Download Amphotericin B

Brian X Weaver MS, RRT-NPS, RPFT
Director of Respiratory Therapy ( Rt.)
University Hospital / UMDNJ, Newark, N.J.
Assistant Director CardioPulmonaryNeurodiagnostics Services
On-Site Manager MMC Southern Campus
600 River Avenue | Lakewood | NJ 08701
[email protected]
 Regularly nebulized medication
 Non-conventional nebulized medication
 Respiratory meds in reverse
 Current Nebulizers
 Finally presented some fundamental mechanics review
Albuterol
β2-adrenergic agonists(receptor agonists)
 Smooth muscle relaxation.
Beta-adrenergic receptors
• Cyclic Adenosine MonoPhosphate (cAMP)
Albuterol; Proventil, Ventolin, Levalbuterol; Xopenex, Terbutaline ,
Metaproterenol; Alupent
Jill A. Ohar; James F. Donohue, Mono- and Combination Therapy of Long-acting Bronchodilators and Inhaled Corticosteroids in Advanced
COPD, Respir Crit Care Med. 2010;31(3):321-333.
Salmeterol:
Serevent Diskus,
Formoterol;
Foradil,
Symbicort
Their long duration of action is due to the addition of a long,
lipophilic side-chain that
binds
unbinds
binds.
unbinds
Epinephrine vs Adrenalin
 John Able 1897 ---- Epinephrine
 extracts he prepared from the adrenal
 Iokichi Takamine 1901 ----- Adrenalin
 patented a purified adrenal extract, and the name trademarked
by Park, Davis & Co in the U.S.
Epinephrine became the generic name in the U.S.
The British term for this chemical is Adrenaline
http://www.britannica.com/biography/Jokichi-Takamine
Dictionary of Scientific Biography | 2008 COPYRIGHT 2008 Charles Scribner's Sons
 Ipratropium exhibits

Cyclic Guanosine MonoPhosphate (cGMP)
 decreased contractility of smooth muscle in the lung,
Peanut allergy
Atrovent inhalers used chlorofluorocarbon (CFC) as a propellant and contained
soy lecithin in the propellant
……………………………..CFC inhalers were phased ……………………………………………..
It has never been a contraindication when administered as a nebulized solution.


http://www.drugs.com/pro/ipratropium.html
The Ritedose Corporation
 Antibiotic


.
Used to treat bacterial Gram-negative Pseudomonas
reduce mucus viscosity by splitting disulfide bonds
 Dornase alfa

enzyme >> cleaves DNA
 hydrolyzes the DNA present in sputum/mucus and reduces
viscosity
 Regularly nebulized medication
 Non-conventional nebulized medication
 Respiratory meds in reverse
 Current Nebulizers
 Finally presented some fundamental mechanics review
Aerosolized drugs have several advantages over
other drug formulations,
• Quick onset of action
• Low incidence of systemic adverse effects.
• No pain to the patient
• Convenient method of drug delivery.
 Disadvantage is the generally lower percentage of drug
delivered to the site of action compared with other
methods of administration;

Mary Beth Shirk; Kevin R. Donahue; Jill Shirvani, Unlabeled Uses of Nebulized Medications, Am J
Health Syst Pharm. 2006;63(18):1704-171
More research is needed to develop
guidelines for their use since
nebulization may provide benefits to
many patients who otherwise cannot be
treated or would be at risk of systemic
adverse effects of the drugs.
NEW JERSEY ADMINISTRATIVE CODE
TITLE 13
LAW AND PUBLIC SAFETY
CHAPTER 44F
STATE BOARD OF RESPIRATORY CARE
For the purposes of treating, managing, controlling and
caring for patients with deficiencies and abnormalities
of the cardiac and pulmonary system, a respiratory care
practitioner may perform the following duties under the
direction or supervision of a physician:
 4) Administration of drugs and medications;
 Prostacyclin
 Opioids
 Lidocaine
 Magnesium
 Amphotericin B
 Antibiotic
 Heparin
 Insulin
 And others
Prostacyclin
 Naturally occurring prostaglandin

Potent vasodilator that increases intracellular cAMP


Prostacyclin synthase ( enzyme responsible for the formation of prostacyclin),
Deficient in the pulmonary endothelium
 Three prostacyclin analogs are FDA-approved for the
treatment of PAH: Epoprostenol, Treprostinil and
Iloprost.
Tuder RM, Cool CD, Geraci MW et al. Prostacyclin synthase expression is decreased in lungs from
patients with severe pulmonary hypertension. Am. J. Respir. Crit. Care Med. 159(6), 1925–1932 (1999).
 Iloprost is a synthetic prostacyclin
 half-life of only 20–30 min, it requires 6–9
inhalation sessions throughout the day
 specially approved inhalation system.
Ventavis®, package insert. Actelion Pharmaceuticals US Inc., CA, USA.
 Prostacyclin
 Opioids
 Lidocaine
 Magnesium
 Amphotericin B
 Antibiotic
 Heparin
 Insulin
 And others
opioids.
One class of drugs that is frequently used in a nebulized form
is the opioids.
The mechanism of action of nebulized opioids is uncertain,
Dyspnea
end-stage
can typically be done at home, which can provide additional
psychological comfort to the patient.

Foral PA, Malesker MA, Huerta G et al. Nebulized opioids use in COPD. Chest. 2004; 125:691–4
 The most common nebulized opioids:
Morphine
Hydromorphone

Generic Name: hydromorphone (oral) (HYE droe MOR fone)
Brand Name: Dilaudid, Dilaudid-5, Exalgo
 Hydromorphone is much more soluble in water than morphine ---deliver the drug in
a smaller volume of water.
Fentanyl

Fentanyl is approximately 80 to 100 times more potent than
morphine and roughly 40 to 50 times more potent than
pharmaceutical grade (100% pure) heroin.
Limited research has also investigated
nebulized-opioid use in the management of
stable chronic obstructive pulmonary disease
(COPD) and other respiratory diseases, but
the results are conflicting.
Foral PA, Malesker MA, Huerta G et al. Nebulized opioids use in COPD. Chest. 2004; 125:691–4.
Farncombe M, Chater S. Clinical application of nebulized opioids for treatment of dyspnoea in patients with malignant
disease. Support Care Cancer. 1994; 2:184–7.
patients reported a decrease in shortness
of breath, greater feelings of relaxation,
and more exercise tolerance. They also
reported no significant adverse effects.
63% of all patients and in 81% of patients who received more
than three doses.
Farncombe M, Chater S, Gillin A. The use of nebulized opioids for breathlessness: a chart review. Palliat Med. 1994; 8:306–12
Non-regularly nebulized
 Prostacyclin
medication
 Opioids
 Lidocaine
 Magnesium
 Amphotericin B
 Antibiotic
 Heparin
 Insulin
 And others
 Lidocaine is a common local anesthetic frequently
nebulized during bronchoscopy procedures
 Lidocaine toxicity is a serious concern, and
concentrations of serum lidocaine over 5 mg/L can
lead to lightheadedness, tremors, hallucinations,
and cardiac arrest.
Wu FL, Razzaghi A, Souney PF. Seizure after lidocaine for bronchoscopy: case report and review of the use of lidocaine in airway
anesthesia. Pharmacotherapy. 1993; 13:72–8.
Langmack EL, Martin RJ, Pak J et al. Serum lidocaine concentrations in asthmatics undergoing research bronchoscopy. Chest. 2000;
117:1055–60.
 Lidocaine treatment is to manage bronchial
hyperactivity.
 Studies examined the use of nebulized lidocaine
in managing cough and asthma symptoms.
 Cough could be reduced with inhaled lidocaine
acting locally in the tracheobronchial airways.

Hansson L, Midgren B, Karlsson JA. Effects of inhaled lignocaine and adrenaline on capsaicin-induced cough in
humans. Thorax. 1994; 49:1166–8.
 Study, evaluated nebulized lidocaine in the management of
asthma.
 50 Patients were given 100 mg of 4% lidocaine or
placebo four times daily.
 Asthma severity indicators such as FEV1, symptoms,
bronchodilator use, blood eosinophil counts, and
nighttime awakenings showed improvement in the
lidocaine-treated group by the end of the treatment
period.
 nine of the patients in the lidocaine group had to stop
treatment due to worsening asthma symptoms,
 Hunt LW, Frigas E, Butterfield JH et al. Treatment of asthma with nebulized lidocaine: a
randomized, placebo controlled study. J Allergy Clin Immunol. 2004; 113:853–9.
Non-regularly nebulized medication
 Prostacyclin
 Opioids
 Lidocaine
 Magnesium
 Amphotericin B
 Antibiotic
 Heparin
 Insulin
 And others
Currently, the most widely accepted treatments for asthma
include ß2-adrenergic agonists and corticosteroids.
 The search for treatment alternatives led to nebulized magnesium
sulfate.
 The Action; it is associated with cellular homeostasis and frequently
acts as a cofactor in enzymatic reactions. It has also been suggested
that magnesium acts as a smooth muscle relaxant by interfering
with calcium uptake.
Mahajan P, Haritos D, Rosenberg N et al. Comparison of nebulized magnesium sulfate plus albuterol to nebulized
albuterol plus saline in children with acute exacerbations of mild to moderate asthma. J Emerg Med. 2004; 27:21–5.
 A randomized, double-blind, controlled clinical study
compared nebulized magnesium sulfate with nebulized
albuterol in 33 patients with asthma (ages 12–60 years).
 The Fischl index score showed both groups improved by a
significant amount (p < 0.05), and the improvements were
similar between the two groups.

Mangat HS, D’Souza GA, Jacob MS. Nebulized magnesium sulphate versus nebulized salbutamol in
acute bronchial asthma, a clinical trial. Eur Respir J. 1998; 12:341–4.
A different study examined magnesium sulfate as a vehicle for nebulized
albuterol in treating acute asthma.
 35 Random asthma patients received a one-time dose
 2.5 mg of albuterol in
 3 mL of 0.9% sodium chloride
or
3 mL of isotonic magnesium sulfate.
 The magnesium group demonstrated significant
improvements in PEF (61%) compared with the control
(31%) group (p < 0.05).
 the PEF value was 48 L/min greater for the magnesium group.
 None of the test subjects reported any adverse events during treatment.
Nannini LJ, Pendino JC, Corna RA et al. Magnesium sulfate as a vehicle for nebulized salbutamol in acute
asthma. Am J Med. 2000; 108:193–
7.
Non-regularly nebulized
medication
 Prostacyclin
 Opioids
 Lidocaine
 Magnesium
 Amphotericin B
 Antibiotic
 Heparin
 Insulin
 And others
Amphotericin B
 Antifungal drug often used intravenously for
systemic fungal infections . It is the only
effective treatment for some fungal infections
 The toxicity of antifungals when used to
treat a systemic infection is also a concern.
Investigation into alternative methods of
treating these infections is ongoing
Behre GF, Lenz K, Schilling E et al. Aerosol amphotericin B inhalations for prevention of invasive pulmonary
aspergillosis in neutropenic cancer patients. Ann Hematol. 1995; 71:287–91.
One study prospectively examined rates of fungal infections
in patients receiving lung, heart, or heart–lung transplants.
Then 126 patients received 5 mg of nebulized amphotericin B
three times daily, increased to 20 mg three times daily within
five days after surgery.
The rate of fungal infection was compared with 101 patients
who were transplanted without amphotericin B prophylaxis.
Both groups of patients received the same
immunosuppressive therapy after the transplant. The study
found a significant decrease in the rate of fungal
infections in patients receiving nebulized amphotericin
B at 3 and 12 months
Reichenspurner H, Gamberg P, Nitschke M et al. Significant reduction in the number of fungal infections after lung-,
heartlung, and heart transplantation using aerosolized amphotericin B prophylaxis. Transplant Proc. 1997; 26:627–8
 Results from multiple studies demonstrated that
nebulized amphotericin B will not protect against
invasive fungal infections in cases where the
patient had a previous fungal infection during
chemotherapy.
 the optimal time to begin prophylaxis treatment
is during chemotherapy, before transplantation.
Ideally, this would minimize the number of
transplant candidates with preexisting
infections.
Monforte V, Roman A, Gavalda J et al. Nebulized amphotericin B prophylaxis for Aspergillus infection in lung
transplantation: study of risk factors. J Heart Lung Transplant. 2001; 20:1274–81.
Hertenstein B, Kern W, Schmeiser T et al. Low incidence of invasive fungal infections after bone-marrow transplantation in
patients receiving amphotericin B inhalations during neutropenia. Ann Hematol. 1994; 68:21–6.
Non-regularly nebulized
medication
 Prostacyclin
 Opioids
 Lidocaine
 Magnesium
 Amphotericin B
 Antibiotic
 Heparin
 Insulin
 And others
FDA non-labeled nebulization reported in the literature.
 Amikacin
Antibiotic -hospital-acquired infections with MDR Gram Neg bacteria ( Kidney)
 Carbenicillin
Antibiotic belonging to the subgroup of the Penicillins - Tx UTI ( Kidney)
 Ceftazidime –


Antibiotic -It is a third-generation Cephalosporin - activity against both Gram-positive and Gramnegative bacteria ( few)
 Gentamicin –


Antibiotic - wide range of bacterial infections, mostly Gram-negative bacteria but some Grampositive ( inner ear –Kindney)

Has been reported in the cystic fibrosis population
.
Palmer LB, Smaldone GC, Simon SR et al. Aerosolized antibiotics in mechanically ventilated patients: delivery and
response. Crit Care Med. 1998; 26:31–
9.
Sermet-Gaudelus I, Marquette CH, Wallet F et al. Nebulized antibiotics in cystic fibrosis. Paediatr Drugs. 2002; 4:455–67.
Stead RJ, Hodson ME, Batten JC. Inhaled ceftazidime compared with gentamicin and carbenicillin in older patients with
cystic fibrosis infected with Pseudomonas aeruginosa. Br J Dis Chest. 1987; 81:272–9.
 Antibiotic effective against most Gram negative bacilli
 Colistin is an old drug not used much because of its
nephrotoxicity
 It remains one of the last resorts for treating multidrug-resistant
(MDR) P Aeruginosa , Klebsiella pneumoniae, and
Acinetobacter and Multidrug resistant Enterobacteriaceae.



Falagas ME, Grammatikos AP, Michalopoulos A (October 2008). "Potential of old-generation antibiotics to address current
need for new antibiotics“. Expert review of anti-infective therapy 6 (5): 593–600. doi:10.1586/14787210.6.5.593.
PMID 18847400.
Non-regularly nebulized
medication









Prostacyclin
Opioids
Lidocaine
Magnesium
Amphotericin B
Antibiotic
Heparin
Insulin
And others
Heparin
 Early trials with heparin for the prevention of exercise-
induced asthma have been positive
 Heparin has also been studied to reverse the viscosity
of sputum in patients with cystic fibrosis




Garrigo J, Danta I, Ahmed T. Time course of the protective effect of inhaled heparin on exercise-induced asthma. Am J Respir
Crit Care Med. 1996; 153:1702–
7.
Ahmed T, Garrigo J, Danta I. Preventing bronchoconstriction in exercise-induced asthma with inhaled heparin. N Engl J Med.
1993; 329:90–5.
Polosa R, Magri S, Vancheri C et al. Time course of changes in adenosine 5'-monophosphate airway responsiveness with inhaled
heparin in allergic asthma. J Allergy Clin Immunol. 1997; 99:338–44.
Ledson M, Gallagher M, Hart CA et al. Nebulized heparin in Burkholderia cepacia colonized adult cystic fibrosis patients. Eur
Respir J. 2001; 17:36–
8.
Non-regularly nebulized
medication
 Prostacyclin
 Opioids
 Lidocaine
 Magnesium
 Amphotericin B
 Antibiotic
 Heparin
 Insulin
 And others
 powdered via nebulizer
 2007 as effective, but not better than injected
 Cost prohibitive
 Exubera, by Pfizer in 2006
 poor sales led Pfizer to withdraw it in 2007.[3]
 Afrezza, developed by Mannkind,
 approved by the FDA in 2014.




IMPORTANT SAFETY INFORMATION FOR AFREZZA® (INSULIN HUMAN) INHALATION
POWDER
WARNING: RISK OF SUDDEN LUNG PROBLEMS (BRONCHOSPASM) IN PATIENTS WITH LONGTERM (CHRONIC) LUNG DISEASE
Sudden lung problems (acute bronchospasm) have been seen in patients with asthma and COPD
(chronic obstructive pulmonary disease) using Afrezza®.
Afrezza® is not to be used in patients with long-term lung disease such as asthma or COPD.
Non-regularly nebulized
medication
 Prostacyclin
 Opioids
 Lidocaine
 Magnesium
 Amphotericin B
 Antibiotic
 Heparin
 Insulin
 And others
 Protein involved in the breakdown of blood clots.
 Serine protease ; In the cells that line the blood
 vessels
An enzyme responsible for clot breakdown.
 Is used to treat strokes, PE, MI and DVT’

Rivera-Bou WL, Cabanas JG, Villanueva SE (2008-11-20). "Thrombolytic Therapy". Medscape.
Dwayne Scott F, Wardlaw JM, Murray V, Berge E, del Zoppo G, Sandercock P, Lindley RL, Cohen G (June 2012). "Recombinant tissue plasminogen
activator for acute ischaemic stroke: an updated systematic review and meta-analysis". Lancet 379 (9834): 2364–72. doi:10.1016/S0140-6736(12)60738-7.
PMC3386494. PMID22632907. Vancouver style error (help)
DeMers G, Meurer WJ, Shih R, Rosenbaum S, Vilke GM (December 2012). "Tissue plasminogen activator and stroke: review of the literature for the
clinician". J Emerg Med 43 (6): 1149–54. doi:10.1016/j.jemermed.2012.05.005. PMID22818644.
 Plastic bronchitis is a lymphatic flow disorder
 that causes severe respiratory issues. In
 children with plastic bronchitis, lymph fluid
 builds in the airways and forms rubbery or caulk like plugs (known as casts). These casts block
 the airways, making it difficult to breathe.
http://www.chop.edu/conditions-diseases/plastic-bronchitis
The patient was extubated on hospital day 12 and was maintained on therapy with
albuterol, N-acetylcysteine, budesonide, deoxyribonuclease (DNase) by
nebulization, and oral sildenafil. Despite such therapy, other two episodes of
respiratory deterioration occurred over the following 10 days, each requiring
bronchoscopic removal of casts from the bronchial tree. After the latest episode,
treatment with aerosolized t-PA (Actilyse, Boehringer Ingelheim) was added to
the previous therapy. A total of 5 ml of the drug diluted to 1 mg/ml of normal
saline was delivered every 6 hours via a Pari TurboBoy S compressor with a Pari LC
Sprint reusable nebulizer and a mask (Pari GmbH, Starnberg, Germany). Over the
next few days, the child started expectorating thinner bronchial secretions and his
condition improved gradually, with clearing of areas of atelectasis and no
recurrence of respiratory symptoms. The patient was discharged home receiving
budesonide (0,5 mg twice daily), DNase (1,25 mg twice daily) and t-PA (5 mg four
times daily) by nebulization, oral sildenafil, and chest physiotherapy.

Massimo Colaneri,1 Andrea Quarti,1 Marco Pozzi,1 Stefano Gasparini,2 Ines Carloni,3 and Fernando
Maria de Benedictis, Management of plastic bronchitis with nebulized tissue plasminogen activator:
another brick in the wall , Ital J Pediatr. 2014; 40: 18. Published online 2014 Feb 13. doi: 10.1186/18247288-40-18, PMCID: PMC3974171
Nicolas Santos – Born with Hypoplastic Left Heart Syndrome 9-25-2000
 Norwood Procedure at age of 4 days
 Bilatteral, birerectional Glenn at age of 5 ½ months
 Ruptured aorta during the Glenn procedure- Aortic reconstruction performed
 Fontan Procedure performed at age 3
 Mid 2005, developed constant, ongoing and progressively worsening cough
 June 5, 2006 – Hospitalized due to severe respiratory distress
 June 11, 2006 Cardiac/Respiratory arrest. Diagnosed with Plastic Bronchitis
Late June 2006 –
Subsequent Respiratory
Arrests, Multiple
Bronchoscopies to remove
significant casts. Placed on
ECMO for cardiac and
respiratory support
Nicolas Santos – Started on Nebulized tPA
Picture of Nick’s first cast removed during Bronch
 tPA- 12 vials per day from June of 2006 to November of
2013.
Nick in August of
2006- After
overcoming
ECMO, multi
organ failure,
dialyses 8
bronchoscopies.
On a slow road to
recovery. Left
hospital on
October 13, 2006.
Because respiratory
treatments and airway
clearance therapy
would last over 1
hours-4x per day,
during the last year+
of his life, several of
Nick’s nebulized meds
were replaced with
inhalers. This was
done strictly for
quality of life purposes
tPA broke down the vicious casts to loosely formed plugs that
Nick was able to cough up or would be suctioned out. It was
not unusual for Nick to soak 2 shirts per night front and back
with the frothy secretions that would come from his trach.
Nebulized Bicarbonate
1. The bronchial secretions acidity imparts
stickiness
2. Aerosol use of bicarbonate for lung and
bronchial adenocarcinoma.
3. Dr. Lewis Nelson, a specialist in emergency
medicine says, “Nebulized sodium bicarbonate
has been shown to provide symptomatic relief
in patients exposed to chlorine, and it is
probably useful with all irritant gases that
liberate acid.
Nebulized Peroxide
 Hydrogen peroxide has been used for decades to
conquer viral infections
 Dr. Shallenberger testimony: I have treated hundreds
of cases of colds, flus, sinusitis, and bronchitis all with
the same great results. “not only is the hydrogen
peroxide being disseminated into the entire body
through the lungs, it is also going directly to the areas
of the body that are most affected by viruses – the
sinuses, throat, bronchial tract, and lungs.”
Nebulized Iodine
1. Nebulization with iodine offers an extremely
strong therapy which can clear the lungs quite
rapidly of infections
2. When it comes to using iodine in a nebulizer
special caution is needed. The choice of iodine
is important because putting in potassium,
which is found in Lugol’s, is
dangerous. Potassium chloride, another salt of
potassium, is used for lethal injection so I
recommend only Nascent Iodine..
Nebulized Glutathione
Glutathione :. One role is to enable the liver to remove
toxins, medications and other substances from the body.
2. The glutathione level of the epithelial lining fluid is
decreased in severe inflammatory lung diseases
including in cases with Cystic fibrosis.
3. In a case of a 95-year-old man with an acute respiratory
crisis secondary to emphysema and apparent bronchial
infection treatment with nebulized glutathione led to a
rapid resolution of the crisis, as well as a marked
improvement in the chronic course of the disease. This
treatment has been used since for a number of patients
with emphysema. The safety and bioavailability of this
method of delivery have been established in human
studies.
1.
 Regularly nebulized medication
 Non-regularly nebulized medication
 Respiratory meds in reverse
 Current Nebulizers
 Finally presented some fundamental mechanics review
 When taken by mouth , acetylcysteine is used to
 prevent liver damage from Acetaminophen
 overdose.
 This drug may also be taken by mouth to prevent
 Kidney damage due to dyes from certain X-ray
 procedures (such as CT Scan).

http://www.webmd.com/drugs/2/drug-63406/mucomyst/details
Ophthalmic is used in the eye
to treat bacterial infections of
the eye. Tobramycin works by
killing bacteria.
 Generic Name: albuterol inhalation (all-Bet-ter-all)
Brand Names: I ordered it-Just do it, Patient wants it,
their ear hurts, their foot hurts, just shut them up, I don’t
know what else to do.
 For the treatment of just about anything that there is no
particular treatment for. Including squeaky draws and
cleaning truck parts.
Medical Training instructions for idiots.com
 Regularly nebulized medication
 Non-regularly nebulized medication
 Respiratory meds in reverse
Nebulizers
 Finally presented some fundamental mechanics review
They are being developed in
cooperation with pharmaceutical
companies to deliver expensive
formulations with which precise
dosing is needed.
Some drug solutions are only approved for delivery with specific
nebulizers
Respirgard II for aerosolized Pentamidine
The Respirgard II is fitted with one-way
valves and filters to minimize gross
contamination of the environment.
The Circulaire nebulizer reduces waste from a constant-output
nebulizer by attachment of a storage bag with a one-way valve in
the mouthpiece connector
The AeroEclipse nebulizer has a breath-actuated valve that triggers
aerosol generation only during inhalation, eliminating the need for
a storage bag or reservoir.

Rau, JL, Ari, A, Restrepo, RD. Performance comparison of nebulizer designs: constant-output, breathenhanced, and dosimetric. Respir Care 2004; 49:174.
 Ultrasonic nebulizers energy to high-frequency
ultrasonic waves with a frequency of 1.63 megahertz.
 A piezoelectric element in the transducer vibrates at the
same frequency as the applied wave.
.
Small volume ultrasonic nebulizers
are commercially available for
delivery of inhaled bronchodilators;
large volume ultrasonic nebulizers
are used for sputum induction.
Vibrating mesh nebulizers — Several manufacturers
have developed aerosol devices that use a vibrating
mesh or plate
It will generate aerosols with
a high fine-particle
fraction, which results
in more efficient drug
delivery compared to
conventional nebulizers.

Dhand, R. New frontiers in aerosol delivery during mechanical ventilation. Respir Care 2004; 49:666.
 The Aerogen® Solo Specifications
 The Aerogen® Solo is a compact, single patient use
nebulizer for aerosol therapy, which can be used for
continuous and/or intermittent nebulization.
 The Aerogen® Solo nebulizer produces a fine particle,
low velocity aerosol optimized for targeted drug
delivery.
The iNeb nebulizer uses vibrating mesh technology with
adaptive aerosol delivery (ADD). ADD monitors the patient's
breathing pattern and injects the aerosol at the beginning of
inhalation.
This nebulizer is used specifically for the administration of
Ventavis® (iloprost) Inhalation Solution (CoTherix, Inc) for the
treatment of pulmonary arterial hypertension
 The Small-Particle Aerosol Generator (SPAG) was designed
specifically to aerosolize Ribavirin.
 It consists of a nebulizer and drying chamber that
reduce the MMAD to about 1.3 µm, which optimizes
drug delivery to distal airspaces. The SPAG is used with a
scavenging system to minimize contamination of the
ambient environment.
;
 Regularly nebulized medication
 Properties of Nebulization
 Non-regularly nebulized medication
 Respiratory meds in reverse
 Nebulizers
Gas density ;
 Albuterol with helium and oxygen (heliox).
 The flow to the nebulizer should be
increased by 50 percent if it is powered with
heliox
Hess, DR, Acosta, FL, Ritz, RH, et al. The effect of heliox on nebulizer function
using a bet agonist bronchodilator. Chest 1999; 115:184.
Smaller particles tend to reach the lower respiratory tract with greater
regularity but are more easily exhaled without reaching their targeted
absorption site.
Larger particles are more likely to have an effect on the upper respiratory
tract but have a greater chance of not reaching the respiratory tract.
 A gas flow rate of 8 L/min has been recommended
because that rate seems to balance the variables of
nebulization time and particle size.
Dolovich, MB, Ahrens, RC, Hess, DR, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines:
American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest 2005; 127:335.
Rau, JL. Design principles of liquid nebulization devices currently in use. Respir Care 2002; 47:1257.
A jet flow of driving gas creates
an area of low pressure above
the medication reservoir,
generating an aerosol. The baffle
helps insure the formation of
respirable particles, and prevents
inhalation of oversized droplets
of medication. Most nebulizers
require a flow rate of 8 liters
per minute for optimum performance
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