1. The Aerosol Drug Management Improvement Team
ADMIT
Slide Deck 2018

2. Part 9
Inhalation therapy
in special populations
Walter Vincken

3. Inhalation therapy in mechanically ventilated patients

4. Options for IT in MV patients
pMDI + in-line spacer chamber
DPI : NOT suitable
Nebulizer
Jet nebuliser
Vibrating mesh nebulizer (investigational, little clinical information available)
Ultrasonic nebuliser: NOT suitable
SMI (Respimat®)
Ari A et al. 2012

5. Advantages using a pMDI in MV patients (as compared to nebuliser)
Easy to administer, more convenient
Less personnel time, lower cost
Provides reliable dose
No risk of bacterial contamination
Reduced risk of damaging flow sensors
Using an in-line spacer:
Lowers risk of VAP
Prevents loss of PEEP

6. Factors affecting aerosol delivery during mechanical ventilation
Dean Hess. Delivery of inhaled medicatioin in adults. (last updated March 07, 2014)

7. Humidification of inhaled gas decreases lung deposition by 40%
Good to know
Humidification of inhaled gas decreases lung deposition by 40%
Therefore, increased dosage of drug is often required in MV patients
Helium-oxygen (heliox) mixtures increase lung deposition by 50%
Vt > 0.5 L guarantees drug delivery to the lower respiratory tract

8. Inhaled drugs used during MV
Mainly bronchodilators
SABA (e.g. salbutamol 4 x 100 µg with pMDI+spacer, or 2.5 mg with nebuliser; fenoterol 0.4 mg with nebuliser)
SAMA (ipratropium)
SABA + SAMA: combination more effective
LABA + iCS
Rarely
Inhaled corticosteroids: role debated because
Many MV patients are already on systemic corticosteroids
Risk of pneumonia (VAP)
Prostacyclin, prostaglandin E
Muco-active drugs
Dornase-α
Surfactant
Antibiotics (in CF patients)
Ari A et al. 2012

9. Indications for bronchodilator therapy in MV patients
Severe asthma
COPD
Acute bronchospasm/wheezing
Increased Raw
Dynamic hyperinflation/iPEEP
Difficulty in weaning
Chronic ventilator dependence
Ari A et al. 2012

10. Goals of bronchodilator therapy in MV patients
Reverse bronchoconstriction
Reduce work of breathing
Relieve dyspnoea
Ari A et al. 2012

11. pMDI in MV patients: optimal technique
Clear airway / remove airway secretions
Shake pMDI vigorously
Prime pMDI before first use and if not used during the previous 24 h
Place pMDI canister in the actuator/adapter of a cylindrical spacer chamber (placed in line in the inspiratory limb of the ventilator circuit, 15 cm from ETT)
Remove or bypass HME / do not disconnect humidifier
Synchronise pMDI actuation with precise onset of inspiration
Wait seconds between successive actuations; repeat actuations until the total dose is administered
Reconnect HME
Adapted from Ari A et al. 2012

12. Inline metered dose inhaler spacing device
Using a chamber results in a four- to six-fold greater delivery of aerosol than actuation into a connector attached directly to the endotracheal tube, or into an inline device that lacks a chamber
Dean Hess. Delivery of inhaled medicatioin in adults. (last updated March 07, 2014)

13. Circuvent® device for delivery of MDI or nebulised medication during mechanical ventilation
The CircuVent® device allows delivery of aerosolised medications (MDI or nebulised) to mechanically ventilated patients without removing the heat and moisture exchanger (HME). Using a valve system, air bypasses the HME during delivery of the aerosol.
Reproduced with permission from: Smiths Medical, Copyright© 2012.
All rights reserved

14. Heat and moisture exchange (HME) selection device
The heat and moisture exchange (HME) selection device uses a rotating collar to allow switching form HME mode for heat and moisture exchange to AEROSOL mode without opening the ventilator circuit. In HME mode, the unit functions as a heat and moisture exchanger. In AEROSOL mode, the heat and moisture function is bypassed for administration of an aerosolised or MDI medication. HME: heat and moisture exchanger; MDI: metered dose inhaler
Reproduced with permission : Copyright© 2012 Teleflex Incoroporated

15. Jet nebuliser in MV patients: optimal technique
Clear airway / remove airway secretions
Place drug in nebuliser
Place nebuliser in inspiratory limb of the ventilator circuit, cm from Y-connector (using the inspiratory tubing as a spacer)
Remove HME / do not disconnect humidifier
Set gas flow to nebuliser at 2-10 L/min
Use ventilator to power nebuliser, or
Use continuous flow from external source
Adapted from Ari A et al. 2012

16. Jet nebulizer in MV patients: optimal technique
Adjust ventilator volume and pressure limit and alarms to compensate for added flow
Run until nebuliser begins to sputter
Remove nebuliser from circuit, rinse with sterile water, run dry and store in safe place
Reconnect HME
Return ventilator settings and alarms to previous values
Adapted from Ari A et al. 2012

17. Valved T-adaptor for nebulisation during mechanical ventilation
The valved T-adaptor can be used as a permanent part of ventilator tubing. A spring-loaded valve opens and closes the circuit during nebuliser insertion and removal for addition of medication
Photo reproduced with the permission of CareFusion corporation Copyright© All rights reserved

18. Aerosolised medications, either by nebuliser or MDI, can be administered during NPPV
Nebuliser and NPPV
MDI/spacer and NPPV
Dean Hess. Delivery of inhaled medicatioin in adults. (last updated March 07, 2014)

19. Equipment for aerosol delivery to a tracheostomy in spontaneously breathing patients
Photo reproduced with the permission of CareFusion corporation. Copyright© All rights reserved

20. Inhalation therapy in elderly patients

21. Problems with IT in elderly
Cognitive decline
Mini-mental test score > 23/30 or a Hodkinson mental test score > 7/10 required for correct use of pMDI*
Manual dexterity loss
Visual acuity loss
Ageing-related changes in respiratory function
*Allen SC, Ragab S. Ability to learn inhaler technique in relation to cognitive scores and tests of praxis in old age. Postgrad Med J 2002;78:37-39

22. Ageing-related changes in respiratory function
Enlargement of distal airspaces (‘emphysema-like’)
Reduced surface area for gas exchange
Reduced carbon monoxide transfer (TLCO)
Reduced lung elastic recoil
Premature closing of dependent airways
Increased heterogeneity of ventilation/perfusion distribution
Reduced radial traction of lung tissue on peripheral airways
Reduced maximal end-expiratory flow rates (‘small airway disease’)
Air trapping and hyperinflation (increased RV and FRC)
Reduced chest wall compliance (stiffening of the chest wall)
Decreased respiratory muscle strength

23. IT in elderly: preferred device
pMDI + spacer chamber
Cave: problems in assembling pMDI & spacer
Breath-actuated pMDI
Nebuliser
Cumbersome
DPI
pMDI without spacer
To be avoided