Nebulization during spontaneous breathing, CPAP and Bilevel: a

randomized analysis of pulmonary radioaerosol deposition

RESPIRATORY CARE APRIL 2014 VOL 59 NO 4

Douglas S. Gardenhire, EdD, RRT-NPS, FAARCGeorgia State University

Background

• What do we know about aerosol and non-invasive ventilation?• No guidelines exist for aerosol delivery with non-

invasive ventilation.• Small number of studies exist in topic.• Large number of variables encountered.• As a practicing respiratory therapist what variables do

you think play a role in delivering aerosol to patients receiving CPAP or BiPAP?

Background

• What is scintigraphy?• What is technetium?

Research Question

Does pulmonary regional deposition of radioaerosol administered by nebulization to healthy individuals, during spontaneous breathing, CPAP and BiPAP differ?

• Is this research question relevant to your clinical practice?

Methods• Study design– Crossover and Observational– What are the positives to this design? Negative?

• Exclusion criteria were: – < 18 or > 60 years– History of smoking– History of respiratory diseases (COPD, asthma or tuberculosis)– History cardiac disease– Pregnancy– Conditions requiring systemic corticosteroids,– FEF1 < 2 L– peak expiratory flow < 300 Liters/min– BMI > 30 Kg/m2– Neuromuscular disease diagnosis or maximal inspiratory pressure

(MIP) > -30 cmH2O.

Methods(Cont.)

• Control group was each patient.• Sample size small.

• Do you see these as issues with the study?

Methods(Cont.)

Do you think the statistical analysis is appropriate for this

observational study?

• No ethical concerns noted for this paper.

Results

• Main results– Statistically no difference between spontaneous

breathing, CPAP and BiPAP when using a jet nebulizer.

– Why are they not different?

Results (cont.)

Results (cont.)

• Why do you think the researchers found more aerosol in the stomach with BiPAP?

Discussion

• What do these finding mean to you as a respiratory therapist using CPAP and BiPAP?

• The current study was very similar to:França EET, Andrade AFD, Cabrala G, Filho PA, Silva KC, Filho VCG, etal. Nebulization associated with Bi-level noninvasive ventilation: analysisof pulmonary radioaerosol deposition. Respir Med 2006;100:721-728.

• Franca, et al. found a decrease in aerosol when using BiPAP in healthy volunteers.

Discussion (cont.)

• How does albuterol behave with the use of BiPAP in mild to moderate asthma?

Pollack CV Jr, Fleisch KB, Dowsey K. Treatment of acute bronchospasm

with beta-adrenergic agonist aerosols delivered by a nasal bilevelpositive airway pressure circuit. Ann Emerg Med 1995;26(5):552–

557.

• Pollack et al. found an improvement in peak flows of asthmatics when using BiPAP.

Discussion (cont.)

• How does bronchodilator behave with the use of BiPAP in moderate to severe asthma?

Galindo-Filho VC, Dornelas-de-Andrade A, Brandão DC, de Cássia S,Ferreira R, Menezes MJ, et al. Noninvasive ventilation coupledwith nebulization during asthma crises: A randomized controlled trial.Resp Care 2013;58(2):241-249.

• Deposition did not change, but patient outcomes improved via PFT values.

• Could pressure differences make a difference?

Discussion (cont.)

• What additional work is needed in this area?– More is needed. More clinical evaluations.– Bench work is also important.– Cost may play a factor.

Conclusions

• Authors’ conclusions…– Aerosol deposition is equivalent in healthy

volunteers during spontaneous breathing, CPAP and BiPAP.

• Should this affect your practice?• Take-home message…..– Aerosol can be given during CPAP and BiPAP– Evaluate patients– Be consistent