Aerosol therapy in adult critically ill patients: a consensus statement regarding aerosol administration strategies during various modes of respiratory support

Jie Li^#¹, Kai Liu^#², Shan Lyu^#³, Guoqiang Jing^#⁴, Bing Dai^#⁵, Rajiv Dhand⁶, Hui-Ling Lin⁷, Paolo Pelosi^{8

9}, Ariel Berlinski¹⁰, Jordi Rello^{11

12

13}, Antoni Torres^{14

12}, Charles-Edouard Luyt¹⁵, Jean-Bernard Michotte¹⁶, Qin Lu¹⁷, Gregory Reychler^{18

19

20}, Laurent Vecellio²¹, Armèle Dornelas de Andrade²², Jean-Jacques Rouby²³, James B Fink^{24

25}, Stephan Ehrmann²⁶

Affiliations

¹ Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA. Jie_Li@rush.edu.
² Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
³ Critical Care Medicine, Peking University People's Hospital, Beijing, China.
⁴ Department of Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China.
⁵ Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China.
⁶ Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
⁷ Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan.
⁸ Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.
⁹ Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
¹⁰ Pulmonary and Sleep Medicine Division, Department of Pediatrics, University of Arkansas for Medical Sciences, and Pediatric Aerosol Research Laboratory at Arkansas Children's Research Institute, Little Rock, AR, USA.
¹¹ Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.
¹² Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
¹³ Clinical Research in the ICU, Anaesthesia Department, CHU Nimes, Université de Nimes-Montpellier, Nimes, France.
¹⁴ Servei de Pneumologia, Hospital Clinic, University of Barcelona, IDIBAPS CIBERES, Icrea, Barcelona, Spain.
¹⁵ Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, and INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
¹⁶ School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts of Western Switzerland, Lausanne, Switzerland.
¹⁷ Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, and Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China.
¹⁸ Secteur de Kinésithérapie et Ergothérapie, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
¹⁹ Service de Pneumologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
²⁰ Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL and Dermatologie, Université Catholique de Louvain, Brussels, Belgium.
²¹ PST-A, Faculté de Médecine, Université de Tours, Tours, France.
²² Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil.
²³ Research Department DMU DREAM and Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Sorbonne University of Paris, Paris, France.
²⁴ Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA.
²⁵ Chief Science Officer, Aerogen Pharma Corp, San Mateo, CA, USA.
²⁶ CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, and INSERM, Centre d'étude des Pathologies Respiratoires, U1100, Université de Tours, Tours, France.

^# Contributed equally.

PMID: 37436585
PMCID: PMC10338422
DOI: 10.1186/s13613-023-01147-4

Aerosol therapy in adult critically ill patients: a consensus statement regarding aerosol administration strategies during various modes of respiratory support

Jie Li et al. Ann Intensive Care. 2023.

. 2023 Jul 12;13(1):63.

doi: 10.1186/s13613-023-01147-4.

Authors

Affiliations

¹ Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA. Jie_Li@rush.edu.
² Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
³ Critical Care Medicine, Peking University People's Hospital, Beijing, China.
⁴ Department of Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China.
⁵ Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China.
⁶ Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
⁷ Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan.
⁸ Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.
⁹ Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
¹⁰ Pulmonary and Sleep Medicine Division, Department of Pediatrics, University of Arkansas for Medical Sciences, and Pediatric Aerosol Research Laboratory at Arkansas Children's Research Institute, Little Rock, AR, USA.
¹¹ Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.
¹² Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
¹³ Clinical Research in the ICU, Anaesthesia Department, CHU Nimes, Université de Nimes-Montpellier, Nimes, France.
¹⁴ Servei de Pneumologia, Hospital Clinic, University of Barcelona, IDIBAPS CIBERES, Icrea, Barcelona, Spain.
¹⁵ Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, and INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
¹⁶ School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts of Western Switzerland, Lausanne, Switzerland.
¹⁷ Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, and Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China.
¹⁸ Secteur de Kinésithérapie et Ergothérapie, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
¹⁹ Service de Pneumologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
²⁰ Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL and Dermatologie, Université Catholique de Louvain, Brussels, Belgium.
²¹ PST-A, Faculté de Médecine, Université de Tours, Tours, France.
²² Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil.
²³ Research Department DMU DREAM and Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Sorbonne University of Paris, Paris, France.
²⁴ Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA.
²⁵ Chief Science Officer, Aerogen Pharma Corp, San Mateo, CA, USA.
²⁶ CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, and INSERM, Centre d'étude des Pathologies Respiratoires, U1100, Université de Tours, Tours, France.

^# Contributed equally.

PMID: 37436585
PMCID: PMC10338422
DOI: 10.1186/s13613-023-01147-4

Abstract

Background: Clinical practice of aerosol delivery in conjunction with respiratory support devices for critically ill adult patients remains a topic of controversy due to the complexity of the clinical scenarios and limited clinical evidence.

Objectives: To reach a consensus for guiding the clinical practice of aerosol delivery in patients receiving respiratory support (invasive and noninvasive) and identifying areas for future research.

Methods: A modified Delphi method was adopted to achieve a consensus on technical aspects of aerosol delivery for adult critically ill patients receiving various forms of respiratory support, including mechanical ventilation, noninvasive ventilation, and high-flow nasal cannula. A thorough search and review of the literature were conducted, and 17 international participants with considerable research involvement and publications on aerosol therapy, comprised a multi-professional panel that evaluated the evidence, reviewed, revised, and voted on recommendations to establish this consensus.

Results: We present a comprehensive document with 20 statements, reviewing the evidence, efficacy, and safety of delivering inhaled agents to adults needing respiratory support, and providing guidance for healthcare workers. Most recommendations were based on in-vitro or experimental studies (low-level evidence), emphasizing the need for randomized clinical trials. The panel reached a consensus after 3 rounds anonymous questionnaires and 2 online meetings.

Conclusions: We offer a multinational expert consensus that provides guidance on the optimal aerosol delivery techniques for patients receiving respiratory support in various real-world clinical scenarios.

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Conflict of interest statement

JL discloses research funding from Fisher & Paykel Healthcare Ltd, Aerogen Ltd, American Association for Respiratory Care (AARC), and Rice Foundation, and speaker fees from AARC, Aerogen Ltd, Heyer Ltd, and Fisher & Paykel Healthcare Ltd. HL discloses research funding from Chang Fung Memorial Foundation. AT discloses research funding from Bayer, and Cardeas. AB discloses research funding from Trudell Medical International, participation in clinical advisory board of Hollo Medical Inc, and participation as science advisor to International Pharmaceutical Aerosol Consortium on Regulation and Science. JR discloses grants or consultancies from ESCMID, European Respiratory Society, Bayer, and Genentech, speaker’s bureau for Norma Hellas. CEL discloses consultancies from Aerogen Ltd, AdvanzPharma, Merck and Pfizer. RD reports personal fees from Astra-Zeneca, Boehringer-Ingelheim, Mylan, UptoDate, and Teva. He is the recipient of research grants form Mylan, Viatris and GSK. AT discloses research funding from Bayer, and Cardeas. LV was employed by DTF Medical from 2001 to 2018 and by Nemera from 2018 to 2020. JBF is Chief Science Officer for Aerogen Pharma Corp 2016 to present and previously Chief Clinical Officer at Aerogen Ltd. SE discloses consultancies from Aerogen Ltd, research support, speaker fees, and travel support from Aerogen Ltd and Fisher & Paykel healthcare. Others do not have any conflict of interest to disclose.

Figures

**Fig. 1**
Flowchart of literature search and selection. *NIV* noninvasive ventilation, *HFNC* high-flow nasal cannula

**Fig. 2**
Detailed information on each round of deliberations and online meetings. *NIV* noninvasive ventilation, *HFNC* high-flow nasal cannula

**Fig. 3**
Graphic synopsis of recommendations on aerosol delivery via mechanical ventilation, noninvasive ventilation, and high-flow nasal cannula

See this image and copyright information in PMC

References

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Aerosol therapy in adult critically ill patients: a consensus statement regarding aerosol administration strategies during various modes of respiratory support

Affiliations

Aerosol therapy in adult critically ill patients: a consensus statement regarding aerosol administration strategies during various modes of respiratory support

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources