Mdi Presentation

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  • Search Strategy: 1. exp *HIGH-FREQUENCY JET VENTILATION/ OR exp *HIGH-FREQUENCY VENTILATION/ OR exp *INTERMITTENT POSITIVE-PRESSURE VENTILATION/ OR exp *RESPIRATION, ARTIFICIAL/ 2. “artificial respiration”.af.OR “mechanical ventilation”.af 3. 1 OR 2 4. exp *METERED DOSE INHALERS/ 5. "metered dose inhaler*".af 6. 4 OR 5 7. 3 AND 6
  • Mdi Presentation

    1. 1. Delivery of bronchodilators with metred-dose inhalers (MDI) in mechanically ventilated patients: Should We Invest? Sharon Lamb
    2. 2. <ul><li>Intensive Care Unit, Aintree University Hospitals NHS Foundation Trust – currently considering metred-dose inhalers to deliver bronchodilators in mechanically ventilated patients </li></ul><ul><li>Prompted by equipment change </li></ul><ul><li>Literature review to establish evidence base to underpin decision making </li></ul><ul><li>Pros and Cons </li></ul><ul><li>Consider nursing implications </li></ul><ul><li>Outline </li></ul>
    3. 3. <ul><li>British Nursing Index </li></ul><ul><li>CINAHL </li></ul><ul><li>Cochrane Library </li></ul><ul><li>HMIC </li></ul><ul><li>Medline </li></ul><ul><li>Web of Science </li></ul><ul><li>Search strategy developed using thesaurus terms and natural language key terms </li></ul><ul><li>Identifying the Evidence Base </li></ul>
    4. 4. <ul><li>Ease of Administration </li></ul><ul><li>Decreased Costs </li></ul><ul><li>Reliable Dosing </li></ul><ul><li>Freedom from Contanimation </li></ul><ul><li>But in mechanical ventilation it deposits in the endotracheal tube and ventilator circuit making it inefficient. </li></ul><ul><li>However evidence shows despite smaller doses reaching the lower lung significant bronchodilator effect is achieved. </li></ul><ul><li>The Theory Underpinning Use of MDIs </li></ul>Dhand and Tobin (1996)
    5. 5. <ul><li>Device </li></ul><ul><li>Ventilator used </li></ul><ul><li>Ventilator Mode/Settings </li></ul><ul><li>Location in Circuit </li></ul><ul><li>Humidification </li></ul><ul><li>Density of inhaled gas </li></ul><ul><li>Spacer use impacts: </li></ul><ul><ul><li>Ventilator deposition </li></ul></ul><ul><ul><li>Lung deposition </li></ul></ul><ul><li>Patient Condition </li></ul><ul><ul><ul><ul><ul><li>Garner et al , 2002 </li></ul></ul></ul></ul></ul><ul><li>Key elements for success </li></ul>
    6. 6. <ul><li>In Vitro testing of the use of MDI to deliver dry powder bronchodilators shows that 16.2% - 20% of drugs could be delivered to the patient (Everard, Devadason and Le Soeuf, 1996 and Fink et al 1999) </li></ul><ul><li>Georgopoulos et al (2000) indicates that MDI achieves similar results to bronchodilators delivered by nebulizers at reduced dose </li></ul><ul><li>Simplicity of use is cited by Hess (1991), </li></ul><ul><li>Dhand (1996) and Georgopoulos (2000) </li></ul><ul><li>and results from integration with the </li></ul><ul><li>ventilator circuit. </li></ul>The Evidence for MDI Use
    7. 7. <ul><li>Georgopoulous et al, 2000 make an economic case for the use of MDI suggesting cost savings per year of $300,000 per year in a typical 700 bed hospital. Given the state of NHS finances this level of saving may be attractive to management! </li></ul><ul><li>Nebulizer use can lead patient/ventilator dyssynchrony if the inline nebulizer exceeds the patients inspiratory flow rate, Beaty et al 1989. </li></ul>The Evidence for MDI Use
    8. 8. <ul><li>Garner et al (2002) found no significant change in respiratory mechanics or haemodynamics when comparing delivery by MDI or Nebulizer. </li></ul><ul><li>Marik et al (1999) report that nebulizers deliver the highest dosage, however they do suggest the use of MDI produces equal if not better results. </li></ul><ul><li>Training </li></ul><ul><li>Experience, change management </li></ul><ul><li>Time </li></ul><ul><li>Using Nebulizers in Ventilated Patients </li></ul><ul><li>Implications for Nursing </li></ul>
    9. 9. <ul><li>In Vitro tests by Fink et al (1999) suggest that for optimum delivery humidification should not be used this is not a realistic option for patients in the intensive care unit where humidification is used to prevent damage of the airway mucosa (Lange and Finlay, 2000) </li></ul><ul><li>The majority of articles cite reduced levels of infection a reason for MDI use, however they fail to detail evidence to justify this claim. It must therefore be discounted. </li></ul><ul><li>Cost-effectiveness </li></ul><ul><ul><li>Greek Study – translatable? </li></ul></ul><ul><ul><li>ICU organisation </li></ul></ul><ul><ul><li>Pharmaceutical costs </li></ul></ul><ul><ul><ul><ul><li>Georgopoulos et al (2000) </li></ul></ul></ul></ul><ul><li>Conclusion </li></ul>
    10. 10. <ul><li>There are many variables impacting delivery </li></ul><ul><ul><li>Device </li></ul></ul><ul><ul><li>Equipment Used </li></ul></ul><ul><ul><li>Settings </li></ul></ul><ul><ul><li>Location in Circuit </li></ul></ul><ul><ul><li>Spacer </li></ul></ul><ul><ul><li>Staff Experience </li></ul></ul><ul><li>Literature base – evidence base is not new, the range of articles is from the late 80's to 2002. </li></ul><ul><li>Conclusion </li></ul>
    11. 11. <ul><li>References </li></ul><ul><li>Beaty, C.D., Ritz, R.H, and Benson, M.S. (1989) Continuous in-line nebulizers complicate pressure support ventilation. Chest 96 pp.1360–1363. </li></ul><ul><li>Dhand, R. and Tobin, M.J. (1996) Bronchodilator delivery with metered-dose inhalers in mechanically-ventilated patients. European Respiratory Journal. 9 pp.585-595. </li></ul><ul><li>Everard, M.L., Devadason, S.G. and Le Souef, P.N. (1996) In vitro assessment of drug delivery through an endotracheal tube using a dry powder inhaler delivery system. Thorax 51 pp.75-77. </li></ul><ul><li>Fink, J.B., Dhand, R., Grychowski, J., Fahey, P.J. And Tobin, M.J. (1999) Reconciling In Vitro and In Vivo measurements of aerosil delivery from a metred-dose inhaler during mechanical ventilation and defining efficiency enhancing factors. Am J Resp Crit Care Med 159 pp.63-68. </li></ul><ul><li>Garner, S.S., Weist, D.B., Bradley, J.W. And Habib, D.M. (2002) Two administration methods for inhaled albutamol in intubated patients. Archives of Diseases in Childhood 87 pp.49-5 </li></ul><ul><li>Georgopoulos, D., Moulidi,E., Kondili, E. and Klimathianki, M. (2000) Bronchodilator deliverpy with metered-dose inhaler during mechanical ventilation. Critical Care 4 pp.227-234 </li></ul><ul><li>Hess, D. (1991) Aerosol bronchodilator delivery during mechanical ven tila ti on. Nebulizer or inhaler?. Chest 100 (4) p.1103. </li></ul><ul><li>Lange, C. and Finlay, W. (2000) Overcoming the adverse effects of hum idity in aerosol delivery via presurised metered-dose inhalers during mechanical ventilation. A m J R esp Crit Care Med. 161 pp.1614-1618. </li></ul>

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