1. Nebulization during spontaneous breathing, CPAP and Bilevel: a randomized analysis of pulmonary radioaerosol deposition RESPIRATORY 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 radioaerosol administered by nebulization to healthy individuals, during spontaneous breathing, CPAP and BiPAP differ? Is this research question relevant to your clinical practice?

5. Methods Study design – Crossover and Observational – What are the positives to this design? Negative? Exclusion criteria were: – 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. 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: França EET, 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-Filho VC, 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. Resp Care 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