Medicated Aerosol Delivery Using A Jet Nebulizer Versus A Vibrating Mesh Nebulizer in COPD Exacerbation

Overview

Delivery of inhaled short-acting bronchodilators (SABD) is standard of care in the emergency department (ED) for exacerbation of COPD, the goal of such being rapid reversal of airflow obstruction. However, current guidelines for the delivery of SABDs in spontaneously breathing patients make no distinction whether these medications should be delivered via metered dose inhaler (MDI) or jet nebulizer (JN), the specific medication delivery device having no significant effect on hospital admission or reversal of flow obstruction. However, advancements in nebulizer design, namely FDA-approved vibrating mesh technology, have demonstrated significant improvements relative to JNs and metered dose inhalers in efficiency and amount of drug delivered in in vivo and in vitro studies. Currently there are no clinical trials comparing the use of vibrating mesh nebulizers (VMN) to JNs and their effect on clinically important outcomes. This prospective randomized controlled pilot trial seeks to determine if there are differences in hospital admission due to COPD when a vibrating mesh nebulizer is used versus a jet nebulizer.

Patients ordered to receive a SABD, will be screened for presence of moderate to severe COPD exacerbation; spontaneously breathing patients as well those supported with non-invasive ventilation (NIV) will be screened for inclusion. Upon consent, the patient will be randomized to receive the ordered SABD via a JN (MistyFast, Carefusion-BD, CA) or VMN (Aerogen Ultra, Aerogen, Galway, Ireland). Included subjects will receive therapy with a mouthpiece interface. In the case a patient is unable to tolerate, maintain a tight seal around the mouthpiece or otherwise not perform aerosol therapy with a mouthpiece, a valved-aerosol mask (I-Guard aerosol mask, Salter Labs, Lake Forest, IL) will be utilized. Subjects that require NIV, whether on admission to the ED or in the face of escalating therapy, will receive NIV via a non-vented, oronasal mask and the allocated nebulizer will be placed distal to the leak in the NIV circuit (between the mask and circuit). Patients will receive positive expiratory and/or inspiratory pressure at specific settings determined by the prescribing physician and clinical team. Subjects will be re-evaluated and clinical data collected following delivery of the initial SABD treatment that includes signs of possible side effects. The prescribing physician and clinical team will determine the need for additional SABD therapy beyond the initial therapy. Subjects indicated and ordered for additional administration of SABD will continue to receive SABD with the randomly allocated aerosol delivery device. Subjects will be re-evaluated and assessed for possible side effects after delivery of the additional SABD. The initial order, as well as all subsequent orders for SABD medication will be at the discretion of the physician and clinical team. The type and dosage of medication and the approximate timing of medication delivery designated in the study protocol is according to and correlates with the standard practices. The process of determining need by the clinical team and administering additional SABD, followed by evaluation, will continue up to a total of four SABD treatments. If at any point following a SABD treatment, the clinical team assesses the subject and determines that no additional therapy is indicated, the subject will not receive additional SABD. Clinical data will be collected following each SABD administered (approximately every 30 minutes) and conclude at 120 min after randomization. Subjects requiring the need for endotracheal intubation and mechanical ventilator support, immediate or in escalation of support, will be at the discretion of the attending physician. Subjects requiring endotracheal intubation as escalation of therapy following study enrollment will be included in the study analysis. Those subjects requiring the immediate need for endotracheal intubation prior to randomization will be excluded from the study. Individualized decision regarding hospitalization or discharge to home will be according to the attending physician. Subjects admitted to the hospital for continued inpatient care will continue to receive nebulized bronchodilator therapy, as indicated and ordered, with an aerosol delivery device according to the MWHC bronchodilator protocol and standard practices.