Aerogen Solo, Aerogen Ultra and Aerogen Pro can nebulize physician-prescribed medications for inhalation which are approved for use with a general purpose nebulizer.
Aerogen Solo and Aerogen Pro can be used to nebulize all physician-prescribed drugs approved for use with a general-purpose nebulizer.
Aerogen Ltd cannot provide specific advice on medication dose as the company does not have regulatory approvals for drug/device combinations at this time. Information on drug dosing with specific nebulizers must be sourced from the manufacturer’s approved prescribing information for the inhaled formulation. Bear in mind published clinical research examining the efficiency of the different nebulizer technologies in terms of delivering therapeutic/effective drug levels in the lungs for specific medications.
Should you require information regarding published clinical research for nebulization of specific medications with Aerogen devices, please contact our Clinical Team directly at firstname.lastname@example.org (US)/Canada or email@example.com (Rest of World).
It is recognised that physicians prescribe medications for nebulization that are not approved for use with a general purpose nebulizer based on their perceived clinical need and the Risk:Benefit Ratio for the patient. This is classified as ‘off label’ use of those medications: Aerogen Ltd cannot and does not promote ‘off label’ use of our devices.
Many bench models show increased inhaled dose with dry gas, from pMDI, jet nebulizer, ultrasonic and vibrating mesh nebulizers.1 However, Lin et al., (2009) showed that turning off the humidifier for 30 minutes did not increase the inhaled dose2. Cold dry air can cause bronchospasm – given that the majority of drugs delivered via the ventilator are bronchodilators, it does not make sense to turn off the humidifier (creating bronchospasm) to give more bronchodilator.3 A bigger risk is to forget to turn the humidifier back on after the treatment.
A lot of users have used this configuration (what configuration?) and have not reported any problems. Occasionally, there can be a change in the colour of the water in the heated humidifier, e.g., adrenalin/epinephrine and ipratropium bromide/salbutamol can turn the water brown. Any medication which rains out in the chamber will not be aerosolized. A study presented at the International Society of Aerosols in Medicine Conference in 2017 investigated the chemical stability of specific drugs after incubation at 50oC for 7 days to mimic a humidifier chamber. All drugs retained their integrity with the exception of acetyl cysteine which had a new peak present in an HPLC chromatogram4. If the physician is concerned, they could place the nebulizer at the wye. Please see articles which show deposition rates in these different positions1, 5, 6.
If you get crystallization in the nebulizer chamber after use of hypertonic saline, you can aerosolize a few drops of normal saline to clear any residual hypertonic saline and prevent further crystal formation in the Aerogen Solo chamber.
Rainout is usually condensation of humidified gas and to a lesser extent aerosolized drug that deposits as droplets within the breathing circuit. Drug in the form of rainout will not be aerosolized and, therefore, will not be inhaled by the patient.
In order to remove any residues of viscous drugs you can nebulize a few drops of normal saline.
In vitro studies by Ari et al., (2010) assessing aerosol delivery during mechanical ventilation in the presence of bias flow determined that you receive optimal deposition if you place the nebulizer pre-humidifier. In the absence of bias flow, optimal deposition was observed when the nebulizer was placed at or close to the wye1, 5. Berlinski & Willis (2013) demonstrated that, in the presence of bias flow in a pediatric model, nebulizers were more effective when placed back at the humidifier as compared to closer to the wye6.
Because neonate patients have very small tidal volume, it is optimal to place the Aerogen Solo at the wye as demonstrated by Berlinski et al. (2016).7 Placement at the humidifier is acceptable, however, if there are concerns with weight or rainout associated with placement at the wye.
Aerogen Solo can be used with a HME/HMEf which may contain a filter. Only an HME/HMEf that is approved for use with a nebulizer should be used. Follow the HME/HMEf manufacturer instructions regarding use with a nebulizer. Ensure that the combination of nebulizer, T-piece and HME/HMEf volumes is suitable for the tidal volume being delivered, particularly when treating patients with small tidal volumes, e.g., small children.
The main disadvantage of using an ultrasonic nebulizers is that heat is generated in the process of producing aerosol – this can break down complex proteins in some of the inhaled medications8. Furthermore, ultrasonic nebulisers (USN) are not recommended for administration of suspensions such as Pulmicort (Budesonide)8.
Both types of devices show similar aerosol delivery performance in an adult model when placed in the inspiratory limb at the wye and back at the humidifier when there is no bias used1. In a paediatric model with bias flow, Aerogen Solo performed better than a USN when placed on the humidifier; similar deposition was observed at the wye6. Aerogen devices and USNs are both powered by controllers – the ultrasonic nebuliser’s controller is bigger, bulkier and heavier. Aerogen devices leave a minimal residual volume after nebulization compared with the USN. 8 Below the ventilator circuit, there is a greater risk that contaminated fluids in the circuit may enter the nebulizer. 8
Several in vitro studies have evaluated inhaled dose of albuterol/salbutamol during HFNC. Ari, et al., (2011) assessed aerosol delivery when the Aerogen Solo was placed inline on the humidifier with HFNC in a pediatric model at 3 and 6 L/min flow9. Inhaled dose was improved at 3 L/min and, as flow increased, dose decreased. Reminiac et al., (2016) recently published an article assessing aerosol deposition in a toddler simulated breathing model and an animal model of a newborn10. They demonstrated that using the Aerogen Solo inline during HFNC (attached to the humidifier) can provide similar aerosol deposition as using a jet nebulizer independent of the HFNC system. When the jet nebulizer was used with a mask over the HFNC cannula or inline, the results were minimal. Therefore, Aerogen provides a similar dose to the patient with the added advantage of providing simultneous HFNC.
Lung dose during HFNC is affected by the flow rate. At lower flow rates, a higher inhaled mass is available. Alcoforado et al., (2016) performed an imaging study that showed that at flow rates of 10-50L/min, between 2-12% lung dose can be achieved where 3.76% of the aerosol dose is available at 30L/min11. Flow rate does affect aerosol deposition – lower flow rates will provide higher lung dose.
Data from an interim analysis of Reminiac et al. looking at the effect of HFNC with patients with documented airflow obstruction suggested that using the Aerogen Solo in line during HFNC at 30L/min produced significant bronchodilation that was similar to using a standard jet nebuliser without HFNC 12.
1. Ari A, Atalay OT, Harwood R, Sheard MM, Aljamhan EA and Fink JB. Respiratory care. 2010;55:845-51. 2. Lin HL, Fink JB, Zhou Y and Cheng YS. Influence of moisture accumulation in inline spacer on delivery of aerosol using metered-dose inhaler during mechanical ventilation. Respiratory care. 2009;54:1336-41 3. Kaminsky DA, Bates JH and Irvin CG. Effects of cool, dry air stimulation on peripheral lung mechanics in asthma. American journal of respiratory and critical care medicine. 2000;162:179-86. 4. Saeed A, Abdelrahim ME and Fink JB. The effect of heat and humidification on commonly nebulized drugs. Poster presentation at ISAM. 2017. 5. Ari A, Atalay OT, Harwood R, Sheard MM, Aljamhan EA and Fink JB. Influence of nebulizer type, position, and bias flow on aerosol drug delivery in simulated pediatric and adult lung models during mechanical ventilation. Respiratory care. 2010;55:845-51. 6. Berlinski A and Willis JR. Albuterol delivery by 4 different nebulizers placed in 4 different positions in a pediatric ventilator in vitro model. Respiratory care. 2013;58:1124-33. 7. Berlinski A and Kumaran S. Particle Size Characterization of Nebulized Albuterol Delivered by a Vibrating Mesh Nebulizer Through Pediatric Endotracheal Tubes. Poster Presentation at ATS. 2016. 8. Ari A and Fink JB. Aerosol Drug Delivery During Mechanical Ventilation: Devices, Selection, Delivery Technique, and Evaluation of Clinical Response to Therapy. Clinical Pulmonary Medicine. 2015;22:79-86. 9. Ari A, Harwood R, Sheard M, Dailey P and Fink JB. In vitro comparison of heliox and oxygen in aerosol delivery using pediatric high flow nasal cannula. Pediatric pulmonology. 2011;46:795-801. 10. Reminiac F, Vecellio L, Loughlin RM, Le Pennec D, Cabrera M, Vourc’h NH, Fink JB and Ehrmann S. Nasal high flow nebulization in infants and toddlers: An in vitro and in vivo scintigraphic study. Pediatric pulmonology. 2016. 11. Alcoforado L, Ari A, De Melo Barcelar J, Brandao SS, Fink JB and Dornelas De Andrade A. Comparison of Aerosol Deposition with Heated and Unheated High Flow Nasal Cannula (HFNC) in Healthy Adults. Poster presentation at ATS. 2016. 12. Reminiac F, Gissot V, Vecellio L, Plantier L and Ehrmann S. Nebulization during nasal high flow therapy: Interim results of a randomized clinical trial. Poster Presentation at International Society of Aerosols in Medicine. 2017. 13. Aerogen Solo System Instruction manual Aerogen Ltd. Part No. AG-AS3050 P/N 30-354.