Aerosolized albuterol delivery is a mainstay treatment for bronchoconstriction; however, almost no data exist that evaluate the clinical outcome of instillation of an endotracheal liquid bolus (ELB) of a bronchodilator directly into the airway.
METHODS:
This randomized trial sought to evaluate the efficacy of albuterol lavage via artificial airway with accompanied patient positioning. Subjects receiving mechanical ventilation for acute respiratory failure with clinical manifestations of bronchoconstriction were assigned to initially receive either traditional albuterol via metered-dose inhaler (MDI) or albuterol via ELB lavage with follow-up administration of the other therapy after a 4-h washout period. Clinical data were collected at baseline and at 5 and 30 min post-treatment.
RESULTS:
Fourteen subjects (5 males, 9 females; mean age of 57.5 y) were included in this study. In the group receiving initial ELB, peak airway pressure decreased significantly (P = .02), and a significant decrease in airway resistance mean scores was seen from baseline to 30 min post-treatment (P < .001) and from 5 to 30 min post-treatment (P = .003), with no significant effects seen with follow-up MDI. In the initial MDI treatment group, no significant effect on peak airway pressure or airway resistance was noted. SpO2 increased at 5 min post-treatment with ELB. In contrast, SpO2 decreased 30 min post-treatment with MDI. Mean arterial pressure decreased post-treatment with ELB. The pattern in heart rate change post-treatment with ELB was similar to that post-treatment with MDI, with a significant increase at the 5-min interval from baseline (P < .01), followed by a significant decrease at the 30-min interval (P < .001). There were no differences in dynamic compliance at each time interval following administration of both the MDI (P = .92) and ELB conditions (P = .18).
CONCLUSIONS:
ELB albuterol lavage may be a viable option to reverse bronchoconstriction in intubated patients with limited response to traditional aerosolized albuterol via MDI.
MoormanJE, ZahranH, TrumanB, MollaM. (2011) Current Asthma Prevalence—United States, 2006–2008. Atlanta: Epidemiology and Analysis Program office.
2.
SchillerJS, LucasJW, PeregoyJA. (2012) Summary health statistics for US adults: National Health Interview Survey, 2011. National Center for Health Statistics. Vital Health Stat, 10(256).
3.
ChippsBE, ZeigerRS, BorishL, WenzelSE, YeginA, HaydenML, et al. Key findings and clinical implications from The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study. J Allergy Clin Immunol, 2012; 130(2):332e10–342.e10.
GriswoldSK, NordstromCR, ClarkS, GaetaTJ, PriceML, CamargoCAJr. Asthma exacerbations in North American adults: who are the “frequent fliers” in the emergency department?. Chest, 2005; 127(5):1579–1586.
6.
StridJM, GammelagerH, JohansenMB, TønnesenE, ChristiansenCF. Hospitalization rate and 30-day mortality among patients with status asthmaticus in Denmark: a 16-year nationwide population-based cohort study. Clin Epidemiol, 2013; 5:345–355.
7.
PetersJI, StupkaJE, SinghH, RossruckerJ, AngelLF, MeloJ, LevineSM. Status asthmaticus in the medical intensive care unit: a 30-year experience. Respir Med, 2012; 106(3):344–348.
8.
RodrigoG. Asthma in adults (acute). Clin Evid, 2011; 2011:1513.
O'GradyK, DoyleDJ, IrishJ, GullaneP. Biophysics of airflow within the airway: a review. J Otolaryngol, 1997; 26(2):123–128.
11.
TashiroK, YamadaK, LiWZ, MatsumotoY, KobayashiT. Aerosolized and instilled surfactant therapies for acute lung injury caused by intratracheal endotoxin in rats. Crit Care Med, 1996; 24(3):488–494.
12.
UedaT, IkegamiM, RiderED, JobeAH. Distribution of surfactant and ventilation in surfactant-treated preterm lambs. J Appl Physiol, 1994; 76(1):45–55.
13.
HalpernD, FujiokaH, TakayamaS, GrotbergJB. Liquid and surfactant delivery into pulmonary airways. Respir Physiol Neurobiol, 2008; 163(1-3):222–231.
14.
WatersSL, RothbergJB. The propagation of a surfactant laden liquid plug in a capillary tube. Physics Fluids, 2002; 14(2):471–480.
15.
DhandR. Basic techniques for aerosol delivery during mechanical ventilation. Respir Care, 2004; 49(6):611–622.
16.
EbertJ, AdamsAB, Green-EideB. An evaluation of MDI (metered dose inhaler) spacers and adapters: their effect on the respirable volume of medication. Respir Care, 1992; 37(8):862–868.
17.
RauJL, DunlevyCL, HillRL. A comparison of inline MDI actuators for delivery of a beta agonist and a corticosteroid with a mechanically ventilated lung model. Respir Care, 1998; 43(9):705–712.
18.
CottrelGP, SurkinHB. Pharmacology for respiratory care practitioners. Philadelphia: FA Davis; 1995.
19.
CooperPR, PanettieriRAJr. Steroids completely reverse albuterol-induced beta2-adrenergic receptor tolerance in human small airways. J Allergy Clin Immunol, 2008; 122(4):734–740.
20.
BeasleyR, FishwickD, MilesJF, HendelesL. Preservatives in nebulizer solutions: risks without benefit. Pharmacotherapy, 1998; 18(1):130–139.
21.
BatemanE, SinghD, SmithD, DisseB, TowseL, MasseyD, et al. Efficacy and safety of tiotropium Respimat SMI in COPD in two 1-year randomized studies. Int J Chron Obstruct Pulmon Dis, 2010; 5:197–208.
22.
AlothmanGA, AlsaadiMM, HoBL, HoSL, DupuisA, CoreyM, CoatesAL. Evaluation of bronchial constriction in children with cystic fibrosis after inhaling two different preparations of tobramycin. Chest, 2002; 122(3):930–934.
23.
DhandR, JubranA, TobinMJ. Bronchodilator delivery by metered-dose inhaler in ventilator-supported patients. Am J Respir Crit Care Med, 1995; 151(6):1827–1833.
24.
SennS. Testing for baseline balance in clinical trials. Stat Med, 1994; 13(17):1715–1726.
25.
BarnesPJ. Severe asthma: advances in current management and future therapy. J Allergy Clin Immunol, 2012; 129(1):48–59.
26.
National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Summary Report 2007. J Allergy Clin Immunol, 2007; 120(5 Suppl):S94–S138.
27.
American Thoracic Society. Proceedings of the ATS workshop on refractory asthma: current understanding, recommendations, and unanswered questions. Am J Respir Crit Care Med, 2000; 162(6):2341–2351.
28.
EvansDJ, CullinanP, GeddesDM. Cyclosporin as an oral corticosteroid sparing agent in stable asthma. Cochrane Database Syst Rev, 2001(2):CD002993.
29.
DeanT, DeweyA, BaraA, LassersonTJ, WaltersEH. Azathioprine as an oral corticosteroid sparing agent for asthma. Cochrane Database Syst Rev, 2004(1):CD003270.
30.
EvansDJ, CullinanP, GeddesDM. Gold as an oral corticosteroid sparing agent in stable asthma. Cochrane Database Syst Rev, 2001(2):CD002985.
31.
DaviesH, OlsonL, GibsonP. Methotrexate as a steroid sparing agent for asthma in adults. Cochrane Database Syst Rev, 2000(2):CD000391.
32.
DeanT, DeweyA, BaraA, LassersonTJ, WaltersEH. Chloroquine as a steroid sparing agent for asthma. Cochrane Database Syst Rev, 2003(4):CD003275.
TorregoA, SolàI, MunozAM, Roqué i FigulsM, Yepes-NuñezJJ, Alonso-CoelloP, PlazaV. Bronchial thermoplasty for moderate or severe persistent asthma in adults. Cochrane Database Syst Rev, 2014;(3)CD009910.
35.
Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention, 2011. http://www.ginasthma.org/. Accessed November 26, 2014.
36.
ElersJ, PedersenL, HenningeJ, LundTK, HemmersbachP, DalhoffK, BackerV. Blood and urinary concentrations of salbutamol in asthmatic subjects. Med Sci Sports Exerc, 2010; 42(2):244–249.
DolovichMB, AhrensRC, HessDR, AndersonP, DhandR, RauJL, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest, 2005; 127(1):335–371.
39.
TraversAH, MilanSJ, JonesAP, CamargoCAJr, RoweBH. Addition of intravenous beta2-agonists to inhaled beta2-agonists for acute asthma. Cochrane Database Syst Rev, 2012;(12):CD010179.
40.
CarrollCL, GoodmanDM. Endotracheal albuterol treatment of acute bronchospasm. Am J Emerg Med, 2004; 22(6):506–507.
41.
HessDR. Aerosol delivery devices in the treatment of asthma. Respir Care, 2008; 53(6):699–723; discussion 723-725.
42.
KacmarekRM, StollerJK, HeuerAJ. Egan's fundamentals of respiratory care, 10th edition. St Louis: Elsevier Mosby; 2013.
43.
DolovichMA, MacIntyreNR, AndersonPJ, CamargoCAJr, ChewN, ColeCH, et al. Consensus statement: aerosols and delivery devices. American Association for Respir Care. Respir Care, 2000; 45(6):589–596.
44.
DuarteAG. Inhaled bronchodilator administration during mechanical ventilation. Respir Care, 2004; 49(6):623–634.
45.
HasegawaEA. The endotracheal use of emergency drugs. Heart Lung, 1986; 15(1):60–63.
46.
NeumarRW, OttoCW, LinkMS, KronickSL, ShusterM, CallawayCW, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2010; 122(18 Suppl 3):S729–S767.
47.
PillowJJ, MinocchieriS. Innovation in surfactant therapy II: surfactant administration by aerosolization. Neonatology, 2012; 101(4):337–344.
48.
PolinRA, CarloWA. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics, 2014; 133(1):156–163.
49.
MacIntyreNR. Intratracheal catheters as drug delivery systems. Respir Care, 2001; 46(2):193–197.
50.
GillisHL, LutchenKR. How heterogeneous bronchoconstriction affects ventilation distribution in human lungs: a morphometric model. Ann Biomed Eng, 1999; 27(1):14–22.
51.
ByronPR, HindleM, LangeCF, LongestPW, McRobbieD, OldhamMJ, et al. In vivo-in vitro correlations: predicting pulmonary drug deposition from pharmaceutical aerosols. J Aerosol Med Pulm Drug Deliv, 2010; 23(Suppl 2):S59–S69.
52.
AARC clinical practice guideline: selection of device, administration of bronchodilator, and evaluation of response to therapy in mechanically ventilated patients. Respir Care, 1999; 44(1):105–113.
53.
MacIntyreNR. Aerosol delivery through an artificial airway. Respir Care, 2002; 47(11):1279–1288; discussion 1285-1289.
54.
DuarteAG, MomiiK, BidaniA. Bronchodilator therapy with metered-dose inhaler and spacer versus nebulizer in mechanically ventilated patients: comparison of magnitude and duration of response. Respir Care, 2000; 45(7):817–823.
55.
HendelesL, HattonRC, CoonsTJ, CarlsonL. Automatic replacement of albuterol nebulizer therapy by metered-dose inhaler and valved holding chamber. Am J Health Syst Pharm, 2005; 62(10):1053–1061.
