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Table 1 Strategy used in our unit for MDI bronchodilator therapy

From: Bronchodilator delivery with metered-dose inhaler during mechanical ventilation

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§
  1. *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.