Noninvasive Ventilation Coupled With Nebulization During Asthma Crises: A Randomized Controlled Trial

Abstract

BACKGROUND: Despite the clinical improvements attributed to noninvasive ventilation (NIV) during asthma crises, and the well established effects of nebulization, there are few studies on the effects of these interventions together. We hypothesized that nebulization coupled to NIV should raise radio-aerosol pulmonary deposition in asthmatics. The aims of this study were to assess the effects of coupling ␤-agonist nebulization and NIV during asthma exacerbations on radio-aerosol pulmonary deposition, using scintigraphy and cardiopulmonary parameters, to correlate pulmonary function with radio-aerosol deposition index, radio-aerosol penetration index, and pulmonary clearance. METHODS: In this controlled trial, 21 adults with moderate to severe asthma attack were randomized to a control group (n ‫؍‬ 11) or experimental group (NIV ؉ nebulizer group, n ‫؍‬ 10). All subjects inhaled bronchodilators for 9 minutes, and after particles were counted with a gamma camera to analyze regions of interest and pulmonary clearance at 0, 15, 30, 45, and 60 min. RESULTS: Breathing frequency (P ‫؍‬ < .001) and minute ventilation (P ‫؍‬ .01) were reduced, and tidal volume was increased (P ‫؍‬ .01) in the NIV ؉ nebulizer group, compared with the control group. The NIV ؉ nebulizer group had improvement from baseline values, compared to the control group in the following parameters: FEV 1 46.7 ؎ 0.5% of predicted vs 29.8 ؎ 8.9% of predicted, P ‫؍‬ .02), FVC (41.2 ؎ 1.5% of predicted vs 23.2 ؎ 7.1% of predicted, P ‫؍‬ .02), peak expiratory flow (67.3 ؎ 38.3% of predicted vs 26.9 ؎ 12.1% of predicted, P ‫؍‬ .01), and inspiratory capacity (54.9 ؎ 28.8% of predicted vs 31.2 ؎ 9.1% of predicted, P ‫؍‬ .01). No differences were observed between groups regarding radio-aerosol deposition index or pulmonary clearance. Negative correlations were found between FEV 1 , forced expiratory flow during the middle half of the FVC maneuver (FEF 25-75% ), inspiratory capacity, and radio-aerosol penetration index. CONCLUSIONS: Coupling nebulization and NIV during asthma exacerbation did not improve radio-aerosol pulmonary deposition, but we observed clinical improvement of pulmonary function in these subjects. (ClinicalTrials.gov registration NCT01012050)

Noninvasive Ventilation for Acute Respiratory FailureDiscussion

“…156 Despite the impediments to efficient aerosol delivery with a bi-level ventilator, due to the continuous gas flow and leaks, substantial therapeutic effects are achieved after inhaled bronchodilator administration to patients with asthma and COPD. Galindo-Filho and colleagues 157 reported that, al-though coupling nebulization and NIV during an asthma exacerbation did not improve radio-aerosol pulmonary deposition, it did result in clinical improvement of pulmonary function in these patients. Careful attention to the technique of drug administration is required to optimize therapeutic effects of inhaled drugs during NIV.…”

Aerosol Therapy During Noninvasive Ventilation or High-Flow Nasal Cannula

“…The observation by Galindo-Filho et al 22 of an improvement in lung function without an increase in aerosol deposition during NIV suggests that there might be a bronchodilator effect of NIV unrelated to aerosol bronchodilator delivery. This is supported by the improvement in spirometry shown by Brandão et al 21 with a higher level of expiratory pressure.…”

“…Galindo-Filho et al 22 conducted a study to assess the effects of coupling ␤-agonist nebulization and NIV during asthma exacerbations. Specifically, they evaluated radioaerosol pulmonary deposition using scintigraphy and cardiopulmonary parameters to correlate pulmonary function with radioaerosol deposition index, radioaerosol penetration index, and pulmonary clearance.…”

Noninvasive Ventilation for Severe Acute Asthmatic Attacks

“…The latest RCT was recently published in 2013, and the authors evaluated the effects of NIV on the pulmonary distribution of nebulized bronchodilators using pulmonary scintigraphy (20). Twenty-one patients who had presented to the ER with moderate-severe asthmatic attacks were randomized into two groups as follows: those receiving NIV and bronchodilator nebulization (10 patients) and the control group receiving nebulization without PS (11 patients).…”