Delivery of Beta-2-Agonists in Intubated Patients
OVERVIEW
- need to consider:
- -> dose
- -> side effect profile
- -> effectiveness
- -> cost
IV
- excellent systemic delivery
- may have variable delivery to the areas that are not perfused
- systemic effects and side effects maximal
SC
- easy to administer
- less predictable onset
- lower bioavailability
- systemic side effects are more pronounced
MDI
- easy to administer via an adapter
- adaptor must be close to ETT
- multiples of dose in non-intubated are required (10 puffs/treatment)
- give on inspiration
- slow inspiratory flow rates (increased inspiratory time) increases delivery to airways
- large TV (> 500mL) ensure optimal delivery
- ideally patient should have a large ETT (>7.0)
- helium-oxygen mixtures increase deposition to lower airways
- does not require break in circuit
- optimal = inline spacer (increased cost + may become reservoir for infection)
- minimal systemic side effects
- humidification can decrease delivery to the respiratory tract c/o greater deposition in the ventilator circuit
Nebulisers
- high flow of gas (6-8L/min) -> producers small respirable particles
- in the spontaneously breathing patient only 10% reaches the lower respiratory tract
- in the mechanically ventilated 1-15% reaches the LRT
- can be given continuously
- maximises local delivery while minimizing system absorption
- easy to administer
- requires break in circuit for each treatment
- variable interaction with ventilator (some cannot compensate for flow)
References and Links
CCC Pharmacology Series
Respiratory: Bosentan, Delivery of B2 Agonists in Intubated Patients, Nitric Oxide, Oxygen, Prostacyclin, Sildenafil
Cardiovascular: Adenosine, Adrenaline (Epinephrine), Amiodarone, Classification of Vasoactive drugs, Clevidipine, Digoxin, Dobutamine, Dopamine, Levosimendan, Levosimendan vs Dobutamine, Milrinone, Noradrenaline, Phenylephrine, Sodium Nitroprusside (SNiP), Sotalol, Vasopressin
Neurological: Dexmedetomidine, Ketamine, Levetiracetam, Lignocaine, Lithium, Midazolam, Physostigmine, Propofol, Sodium Valproate, Sugammadex, Thiopentone
Endocrine: Desmopressin, Glucagon Therapy, Medications and Thyroid Function
Gastrointestinal: Octreotide, Omeprazole, Ranitidine, Sucralfate, Terlipressin
Genitourinary: Furosemide, Mannitol, Spironolactone
Haematological: Activated Protein C, Alteplase, Aprotinin, Aspirin, Clopidogrel, Dipyridamole, DOACs, Factor VIIa, Heparin, LMW Heparin, Protamine, Prothrombinex, Tenecteplase, Tirofiban, Tranexamic Acid (TXA), Warfarin
Antimicrobial: Antimicrobial Dosing and Kill Characteristics, Benzylpenicillin, Ceftriaxone, Ciprofloxacin, Co-trimoxazole / Bactrim, Fluconazole, Gentamicin, Imipenem, Linezolid, Meropenem, Piperacillin-Tazobactam, Rifampicin, Vancomycin
Analgesic: Alfentanil, Celecoxib, COX II Inhibitors, Ketamine, Lignocaine, Morphine, NSAIDs, Opioids, Paracetamol (Acetaminophen), Paracetamol in Critical Illness, Tramadol
Miscellaneous: Activated Charcoal, Adverse Drug Reactions, Alkali Therapies, Drug Absorption in Critical Illness, Drug Infusion Doses, Epidural Complications, Epidural vs Opioids in Rib Fractures, Magnesium, Methylene Blue, Pharmacology and Critical Illness, PK and Obesity, PK and ECMO, Sodium Bicarbonate Use, Statins in Critical Illness, Therapeutic Drug Monitoring, Weights in Pharmacology
Toxicology: Digibind, Flumazenil, Glucagon Therapy, Intralipid, N-Acetylcysteine, Naloxone, Propofol Infusion Syndrome
- Dhand R, Tobin MJ. Bronchodilator delivery with metered-dose inhalers in mechanically-ventilated patients. Eur Respir J. 1996 Mar;9(3):585-95. PMID: 8730023.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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