NIV and Aerosoltherapy Workshop Jean-Bernard Michotte (Lausanne-CH) Simone Gambazza (Milano-IT) Jean-Bernard Michotte Haute Ecole de Santé Vaud, 1011 Lausanne - Suisse Cliniques Universitaires Saint-Luc, 1200 Bruxelles - Belgique
Introduction Single-limb circuit Nebulization Adulte
Nebulization Adulte Bilevel ventilator
Introduction Very few studies Guidelines??? Factors influencing the aerosol delivery during NIV? Flow Modes, settings, Exhalation port Interfaces Single limb circuit.
NIV and Aerosoltherapy? NIV work of breathing dyspnea pulmonary gas exchange Alveolar ventilation Aerosoltherapy airway resistance dynamic hyperinflation dyspnea.. What benefits?
NIV and Aerosoltherapy? Respir Care 2013;58(2):241 249 β-2 agonists : 21 asthmatics
NIV and Aerosoltherapy? Tc 99m DTPA Tc 99m DTPA Respir Care 2013;58(2):241 249 β-2 agonists : 21 asthmatics
NIV and Aerosoltherapy? Tc 99m DTPA Tc 99m DTPA Pulmonary function tests = NIV group Respir Care 2013;58(2):241 249 β-2 agonists : 21 asthmatics Pulmonary deposition = no difference
NIV and Aerosoltherapy? Journal of Asthma, 46:356 361, 2009 36 severe asthmatics Pulmonary function tests = NIV group Neb VNI (15/5) VNI (15/10)
NIV and Aerosoltherapy? NIV and Aerosoltherapy = feasible Pulmonary deposition NIV vs spontaneous No difference in patients with asthma Increased in cystic fibrosis patients (Fauroux B. : Am J Respir Crit Care Med Vol 162. pp 2265 2271, 2000) Improvement in pulmonary function tests Pulmonary dose??? Spontaneous > CPAP (Reychler G. : Respir Med. 2007 Oct;101(10):2051-5)
Factors related to NIV Bilevel ventilator Inhaled dose Settings Exhalation port Mask Pneumatic Ultrasonic Mesh Nebulizers Positions
Which nebulizer? Bilevel ventilator Inhaled dose Position Near the ventilator Position Near the patient Pneumatic Ultrasonic Mesh Nebulizers
J Aerosol Med Pulm Drug Deliv. 2014 Dec;27(6):430-40 Lung model A B Bilevel ventilator VT = 400 ml Freq = 16/min I:E = 1:3 Patient side Ventilator side Amikacin 5mg/4 ml IPAP = 20 EPAP = 5
Inhaled dose: Patient side p <0.001 J Aerosol Med Pulm Drug Deliv. 2014 Dec;27(6):430-40
Inhaled dose: Ventilateur side p <0.001 p <0.01 J Aerosol Med Pulm Drug Deliv. 2014 Dec;27(6):430-40
Which position? Bilevel ventilator Inhaled dose Ventilateur side Patient side Mesh Nebulizer
Reservoir effect? J Aerosol Med Pulm Drug Deliv. 2012 Apr;25(2):63-78.
Inhaled dose: Patient side vs Ventilateur side p <0.001 p <0.001 p <0.001 p <0.5 p <0.001 J Aerosol Med Pulm Drug Deliv. 2014 Dec;27(6):430-40
Expiratory wasted dose : Patient side vs Ventilateur side p <0.001 p <0.001 p <0.001 «Reservoir» effect? p <0.001 p <0.01 J Aerosol Med Pulm Drug Deliv. 2014 Dec;27(6):430-40
NIV : 15/5, 25/5, 15/10 et 25/10 Pneumatic nebulizer Albuterol : 5mg/4ml J Aerosol Med Pulm Drug Deliv. 2014 Apr;27(2):125-32.
J Aerosol Med Pulm Drug Deliv. 2014 Apr;27(2):125-32. Proximal = Ventilateur side Distal = Patient side Pneumatic nebulizer position?
Vented mask or exhalation device? Bilevel ventilator Inhaled dose Exhalation device? Vented mask?
Respir Care 2005;50(12):1649 1653. Exhalation port NIV : 15/5 Pneumatic nebulizer Albuterol 5mg/4ml Vented mask Freq : 20 VT : 400
Respir Care 2005;50(12):1649 1653. p <0.001 NIV : 15/5 Albuterol 5mg/4ml Exhalation port Vented mask Exhalation port > Vented mask (Pneumatic nebulizer)
Settings? Bilevel ventilator Inhaled dose Settings
Crit Care Med 2002; 30:2515 2519 Pneumatic nebulizer Albuterol 5mg/4mL Ventilateur side Patient side Patient side ou ventilator side Frequency 10 vs Frequency 20 PS 5 vs PS 10 vs PS 15 PEEP 5 vs PEEP 10
Patient side Ventilateur side Settings : Higher inhaled dose with higher Pressure support Lower inhaled dose with higher PEEP Crit Care Med 2002; 30:2515 2519
Bilevel ventilator PS level Conclusions Non-vented mask Patient side Inhaled dose PEEP level Nebulizer Mesh
Conclusions NIV + Aerosoltherapy = feasible Optimizing NIV in acute respiratory failure = Priority for patients «Patient» + NIV Settings >< «Nebulization» + NIV settings Pneumatic nebulizer (position? FiO 2? ) Wastage of drug!!! Synchronized nebulization? Exhalation port Non intentional leaks Metered Dose Inhaler?
Mechanical ventilation and Aerosoltherapy Workshop Jean-Bernard Michotte (Lausanne-CH) Simone Gambazza (Milano-IT) Jean-Bernard Michotte Haute Ecole de Santé Vaud, 1011 Lausanne - Suisse Cliniques Universitaires Saint-Luc, 1200 Bruxelles - Belgique
Introduction 20 years ago Scintigraphy studies (99mTc-HSA) Studies Nebulizers Residual fraction Endotracheal Tube Circuits Pulmonary fraction Exhaled fraction Thomas, 1993 Pneumatic 50% 1% 32% 2.2% 11.5% O Doherty, 1995 Pneumatic 46.2% 1.14% 32% 2.2% 18% Pneumatic + Spacer 47.1% 1.48% 35% 3% 15% Low deposition (2 to 3%) Limits: Nebulizer performances, clinical guidelines,
Introduction Experimental models (Antibiotics) Studies Nebulizers Residual fraction Endotracheal Tube Circuits Pulmonary fraction Exhaled fraction Ferrari, 2008 Mesh 4±2% 3±1% 18±5% 66% 9±4% Ferrari, 2009 Lu, 2010 Mesh 10.1±6.7% 2.8±0.6% 29±7.3% 40% 17±9.1% Mesh 3±1% 1±1% 26±8% 60% 10±3% 2 approaches: Make particles available Guidelines for nebulization
Factors influencing aerosol delivery Respir Care 2004;49:611-22
Deposition in mechanical ventilation (MV) Pulmonary distribution of inhaled radioactive particles (99mTc-DTPA) in mechanical ventilation Deposition? Where? Courtesy of Dugernier J (in press)
Lost dose in mechanical ventilation (MV) Courtesy of Dugernier J
Computational fluid dynamics simulations Respir Care 2014;59(5):686 698
Computational fluid dynamics simulations Respir Care 2014;59(5):686 698
Lost dose in mechanical ventilation (MV) Proximal flow sensor (PFS)? J Aerosol Med Pulm Drug Deliv 2014 Nov
Low deposition in mechanical ventilation Humidification? J Aerosol Med Pulm Drug Deliv 2012;25:63-78
Low deposition in mechanical ventilation Remove HME Protect the ventilator
Low deposition in mechanical ventilation Airways obstruction «Clean» airways Secretion removal before aerosoltherapy!!!! ARRD 1986;133:740-3
Which position? Réanimation (2012) 21:42-54
Which position? Aerosol Systems Pneumatic (A) Ultrasonic (B) Expi Inspi Mesh (C) MDI + Spacer (D) Humidification Respir Care 2010;55:837-44
Synchronized nebulization mode Synchronized mode Continuous mode p<0.05 Dry circuit Humidified circuit Am J Respir Crit Care Med;168:1205-9
Synchronized nebulization mode Respir Care 2014;59:1508-16
Synchronized nebulization mode Pulmonary Drug Delivery System (PDDS)
Which settings? Aeroneb Solo with Volume control : Decelarating flow vs constant flow (with PFS) Decelerating flow Constant flow * p<0.05 J Aerosol Med Pulm Drug Deliv 2014 Nov
Which settings? Am J Respir Crit Care Med. 1999; 159:63 68
Which settings? 80 L/min 30 L/min
Conclusions «The devil is in the details» Nebulizer: - Frequent circuit disconnection - Cleaning and disinfection - Risk de Ventilator-associated pneumonia Use of MDI + Spacer?