Monday, June 2, 2008

Nebulizers or MDI's inline with a Ventilator?

Here at my hospital we seem to go through streaks of how we give medication to patients on ventilators. For a couple of months we might use MDI's and then we might just switch over to Nebulizers inline for a couple of months, and it is normally the same doctor who will oversee these patients on vents, it would be our pulmonologist who does it.

Tonight I just came back from being off for 2 days and we now have 3 ventilators running and all three of them are getting nebulized medications. One of the vent patients used to be getting MDI treatments but has now been switched over to nebulizer treatments. So I got to thinking which is better? Could this just be because he has Xopenex ordered as one of the medications along with Atrovent? Shouldn't be the reason we carry these by MDI also I have heard, even though I have yet to see a Xopenex MDI here at this hospital.

Doing some reading online and my own personal experience I have found different pro's and con's of using either a nebulizer or MDI with a ventilated patient, this is what I'm going to try and share with everyone, and I am looking forward to any opinions you might have for either side.

Metered Dose Inhalers Inline with a Ventilator
  • MDI's have to be perfectly timed with a vent cycle
  • MDI's give better deposition
  • You need more puffs from the MDI to get a regular dose to a patient due to the moisture in the ETT that will cause the medication to stick to the ETT or inspiratory limb of the vent circuit. I have seen anywhere from 4 to 24 puffs given at any one time.
  • MDI's treatments are faster than nebs.
  • Need to give a pause after the breath otherwise the majority of the medication could possible go out the exhalation limb.
  • You have to push the MDI right after the inhalation cycle starts or if your to early a lot of the medication goes out the exhalation side, you can actually watch this.

Nebulized medications Inline with a Ventilator
  • Becomes a vapor like the humidification
  • Do Not have to time with the ventilation cycle
  • Same dose as you would use with a non ventilated patient
  • Does take longer
  • Does increase measured exhaled tidal volume and minute volume
  • decreases the trigger sensitivity of the pressure supported breaths due to higher flow making a bigger negative pressure necessary, increasing he work of breathing in the patient
  • may cause problems with the internal ventilator components due to the medication sticking to the components
  • should possibly use a extra expiratory filter and maybe a inspiratory filter to protect the ventilator
Those are just some quick little notes of interest I have come across in my researching information for this article along with information I have learned as my time of being a RT.

Some more information I have learned about the placement of the nebulizer and MDI's when you give the treatments I have found and some I have known or used in the past.

When giving a MDI through a ventilator you should put the MDI inline as close to the wye as possible and up to 6 inches behind the wye. Always give the puff timed with a inhalation cycle or it will go down the exhalation side and not to the patient.

With the nebulizer inline I was really curious about the best way to place the nebulizer inline as to get the best treatment and from what I found which was the consensus was to put the nebulizer as far back from the wye on the inspiratory side as possible. Some even will put it behind the humidifier as they found that the aerosol of the nebulizer will mix with the humidified water aerosol, which are basically both the same. The reason it is said to place it farther back is so the inspiratory limb on exhalation will fill up with the nebulized medication aerosol and on inhalation there is a larger concentration of medication given to the patient. There is also the old law that says a gas will go towards the area with the least resistance, so if its closer to the wye the exhalation flow will be the area of least resistance due to the flow and there is a entrainment aspect to that side of the tubing also. Which makes sense to me.

I now after reading am more partial towards the use of nebulizers inline with a vent than MDI's at this time. I also will be moving my nebulizers farther back from the wye, which I will do here in about a hour's time. I lot of my questions were answered by doing some research and I hope I might of given you some more information that you never really knew.

One more thing, DON'T Forget to remove the HME before you give a treatment!!!

Drive on RT's


Intubate Em!!! said...

Sometimes patients know best! Right now I have a patient on his home vent. His parents insist that we either take out the hme during tx or change it out after each tx.

No xopenex mdi at my hospital either.

Freadom said...

Most hosps in this area, including ours, do not do nebs inline for 3 reasons 1) studies show Ventolin relatively inefective inline, 2) MDI and aerosol have = efficacy if MDI used properly and with a proper spacer, and 3) the mist ruins the inner parts of the vent.

What I think is neat is that when a doctor orders a neb, we now have authority to overrule the doctor and give MDIs.

SVG said...

I hope to see more input on this, but here are my findings.

There have been studies comparing the inline MDI vs HHN. The MDI was shown to be more effective with better particle dispostion when compared to the HHN.

What are the challenges?

1) A patient using a HME. Do we take the HME on and off in between treatments? This defeats the idea of a closed circuit.

2)Type of adapter, proper technique and MDI adapter placement. Does the mist spray both ways or just towards the patient. HME near adapter? Must time inpiration. a Given. Must be on inspiratory side of circuit.

Djanvk said...

I have always been taught that you take the HME out. Does it filter the MDI out? I don't know.

And another note, I was giving a MDI in a vent tonight and was looking very closely and noticed that you need to push the button after the breath starts or you can watch some of the MDI go down the exhalation side.

KokomoCRT said...

Our hospital uses a swivel to sidestep the nebulizer when we give the treatment. I haven't ever given a MDI at this hospital per vent. But in the past we did double up the puffs usually. We also don't have xopenex inhalers! I am also curious- do you find that most vent patients if properly "cleaned out" dont require routine rx, every now and then you get a "wheezer" but most of them are clear as long as you suck them out first!

Anonymous said...

We have tried MDI, HHN and by far the best device is the AERONEB.

Anonymous said...

Our facility uses MDI's unless the medication is unavailable(tobramycin for example. This is part of our VAP prevention protocol. We place a mdi spacer inline on the patient side of the HME, this reduces how frequently you break the circuit. We haven't had a case of VAP in months so it seems to work.

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