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Nursing in Critical Care 2010Bronchodilators are increasingly being used in patients undergoing mechanical ventilation. There are multiple factors that affect bronchodilator delivery during... (Review)
Review
BACKGROUND
Bronchodilators are increasingly being used in patients undergoing mechanical ventilation. There are multiple factors that affect bronchodilator delivery during mechanical ventilation. These factors can be classified into three categories: ventilator-related factors, circuit-related factors and device-related factors.
AIMS
The purpose of this paper is to review in depth each of the factors affecting bronchodilator delivery during mechanical ventilation.
SEARCH STRATEGIES
A literature search was undertaken using several databases including Cochrane, Pubmed, Medline, Cinahl and Science Direct. The literature search, although limited to the English language, covered materials from 1985 to May 2009.
CONCLUSION
Aerosolized bronchodilator delivery to mechanically ventilated patients is complex as a result of the multiple factors that affect the amount of aerosol deposited in the lower respiratory tract. When these factors are not carefully controlled and the optimum technique for aerosol delivery is not utilized, a greater proportion of the aerosol will deposit in the ventilator circuits and artificial airways decreasing the available dose to the patient. Attention to these factors and optimizing aerosol delivery techniques will help to reach therapeutic endpoints of bronchodilator therapy in patients receiving ventilatory support.
RELEVANCE TO CLINICAL PRACTICE
Bronchodilator delivery during mechanical ventilation is factor and technique dependent. A clear understanding of the factors affecting aerosol drug delivery during mechanical ventilation is very important in optimizing the efficiency of bronchodilator delivery in mechanically ventilated adults. Through the recommendations made in this paper, clinicians will be able to optimize both their technique and the therapeutic outcomes of aerosol drug delivery in patients receiving ventilator support.
Topics: Adult; Aerosols; Biological Availability; Bronchodilator Agents; Drug Delivery Systems; Humans; Nebulizers and Vaporizers; Respiration, Artificial
PubMed: 20626796
DOI: 10.1111/j.1478-5153.2010.00395.x -
Respiratory Medicine 2023Nocturnal and early morning symptoms are common and uncomfortable in many patients with COPD, and are likely to affect their long-term outcomes. However, it is still... (Review)
Review
Nocturnal and early morning symptoms are common and uncomfortable in many patients with COPD, and are likely to affect their long-term outcomes. However, it is still debated whether it is better to give long-acting bronchodilators once- or twice-daily to symptomatic COPD patients. The functional link between circadian rhythms of autonomic tone and airway calibre explains why the timing of administration of bronchodilators in chronic airway diseases can induce different effects when taken at different biological (circadian) times. However, the timing also depends on the pharmacological characteristics of the bronchodilator to be used. Because the profile of bronchodilation produced by once-daily vs. twice-daily long-acting bronchodilators differs throughout 24 h, selecting long-acting bronchodilators may be customized to specific patient preferences based on the need for further bronchodilation in the evening. This is especially helpful for people who experience respiratory symptoms at night or early morning. Compared to placebo, evening bronchodilator administration is consistently linked with persistent overnight improvements in dynamic respiratory mechanics and inspiratory neural drive. The current evidence indicates that nocturnal and early morning symptoms control is best handled by a LAMA taken in the evening. In contrast, it seems preferable to use a LABA for daytime symptoms. Therefore, it can be speculated that combining a LAMA with a LABA can improve bronchodilation and control symptoms better. Both LAMA and LABA must be rapid in their onset of action. Aclidinium/formoterol, a twice-daily combination, is the most studies of the available LAMA/LABA combinations in terms of impact on daytime and nocturnal symptoms.
Topics: Humans; Bronchodilator Agents; Adrenergic beta-2 Receptor Agonists; Pulmonary Disease, Chronic Obstructive; Asthma; Muscarinic Antagonists; Administration, Inhalation; Drug Combinations
PubMed: 37879449
DOI: 10.1016/j.rmed.2023.107439 -
Current Clinical Pharmacology Feb 2011Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, and its prevalence is rising worldwide. Bronchodilators remain the cornerstone... (Review)
Review
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, and its prevalence is rising worldwide. Bronchodilators remain the cornerstone of COPD treatment, especially inhaled β2-adrenergic receptor agonists and inhaled anticholinergics. Long-acting bronchodilators are considered more effective and convenient than short-acting bronchodilators for the maintenance treatment in patients with moderate to very severe COPD. There are currently 3 long-acting inhaled bronchodilators available in the United States: the β2-adrenergic receptor agonists formoterol and salmeterol, and the anticholinergic, tiotropium. All 3 long-acting bronchodilators have been shown to be effective and well tolerated for the management of patients with stable COPD in clinical studies. The combination of β2-adrenergic receptor agonists and anticholinergics has been shown to provide superior bronchodilatory effect than either agent alone, possibly because of different mechanisms of action of these agents. The current treatment guidelines recommend the use of one or more long-acting bronchodilators for patients with moderate to severe stable COPD who remain symptomatic with single-agent bronchodilator therapy. The objective of this article is to review clinical data on combined bronchodilator therapy with β2-adrenergic receptor agonists and anticholinergics in patients with COPD.
Topics: Administration, Inhalation; Adrenergic beta-2 Receptor Agonists; Bronchodilator Agents; Cholinergic Antagonists; Drug Therapy, Combination; Humans; Practice Guidelines as Topic; Pulmonary Disease, Chronic Obstructive; Severity of Illness Index
PubMed: 21235463
DOI: 10.2174/157488411794941331 -
Current Drug Targets 2018Although β2-receceptor agonists are powerful bronchodilators and are at the forefront of asthma symptom relief, patients who use them frequently develop partial... (Review)
Review
Although β2-receceptor agonists are powerful bronchodilators and are at the forefront of asthma symptom relief, patients who use them frequently develop partial resistance to them. This can be a particularly serious problem during severe attacks, where high dose β2-agonist treatment is the front line therapy. Alternative bronchodilators are urgently needed. In this article we review the evidence for the bronchodilator effects of the cannabinoid CB1 receptor tetrahydrocannabinol (THC) and suggest that the mechanisms of action for these effects are sufficiently independent of the mechanisms of standard bronchodilators to warrant clinical investigation. Specifically, clinical trials testing the bronchodilator effects of THC in β2 agonist resistant asthmatic patients would show whether THC could fill the role of rescue bronchodilator in cases of β2 agonist resistance.
Topics: Adrenergic beta-2 Receptor Agonists; Asthma; Bronchodilator Agents; Clinical Trials as Topic; Dronabinol; Drug Resistance; Humans; Molecular Targeted Therapy; Receptor, Cannabinoid, CB1
PubMed: 28641517
DOI: 10.2174/1389450118666170615101220 -
International Journal of Chronic... Apr 2010Exercise tolerance is an important parameter in patients with COPD and a primary goal of treatment is to reduce dyspnea to facilitate physical activities and improve... (Review)
Review
Exercise tolerance is an important parameter in patients with COPD and a primary goal of treatment is to reduce dyspnea to facilitate physical activities and improve health-related quality of life. This review examines the link between expiratory flow limitation and dyspnea to explain the rationale for the use of bronchodilators and review the characteristics of different types of exercise tests, with specific focus on which tests are likely to show a response to bronchodilators. An earlier literature search of studies published up to 1999 assessed the effects of bronchodilatort therapy on dypsnea and exercise tolerance among patients with COPD. This current review examines the clinical evidence published since 1999. Thirty-one randomized studies of exercise tolerance associated with short- and long-acting beta(2)-agonists and anticholinergics were identified. Evidence for the efficacy of bronchodilators in enhancing exercise capacity is often contradictory and possibly depends on the exercise test and study methodology. However, further studies should confirm the benefit of long-acting bronchodilators in improving spontaneous everyday physical activities.
Topics: Bronchodilator Agents; Exercise Tolerance; Humans; Pulmonary Disease, Chronic Obstructive; Young Adult
PubMed: 20463947
DOI: 10.2147/copd.s7404 -
Journal of Medical Case Reports Jul 2023Bronchiolar obstruction, which causes airway obstruction in hyperresponsive airways, often results from the contraction of the airway's smooth muscles, increased viscid...
BACKGROUND
Bronchiolar obstruction, which causes airway obstruction in hyperresponsive airways, often results from the contraction of the airway's smooth muscles, increased viscid mucous secretions, and mucosal oedema consequent upon a reduced cyclic 3,5-adenosine monophosphate (c-AMP). These processes respond to bronchodilators. The six cases presented to us, in Edward Francis Small Teaching Hospital (EFSTH), Banjul, The Gambia, in the newborn period with clinical features suggesting obstruction with airway reactivity with response to bronchodilator treatment are presented here. Our capacity-limited literature search did not show any such report in neonates. This report highlights the need for this condition to be sought in neonates, medically managed in resource-poor countries without resorting to high-cost equipment use, and for its possible future classification.
CASE PRESENTATION
We report six cases of Gambian neonates consisting of four males and two females ages 2-27 days who presented to us with histories of fast breathing of a few hours duration and expiratory respiratory distress. All were term babies with rhonchi and demonstrable prolonged expiration with terminal effort. They all had a diagnosis of hyperreactive airway disease with bronchiolar obstruction. Five cases were first-time wheezers, while one was a recurrence. All were eventually treated with bronchodilators and steroids with good results. The median duration for resolution of most symptoms with treatment was two days, with a range of 1-5 days.
CONCLUSION
Clinically determined bronchiolar obstructions in term neonates can be relieved with bronchodilators and steroids, and this treatment modality, if employed where the pathological process can be established, can reduce the demand on scarce resources in resource-poor countries.
Topics: Male; Infant, Newborn; Female; Humans; Bronchodilator Agents; Airway Obstruction; Gambia
PubMed: 37518070
DOI: 10.1186/s13256-023-04035-4 -
Respiratory Care Jun 2004Inhaled bronchodilators are routinely administered to mechanically ventilated patients to relieve dyspnea and reverse bronchoconstriction. A lower percentage of the... (Review)
Review
Inhaled bronchodilators are routinely administered to mechanically ventilated patients to relieve dyspnea and reverse bronchoconstriction. A lower percentage of the nominal dose reaches the lower respiratory tract in a mechanically ventilated patient than in a nonintubated subject, but attention to device selection, administration technique, dosing, and patient-ventilator interface can increase lower-respiratory-tract deposition in a mechanically ventilated patient. Assessing the airway response to bronchodilator by measuring airway resistance and intrinsic positive end-expiratory pressure helps guide dosing and timing of drug delivery. Selecting the optimal aerosol-generating device for a mechanically ventilated patient requires consideration of the ease, reliability, efficacy, safety, and cost of administration. With careful attention to administration technique, bronchodilator via metered-dose inhaler or nebulizer can be safe and effective with mechanically ventilated patients.
Topics: Administration, Inhalation; Aerosols; Bronchodilator Agents; Dose-Response Relationship, Drug; Drug Monitoring; Equipment Design; Heating; Humans; Humidity; Intubation, Intratracheal; Nebulizers and Vaporizers; Patient Selection; Respiration, Artificial
PubMed: 15165297
DOI: No ID Found -
Journal of Aerosol Medicine and... Mar 2008Bronchodilators are frequently used in ICU patients, and are the most common medications administered by inhalation during mechanical ventilation. The amount of... (Review)
Review
Bronchodilators are frequently used in ICU patients, and are the most common medications administered by inhalation during mechanical ventilation. The amount of bronchodilator that deposits at its site of action depends on the amount of drug, inhaled mass, deposited mass, and particle size distribution. Mechanical ventilation challenges both inhaled mass and lung deposition by specific features, such as a ventilatory circuit, an endotracheal tube, and ventilator settings. Comprehensive in vitro studies have shown that an endotracheal tube is not as significant a barrier for the drug to travel as anticipated. Key variables of drug deposition are attachments of the inhalation device in the inspiratory line 10 to 30 cm to the endotracheal tube, use of chamber with metered-dose inhaler, dry air, high tidal volume, low respiratory frequency, and low inspiratory flow, which can increase the drug deposition. In vivo studies showed that a reduction by roughly 15% of the respiratory resistance was achieved with inhaled bronchodilators during invasive mechanical ventilation. The role of ventilatory settings is not as clear in vivo, and primary factors for optimal delivery and physiologic effects were medication dose and device location. Nebulizers and pressurized metered-dose inhalers can equally achieve physiologic end points. The effects of bronchodilators should be carefully evaluated, which can easily be done with the interrupter technique. With the non-invasive ventilation, the data regarding drug delivery and physiologic effects are still limited. With the bilevel ventilators the inhalation device should be located between the leak port and face mask. Further studies should investigate the effects of inhaled bronchodilators on patient outcome and methods to optimize delivery of inhaled bronchodilators during non-invasive ventilation.
Topics: Administration, Inhalation; Aerosols; Bronchodilator Agents; Critical Care; Drug Delivery Systems; Humans; Nebulizers and Vaporizers; Respiration, Artificial; Tissue Distribution
PubMed: 18518835
DOI: 10.1089/jamp.2007.0630 -
Comprehensive Therapy Aug 1995Bronchodilator management of acute severe asthma has evolved considerably in recent years. beta-adrenergic agonists have emerged as the single most potent class of... (Review)
Review
Bronchodilator management of acute severe asthma has evolved considerably in recent years. beta-adrenergic agonists have emerged as the single most potent class of bronchodilator available, and the inhalational route of administration has proven to be the most effective and least toxic method of delivery except among apneic or highly uncooperative patients. Other bronchodilators, including aminophylline, inhaled anticholinergics, and intravenous magnesium sulfate, are significantly less potent drugs for reversal of bronchoconstriction. In most patients these agents do not promote significant bronchodilation beyond that achieved with an intensive regimen of inhaled beta agonists; subsets of patients that might benefit from these other agents remain to be identified. Questions remain as to the optimal dose, frequency of administration, and mode of inhalational delivery of the beta agonists in acute asthma. Finally, it is important to remember that bronchodilator therapy constitutes only one component in the treatment of acute severe asthma. Treatment of airway inflammation with systemic corticosteroids is another vital component, as are supplemental oxygen in the hypoxemic patient, close monitoring of lung function, attention to the possibility of hypercapnic respiratory failure, patient education, and a plan of care following emergency department discharge.
Topics: Acute Disease; Administration, Inhalation; Adrenergic beta-Agonists; Asthma; Bronchodilator Agents; Humans
PubMed: 8536441
DOI: No ID Found -
Archivos de Bronconeumologia Oct 2017To describe the evidence- and experience-based expert consensus on the use of single-agent bronchodilators in patients with stable mild-moderate chronic obstructive... (Review)
Review
OBJECTIVE
To describe the evidence- and experience-based expert consensus on the use of single-agent bronchodilators in patients with stable mild-moderate chronic obstructive pulmonary disease (COPD).
METHODS
Using Delphi methodology, a panel of 7 respiratory medicine experts was established, who, in the first nominal group meeting defined the scope, users, and document sections. The panel drew up 14 questions on the use of single-agent bronchodilators in patients with mild-moderate stable COPD to be answered with a systematic review of the literature. The results of the review were discussed in a second nominal group meeting and 17 statements were generated. Agreement/disagreement with the statements was tested among16 different experts including respiratory medicine experts and primary care physicians. Statements were scored from1 (total disagreement) to10 (total agreement). Agreement was considered if at least 70% voted ≥7. The level of evidence and grade of recommendation of the systematic literature review was assessed using the Oxford Centre for Evidence-based Medicine levels.
RESULTS
A total of 12 of the 17 statements were selected. Specific statements were generated on different profiles of patients with stable mild-moderate COPD in whom single-agent bronchodilators could be prescribed.
CONCLUSIONS
These statements on the use of single-agent bronchodilators might improve the outcomes and prognosis of patients with stable mild-moderate COPD.
Topics: Administration, Inhalation; Adult; Aged; Aged, 80 and over; Bronchodilator Agents; Delphi Technique; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Practice Guidelines as Topic; Pulmonary Disease, Chronic Obstructive
PubMed: 28495073
DOI: 10.1016/j.arbres.2017.03.022