Bronchodilator delivery with metered-dose inhaler during mechanical ventilation

Table 1 Strategy used in our unit for MDI bronchodilator therapy

Step	Details
1	Place a spacer device in the inspiratory line of the ventilator
	circuit^* (see Fig. 3)
2	Shake the MDI vigorously
3	Adapt the MDI to the spacer device
4	Remove the heat and moisture exchanger^† (if used)
5	Do not change the ventilator settings^‡
6	Actuate MDI to synchronize with the onset of inspiratory flow
7	Repeat actuation after 20-30 s until the total dose is
	delivered
8	Start with four to six puffs and observe the response
9	Repeat bronchodilator treatment after 3-4 h^§

^*The spacer device remains in the circuit so that disconnection and manipulation of the ventilator circuit is minimized. ^†The effect of the heat-moisture exchanger on the efficiency of bronchodilator therapy has not been studied; if a humidifier is used it should not be bypassed, but the drug dose may need to be increased. ^‡If the tidal volume is less that 400 ml, an increased dose may be required; this has not been studied. ^§A shorter interval may be needed in some patients, particularly those with status asthmaticus.

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