Surfactant therapy using vibrating-mesh nebulizers in adults with COVID-19-induced ARDS: A case series.

Coronavirus adult respiratory distress syndrome, characterized by decreased surfactant due to lysis of type II pneumocytes and hyaline membrane formation, contributes to severe hypoxemia. The administration of surfactant via high-flow nasal cannula (HFNC) may positively affect lung structure and function in this context. In this study, we report on five clinical cases, encompassing patients aged 40-60 years of both sexes, who tested positive for coronavirus disease 2019 via real-time polymerase chain reaction and exhibited significant pulmonary compromise with elevated inflammatory biomarkers. These patients were treated with aerosol therapy using surfactant delivered through vibrating-mesh nebulizers alongside HFNC. Of these patients, four demonstrated positive responses to the treatment, suggesting that aerosol therapy with surfactant through vibrating-mesh nebulizers could be a viable rescue therapy in adults receiving HFNC oxygen therapy for hypoxemic respiratory failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Unfortunately, one patient had a negative outcome and succumbed. The findings from these cases indicate that the use of aerosol therapy with vibrating-mesh nebulizers as rescue therapy might offer an alternative approach for managing adults with hypoxemic respiratory failure due to SARS-CoV-2, as evidenced by the positive outcomes in four out of the five cases presented.

Influence of Mechanical Ventilation Modes on the Efficacy of Nebulized Bronchodilators in the Treatment of Intubated Adult Patients with Obstructive Pulmonary Disease.

BACKGROUND: Little has been reported in terms of clinical outcomes to confirm the benefits of nebulized bronchodilators during mechanical ventilation (MV). Electrical Impedance Tomography (EIT) could be a valuable method to elucidate this gap. OBJECTIVE: The purpose of this study is to evaluate the impact of nebulized bronchodilators during invasive MV with EIT by comparing three ventilation modes on the overall and regional lung ventilation and aeration in critically ill patients with obstructive pulmonary disease. METHOD: A blind clinical trial in which eligible patients underwent nebulization with salbutamol sulfate (5 mg/1 mL) and ipratropium bromide (0.5 mg/2 mL) in the ventilation mode they were receiving. EIT evaluation was performed before and after the intervention. A joint and stratified analysis into ventilation mode groups was performed, with p < 0.05. RESULTS: Five of nineteen procedures occurred in controlled MV mode, seven in assisted mode and seven in spontaneous mode. In the intra-group analysis, the nebulization increased total ventilation in controlled (p = 0.04 and ⅆ = 2) and spontaneous (p = 0.01 and ⅆ = 1.5) MV modes. There was an increase in the dependent pulmonary region in assisted mode (p = 0.01 and ⅆ = 0.3) and in spontaneous mode (p = 0.02 and ⅆ = 1.6). There was no difference in the intergroup analysis. CONCLUSIONS: Nebulized bronchodilators reduce the aeration of non-dependent pulmonary regions and increase overall lung ventilation but there was no difference between the ventilation modes. As a limitation, it is important to note that the muscular effort in PSV and A/C PCV modes influences the impedance variation, and consequently the aeration and ventilation values. Thus, future studies are needed to evaluate this effort as well as the time on ventilator, time in UCI and other variables.

Efficacy of an educational intervention in the management of an inhalation device among nursing professionals of an emergency department.

OBJECTIVE: To explore the most frequent errors of the inhalation technique (main topic for the pharmacological treatment of exacerbations of asthma and/or chronic obstructive pulmonary disease) in the nursing staff of an emergency department, and to evaluate the efficacy of an educational intervention. METHODS: Prospective quasi-experimental study, carried out in a hospital in Argentina during 2019. For the evaluation of the nursing staff, the steps of the Separ-Alat Consensus were used. The educational intervention consisted of oral explanation and visual demonstration of the inhalation technique. Paired data analysis was performed, and absolute and relative frequencies were calculated with their respective 95% confidence intervals. RESULTS: A consecutive sample of 72 nurses was included, of which 95.83% (95%CI 88.30-99.13) made at least one error in the baseline assessment. The most frequent errors were the lack of indication to the patient to exhale prior to inhalation (83.72%), forgetting to remove the air chamber and repeat the steps before the second dose (81.40%). After immediate evaluation after receiving the educational intervention, 74.42% (95%CI 58.83-86.49) corrected the technique. However, at one month, 53.49% (23/43; 95%CI 37.66-68.86) performed the technique correctly. CONCLUSIONS: The educational intervention could be effective in correcting errors in this practice, although its effects tend to fade over time. Therefore, we consider periodic and systematic education relevant to maintain a correct inhalation technique among professionals.

Association between beta-2 adrenergic receptor variants and clinical outcomes in children and adolescents with acute asthma

ABSTRACT Objective To investigate whether different genotypes of p.Arg16Gly, p.Gln27Glu, p.Arg19Cys and p.Thr164Ile variants interfere in response to treatment in children and adolescents with moderate to severe acute asthma. Methods This sample comprised patients aged 2 to 17 years with a history of at least two wheezing episodes and current moderate to severe asthma exacerbation. All patients received multiple doses of albuterol and ipratropium bromide delivered via pressurized metered-dose inhaler with holding chamber and systemic corticosteroids. Hospital admission was defined as the primary outcome. Secondary outcomes were changes in forced expiratory volume in the first second after 1 hour of treatment, and for outpatients, length of stay in the emergency room. Variants were genotyped by sequencing. Results A total of 60 patients were evaluated. Hospital admission rates were significantly higher in carriers of the genotype AA relative to those with genotype AG or GG, within the p.Arg16Gly variant (p=0.03, test χ2, alpha=0.05). Secondary outcomes did not differ between genotypes. Conclusion Hospital admission rates were significantly higher among carriers of the genotype AA within the p.Arg16Gly variant. Trial registration: ClinicalTrials.gov: NCT01323010

Environmental impact of inhaler devices on respiratory care: a narrative review / Impacto ambiental dos dispositivos inalatórios nos cuidados respiratórios: uma revisão narrativa

ABSTRACT Climate change is a huge and present threat to human health. This article aims to deepen the knowledge about the environmental impact of inhaler devices on their carbon footprint for patients and health professionals, providing information that allows a better choice of the type of device to be prescribed for the treatment of asthma and COPD. This narrative and nonsystematic review was carried out by searching databases (PubMed, Google Scholar, SciELO, and EMBASE) for articles published between 2017 and 2022, written in Portuguese or in English, using the search words "inhalation device" OR "environmental." The review showed that global warming cannot be addressed by focusing only on inhaler devices. However, the devices that we use to treat respiratory diseases such as asthma and COPD, which are diseases that are aggravated by climate change, are also causing that change. Therefore, health professionals, patient organizations, and industries should take a lead in health policies to offer affordable alternatives to inhalers containing hydrofluoroalkane.

RESUMO As mudanças climáticas são uma ameaça enorme e presente para a saúde humana. Este artigo visa aprofundar o conhecimento sobre o impacto ambiental dos dispositivos inalatórios na pegada de carbono para pacientes e profissionais de saúde, fornecendo informações que permitem uma melhor escolha do tipo de dispositivo a ser prescrito para o tratamento da asma e da DPOC. Esta revisão narrativa e não sistemática foi realizada por meio de busca nas bases de dados PubMed, Google Acadêmico, SciELO e EMBASE de artigos publicados entre 2017 e 2022, escritos em português ou inglês, utilizando as palavras de busca "inhalation device" OR "environmental". A revisão mostrou que o aquecimento global não pode ser abordado com foco em dispositivos inalatórios apenas. No entanto, os dispositivos que utilizamos para tratar doenças respiratórias como asma e DPOC, que são doenças agravadas pelas mudanças climáticas, também estão causando essa mudança. Portanto, profissionais de saúde, organizações de pacientes e indústrias devem assumir a liderança nas políticas de saúde para oferecer alternativas acessíveis aos inaladores contendo hidrofluoralcano.

Nivel de adhesión y prevalencia a inhaladores en pacientes ambulatorios con Asma y Enfermedad Pulmonar Obstructiva Crónica / Level of inhaler adhesion and prevalence in outpatients with Asthma and Chronic Obstructive Pulmonary Disease

INTRODUCCIÓN. Para el tratamiento farmacoterapéutico de enfermedades respi-ratorias, el uso de herramientas para abordar la vía inhalatoria es de elección por su mayor eficacia y menos efectos secundarios; registrar su adhesión y prevalencia es importante. OBJETIVO. Determinar el nivel y la prevalencia de adhesión al uso de inhaladores en pacientes con Asma y Enfermedad Pulmonar Obstructiva Cróni-ca. MATERIALES Y MÉTODOS. Estudio analítico transversal. Población de 215 y muestra de 121 Historias Clínicas. Se aplicó el Test de Adhesión a Inhaladores, que consistió en dos cuestionarios complementarios: el de 10 ítems, que valoró el nivel de adhesión, y el de 12 que identificó el tipo de incumplimiento en pacientes de Consulta Externa de la Unidad Técnica de Neumología del Hospital de Especialidades Carlos Andrade Marín, periodo julio 2018 - enero 2019. La tabulación y análisis de datos se realizó con el programa Excel. RESULTADOS. La prevalencia de mala adhesión en asmáticos fue de 83,33% y en Enfermedad Pulmonar Obstructiva Crónica 13,33%. En cuanto al sexo, la prevalencia de mala adhesión fue de 15,28% en hombres y de 40,82% en mujeres, con una p<0,05. No se encontró diferencia significativa respecto a los niveles de instrucción. CONCLUSIÓN. La prevalencia de mala adhesión al uso de inhaladores en pacientes con Asma y Enfermedad Pulmonar Obstructiva Crónica fue alta sobre todo en los asmáticos.

INTRODUCTION. For respiratory diseases and their pharmacotherapeutic treatment, the use of tools to address the inhalation route is chosen due to its greater efficacy and fewer secondary effects; then record the adherence and prevalence is important. OBJECTIVE. To determine both level and prevalence of adherence to the use of inhalers in patients with Asthma and Chronic Obstructive Pulmonary Disease. MATE-RIALS AND METHODS. Cross-sectional analytical study. Population of 215 and sam-ple of 121 patients. The Inhaler Adherence Test was applied, which consisted of two complementary questionnaires: a 10-item questionnaire, which assessed the level of adherence, and a 12-item questionnaire that identified the type of non-compliance in patients of the Pneumology Technical Unit of the Hospital de Especialidades Carlos Andrade Marín, period July 2018 - January 2019. The tabulation and data analysis was performed with Microsoft Excel program. RESULTS. The prevalence of poor ad-herence in asthmatics was 83.33% and in Chronic Obstructive Pulmonary Disease was 13.3%. Regarding gender, the prevalence of poor adherence was 15.28% in men and 40.82% in women, with a p <0.05. No significant differences were found regarding the levels of instruction. CONCLUSION. The prevalence of poor adherence to the use of inhalers in patients with Asthma and Chronic Obstructive Pulmonary Disease was high, especially in asthmatics

Asma: uso adecuado de dispositivos para inhalación / Asthma: correct use of inhalation drug-delivery devices

Resumen La terapia inhalada se considera la piedra angular del manejo del asma. Sin embargo, a pesar de ser la forma ideal de administración de estos medicamentos, solamente el 70% de los pacientes cumple el tratamiento adecuadamente y sólo del 39 al 67% de los médicos conocen y pueden explicar de forma adecuada las distintas técnicas de inhalación. La terapia inhalada tiene características muy particulares. El depósito pulmonar de un medicamento inhalado a través del tracto respiratorio es más complejo que cuando se administra por vía oral, y varía dependiendo de varios factores, tanto inherentes al medicamento como a la forma de administrarlo. Para que la terapia inhalada sea exitosa, se requiere que se generen partículas del medicamento de un tamaño apropiado que penetren más allá de la orofaringe y la laringe, y que puedan depositarse en los pulmones. Existen múltiples dispositivos para la administración de medicamentos en la vía respiratoria baja. Cada uno ha probado tener una eficacia similar, siempre y cuando se utilicen con la técnica correcta. La decisión para su uso se realiza con base en la edad del paciente, la capacidad de coordinar entre la inhalación y la activación del dispositivo y la presencia de síntomas agudos. La elección del dispositivo a utilizar siempre deberá hacerse de forma conjunta, evaluando pros y contras de cada uno de los dispositivos y siempre de forma individualizada.

Abstract Inhaled therapy is considered the cornerstone of asthma treatment. However, despite being the ideal form of drug delivery, it is recognized that only 70% of patients have an adequate attachment to their treatment and only 39-67% of physicians can explain the optimal inhaler technique. Inhaled therapy has very specific characteristics. Pulmonary deposit of an inhaled medication through the respiratory tract is more complex than when administered orally and depends on several factors inherent to both the medication and the administration. For successful inhaled therapy, the drug needs to be converted into particles of an appropriate size, which can enter beyond the oropharynx and larynx, and be deposited in the lungs. There are multiple devices for the administration of drugs in the lower respiratory tract, each one with a similar efficacy as long as it is used with the correct technique. The decision of which device should be used is made based on the age of the patient, the ability to coordinate between the inhalation and activation of the device, and the presence of acute symptoms. The choice of the device must be evaluated individually.

Asma: uso adecuado de dispositivos para inhalación.

Inhaled therapy is considered the cornerstone of asthma treatment. However, despite being the ideal form of drug delivery, it is recognized that only 70% of patients have an adequate attachment to their treatment and only 39-67% of physicians can explain the optimal inhaler technique. Inhaled therapy has very specific characteristics. Pulmonary deposit of an inhaled medication through the respiratory tract is more complex than when administered orally and depends on several factors inherent to both the medication and the administration. For successful inhaled therapy, the drug needs to be converted into particles of an appropriate size, which can enter beyond the oropharynx and larynx, and be deposited in the lungs. There are multiple devices for the administration of drugs in the lower respiratory tract, each one with a similar efficacy as long as it is used with the correct technique. The decision of which device should be used is made based on the age of the patient, the ability to coordinate between the inhalation and activation of the device, and the presence of acute symptoms. The choice of the device must be evaluated individually.

La terapia inhalada se considera la piedra angular del manejo del asma. Sin embargo, a pesar de ser la forma ideal de administración de estos medicamentos, solamente el 70% de los pacientes cumple el tratamiento adecuadamente y sólo del 39 al 67% de los médicos conocen y pueden explicar de forma adecuada las distintas técnicas de inhalación. La terapia inhalada tiene características muy particulares. El depósito pulmonar de un medicamento inhalado a través del tracto respiratorio es más complejo que cuando se administra por vía oral, y varía dependiendo de varios factores, tanto inherentes al medicamento como a la forma de administrarlo. Para que la terapia inhalada sea exitosa, se requiere que se generen partículas del medicamento de un tamaño apropiado que penetren más allá de la orofaringe y la laringe, y que puedan depositarse en los pulmones. Existen múltiples dispositivos para la administración de medicamentos en la vía respiratoria baja. Cada uno ha probado tener una eficacia similar, siempre y cuando se utilicen con la técnica correcta. La decisión para su uso se realiza con base en la edad del paciente, la capacidad de coordinar entre la inhalación y la activación del dispositivo y la presencia de síntomas agudos. La elección del dispositivo a utilizar siempre deberá hacerse de forma conjunta, evaluando pros y contras de cada uno de los dispositivos y siempre de forma individualizada.

Microbiological contamination of nebulizers used by cystic fibrosis patients: an underestimated problem / Contaminação microbiológica de nebulizadores usados por pacientes com fibrose cística: um problema subestimado

ABSTRACT Objective: Home nebulizers are routinely used in the treatment of patients with cystic fibrosis (CF). This study aims to evaluate the contamination of nebulizers used for CF patients, that are chronically colonized by Pseudomonas aeruginosa, and the association of nebulizer contamination with cleaning, decontamination and drying practices. Methods: A cross-sectional, observational, multicenter study was conducted in seven CF reference centers in Brazil to obtain data from medical records, structured interviews with patients/caregivers were performed, and nebulizer's parts (interface and cup) were collected for microbiological culture. Results: overall, 77 CF patients were included. The frequency of nebulizer contamination was 71.6%. Candida spp. (52.9%), Stenotrophomonas maltophilia (11.9%), non-mucoid P. aeruginosa (4.8%), Staphylococcus aureus (4.8%) and Burkholderia cepacia complex (2.4%) were the most common isolated pathogens. The frequency of nebulizers' hygiene was 97.4%, and 70.3% of patients reported cleaning, disinfection and drying the nebulizers. The use of tap water in cleaning method and outdoor drying of the parts significantly increased (9.10 times) the chance of nebulizers' contamination. Conclusion: Despite the high frequency hygiene of the nebulizers reported, the cleaning and disinfection methods used were often inadequate. A significant proportion of nebulizers was contaminated with potentially pathogenic microorganisms for CF patients. These findings support the need to include patients/caregivers in educational programs and / or new strategies for delivering inhaled antibiotics.

RESUMO Objetivo: Nebulizadores caseiros são usados rotineiramente no tratamento de pacientes com fibrose cística (FC). Este estudo objetiva avaliar a contaminação de nebulizadores utilizados por pacientes de FC que estão cronicamente colonizados por Pseudomonas aeruginosa e a associação da contaminação do nebulizador com a higienização, esterilização e método de secagem. Métodos: Um estudo transversal, observacional, multicêntrico foi conduzido em sete centros de referência de FC no Brasil para obter dados de registros médicos; foram feitas entrevistas estruturadas com os pacientes/cuidadores e partes de nebulizadores (máscara e copo) foram coletados para cultura microbiológica. Resultados: No geral, 77 pacientes com FC foram incluídos. A frequência da contaminação do nebulizador foi de 71,6%. Candida spp. (52,9%), Stenotrophomonas maltophilia (11,9%), P. aeruginosa não mucoide (4,8%), Staphylococcus aureus (4,8%) e complexo Burkholderia cepacia (2.4%) foram os patógenos isolados mais comuns. A frequência de higienização dos nebulizadores foi de 97,4%, e 70,3% dos pacientes relata higienização, esterilização e secagem dos aparelhos. A lavagem com água da torneira e secagem das partes no tempo, em espaço aberto, aumentou significativamente (9 a 10 vezes) a chance de contaminação dos nebulizadores. Conclusões: Apesar dos relatos de frequente higienização dos nebulizadores, os métodos de limpeza e esterilização usados eram inadequados. Uma proporção significativa de nebulizadores foi contaminada com microrganismos potencialmente patogênicos para pacientes com FC. Estes resultados apoiam a necessidade de inclusão dos pacientes/cuidadores em programas educacionais e/ou novas estratégias para fornecimento de antibióticos inalatórios.

Most frequent errors in inhalation technique of patients with asthma treated at a tertiary care hospital / Erros mais frequentes na técnica inalatória de pacientes com asma brônquica em tratamento em hospital terciário

ABSTRACT Objective: To demonstrate the most frequent errors in inhalation technique in patients with asthma undergoing treatment at a tertiary care hospital. Methods: A cross-sectional study with a convenience sample of asthma patients aged 18 years or over, treated at a pulmonology outpatient clinic of a tertiary care hospital. The assessment of inhalation technique of users of the dry powder inhalers Aerolizer®, Aerocaps and Diskus®, or metered-dose inhalers was based on the manufacturer's instructions for use of each inhaler device. Patients demonstrated the inhalation technique with empty inhaler devices, and it was considered correct when all stages were performed properly, or when errors probably did not interfere with the treatment outcome. Results: Among 71 participants, 43 (60.5%) performed inhalation technique incorrectly. Among metered-dose inhalers and dry powder inhalers users, inhalation technique errors were found in 84.2% and 51.9%, respectively (p=0.013). Errors were more frequent at the exhalation stage (67.4%), followed by breathing in (58.1%) and apnea (51.2%). In the group using dry powder inhalers, the most common errors occurred during exhalation and, for those using metered-dose inhalers, the most compromised stage was aspiration. Conclusion: Errors were more frequent among those using metered-dose inhalers compared with dry powder inhalers. Misconceptions are more common at the expiration stage among users of dry powder inhalers and in aspiration among those on metered-dose inhalers.

RESUMO Objetivo: Demonstrar os erros mais frequentes na técnica inalatória de pacientes com asma brônquica em tratamento em hospital terciário. Métodos: Estudo transversal, com amostra de conveniência de pacientes com asma, com 18 anos ou mais, em tratamento em ambulatório de pneumologia de um hospital terciário. A avaliação da técnica inalatória dos usuários dos dispositivos de pó seco Aerolizer ®, Aerocaps® ou Diskus®, ou de aerossóis dosimetrados teve como base as orientações da bula do fabricante de cada dispositivo inalatório. Os pacientes demonstraram a técnica inalatória com dispositivos inalatórios vazios, e ela foi considerada correta quando todas as etapas foram realizadas de forma apropriada, ou quando os equívocos provavelmente não interferiam no resultado do tratamento. Resultados: Entre os 71 participantes, 43 (60,5%) realizaram a técnica inalatória de forma incorreta. Dentre os usuários de aerossóis dosimetrados e dispositivos de pó seco, ocorreram erros de técnica inalatória em 84,2% e 51,9%, respectivamente (p=0,013). Os erros foram mais frequentes na etapa da expiração (67,4%), seguidos da aspiração (58,1%) e da apneia (51,2%). No grupo que usava dispositivos de pó seco, os erros mais comuns aconteceram na expiração e, nos que utilizavam aerossóis dosimetrados, a etapa mais comprometida foi a aspiração. Conclusão: Os erros foram mais frequentes entre os que usavam aerossóis dosimetrados em comparação com dispositivos de pó seco. Os equívocos foram mais comuns na etapa da expiração entre os usuários de dispositivos de pó seco e na aspiração entre os que usavam aerossóis dosimetrados.

Hipersensibilidad a corticoides y manejo en asma severa. A propósito de un caso / Hipersensitivity to corticosteroids and management of severe bronchial asthma. Case study

Resumen Las reacciones de hipersensibilidad a corticoides son raras en la población general, se dividen en dos categorías: Inmediatas, típicamente mediadas por Inmunoglobulina E (IgE), donde se incluye la anafilaxia luego de la administración de un fármaco en un corto período. Su prevalencia descrita es de 0,3-0,5%. Otra reacción es la 'no inmediata', que se manifiesta en un tiempo mayor de una hora después de la administración del fármaco. Se revisó la literatura con el objetivo de mejorar y aclarar el tratamiento en pacientes asmáticos que poseen esta condición. Se encontró que las vías posibles para generar estas reacciones son intranasal, aerosol por inhalador, oral y parenteral. Frente a esta condición se requiere una evaluación estrecha y detallada de la historia clínica, síntomas y reacciones secundarias al fármaco sospechoso. Finalmente, al momento de elegir tipo de corticoide a usar es primordial la seguridad del paciente logrando, además, el control de la enfermedad.

Hypersensitivity reactions to corticosteroids are rare in the general population, they fall into two categories: 'immediate', typically mediated by immunoglobulin E (IgE), which includes anaphylaxis after administration of a drug in a short period of time. Its reported prevalence is 0.3-0.5%. Another reaction is 'not immediate', which manifests itself in a time longer than one hour after the administration of the drug. We reviewed the literature with the aim of improving and clarifying the treatment in asthmatic patients with this condition. It was found that the possible routes to generate these reactions are intranasal, aerosol by inhaler, oral and parenteral. Facing this condition requires a close and detailed evaluation of the clinical history, symptoms and side reactions to the suspected drug. Finally, when choosing which corticosteroid to use, the patient's safety is paramount, and control of the disease is also essential.

Performance evaluation of nebulizers based on aerodynamic droplet diameter characterization using the Direct Laminar Incidence (DLI)

Abstract Introduction Optical microscope images can be useful to evaluate nebulizers considering the size of droplets produced by these devices. From this perspective, the proposed method was compared to the classic concept of Mass Median Aerodynamic Diameter (MMAD) for the ideal droplet size between 0.5-5.5 µm. Methods We tested a sample of five home nebulizers sold on the Brazilian market. A high-speed camera coupled to a microscope obtained images of the droplets during the nebulization process, which allowed us to characterize the diameter of the aero-dispersed droplets. The Count Median Aerodynamic Diameter (CMAD) was used as measurement parameter. Results The images obtained during the nebulization process with the five different nebulizers provided data to determine the frequency distribution of the aero-dispersed droplet population. Successive images were obtained in the range of 2.0s to evaluate the dynamic behavior of the droplets. The generated data also allowed the elaboration of histograms emphasizing the ideal diameter range of droplets between 0.5 and 5.5 μm. Conclusion The Direct Laminar Incidence (DLI) model using digital image processing technique allowed the characterization of respirable particles. This model proposes the creation of a range of optimum absorption of the droplets by the respiratory tract. Although there is a technical limitation in the direct acquisition of images due to the depth of focus, presenting an error of 9.3%, the described method provides consistent results when compared to other droplets characterization techniques. Thus, the authors believe that Direct Laminar Incidence (DLI) is a viable method to assess the performance of nebulizers despite the requirement of adjustments and possible improvements required to minimize measurement errors.

Cigarrillos eléctrónicos: ¿Podemos recomendar su uso? / Electronic cigarettes: can we recommend its use?

Los cigarrillos electrónicos (Cig-e) son dispositivos que contienen un líquido compuesto por un solvente, saborizantes y, en la mayoría de los casos, nicotina. Este liquido, al ser calentado en el dispositivo, se vaporiza, siendo aspirado por el usuario. En los últimos años, el uso de los Cig-e ha aumentado rápidamente, especialmente entre escolares y gente joven, sin existir hasta el día de hoy evidencias ciertas sobre su seguridad y efectos a largo plazo. En este artículo revisamos la evidencia existente en cuanto a los efectos y seguridad de cada uno de los componentes de los Cig-e y analizamos sus potenciales indicaciones en distintos escenarios clínicos.

Electronic cigarettes (Cig-e) are devices that contain a liquid composed of a solvent, flavors and, in most cases, nicotine. This liquid, when heated in the device, vaporizes, being aspirated by the user. In recent years, the use of Cig-e has increased rapidly, especially among schoolchildren and young people, with no clear evidence of safety and long-term effects to date. In this article we review the existing evidence regarding the effects and safety of each of the components of Cig-e and analyze their potential indications in different clinical scenarios.

Educational interventions to improve inhaler techniques and their impact on asthma and COPD control: a pilot effectiveness-implementation trial / Educação para a melhora da técnica inalatória e seu impacto no controle da asma e DPOC: um estudo piloto de efetividade-intervenção

ABSTRACT To assess the impact that educational interventions to improve inhaler techniques have on the clinical and functional control of asthma and COPD, we evaluated 44 participants before and after such an intervention. There was a significant decrease in the number of errors, and 20 patients (46%) significantly improved their technique regarding prior exhalation and breath hold. In the asthma group, there were significant improvements in the mean FEV1, FVC, and PEF (of 6.4%, 8.6%, and 8.3% respectively). Those improvements were accompanied by improvements in Control of Allergic Rhinitis and Asthma Test scores but not in Asthma Control Test scores. In the COPD group, there were no significant variations. In asthma patients, educational interventions appear to improve inhaler technique, clinical control, and functional control.

RESUMO Para avaliar o impacto do ensino da técnica inalatória no controle clínico e funcional de pacientes com asma ou DPOC, incluíram-se 44 participantes antes e após essa intervenção. Houve uma diminuição significativa no número de erros cometidos, sendo que 20 pacientes (46%) melhoraram significativamente sua técnica na expiração prévia e apneia final. No grupo asma, houve significativa melhora nas médias de FEV1 (6,4%), CVF (8,6%) e PFE (8,3%), e essa melhora correlacionou-se com os resultados no Control of Allergic Rhinitis and Asthma Test, mas não com os do Asthma Control Test. No grupo DPOC, não houve variações significativas. O ensino da técnica inalatória parece melhorar seu desempenho e os controles clínico e funcional em pacientes com asma.

Effect that an educational program for cystic fibrosis patients and caregivers has on the contamination of home nebulizers / Efeito de um programa de educação para cuidadores e pacientes com fibrose cística na contaminação de nebulizadores de uso domiciliar

OBJECTIVE: To describe the pathogens found in home nebulizers and in respiratory samples of cystic fibrosis (CF) patients, and to evaluate the effect that a standardized instruction regarding cleaning and disinfection of nebulizers has on the frequency of nebulizer contamination. METHODS: We included 40 CF patients (22 males), all of whom used the same model of nebulizer. The median patient age was 11.2 ± 3.74 years. We collected samples from the nebulizer mouthpiece and cup, using a sterile swab moistened with sterile saline. Respiratory samples were collected by asking patients to expectorate into a sterile container or with oropharyngeal swabs after cough stimulation. Cultures were performed on selective media, and bacteria were identified by classical biochemical tests. Patients received oral and written instructions regarding the cleaning and disinfection of nebulizers. All determinations were repeated an average of two months later. RESULTS: Contamination of the nebulizer (any part) was detected in 23 cases (57.5%). The nebulizer mouthpiece and cup were found to be contaminated in 16 (40.0%) and 19 (47.5%), respectively. After the standardized instruction had been given, there was a significant decrease in the proportion of contaminated nebulizers (43.5%). CONCLUSIONS: In our sample of CF patients, nebulizer contamination was common, indicating the need for improvement in patient practices regarding the cleaning and disinfection of their nebulizers. A one-time educational intervention could have a significant positive impact. .

OBJETIVO: Descrever os patógenos encontrados nos nebulizadores de uso domiciliar e nas amostras de trato respiratório de pacientes com fibrose cística (FC) e verificar o efeito de uma instrução padronizada de higiene e desinfecção de nebulizadores na contaminação dos mesmos. MÉTODOS: Foram incluídos no estudo 40 pacientes com FC (22 do sexo masculino) que utilizavam um mesmo modelo de nebulizador. A mediana de idade foi de 11,2 ± 3,74 anos. Amostras dos nebulizadores foram coletadas do bocal e do copo reservatório utilizando-se um swab estéril umedecido em solução salina estéril. As amostras de trato respiratório dos pacientes foram colhidas por expectoração em coletor estéril ou com swab de orofaringe após estímulo de tosse. As culturas foram realizadas em meios seletivos, e a identificação bacteriana foi feita através de provas bioquímicas clássicas. Instruções verbais e escritas sobre higiene e desinfecção dos nebulizadores foram ministradas. Todas as determinações foram repetidas dois meses após, em média. RESULTADOS: A contaminação de alguma parte dos nebulizadores foi observada em 23 casos (57,5%). A contaminação do bocal e do copo foi similar, em 16 (40.0%) e 19 casos (47.5%), respectivamente. Houve uma redução significativa da proporção de nebulizadores contaminados (43,5%) após a instrução padronizada. CONCLUSÕES: Nesta amostra de pacientes com FC, a contaminação dos nebulizadores foi alta, o que indica a necessidade de melhoria nas práticas de higiene e desinfecção dos nebulizadores de pacientes com FC. Uma única intervenção educacional pode ter um impacto positivo significativo. .

Impacto na produção e qualidade do leite pela combinação ou não de volumososem dietas de vacas Holandesas / Impact on production and milk quality by mixture or not roughagesdiets of Holstein cows

Objetivou-se avaliar o desempenho produtivo de vacas em lactação submetidas à dieta, composta por volumosos suplementares e concentrados com densidades energéticas distintas, em condição ambiente diferenciado, a fim de detectar os principais fatores que mais interferem na produção e qualidade do leite. Foram utilizados 8 vacas Holandesas, em quadrado latino 8 x 8, em esquema fatorial 2x2x2, com os seguintes fatores: dieta para níveis de exigência de produção de 20 e de 40 kg de leite/dia, duas fontes de volumosos (silagem de milho: SM, combinação de cana-de-açúcar com silagem de milho 1:1 na MS: CSM) e duas condições ambientais (com e sem ventiladores e nebulizadores: CVN e SVN, respectivamente), com períodos de 20 dias, sendo 11 dias de adaptação e 9 dias de coleta, com duração de 160 dias. Analisando os resultados, constatou-se que houve maior ingestão de matéria seca (IMS) em percentagem do peso corporal (4,14% x 3,79% PC) para dieta programada para produção 40 L leite/dia (P≤0,05), entretanto, a conversão e eficiência alimentar foram melhores para dieta de 20 (0,91 x 1,01; 112,6% x 103,9%, respectivamente) (P≤0,05). Avaliando a IMS, de maneira fracionada, constatou-se que a dieta 40 propiciou as maiores ingestões de concentrado (10,8 x 9,3 kg/dia), forragens (11,3 x 10,4 kg/dia) e ureia (0,303 x 0,280 kg/dia); enquanto que para o efeito volumoso, a CSM propiciou maior ingestão de concentrado (10,9 x 9,1 kg/dia) e ureia (0,333 x 0,278 kg/dia) e menor ingestão da forragem (10,1 x 11,6 kg/dia) (P≤0,05)...

This study aimed to evaluate the performance of lactating cows subjected to diet, consisting of additional bulky and concentrates with different energy densities in different environment conditions in order to detect the main factors that influence the production and quality of milk . 8 Holstein cows were used in a latin square 8 x 8 in a 2x2x2 factorial with the following factors: diet for levels of production requirement of 20 and 40 kg milk/day, two sources of roughage (corn silage: SM, combination of cane sugar with corn silage 1:1 in MS:CSM ) and two environmental conditions (with and without ventilators and nebulizers: CVN and SVN, respectively), with periods of 20 days and 11 days of adaptation and 9 days of collection, lasting 160 days. Analyzing the results, it was found that there was a higher dry matter intake (DMI) as a percentage of body weight (4,14 % vs. 3,79 % BW ) for diet programmed to produce 40L milk/day (P≤ 0.05), however, the conversion and feed efficiency were better diet for 20 (0,91 x 1,01; % 112,6 x 103,9 %, respectively) (P ≤ 0,05). Evaluating IMS, fractional way, it was found that the diet of 40 provided the greatest intakes of concentrate (10,8 x 9,3 kg/day), forage (11,3 x 10,4 kg/day) and urea (0,303 x 0,280 kg/day), while for the massive effect, CSM provided greater intake of concentrate (10,9 x 9,1 kg/day) and urea (0,333 x 0,278 kg/day) and lower intake of forage (10,1 x 11,6 kg/day) (P≤0,05). For the purpose of production and quality of milk from the diet led to 40, higher concentration of milk urea nitrogen (UN) ( 22,...

Aerossolterapia / Aerossoltherapy

As doenças do trato respiratório têm uma elevada prevalência emnosso meio. A via inalatória é a preferida para a administração da terapia. Vários dispositivos, com diferentes características, estão disponíveis no mercado. Esta revisão teve o objetivo de descrever os tipos de dispositivos, suas vantagens e desvantagens, e indicações de uso conforme cada faixa etária, além de abordar alguns aspectos técnicos relevantes para a obtenção de melhores resultados com a terapia inalatória. Evidências científicas enfatizam novas formas de administração de medicação inalatória. Nebulizadores convencionais apresentam numerosos inconvenientes. Aerossóis com espaçadores/aerocâmaras permitem melhora na deposição pulmonar, resultando, principalmente em pacientes sem coordenação adequada, em uma melhor relação custo-benefício do que outros métodos tradicionalmente utilizados. Naqueles que conseguem gerar altos fluxos inspiratórios, os inaladores de pó seco podem ser utilizados.

The prevalence of respiratory diseases is high in Brazil. Inhalation isthe preferred route of delivery for therapy. Various inhalation devices, with different characteristics, are available. The objective of this review was to describe those devices, their advantages, disadvantages, and indications for each age group, as well as to address certain relevant technical aspects of obtaining optimal results with inhalation therapy. New means of delivering inhaled therapy have been described. Conventional nebulizers have a number of disadvantages. Aerosol inhalation via spacers or holding chambers seems to be another method, resulting, specifically in patients without adequate coordination, in a relative superior cost-benefit relationship in comparison with traditional methods. In patients who can generate high inspiratory flow rates, dry power inhalers can be used.

Encuesta sobre humidificación de la vía aérea en unidades de cuidados intensivos de adultos de Chile / Airway humidification practices in Chilean intensive care units

Background: In patients with an artificial airway, inspired gases can be humidified and heated using a passive (heat and moisture exchange filter - HMEF), or an active system (heated humidifier). Aim: To assess how humidification is carried out and what is the usual clinical practice in this field in Chilean intensive care units (ICUs). Material and Methods: A specific survey to evaluate humidification system features as well as caregivers' preferences regarding humidification systems, was carried out on the same day in all Chilean ICUs. Results: Fifty-five ICUs were contacted and 44 of them completed the survey. From a total of 367 patients, 254 (69%) required humidification because they were breathing through an artificial airway. A heated humidifier was employed only in 12 patients (5%). Forty-three ICUs (98%) used HMEF as their routine humidification system. In 52% of surveyed ICUs, heated humidifiers were not available. Conclusions: In Chile the main method to humidify and heat inspired gases in patients with an artificial airway is the HMEF. Although there are clear indications for the use of heated humidifiers, they are seldom employed.

Manejo de crises asmáticas em crianças: conhecimento de profissionais de saúde quanto ao tópico em hospitais-escola do Recife (PE) / Acute asthma management in children: knowledge of the topic among health professionals at teaching hospitals in the city of Recife, Brazil

OBJETIVO: O conhecimento sobre o manejo da asma aguda em crianças é um tema pouco explorado. O objetivo deste estudo foi avaliar o conhecimento de profissionais de saúde do Recife (PE) sobre o assunto. MÉTODOS: Estudo transversal de tipo inquérito com 27 médicos e 7 enfermeiros, com mais de 2 anos de trabalho, de dois grandes hospitais-escola de pediatria do Recife, avaliados através de questionários autoaplicáveis com questões fechadas. RESULTADOS: Tanto os pediatras quanto os enfermeiros apresentaram conhecimento inadequado sobre o uso de inaladores dosimetrados, nebulização, tipo e dosagem dos medicamentos, assim como técnicas de descontaminação e desinfecção do material. CONCLUSÕES: O conhecimento inadequado do manejo da asma aguda em crianças pode refletir em um tratamento menos efetivo nesses hospitais. Medidas educativas são necessárias para minimizar o problema.

OBJECTIVE: Knowledge of acute asthma management in children is a subject that has rarely been explored. The objective of this study was to assess the level of such knowledge among health professionals in the city of Recife, Brazil. METHODS: This was a cross-sectional survey involving 27 pediatricians and 7 nurses, all with at least two years of professional experience, at two large pediatric teaching hospitals in Recife. The participants completed a self-administered multiple-choice questionnaire. RESULTS: The pediatricians and nurses all possessed insufficient knowledge regarding the use of metered dose inhalers, nebulization, and types/doses of medications, as well as techniques for decontamination and disinfection of the equipment. CONCLUSIONS: Insufficient knowledge of acute asthma management in children can lead to less effective treatment in hospitals such as those evaluated here. Educational programs should be developed in order to minimize this problem.

Nebulizadores: fonte de contaminação bacteriana em pacientes com fibrose cística? / Nebulizers in cystic fibrosis: a source of bacterial contamination in cystic fibrosis patients?

OBJETIVO: Determinar se os nebulizadores de pacientes com fibrose cística são fonte de contaminação microbiana e verificar se a técnica e a frequência de desinfecção dos nebulizadores é apropriada. MÉTODOS: Estudo de corte transversal observacional, sem grupo controle. Foram coletadas amostras de 28 pacientes com fibrose cística, no domicílio do paciente, sem aviso prévio sobre o motivo da visita. Foram colhidas três amostras por paciente: do reservatório do nebulizador, da máscara/bocal e do próprio paciente (swab da orofaringe/escarro). As amostras foram acondicionadas adequadamente e levadas para análise. Os pacientes, seus pais ou responsáveis preencheram um questionário sobre métodos de limpeza e desinfecção dos nebulizadores. RESULTADOS: Foram obtidas 84 amostras dos 28 pacientes. Destes, 15 (53,5 por cento) eram do gênero masculino. A mediana de idade foi de 11 anos (variação: 1-27 anos). Dos 28 pacientes, 15 apresentaram culturas de escarro/orofaringe positivas. As bactérias encontradas com maior frequencia foram Streptococcus aureus (8/15) e Pseudomonas aeruginosa (4/15). A cultura obtida dos nebulizadores identificou diversos patógenos, sem nenhum predominante. Não houve associações entre os resultados das culturas obtidas dos nebulizadores e aquelas dos pacientes em 27 casos (96,7 por cento). A limpeza e a desinfecção não eram realizadas de forma adequada em 22 casos (78,6 por cento). CONCLUSÕES: Nesta amostra de pacientes, apesar das técnicas de desinfecção inadequadas, os nebulizadores não foram uma fonte de contaminação microbiana.

OBJECTIVE: To determine whether nebulizers are a source of microbial contamination in patients with cystic fibrosis, as well as whether the technique and frequency of disinfection of these devices is appropriate. METHODS: This was a cross-sectional, uncontrolled observational study. Samples were collected from 28 patients with cystic fibrosis. Samples were collected at the homes of the patients, who were not previously informed of the purpose of the visit. Three samples were collected from each patient: one from the nebulizer chamber, one from the mask/mouthpiece, and one from the patient (oropharyngeal swab /sputum). The samples were properly stored and taken for analyses. The patients, their parents, or their legal guardians completed a questionnaire regarding nebulizer cleaning and disinfecting methods. RESULTS: We collected 84 samples from the 28 patients. Of those 28 patients, 15 (53.5 percent) were male. The median age of the patients was 11 years (range, 1-27 years). Of the 28 patients, 15 presented with positive oropharyngeal swab /sputum sample cultures. The most common bacterial isolates were Staphylococcus aureus (in 8 patients) and Pseudomonas aeruginosa (in 4 patients). Although the samples obtained from the nebulizers presented with various pathogens in culture, no specific species predominated. In 27 cases (96.7 percent), there were no associations between the samples obtained from the nebulizers and those obtained from the patients in terms of the results of the cultures. Cleaning and disinfection of nebulizers were inappropriate in 22 cases (78.6 percent). CONCLUSIONS: In this sample of patients, despite the inappropriate disinfection techniques, nebulizers were not found to be a source of microbial contamination.