Testing of Nebulizers for Delivering Magnesium Sulfate to Pediatric Asthma Patients in the Emergency Department

Coates, Allan L.; Leung, Kitty; Vecellio, Laurent; Schuh, Suzanne

doi:10.4187/respcare.00826

Cited by 16 publications

(21 citation statements)

References 30 publications

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“…The in vivo respirable fraction of 0.57 Ϯ 0.05 agreed with that measured via laser diffraction in vitro (0.59 Ϯ 0.0), 10 which corresponded to a mass median diameter of 4.4 Ϯ 0.1 m, assuming unit density. The in vitro respirable fraction depends only on measured particle size distribution 21 and is based on the probability that this fraction of the mass of the particles within a certain size range will, if entering the upper airway, deposit below the vocal cords.…”

Section: Discussionsupporting

confidence: 73%

“…Expressing the data in the in vitro study 10 as the mean and 95% CI, the 16.0 mg/min (95% CI 15.6 -16.5 mg/min) does not overlap the 12.6 mg/min (95% CI 10.9 -14.2 mg/min) of the in vivo study, implying significant differences.…”

Section: Resultsmentioning

confidence: 97%

“…Since there was no reason to suspect that saline would deposit any differently than the aqueous solution MgSO 4 , normal saline was used in its place, to avoid any pharmacologic effect in the subjects. Based on in vitro data, 10 approximately 100 MBq of technetium attached to diethylenetriaminepentaacetic acid ( 99m Tc-DTPA) was added to 6 mL of normal saline and placed in the reservoir of the AeroNeb Go, coupled to an Idehaler Pocket holding chamber and a face mask as the patient interface (see Fig. 1).…”

Section: Methodsmentioning

confidence: 99%

“…9 In preparation for a large multicenter study to test the benefit of inhaled MgSO 4 , in vitro studies were done to select an appropriate delivery system. 10 Due to both the wide age range of the proposed subjects and the desire to use a single aerosol delivery system, a face mask rather than a mouth piece was required, which precluded the use of high efficiency breath-enhanced or breath-actuated nebulizers, since they require one-way valves and a tight fit with the airway opening. Using breathing patterns ranging from that of adults to small children, in vitro studies suggested that the AeroNeb Go (Aerogen, Galway, Ireland) vibrating-mesh nebulizer, coupled with the novel Idehaler Pocket holding chamber (La Diffusion Technique Francaise, St Etienne, France) ( Fig.…”

Section: Introductionmentioning

confidence: 99%

“…1), with a charge volume of 6 mL, would deliver approximately 16 mg/min of a 100 mg/mL solution of MgSO 4 in older children and adults, and roughly a fifth of this when using a breathing pattern suitable for toddlers. 10 In that study the in vitro respirable fraction was defined as the mass of aerosol carried in particles Յ 5 m, with the expectation that particles in this size range would, if inhaled, deposit below the vocal cords. Hence, respiratory system deposition was estimated by multiplying the amount of aerosol collected at the filter at the "mouth" by the respirable fraction.…”

Section: Introductionmentioning

confidence: 99%

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Respiratory System Deposition with a Novel Aerosol Delivery System in Spontaneously Breathing Healthy Adults

Coates¹,

Leung²,

Chan

et al. 2013

Respir Care

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BACKGROUND: Intravenous magnesium sulfate (MgSO 4 ) in children and adults with refractory acute asthma is effective, but therapy may be limited by systemic hypotension that might be avoided with the aerosol route. Inhaled MgSO 4 has a relatively high dose (volume) requirement. This, plus the use of inefficient delivery systems, may explain the lack of efficacy of inhaled MgSO 4 in some studies. An in vitro study suggested that the AeroNeb Go with the Idehaler Pocket and a face mask would deliver 16 mg/min of MgSO 4 to the respiratory system in older children, and approximately a fifth for toddlers, but no in vivo data exist. METHODS: Saline mixed with a radiolabel was used as a proxy for the 100 mg/mL MgSO 4 solution. In 5 adult males the rate of deposition was measured using nuclear medicine techniques. The radiolabel deposition below the vocal cords was converted to the rate of deposition of MgSO 4 and compared to the results from an in vitro model using adult respiratory patterns. RESULTS: The mean ؎ SD rate of deposition was 12.6 ؎ 1.9 mg/min. The reasons for this lower deposition, compared to the in vitro estimate, was most likely the exhalation of anatomical dead space aerosol, which would have been captured on the inspiratory filter in vitro. CONCLUSIONS: These in vivo data confirm the deposition data predicted in the in vitro study, although caution should be used in extrapolating the results to children. This device appears suitable for the clinical trial of inhaled MgSO 4 in children and adults with refractory asthma.

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Section: Discussionsupporting

confidence: 73%

Section: Resultsmentioning

confidence: 97%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Respiratory System Deposition with a Novel Aerosol Delivery System in Spontaneously Breathing Healthy Adults

Coates¹,

Leung²,

Chan

et al. 2013

Respir Care

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Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department

Schuh

Sweeney

Rumantir

et al. 2020

JAMA

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IMPORTANCE While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown.OBJECTIVE To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy. DESIGN, SETTING, AND PARTICIPANTSA randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed.INTERVENTIONS Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408). MAIN OUTCOMES AND MEASURESThe primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes. RESULTS Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, −4.2%; absolute risk difference 95% [exact] CI, −11% to 2.8%]; P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, −0.23 to 0.50]; P = .46); respiratory rate (0.17 breaths/min [95% CI, −1.32 to 1.67]; P = .82); oxygen saturation (−0.04% [95% CI, −0.53% to 0.46%]; P = .88); systolic blood pressure (0.78 mm Hg [95% CI, −1.48 to 3.03]; P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11]; P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%).CONCLUSIONS AND RELEVANCE Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma.

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Association Between Intravenous Magnesium Therapy in the Emergency Department and Subsequent Hospitalization Among Pediatric Patients With Refractory Acute Asthma

et al. 2021

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IMPORTANCE Despite guidelines recommending administration of intravenous (IV) magnesium sulfate for refractory pediatric asthma, the number of asthma-related hospitalizations has remained stable, and IV magnesium therapy is independently associated with hospitalization.OBJECTIVE To examine the association between IV magnesium therapy administered in the emergency department (ED) and subsequent hospitalization among pediatric patients with refractory acute asthma after adjustment for patient-level variables. DESIGN, SETTING, AND PARTICIPANTSThis post hoc secondary analysis of a double-blind randomized clinical trial of children with acute asthma treated from September 26, 2011, to November 19, 2019, at 7 Canadian tertiary care pediatric EDs was conducted between September and November 2020. In the randomized clinical trial, 816 otherwise healthy children aged 2 to 17 years with Pediatric Respiratory Assessment Measure (PRAM) scores of 5 points or higher after initial therapy with systemic corticosteroids and inhaled albuterol with ipratropium bromide were randomly assigned to 3 nebulized treatments of albuterol plus either magnesium sulfate or 5.5% saline placebo. EXPOSURES Intravenous magnesium sulfate therapy (40-75 mg/kg). MAIN OUTCOMES AND MEASURESThe association between IV magnesium therapy in the ED and subsequent hospitalization for asthma was assessed using multivariable logistic regression analysis.Analyses were adjusted for year epoch at enrollment, receipt of IV magnesium, PRAM score after initial therapy and at ED disposition, age, sex, duration of respiratory distress, previous intensive care unit admission for asthma, hospitalizations for asthma within the past year, atopy, and receipt of oral corticosteroids within 48 hours before arrival in the ED, nebulized magnesium, and additional albuterol after inhaled magnesium or placebo, with site as a random effect. RESULTS Among the 816 participants, the median age was 5 years (interquartile range, 3-7 years), 517 (63.4%) were boys, and 364 (44.6%) were hospitalized. A total of 215 children (26.3%) received IV magnesium, and 190 (88.4%) of these children were hospitalized compared with 174 of 601 children (29.0%) who did not receive IV magnesium. Multivariable factors associated with

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Testing of Nebulizers for Delivering Magnesium Sulfate to Pediatric Asthma Patients in the Emergency Department

Cited by 16 publications

References 30 publications

Respiratory System Deposition with a Novel Aerosol Delivery System in Spontaneously Breathing Healthy Adults

Respiratory System Deposition with a Novel Aerosol Delivery System in Spontaneously Breathing Healthy Adults

Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department

Association Between Intravenous Magnesium Therapy in the Emergency Department and Subsequent Hospitalization Among Pediatric Patients With Refractory Acute Asthma

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