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Improvised Arrangement of Aerosol Delivery to the Ventilator Dependent

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Improvised Arrangement of Aerosol Delivery to the Ventilator Dependent Indian Journal of Critical Care Medicine June 2014 Vol 18 Issue 6 Achyut Sarkar, Arindam Pande, reducing work of breathing by decreasing pulmonary Naveen G. S. Chandra, Imran Ahmed dynamic hyperinfl ation and resistance of the respiratory Department of Cardiology, IPGMER and SSKM Hospital, Kolkata, system.[2] West Bengal, India Correspondence to: Effective delivery of aerosol to the lungs depends on Dr. Arindam Pande, Department of Cardiology, IPGMER and SSKM Hospital, formulation of drug, aerosol generator, and technique 244, AJC Bose Road, Kolkata - 700 020, of administration. Various devices are used to generate West Bengal, India. E-mail: [email protected] aerosol, but pressurized metered-dose inhaler (pMDI) and nebulizers are the most commonly used in patients References supported by IMV. The commonly used nebulizers 1. Senthilkumaran S, David SS, Jena NN, Menezes RG, are the jet and the ultrasonic devices. Vibrating mesh Thirumalaikolundusubramanian P. Acute myocardial infarction nebulizers and intratracheal nebulizing catheters are and cocaine toxicity: One step closer. Indian J Crit Care Med 2014;18:118. newer aerosol generating devices. These devices are 2. Sarkar A, Pande A, Naveen Chandra GS, Ahmed I. Acute myocardial connected to the inspiratory limb of the ventilator infarction in a young cocaine addict with normal coronaries: Time to circuit by specifi c adaptors attached to the artifi cial raise awareness among emergency physicians. Indian J Crit Care Med 2013;17:56-8. airway. Several ventilator parameters also affect the 3. McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P, effective delivery of aerosol to the patient. pMDI require et al. Management of cocaine-associated chest pain and myocardial a specifi c adaptor, a spacer and synchronization with infarction: A scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. ventilator for effective delivery of aerosol. If properly Circulation 2008;117:1897-907. administered pMDI and nebulizers are equally effective in delivery of aerosol therapy to the mechanically Access this article online ventilated patients although using nebulizers is the Quick Response Code: common practice. Website: www.ijccm.org Jet nebulizers use a jet of compressed air or oxygen, while ultrasonic nebulizers use piezo-electric crystals DOI: 10.4103/0972-5229.133954 vibrations to produce aerosol. New vibrating mesh nebulizers use a vibrating mesh or plate with multiple apertures to generate aerosol. Jet nebulizers are cost-effective and easy to use and adding a reservoir between jet nebulizer and endotracheal tube increases aerosol delivery. Some new generation ventilators have an in-built mechanism for supporting the jet or ultrasonic nebulizers. These ventilators synchronize inspiratory fl ow and volume to activate the jet nebulizer Improvised arrangement intermittently during inspiration.[3] Over a period of time, these compatible jet nebulizers tend to be damaged of aerosol delivery to or lost. Many ventilators are not compatible with jet the ventilator dependent nebulizers or newer aerosol therapy devices. In these situations, often a jet nebulizer operated by compressed patient oxygen from wall system or cylinder, is attached to the inspiratory limb of breathing circuit. A minimum fl ow of 6-8 L is required to generate the aerosol. The volume Sir, added by this method can affect ventilator parameters The patients supported by invasive mechanical and can be very harmful, especially to the pediatric ventilation (IMV) often require aerosol therapy patients who have small lung volumes. for bronchodilators and inhaled corticosteroids. Mucolytics, antibiotics and other medications can Self-inflating manual resuscitator is a breathing also be given by this method.[1] Aerosol therapy is system that uses nonrebreathing unidirectional valves. indicated in these patients for management of asthma, A pressure limiting device is present near inspiratory bronchospasm, increased airway resistance, intrinsic valve to prevent barotrauma in all infant/child and positive end-expiratory pressure, diffi cult to wean, and some adult manual resuscitators. There is a connection ventilator dependent patients. Aerosol therapy helps in port to attach a reservoir bag at the bag inlet.[4] In this 7777 440909 Indian Journal of Critical Care Medicine June 2014 Vol 18 Issue 6 Unusual causes of anaphylaxis during surgery: Gelofusin-induced Kounis syndrome Sir, In the very interesting report[1] published recently Figure 1: Improvized arrangement in IJCCM, a 48-year-old female patient, who was planned to have laparoscopic donor nephrectomy, improvized arrangement, a T-adaptor with jet nebulizer developed atrial premature complexes, flushing assembly is attached to the above mentioned connection of both hands, falling blood pressure, and rising port [Figure 1]. A one-way valve [Direction, Figure 1] pulse rate after gelofusin infusion. Intravenous is attached to the free end of the T-adaptor to prevent hydrocortisone, chlorpheniramine, mephentermine, aerosol loss and direct airfl ow to the bag inlet when it is adrenaline, vasopressors, ipratropiume with re-expanding. Presence of resuscitation bag next to the salbutamol nebulization and positive pressure jet nebulizer and addition of 3-4 mL of normal saline to ventilation improved her condition. The scheduled the drug can help in effective delivery of aerosol. The surgery was postponed, and the allergic skin tests for tidal and minute volumes can be controlled manually to antibiotics, anesthetics and gelofusin showed positive deliver aerosol safely to the ventilator dependent patients skin reaction to gelofusin. This case raises some where compatible aerosol device is not available. important points concerning the cause and the type of this reaction and its pathophysiology. Gelofusin Ashish Saraogi is a macromolecule made from succinylated bovine Department of Anaesthesiology, NIMS Hospital and Medical College, Jaipur, Rajasthan, India gelatin. Gelatins are proteins derived from collagen and are obtained from cow and pig bones and hides Correspondence: and fi sh skin. A similar case diagnosed as Type II Dr. Ashish Saraogi, B6, Faculty B Block, NIMS University Campus, Shobha Nagar, variant of Kounis hypersensitivity-associated syndrome Jaipur-Delhi Highway, Jaipur - 303 121, Rajasthan, India. with peri-operative cardiac arrest due to gelofusin E-mail: [email protected] anaphylaxis, confirmed with skin prick tests, has References been published recently.[2] It concerned a 57-year-old 1. Rubin BK. Air and soul: The science and application of aerosol therapy. patient who developed anaphylactic shock during Respir Care 2010;55:911-21. anesthesia and despite initial management with bolus 2. Guerin C, Fassier T, Bayle F, Lemasson S, Richard JC. Inhaled doses of metaraminol and epinephrine intravenously, bronchodilator administration during mechanical ventilation: How to optimize it, and for which clinical benefit? J Aerosol Med Pulm Drug hypotension worsened, and cardiac output was reduced. Deliv 2008;21:85-96. The patient recovered gradually with intravenous 3. Dhand R. Aerosol delivery during mechanical ventilation: From antihistamines, steroids and myocardial ischemia basic techniques to new devices. J Aerosol Med Pulm Drug Deliv protocol, thus supporting our view that anaphylactic 2008;21:45-60. 4. Dorsch JA, Dorsch SA. Manual resuscitators. In: Understanding shock is a manifestation of Kounis syndrome. In Anaesthesia Equipments. 5th ed. New Delhi: Lippincott William’s and another report, anaphylaxis with cardiovascular Wilkins; 2008. p. 282-93. symptoms such as profound hypotension, tachycardia, and elevated airway pressures have been reported Access this article online following intraosseous gelatin administration.[3] Drug Quick Response Code: capsules, suppositories, plasma expanders, and vaccine Website: stabilizers including diphtheria-tetanus-pertussis, www.ijccm.org measles, mumps, rubella, varicella, yellow fever, rabies, and some infl uenza vaccines contain bovine DOI: 10.4103/0972-5229.133955 and porcine gelatins as heat stabilizers. Since gelatin is contained in various vaccines given in children, then vaccination is regarded as a primary route of 441010 7788.
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