Abstract: Background: Perioperative respiratory adverse events account for a third of all perioperative cardiac arrests, with bronchospasm and laryngospasm being most common. Standard treatment for bronchospasm is administration of inhaled salbutamol, via pressurized metered dose inhaler. There is little evidence on the best method of attaching the pressurized metered dose inhaler to the artificial airway during general anesthesia.
Aim: The aim of this study is to investigate the best method to deliver aerosolized salbutamol via pressurized metered dose inhaler to the lungs of an anesthetized child.
Methods: We measured salbutamol delivered by pressurized metered dose inhaler through different sized tracheal tubes, supraglottic airway devices, and tracheostomies in vitro for methods commonly employed for connecting the pressurized metered dose inhaler to the artificial airway. Breathing was simulated for patients weighing 3, 16, 50, and 75 kg. Pressurized metered dose inhaler actuation coincided with inspiration.
Results: A pressurized metered dose inhaler combined with an in-line non-valved or valved spacer, or the direct method, when delivered via tracheal tube, was linked with improved delivered dose of salbutamol, compared to all other methods for 3 or 50 kg simulated patients weights. The delivered dose when using a non-valved spacer was greater than all methods for 16 and 75 kg patient weights. A spacer improved delivery for the flexible supraglottic airway device type, and there was no difference with or without a spacer for remaining types.
Conclusion: Via tracheal tube and non-valved spacer, the following doses should be delivered after single actuation of a 100 µg labeled-claim salbutamol dose: ~2 µg kg -1 per actuation to a 3 kg neonate, ~1 µg kg -1 per actuation to a 16 kg child, and ~ 0.5 µg kg -1 per actuation for a 50-75 kg child. The least effective methods were the syringe, and the uni- and bidirectional adaptor methods, which require replacement by the direct method if a spacer is unavailable.
(© 2020 John Wiley & Sons Ltd.)
References: Habre W, Disma N, Virag K, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med. 2017;5(5):412-425.
von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. The Lancet. 2010;376(9743):773-783.
Parnis SJ, Barker DS, Van Der Walt JH. Clinical predictors of anaesthetic complications in children with respiratory tract infections. Pediatr Anesth. 2001;11(1):29-40.
von Ungern-Sternberg BS, Boda K, Schwab C, Sims C, Johnson C, Habre W. Laryngeal mask airway is associated with an increased incidence of adverse respiratory events in children with recent upper respiratory tract infections. Anesthesiology. 2007;107(5):714-719.
Ramgolam A, Hall GL, Zhang G, Hegarty M, von Ungern-Sternberg BS. Deep or awake removal of laryngeal mask airway in children at risk of respiratory adverse events undergoing tonsillectomy-a randomised controlled trial. Br J Anaesth. 2018;120(3):571-580.
Dugernier J, Ehrmann S, Sottiaux T, et al. Aerosol delivery during invasive mechanical ventilation: a systematic review. Crit Care. 2017;21(1):264.
Williams JP, Ari A, Shanmugam R, Fink JB. The effect of different closed suction catheter designs and pmdi adapters on aerosol delivery in simulated adult mechanical ventilation with and without exhaled humidity. Respiratory Care. 2018;63(9):1154-1161.
Sanchis J, Gich I, Pedersen S. Systematic review of errors in inhaler use: Has patient technique improved over time? Chest. 2016;150(2):394-406.
Martis EA, Gangrade DM, Advani H. Reverse phase isocratic hplc method for simultaneous estimation of salbutamol sulphate and beclomethasone dipropionate in rotacaps formulation dosage forms. Int J Pharm Pharmaceut Sci. 2011;3(1):64-67.
Schultz RK. Drug delivery characteristics of metered-dose inhalers. J Allergy Clini Immunol. 1995;96(2):284-287.
Tal A, Golan H, Grauer N, Aviram M, Albin D, Quastel MR. Deposition pattern of radiolabeled salbutamol inhaled from a metered-dose inhaler by means of a spacer with mask in young children with airway obstruction. J Pediatr. 1996;128(4):479-484.
Erzinger S, Schueepp KG, Brooks-Wildhaber J, Devadason SG, Wildhaber JH. Facemasks and aerosol delivery in vivo. J Aerosol Med. 2007;20(s1):S78-S84.
Ditcham W, Murdzoska J, Zhang G, et al. Lung deposition of 99mtc-radiolabeled albuterol delivered through a pressurized metered dose inhaler and spacer with facemask or mouthpiece in children with asthma. J Aerosol Med Pulm Drug Deliv. 2014;27(S1):S-63-S-75.
Wildhaber JH, Dore ND, Wilson JM, Devadason SG, LeSouef PN. Inhalation therapy in asthma: nebulizer or pressurized metered-dose inhaler with holding chamber? In vivo comparison of lung deposition in children. J Pediatr. 1999;135(1):28-33.
Garner SS, Wiest DB, Bradley JW. Albuterol delivery by metered-dose inhaler with a pediatric mechanical ventilatory circuit model. Pharmacother. 1994;14(2):210-214.
Ran JL, Harwood RJ, Groff JL. Evaluation of a reservoir device for metered-dose bronchodilator delivery to intubated adults: an in vitro study. Chest. 1992;102(3):924-930.
Fink JB, Dhand R, Grychowski J, Fahey PJ, Tobin MJ. Reconciling in vitro and in vivo measurements of aerosol delivery from a metered-dose inhaler during mechanical ventilation and defining efficiency-enhancing factors. Am J Respir Crit Care Med. 1999;159(1):63-68.
Fuller HD, Dolovich MB, Posmituck G, Wong Pack W, Newhouse MT. Pressurized aerosol versus jet aerosol delivery to mechanically ventilated patients comparison of dose to the lungs. Am Rev Respir Dis. 1990;141(2):440-444.
Fok TF, Monkman S, Dolovich M, et al. Efficiency of aerosol medication delivery from a metered dose inhaler versus jet nebulizer in infants with bronchopulmonary dysplasia. Pediatr Pulmonol. 1996;21(5):301-309.
Barry PW, O'Callaghan C. The effect of delay, multiple actuations and spacer static charge on the in vitro delivery of budesonide from the Nebuhaler. Br J Clin Pharmacol. 1995;40(1):76-78.
Piccuito CM, Hess DR. Albuterol delivery via tracheostomy tube. Respiratory Care. 2005;50(8):1071-1076.
Processing Request
No Comments.