by MDIAerosol delivery by MDI
Is easy to administer Is easy to administer
Involves less personnel time Involves less personnel time
provides a reliable dose of the drugprovides a reliable dose of the drug
Free from the risk of bacterial Free from the risk of bacterial
contamination.contamination.

39. Aerosol delivery by MDIAerosol delivery by MDI
•Using MDI with an in-line spacer with Using MDI with an in-line spacer with
ventilator circuit ventilator circuit ::
Reduce the risk of ventilator-associated Reduce the risk of ventilator-associated
pneumonia. pneumonia.
Prevents the loss of positive end-expiratory Prevents the loss of positive end-expiratory
pressure (PEEP) in patients with acute pressure (PEEP) in patients with acute
respiratory distress syndrome (ARDS)respiratory distress syndrome (ARDS)

40. Disadvantages of nebulizer use during MVDisadvantages of nebulizer use during MV
Circuit contamination Circuit contamination
Decreased ability of the patient to trigger Decreased ability of the patient to trigger
the ventilator the ventilator
Increases in tidal volume and airway Increases in tidal volume and airway
pressure due to nebulizer flow. pressure due to nebulizer flow.
To avoid interruption of mechanical To avoid interruption of mechanical
ventilation for nebulizer insertion and ventilation for nebulizer insertion and
removal Valved removal Valved T-piece devices is used.T-piece devices is used.

41. Valved T-adaptor for nebulization during Valved T-adaptor for nebulization during
mechanical ventilationmechanical ventilation

42. Use of MDI in MVUse of MDI in MV

43. MDI vs neublizerMDI vs neublizer
An MDI with a chamber results in a An MDI with a chamber results in a
four- to six-fold greater delivery four- to six-fold greater delivery of of
aerosol than MDI actuation into a aerosol than MDI actuation into a
connector attached directly to the connector attached directly to the
endotracheal tube, or into an in-line endotracheal tube, or into an in-line
device that lacks a chamberdevice that lacks a chamber
  Properly used, an MDI may deliver a Properly used, an MDI may deliver a
more consistent dose than a nebulizermore consistent dose than a nebulizer

44. Administration of BronchodilatorsAdministration of Bronchodilators
Nebuliser or MDI?Nebuliser or MDI?
Lung deposition of radiolabelled drug*Lung deposition of radiolabelled drug*
–MDI 5.6%MDI 5.6% v Nebuliser 1.2% v Nebuliser 1.2%
4-10 puffs4-10 puffs MDI effective in reducing R MDI effective in reducing RAWAW
* Chest 1999; 115:1653-1657* Chest 1999; 115:1653-1657
**Am Rev Respir Dis 1990; 141:440–444**Am Rev Respir Dis 1990; 141:440–444

45. Choice of deviceChoice of device
The The nebulizernebulizer is less efficient than the is less efficient than the
metered dose inhaler metered dose inhaler during mechanical during mechanical
ventilation, ventilation,
The nebulizer can deliver a greater The nebulizer can deliver a greater
cumulative dose to the lower respiratory cumulative dose to the lower respiratory
tract tract
Nebulizers and MDIs produce similar Nebulizers and MDIs produce similar
therapeutic effects in mechanically therapeutic effects in mechanically
ventilated patients if ventilated patients if used in a proper wayused in a proper way

46. Choice of deviceChoice of device
The use of an MDI for routine bronchodilator The use of an MDI for routine bronchodilator
therapy in ventilator-supported patients is therapy in ventilator-supported patients is
preferred because of the problems associated preferred because of the problems associated
with the use of nebulizers including :with the use of nebulizers including :
contamination contamination
Triggering difficulty Triggering difficulty
Increased pressure and volume delivery.Increased pressure and volume delivery.

47. Dose of Bronchodilator in MV
•
In mechanically ventilated
patients with COPD, administer
4, 8, and 16 puffs of albuterol with
an MDI and cylindrical spacer.

48. Dose of Bronchodilator in
MV
• A significant decrease in airway
resistance was observed after
administration of 4 puffs, with no additional
effect after cumulative doses of 12 and 28
puffs
•. In a separate group of patients with
COPD, the bronchodilator effect of a
single dose of 4 puffs of albuterol was
sustained for at least 60 min

49. Dose of Bronchodilator in
MV
•
• In summary, when the technique of
administration is carefully used, the
majority of stable mechanically
ventilated patients with asthma
&COPD achieved near maximal
bronchodilation with normal dasage.
• .

50. NOTENOTE
When the patient with severe asthma fails When the patient with severe asthma fails
to respond, end on end treatments may be to respond, end on end treatments may be
ordered until the patient “opens up”. ordered until the patient “opens up”.
With severe exacerbation, a patient may With severe exacerbation, a patient may
receive up to 4 - 6 treatments in an hour, receive up to 4 - 6 treatments in an hour,
equivalent to a nebulizer nominal dose of equivalent to a nebulizer nominal dose of
10 - 15 mg of albuterol in an hour. 10 - 15 mg of albuterol in an hour.

51. DOSE OF MDIDOSE OF MDI
• Abuterol administered by MDI through an Abuterol administered by MDI through an
endotracheal tube adapter has no effect in endotracheal tube adapter has no effect in
mechanically ventilated patients with airflow mechanically ventilated patients with airflow
obstructionobstruction . .
•Nebulizer treatments can and should be titrated Nebulizer treatments can and should be titrated to to
higher-than-conventional doseshigher-than-conventional doses, , using toxic side-using toxic side-
effects and physiologic response to guide therapyeffects and physiologic response to guide therapy..

52. Drug Toxicity
•Higher doses of B- agonists delivered via MDI
•hypokalemia
Atrial tachycardia
Ventricular arrhythmias

53. Drug Toxicity
Most investigators have reported no
adverse effects following
administration of albuterol with an MDI.
A dose-dependent increase in heart
rate, which became significant after
administration of a cumulative dose of
28 puffs, has been reported.

54. Bronchodilator Therapy
During Noninvasive Ventilation
Aerosol therapy can also be administered Aerosol therapy can also be administered
during noninvasive positive pressure during noninvasive positive pressure
ventilation (NPPV), using devices adapted ventilation (NPPV), using devices adapted
for inline administration for inline administration
Effective delivery of
 
Effective delivery of
 
albuterol 
by MDI
 
by MDI
during NPPV using a specialized spacer during NPPV using a specialized spacer
has been reported in patients with has been reported in patients with
exacerbations of COPDexacerbations of COPD

55. Aerosolized medications, either by nebulizer or Aerosolized medications, either by nebulizer or
MDI, can be administered during NPPVMDI, can be administered during NPPV

56. noninvasive positive pressure ventilation (NPPV)noninvasive positive pressure ventilation (NPPV)

57. Tracheostomy tubeTracheostomy tube
•Two systems are available for delivery of Two systems are available for delivery of
nebulized medication: either a mask can nebulized medication: either a mask can
be placed over the tracheostomy opening be placed over the tracheostomy opening
or the nebulizer chamber can be attached or the nebulizer chamber can be attached
to the tracheostomy tube using a T-piece to the tracheostomy tube using a T-piece
made of ventilator tubing and a connector. made of ventilator tubing and a connector.
The T-piece approach is preferred The T-piece approach is preferred
because more aerosol is directed into the because more aerosol is directed into the
tracheostomy tubetracheostomy tube..

58. Equipment for aerosol delivery to tracheostomy in Equipment for aerosol delivery to tracheostomy in
spontaneously breathing patientsspontaneously breathing patients

59. Thank you!!

60. Are you still awakeAre you still awake??????