Reprinted from RESPIRATORY CARE (Respir Care 1996; 41(7):647-653)
AARC Clinical Practice Guideline
Selection of a Device for Delivery of Aerosol to the Lung Parenchyma
DALP 1.0 PROCEDURE:
Selection of a device for delivery of aerosol to the lung parenchyma
DALP 2.0 DESCRIPTION:
A device selected for administration of pharmacologically active aerosol to the lung parenchyma should produce particle sizes with a mass median aerodynamic diameter (MMAD) of 1-3 microns.(1-4)
Such devices include ultrasonic nebulizers (USNs, including the Porta-Sonic(5,6)), some large volume nebulizers (LVNs, such as the Small Particle Aerosol Generator(TM), or SPAG, which is intended only for ribavirin delivery(7)), some small volume nebulizers (such as the Circulaire,(8) RespirGard II,(5,6,9) and Pari IS 2,(6)) Other devices including metered dose inhalers (MDIs) may be developed for parenchymal deposition. Although some parenchymal deposition of particles < 1 micron probably does occur, selection of a specific device should be based on its ability to produce particles within MMAD of 1-3 microns.
DALP 3.0 SETTING:
Aerosol therapy can be administered in a number of settings including but not limited to hospital, clinic, extended care facility, or home.
DALP 4.0 INDICATIONS:
The indication for selecting a suitable device is the need to deliver a topical medication (in aerosol form) that has its site of action in the lung parenchyma or is intended for systemic absorption. Such medications may possibly include antibiotics, antivirals, antifungals, surfactants, and enzymes.
DALP 5.0 CONTRAINDICATIONS:
- 5.1 No contraindications exist to choosing an appropriate device for parenchymal deposition.
- 5.2 Contraindications related to the substances being delivered may exist. Consult the package insert for product-specific contraindications to medication delivery.
DALP 6.0 HAZARDS/COMPLICATIONS:
- 6.1 Malfunction of device and/or improper technique may result in underdosing or overdosing.
- 6.2 In mechanically ventilated patients, the nebulizer design and characteristics of the medication may affect ventilator function (eg, filter obstruction, altered tidal volume, decreased trigger sensitivity) and medication deposition.(10,11)
- 6.3 Complications related to specific pharmacologic agents can occur.
- 6.4 Aerosols may cause bronchospasm or irritation of the airway.
- 6.5 Exposure to medications(12-23) and patient-generated droplet nuclei may be hazardous to clinicians.(24)
- 6.5.1 Exposure to medication should be limited to the patient for whom it has been ordered. Nebulized medication that is released into the atmosphere from the nebulizer or exhaled by the patient becomes a form of "secondhand" exposure that may affect health-care providers and others in the vicinity of the treatment.
There has been increased awareness of possible health effects of aerosols, such as ribavirin and pentamidine. Anecdotal reports associate symptoms such as conjunctivitis, decreased tolerance to presence of contact lenses, headaches, bronchospasm, shortness of breath, and rashes in health-care workers exposed to secondhand aerosols. Similar concerns have been expressed concerning health-care workers who are pregnant or are planning to be pregnant within 8 weeks of administration. Less often discussed are the potential exposure effects of aerosolized antibiotics (which may contribute to the development of resistant organisms), steroids, and bronchodilators.(25)
- Because the data regarding adverse health effects on the health-care worker and on those casually exposed are incomplete, the prudent course is to minimize exposure in all situations.(26)
- 6.5.2 The Centers for Disease Control and Prevention recommend addressing exposure control issues by (1) administrative policy, (2) engineering controls, and (3) personal protective equipment, in that order.(27,28)
- 22.214.171.124 Administrative controls:
Should include warning signs to apprise all who enter a treatment area of potential hazards of exposure. Accidental exposures should be documented and reported according to accepted standards.
- Measures to reduce aerosol contamination of room air include:
- 126.96.36.199.1 discontinuing nebulization of medication while patient is not breathing the aerosol;
- 188.8.131.52.2 ensuring that staff who administer medications understand risks inherent with the medication and procedures for safely disposing of hazardous wastes;
- 184.108.40.206.3 screening of staff for adverse effects of exposure to aerosol medication;
- 220.127.116.11.4 providing alternative assignments for those staff who are at high risk of adverse effects from exposure (eg, pregnant women or those with demonstrated sensitivity to the specific agent).
- 18.104.22.168 Engineering controls:
- 22.214.171.124.1 Filters or filtered scavenger systems to remove aerosols that cannot be contained.
- 126.96.36.199.2 Frequent air exchanges to dilute concentration of aerosol in room to eliminate 99% of aerosol before the next patient enters and receives treatment in the area.
- 188.8.131.52.3 Booths or stalls for sputum induction and aerosolized medication administration in areas in which multiple patients are treated. Booths or stalls should be designed to provide adequate air flow to draw aerosol and droplet nuclei from the patient and into an appropriate filtration system, with exhaust directed to an appropriate outside vent.
- 184.108.40.206.4 Handling of filters, nebulizers, and other contaminated components of the aerosol delivery system used with suspect agents (such as pentamidine and ribavirin) as hazardous waste.
- 220.127.116.11 Personal protection devices:
- 18.104.22.168.1 Personal protection devices should be used to reduce exposure when engineering alternatives are not in place or are not adequate. Use properly fitted respirators with adequate filtration when exhaust flow cannot adequately remove aerosol particles.(28)
- 22.214.171.124.2 Goggles, gloves, and gowns should be used as splatter shields and to reduce exposure to medication residues and body substances.
DALP 7.0 LIMITATIONS OF PROCEDURE OR DEVICE:
- 7.1 A relatively small fraction of nebulizer output deposits in the lung parenchyma.(2)
- 7.2 Efficacy of the device is technique dependent (eg, coordination, ability to follow instructions, and breathing pattern including inspiratory flow and inspiratory hold).(2,29-32)
- 7.3 Efficacy of the device is design dependent (ie, output and particle size).(33-36)
- 7.4 The following clinical situations are associated with reduced deposition of aerosol to the lung parenchyma and may require consideration of increased dose:
- 7.4.1 Mechanical ventilation(37-42)
- 7.4.2 Artificial airways(43-45)
- 7.4.3 Reduced airway caliber (eg, infants and pediatrics)(46)
- 7.4.4 Severity of obstruction(4)
- 7.4.5 Hydrophilic formulations(2)
- 7.4.6 Failure of patient to comply with procedure.
- 7.5 Limitation of specific devices:
- 7.5.1 MDI:
- 126.96.36.199 Particle size varies with drug formulation, propellants, evaporation rate, and humidity.
- 188.8.131.52 Accessory device is recommended with MDI use(26,47)
- 184.108.40.206.1 assure optimal deposition
- 220.127.116.11.2 reduce oropharyngeal deposition
- 18.104.22.168.3 decrease caregiver exposure.
- 22.214.171.124 Relatively few formulations are targeted to the lung parenchyma.
- 7.5.2 SPAG(TM)40 (intended only for ribavirin delivery)
- 126.96.36.199 Limited to acute and critical care setting
- 188.8.131.52 Requires close monitoring
- 184.108.40.206 Requires compressed gas source
- 220.127.116.11 Vulnerable to contamination
- 18.104.22.168 Reconcentration of solution may occur over a long period of time due to evaporation by dry gas source.(49-52)
- 7.5.3 SVN:
- 22.214.171.124 Few devices produce particles with MMAD of 1-3 microns.
- 126.96.36.199 MMAD may vary with nebulizer model, medication, gas flow, and gas pressure.
- 188.8.131.52 Requires compressed gas source.
- 184.108.40.206 Vulnerable to contamination.
- 220.127.116.11 Reconcentration may occur.(49-52)
- 7.5.4 LVN:
- 18.104.22.168 Generally limited to acute and critical care setting although anecdote suggest some home use.
- 22.214.171.124 Requires close monitoring.
- 126.96.36.199 Few devices produce particles with MMAD of 1-3 microns.
- 188.8.131.52 Vulnerable to contamination.
- 7.5.5 USN:
- 184.108.40.206 Cost may be a factor.
- 220.127.116.11 May be mechanically unreliable.
- 18.104.22.168 Requires electrical power source.
- 22.214.171.124 Some units do not reliably produce MMAD of 1-3 microns.(44-54)
- 126.96.36.199 Reconcentration of solution may occur over long period of time due to evaporation by heat generated by piezoelectric cell.(53,55) The ultrasonic device may denature the medication.(56,57)
DALP 8.0 ASSESSMENT OF NEED (Selection Criteria for Device):
- 8.1 Availability of prescribed drug in solution or MDI formulation.
- 8.2 Availability of appropriate scavenging or filtration equipment.
- 8.3 Patient preference for a given device that meets therapeutic objectives.
- 8.4 Although specific devices may give known ranges of particle size and output, clear superiority of any one method or device for achieving specific clinical outcomes has not been established. Cost, convenience, effectiveness, and patient tolerance of procedure should be considered.(26,53)
- 8.5 When spontaneous ventilation is inadequate (eg, kyphoscoliosis, neuromuscular disorders, or respiratory failure) consider augmentation with mechanical ventilation.
DALP 9.0 ASSESSMENT OF OUTCOME
Appropriate device selection is reflected by evidence of
- 9.1 use of proper technique in applying device;
- 9.2 patient compliance with procedure;
- 9.3 a positive clinical outcome. (However, appropriate device selection and application does not guarantee a positive outcome.)
DALP 10.0 RESOURCES
- 10.1 Equipment:
- 10.1.1 MDI and accessory device (holding chamber or spacer).
- 10.1.2 SPAG (nebulizer with drying chamber supplied by manufacturer); gas source; tent, hood or ventilator; scavenger or filter system to prevent aerosol from being released outside immediate treatment area.
- 10.1.3 SVN, gas source, tubing, one-way valves, mouthpiece or mask, scavenger or filter system to prevent aerosol from being released outside immediate treatment area.
- 10.1.4 LVN, gas source, flowmeter, connecting tubing, mouthpiece or mask scavenger or filter system to prevent aerosol from being released outside immediate treatment area.
- 10.1.5 Mechanical ventilator with SPAG unit, adapter in inspiratory line of circuit, filter system in expiratory line to prevent obstruction of expiratory valves, scavenger or filter system to prevent aerosol from being released outside immediate treatment area.
- 10.1.6 IPPB machine (ie, pressure-cycled ventilator), nebulizer gas source, connecting tubing, mouthpiece or mask, scavenger or filter system to prevent aerosol from being released outside immediate treatment area.
- 10.2 Personnel
- 10.2.1 Level-II personnel should establish the need for a specific device by patient assessment and complete the first administration of the medication. Level-II personnel should continue to care for the unstable patient. We recommend that the Level-II caregiver be credentialed (eg, RRT, CRTT, RN). Level-II personnel must have documented knowledge of and demonstrated ability to perform regarding:
- 10.2.1.1 Indications and limitations for SPAG, MDI with accessory devices, SVN, LVN, and USN.
- 10.2.1.2 Proper use, maintenance and cleaning of equipment, including filter and scavenging systems.
- 10.2.1.3 Risks inherent to the medications and specific devices.
- 10.2.1.4 Safe disposal of hazardous wastes and medical waste.
- 10.2.1.5 Optimal breathing patterns and coughing techniques.
- 10.2.1.6 Technique modification in response to adverse reactions.
- 10.2.1.7 Dosages and/or frequency modification as prescribed, in response to severity of symptoms.
- 10.2.1.8 Assessment of patient condition and response to therapy.
- 10.2.1.9 Performance of auscultation, inspection, and monitoring of vital signs.
- 10.2.1.10 Performance of peak expiratory flowrate, spirometry, and ventilatory mechanics.
- 10.2.1.11 Recognition and response to therapeutic or adverse response and complications of medication administration and/or the procedure.
- 10.2.1.12 Understanding and compliance with Universal Precautions(58) and guidelines for prevention of the spread of tuberculosis(28,59) and other infection control measures.
- 10.2.2 Level-I caregiver may be the provider of service to the stable patient after Level-II personnel have established need for a specific device by patient assessment and the first administration has been completed. We recommend that Level-I personnel be credentialed (eg, RRT, CRTT, RN). They must have documented knowledge and demonstrated ability to perform related to:
- 10.2.2.1 preparing, measuring, and mixing medication;
- 10.2.2.2 demonstrating proper technique for administration of medication;
- 10.2.2.3 using equipment properly;
- 10.2.2.4 cleaning equipment;
- 10.2.2.5 properly disposing of wastes;
- 10.2.2.6 encouraging effective breathing patterns and coughing techniques;
- 10.2.2.7 modifying technique in response to adverse reactions as instructed, with appropriate communication with physician, in response to severity of symptoms;
- 10.2.2.8 implementing and observing Universal Precautions and guidelines to avoid transmission of tuberculosis and proper infection control.
DALP 11.0 MONITORING:
- 11.1 Performance of the device and scavenging system
- 11.2 Technique of device application
- 11.3 Assessment of patient response
DALP 12.0 FREQUENCY:
A device for delivery of aerosolized medication to the lung parenchyma is selected
- 12.1 on initiation of therapy, after careful assessment of need (as outlined);
- 12.2 when the decision is made to change the device because of a change in patient condition or because the patient is unable to use the specific device.
DALP 13.0 INFECTION CONTROL:
- 13.1 Caregiver should exercise Universal Precautions for body substance isolation and follow CDC recommendations for control of exposure to tuberculosis and droplet nuclei.(28,58)
- 13.2 Nebulizers should not be used between patients without disinfection.
- 13.3 Nebulizers should be changed or sterilized:
- 13.3.1 at conclusion of dose administration or at least every 24 hours;
- 13.3.2 at 24-hour intervals with continuous administration;
- 13.3.3 when visibly soiled.
- 13.4 Nebulizers should not be rinsed with tap water between treatments but may be rinsed with sterile water. CDC Guidelines recommend sterile water rinsing and air drying.(60)
- 13.5 All medications should be handled aseptically.
- 13.6 CDC guidelines suggest that if multidose medications containers are dated upon opening and handled aseptically, medication may be used until exhausted or until the manufacturer's expiration date unless visible or suspected contamination occurs.(61,62) However, it is not clear whether this applies only to solutions containing a bacteriostatic agent. Caution is advised particularly for reconstituted solutions.
Aerosol Therapy Focus Group:
Jon O Nilsestuen PhD RRT, Chairman, Galveston TX
James Fink MS RRT, Hines IL
Theodore Witek Jr DrPH RPFT RRT, Ridgefield CT
James Volpe III RRT MEd, San Diego CA
- Heyder J, Gebbart J, Rudolf G, Stahlhofen W. Physical factors determining particle deposition in the human respiratory tract. J Aerosol Sci 1980;11:505-515.
- Brain JD, Blanchard JD. Mechanisms of particle deposition and clearance. In: Aerosols in medicine: principles, diagnosis and therapy. Moren F, Dolovich M, Newhouse MT, Newman SP, editors. Amsterdam: Elsevier Science Publishers 1993:117-156.
- Newman SP, Pavia D, Moren F, Sheahan NF, Clarke SW. Deposition of pressurized aerosols in the human respiratory tract. Thorax 1981;36:52-55.
- Dolovich M. Physical principles underlying aerosol therapy. J Aerosol Med 1989:2(2);171-186.
- Hager J, Gober K-H, Löhr J-P, Dürr, M. Measurement of particle and mass distribution of pentamidine aerosol by ultrasonic and air jet nebulizers. J Aerosol Med 1992; 5(2):65-79.
- Matthys H, Herceg R. Dosing strategies for aerosol delivery to the lung parenchyma, with specific recommendations for pentamidine. Respir Care 1991;36(9):980-993.
- Smith DW, Frankel, LR, Mathers LH, Tang ATS, Ariagno RL, Prober CG. A controlled trial of aerosolized ribavirin in infants receiving mechanical ventilation for severe respiratory syncytial virus infection. N Engl J Med 1991;325:24-29.
- Mason JW, Miller WC, Small S. Comparison of aerosol delivery via Circulaire system vs conventional small volume nebulizer. Respir Care 1994;39(12):1157-1161.
- Dubois J, Bartter T, Gryn J, Pratter MR. The physiologic effects of inhaled amphotericin B. Chest 1995;108(3): 750-753.
- Demers RR, Parker J, Frankel LR, Smith DW. Administration of ribavirin to neonatal and pediatric patients during mechanical ventilation. Respir Care 1986;31 (12):1188-1195.
- Hess DR, Kacmarek RM. Chapter 30. Secretion clearance, positioning, and inhaled aerosol medication. In: Essentials of mechanical ventilation. New York: McGraw-Hill 1996:205.
- Waskin H. Toxicology of antimicrobial aerosols: a review of aerosolized ribavirin and pentamidine. Respir Care 1991;36(9):1026-1036.
- Fallat RJ, Kandal K. Aerosol exhaust: escape of aerosolized medication into the patient and caregiver's environment. Respir Care 1991;36(9):1008-1016.
- Harrison R. Assessing exposures of health care personnel to aerosols of ribavirin--California. MMWR 1988; 37:560-568.
- Harrison R. Reproductive risk assessment with occupational exposure to ribavirin aerosol. Pediatr Infect Dis J 1990; 9(suppl):S102-S105.
- Arnold SD, Buchan RM. Exposure to ribavirin aerosol. Appl Occup Environ Hyg 1991;6:271-279.
- Rodriguez WJ, Bui RH, Connor JD, Kim HW, Brandt CA, Parrott RH, et al. Environmental exposure of primary care personnel to ribavirin aerosol when supervising treatment of infants with respiratory syncytial virus infections. Antimicrob Agents Chemother 1987;31: 1143-1146.
- Diamond SA, Dupuis LL. Contact lens damage due to ribavirin exposure (letter). DICP 1989;23:428-9.
- Adderley RJ. Safety of ribavirin with mechanical ventilation. Pediatr Infect Dis J 1990;9(Suppl):S112-S114.
- Massachusetts Department of Labor and Industries, Division of Occupational Hygiene. Ribavirin alert DOH #1558, July 1989.
- Kacmarek RM, Kratohvil J. Evaluation of a double-enclosure double-vacuum unit scavenging system for ribavirin administration. Respir Care 1992;37:37-45.
- Charney W, Corkery KJ, Kraemer R. Engineering administration controls to contain the delivery of aerosolized ribavirin: results of simulation and application to one patient. Respir Care 1990;35:1042-1048.
- Cefaratt JL, Steinberg EA. An alternative method for delivery of ribavirin to nonventilated pediatric patients. Respir Care 1992;37:877-881.
- Beck-Sague C, Dooley SW, Hutton MD, Otten J, Breeden A, Crawford JT, et al. Hospital outbreak of multidrug-resistant Mycobacterium tuberculosis infections: factors in transmission to staff and HIV-infected patients. JAMA 1992;268(10)1280-1286.
- Witek TJ, Schachter EN. Pharmacology and therapeutics in respiratory care, Philadelphia: WB Saunders 1994:304.
- Faculty and Working Group. American Association for Respiratory Care. Aerosol Consensus Conference Statement--1991. Respir Care 1991;36:916-921.
- Dooley SW, Castro KG, Hutton MD, Mullan RJ, Polder JA, Snider DE, Jr. Guidelines for preventing the transmission of tuberculosis in health-care setting, with special focus on HIV-related issues. MMWR 1190;39(no. RR-17).
- Centers for Disease Control & Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities. Washington DC: Federal Register 1994;59(208), Friday Oct 28, 1994: 54242-54303.
- Newman SP. Aerosol generators and delivery systems. Respir Care 1991;36:939-951.
- Raabe OG, Lee, JIC, Wong GA. A signal actuated nebulizer for use with breathing machines. J Aerosol Med 1989;2(2):201-210.
- Newman SP, Bateman JRM, Pavia D, Clarke SW. The importance of breath-holding following the inhalation of pressurized aerosol bronchodilators. In: Baran D, editor. Recent advances in aerosol therapy: first Belgian symposium on aerosols in medicine. Brussels 1979:117-122.
- Brain JD, Blanchard JD. Aerosols. In: Bronchial asthma: mechanisms and therapeutics, third edition. Weiss EB, Stein M, editors. Boston: Little Brown & Co, 1993.
- Hallworth GW. The formulation and evaluation of pressurized metered dose inhalers. In: Ganderton D, Jones T, eds. Drug delivery to the respiratory tract. Chichester, England: Ellis Horwood. 1987:87-118.
- Wiener MV. How to formulate aerosols to obtain the desired spray pattern. Soc Cos Chem 1958;9:289-297.
- Kim CS, Trujillo D, Sackner MA. Size aspects of metered-dose inhaler aerosols. Am Rev Respir Dis 1985; 132:137-142.
- Dolovich M, Ruffin RE, Roberts R, Newhouse MT. Optimal delivery of aerosols from metered dose inhalers. Chest 1981;80(suppl):911-915.
- Hughes JM, Saez J. Effects of nebulizer mode and position in a mechanical ventilator circuit on dose efficiency. Respir Care 1987;32:111-113.
- MacIntyre NR, Silver RM, Miller CW, Schuler F, Coleman RE. Aerosol delivery in intubated, mechanically ventilated patients. Crit Care Med 1985;13:81-84.
- Fuller HD, Dolovich MB, Posmituck G, Pack WW, Newhouse MT. Pressurized aerosol versus jet aerosol delivery to mechanically ventilated patients: comparison of dose to the lungs. Am Rev Respir Dis 1990;141: 440-444.
- Dahlback M, Wollmer P, Drefeldt B, Johnson B. Controlled aerosol delivery during mechanical ventilation. J Aerosol Med 1989;4:339-347.
- Rozycki HJ, Byron PR, Dailey K, Gutcher GR. Evaluation of a system for the delivery of inhaled beclomethasone dipropionate to intubated neonates. Dev Pharmacol Ther 1991;16(2):65-70.
- Cameron D, Arnot R, Clay M, Silverman M Aerosol delivery in neonatal ventilator circuits: a rabbit lung model. Pediatr Pulmonol 1991 10(3):208-213.
- Crogan SJ, Bishop MJ. Delivery efficiency of metered dose aerosols given via endotracheal tube, Anesthesiology 1989;70:1008-1010.
- Bishop MJ, Larson RP, Buschman DL. Metered dose inhaler aerosol characteristics are affected by the endotracheal tube actuator/adapter used. Anesthesiology 1990; 73(6):1263-1265.
- Ebert J, Adams AB, Green-Eide B. an evaluation of MDI spacers and adapters: their effect on the respirable volume of medication. Respir Care 1992;37:862-868.
- Newhouse MT, Dolovich M. Aerosol therapy in children: basic mechanisms of pediatric respiratory disease: cellular and integrative. BC Decker 1991.
- American Association for Respiratory Care. Clinical practice guideline: selection of aerosol delivery device. Respir Care 1992;37:891-897.
- Fink J. Humidity and aerosol therapy. In: Scanlan CL, Spearman CB, Sheldon RL, editors. Egan's fundamentals of respiratory care, sixth ed. St Louis: Mosby-Yearbook 1995:676-696.
- Mercer TT, Tillery MI, Chow HY. Operating characteristics of some compressed-air nebulizers. Am Ind Hyg Assoc J 1968;29(1):66-78.
- Young HW, Domnik JW, Walker JS, Larson EW. Continuous aerosol therapy system using a modified Collison nebulizer. J Clin Microbiol 1977;5(2):131-136.
- Robig G, Gebhart J, Porstendorfer J. [Investigations on the stability of droplets from medical jet and ultrasound aerosol atomizers (author's transl)] Z Erkr Atmungsorgane 1977;149(3):372-379.
- Phipps PR, Gonda I. Droplets produced by medical nebulizers: some factors affecting their size and solute concentration. Chest 1990;97(6):1327-1332.
- Doershuk CF, Mathews LW, Gillespie CT, Lough MD, Spector S. Evaluation of jet type and ultrasonic nebulizers in mist tent therapy for cystic fibrosis. Pediatrics 1968;41:723-732.
- Boucher RGM, Kreuter J. Fundamentals of the ultrasonic atomization of medicated solutions. Ann Allergy 1968;26:59.
- Lewis RA, Ellis CJ, Fleming JS, Balachandran W. Ultrasonic and jet nebulizers: differences in the physical properties and fractional deposition on the airway responses to nebulized water and saline aerosols (abstract). Thorax 1984;39:712.
- Smith Al. Principles of microbiology. St Louis: CV Mosby, 1969:235-236.
- Boucher RM, Pisano A. Sterilizing effect of high intensity airborne sound and ultrasound. Ultrasonics 1966; l4:199.
- Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-382,387-388.
- ECRI. Tuberculosis, Part II: respirators and recommendations. Technology for Respiratory Therapy. 1992;13 (1):1-4.
- Center for Disease Control and Prevention. Guideline for the prevention of nosocomial pneumonia. Respir Care 1994;39(12):1191-1236.
- Sheth NK, Post GT, Wisniewski TR, Uttech BV. Multidose vials versus single-dose vials: a study in sterility and cost-effectiveness. J Clin Microbiol 1983; 17(2):377-379.
- Longfield R, Longfield J, Smith LP, Hyams KC, Strohmer ME. Multidose medication vial sterility: an in-use study and a review of the literature. Infect Control 1984;5(4):165-169.
Allen SC, Prior A. What determines whether an elderly patient can use a metered dose inhaler correctly? Br J Dis Chest 1986;80:45-49.
Anzueto A, Baughman RP, Guntupalli KK, Weg JG, Wiedemann HP, Raventos AA et al for the Exosurf Acute Respiratory Distress Syndrome Sepsis Study Group. N Engl J Med 1996;334(22):1417-1421.
Ballard RD, Bogin RM, Pak J. Assessment of bronchodilator response to a B-adrenergic delivered from an ultrasonic nebulizer. Chest 1991:100:410-415.
Centers for Disease Control. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related tissues. MMWR 1990;39 (RR-17):1-29.
Dolovich M, Chambers C, Mazza M, Newhouse MT. Relative efficiency of four metered dose inhaler (MDI) holding chambers (HC) compared to albuterol MDI. Presented at American Lung Association American Thoracic Society 1992 International Conference at the Symposium on Aerosol Delivery Systems.
Fiel SB, Fuchs HJ, Johnson C, Gonda I, Clark AR and the the Pulmozyme rhDNase Study Group. Comparison of three jet nebulizer aerosol delivery systems to administer recombinant human DNase I to patients with cystic fibrosis. Chest 1995;108(1):153-156.
Grainger JR. Correct use of aerosol inhalers. Can Med Assoc J 1977;116:584-585.
Kim CS, Eldridge MA, Sackner MA. Oropharyngeal deposition and delivery aspects of metered-dose inhaler aerosols. Am Rev Respir Dis 1987;135:157-164.
Riley DJ, Liu RT, Edelman NH. Enhanced response to aerosolized bronchodilator therapy in asthma using respiratory maneuvers. Chest 1979;76:501-507.
Shak S. Aerosolized recombinant human DNase I for the treatment of cystic fibrosis. Chest 1995;107(2, suppl): 65S-70S.
Svedmyr N. Clinical advantages of the aerosol route of drug administration. Respir Care 1991;36(9):922-930.
Tag El-Din MA, Palmer LB, El-Tayeb MN. Kalil I, Gabr MS. Nebulizer therapy with antibiotics in chronic suppurative lung disease. J Aerosol Med 1994;7(4):345-350.
Woolf CR. Correct use of pressurized aerosol inhalers. Can Med Assoc J 1979;121:710-711.
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