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, FAARC
Georgia State University
Background
• What do we know about aerosol and noninvasive ventilation?
• No guidelines exist for aerosol delivery with noninvasive 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:
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< 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, et
al. Nebulization associated with Bi-level noninvasive ventilation: analysis
of 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 bilevel
positive 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 coupled
with 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