Aerosol Delivery During

Noninvasive VentilationDean R. Hess PhD RRT

Associate Professor of Anesthesia

Harvard Medical School

Assistant Director of Respiratory Care

Massachusetts General Hospital

Editor in Chief

Respiratory Care

Aerosol DrugsAerosol Drugs

Aerosol Delivery DevicesAerosol Delivery Devices

� Nebulizer: jet, mesh

� Pressurized metered dose inhaler

� Metered inhaler with spacer or valved holding chamber

� Dry powder inhaler

� Results of this systematic review were essentially the same

in each of the clinical settings

� None of the pooled meta-analyses showed a significant

difference between devices in any efficacy outcome in any patient group.

� Each of the devices studied can work equally well in patients who

can use them appropriately.

Chest 2005; 127:335

Dhand, J Aerosol Med 2008; 21:1-16

� Both nebulizers and MDIs can be used to deliver Beta2-agonists to mechanically ventilated patients.

� Cannot use DPI during mechanical ventilation.

� Careful attention to details of the technique employed for administering drugs by MDI or nebulizer to mechanically ventilated patients is critical, since multiple technical factors may have clinically important effects on the efficiency of aerosol delivery.

Chest 2005; 127:335-371

nasal

total face

oronasal pillows

mouthpiece helmet

COPD ExacerbationCOPD Exacerbation

� 14 studies included in the review

� Decreased risk of intubation: NNT 4

� Lower mortality with NIV: NNT 10

Picot, Cochrane Database of Systematic Reviews 2008

Nava et Nava et alalIntensive Care Med 2001; 27:Intensive Care Med 2001; 27:1627 1627

� Albuterol MDI/spacer during NIV in patients with COPD

� NIV with pressure support of 14.3 ± 1.8 cm H2O (tidal volume 10 mL/kg) usingoronasal mask

� Significant increase in FEV1 with albuterol, but not placebo

pre placebo + NPPV

pre albuterol + NPPV∆

FE

V1

(mL)

∆

FE

V1

(mL)

pre placebo + NPPV

pre albuterol + NPPV∆

FE

V1

(mL)

∆

FE

V1

(mL)

FaurouxFauroux et alet alAJRCCM 2000; 162:AJRCCM 2000; 162:2265 2265

� Evaluated deposition of labeled aerosol

in 18 children with cystic fibrosis

� NIV via homecare ventilator and

mouthpiece; PSV 8 - 10 cm H2O,

breath-actuated nebulizer

� Aerosol deposition was about 30%

greater after the NIV session than after

the control session

Control

NIV

Respir Care 2010;55: 536

Scala, RespirCare 2010;55:630

Pollack et Pollack et alalAnn Ann EmergEmerg Med 1995; 26:Med 1995; 26:552 552

� Wheezing patients assigned to

albuterol by nebulizer (n=40) or

BiPAP (n=60) with nasal mask or

oronasal mask (IPAP 10 cm H2O,

EPAP 5 cm H2O)

� Increase in peak flow was greater

in the BiPAP group than the

nebulizer group

peak

exp

irato

ry fl

ow (

L/m

in)

peak

exp

irato

ry fl

ow (

L/m

in)

Ventilators for NIV

None with integrated nebulizer

blower &pressurecontroller

mask

singlehose

leak

humidifier

BilevelBilevel NIV NIV Ventilator DesignVentilator Design

ChatmongkolchartChatmongkolchart et et alalCritCrit Care Med 2002; 30:Care Med 2002; 30:25152515

� Bench study to evaluate affect of nebulizer position in

circuit, respiratory rate, and NIV settings on albuterol

delivery

� Interaction between nebulizer position (ventilator vs

mask), rate (10 vs 20/min), and IPAP/EPAP settings

� Nebulizer flow did not affect function of the ventilator

� Best position was with nebulizer near mask

BranconnierBranconnier and Hess and Hess RespirRespir Care Care 2005; 2005; 1649 1649

� Bench model of NIV to determine effect of albuteroldelivery with nebulizer versus MDI, and leak port in the circuit or the mask

� With the nebulizer, more albuterol delivered when the leak port was in the circuit and more albuterol delivered than with the MDI

� The efficiency of albuterol delivery (% delivered) was similar for nebulizer and MDI with the leak port in the circuit, but better for the MDI with the leak port in the mask

BranconnierBranconnier and Hess and Hess RespirRespir Care Care 2005; 2005; 16491649

0

100

200

300

400

500

600

Spectrum Mirage

albu

tero

l (m

cg)

Nebulizer Inhaler

0

2

4

6

8

10

12

Spectrum Mirage

perc

ent

deliv

ered

Nebulizer Inhaler

circuit leak mask leak

Circuit leak

Mask leak

Inhaled Bronchodilators With Inhaled Bronchodilators With NIVNIV

� Remove patient from ventilator and administer bronchodilator by nebulizer or MDI (Mukhopadhyay, J Crit Care 2009;24:474.e1)

� Administer nebulizer or MDI/spacer inline

Hess, J Aerosol Med 2007; 20 Suppl 1:S85

Iosson, N Engl J Med 2006; 354:e8

SummarySummary

� Available evidence suggests that aerosolized medications can be delivered during NIV using either a nebulizer or MDI/spacer

� The evidence for aerosol delivery during NIV is not nearly as mature as the evidence for aerosol delivery during invasive mechanical ventilation

� Issues related to the optimal interface, ventilator settings, aerosol generator (nebulizer versus MDI), timing (breath actuation), and humidification are largely unexplored