Douglas S. Gardenhire, EdD , RRT-NPS, FAARC Georgia State University

1. Nebulization during spontaneous breathing, CPAP and Bilevel: a randomized analysis of pulmonary radioaerosoldepositionRESPIRATORY CARE APRIL 2014 VOL 59 NO 4 Douglas S. Gardenhire, EdD, RRT-NPS, FAARC Georgia State University

2. Background • What do we know about aerosol and non-invasive ventilation? • No guidelines exist for aerosol delivery with non-invasive 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?

3. Background • What is scintigraphy? • What is technetium?

4. Research Question Does pulmonary regional deposition of radioaerosoladministered by nebulization to healthy individuals, during spontaneous breathing, CPAP and BiPAP differ? • Is this research question relevantto your clinical practice?

5. Methods • Study design • Crossover and Observational • What are the positives to this design? Negative? • Exclusion criteria were: • < 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.

6. Methods(Cont.) • Control group was each patient. • Sample size small. • Do you see these as issues with the study?

7. Methods(Cont.) Do you think the statistical analysis is appropriate for this observational study? • No ethical concerns noted for this paper.

8. Results • Main results • Statistically no difference between spontaneous breathing, CPAP and BiPAP when using a jet nebulizer. • Why are they not different?

9. Results (cont.)

10. Results (cont.) • Why do you think the researchers found more aerosol in the stomach with BiPAP?

11. Discussion • What do these finding mean to you as a respiratory therapist using CPAP and BiPAP? • The current study was very similar to: FrançaEET, 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.

12. 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.

13. Discussion (cont.) • How does bronchodilator behave with the use of BiPAP in moderate to severe asthma? Galindo-FilhoVC, 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. RespCare 2013;58(2):241-249. • Deposition did not change, but patient outcomes improved via PFT values. • Could pressure differences make a difference?

14. 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.

15. 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