Indian Journal of Critical Care Medicine June 2014 Vol 18 Issue 6

Achyut Sarkar, Arindam Pande, Naveen G. S. Chandra, Imran Ahmed

reducing work of breathing by decreasing pulmonary dynamic hyperinflation and resistance of the respiratory system.[2]

Correspondence to: Dr. Arindam Pande, Department of Cardiology, IPGMER and SSKM Hospital, 244, AJC Bose Road, Kolkata - 700 020, West Bengal, India. E-mail: [email protected]

Effective delivery of aerosol to the lungs depends on formulation of drug, aerosol generator, and technique of administration. Various devices are used to generate aerosol, but pressurized metered-dose inhaler (pMDI) and nebulizers are the most commonly used in patients supported by IMV. The commonly used nebulizers are the jet and the ultrasonic devices. Vibrating mesh nebulizers and intratracheal nebulizing catheters are newer aerosol generating devices. These devices are connected to the inspiratory limb of the ventilator circuit by specific adaptors attached to the artificial airway. Several ventilator parameters also affect the effective delivery of aerosol to the patient. pMDI require a specific adaptor, a spacer and synchronization with ventilator for effective delivery of aerosol. If properly administered pMDI and nebulizers are equally effective in delivery of aerosol therapy to the mechanically ventilated patients although using nebulizers is the common practice.

Department of Cardiology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India

References 1.



S e n t h i l ku m a r a n S , D a v i d S S , J e n a N N , M e n e z e s R G , Thirumalaikolundusubramanian P. Acute myocardial infarction and cocaine toxicity: One step closer. Indian J Crit Care Med 2014;18:118. Sarkar A, Pande A, Naveen Chandra GS, Ahmed I. Acute myocardial infarction in a young cocaine addict with normal coronaries: Time to raise awareness among emergency physicians. Indian J Crit Care Med 2013;17:56-8. McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P, et al. Management of cocaine-associated chest pain and myocardial infarction: A scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation 2008;117:1897-907. Access this article online Quick Response Code: Website:

Jet nebulizers use a jet of compressed air or oxygen, while ultrasonic nebulizers use piezo-electric crystals vibrations to produce aerosol. New vibrating mesh nebulizers use a vibrating mesh or plate with multiple apertures to generate aerosol. Jet nebulizers are cost-effective and easy to use and adding a reservoir between jet nebulizer and endotracheal tube increases aerosol delivery. Some new generation ventilators have an in-built mechanism for supporting the jet or ultrasonic nebulizers. These ventilators synchronize inspiratory flow and volume to activate the jet nebulizer intermittently during inspiration.[3] Over a period of time, these compatible jet nebulizers tend to be damaged or lost. Many ventilators are not compatible with jet nebulizers or newer aerosol therapy devices. In these situations, often a jet nebulizer operated by compressed oxygen from wall system or cylinder, is attached to the inspiratory limb of breathing circuit. A minimum flow of 6-8 L is required to generate the aerosol. The volume added by this method can affect ventilator parameters and can be very harmful, especially to the pediatric patients who have small lung volumes.

DOI: 10.4103/0972-5229.133954

Improvised arrangement of aerosol delivery to the ventilator dependent patient Sir, The patients supported by invasive mechanical ventilation (IMV) often require aerosol therapy for bronchodilators and inhaled corticosteroids. Mucolytics, antibiotics and other medications can also be given by this method.[1] Aerosol therapy is indicated in these patients for management of asthma, bronchospasm, increased airway resistance, intrinsic positive end-expiratory pressure, difficult to wean, and ventilator dependent patients. Aerosol therapy helps in

Self-inflating manual resuscitator is a breathing system that uses nonrebreathing unidirectional valves. A pressure limiting device is present near inspiratory valve to prevent barotrauma in all infant/child and some adult manual resuscitators. There is a connection port to attach a reservoir bag at the bag inlet.[4] In this 77


Indian Journal of Critical Care Medicine June 2014 Vol 18 Issue 6

Unusual causes of anaphylaxis during surgery: Gelofusin-induced Kounis syndrome Sir, In the very interesting report[1] published recently in IJCCM, a 48-year-old female patient, who was planned to have laparoscopic donor nephrectomy, developed atrial premature complexes, flushing of both hands, falling blood pressure, and rising pulse rate after gelofusin infusion. Intravenous hydrocortisone, chlorpheniramine, mephentermine, adrenaline, vasopressors, ipratropiume with salbutamol nebulization and positive pressure ventilation improved her condition. The scheduled surgery was postponed, and the allergic skin tests for antibiotics, anesthetics and gelofusin showed positive skin reaction to gelofusin. This case raises some important points concerning the cause and the type of this reaction and its pathophysiology. Gelofusin is a macromolecule made from succinylated bovine gelatin. Gelatins are proteins derived from collagen and are obtained from cow and pig bones and hides and fish skin. A similar case diagnosed as Type II variant of Kounis hypersensitivity-associated syndrome with peri-operative cardiac arrest due to gelofusin anaphylaxis, confirmed with skin prick tests, has been published recently.[2] It concerned a 57-year-old patient who developed anaphylactic shock during anesthesia and despite initial management with bolus doses of metaraminol and epinephrine intravenously, hypotension worsened, and cardiac output was reduced. The patient recovered gradually with intravenous antihistamines, steroids and myocardial ischemia protocol, thus supporting our view that anaphylactic shock is a manifestation of Kounis syndrome. In another report, anaphylaxis with cardiovascular symptoms such as profound hypotension, tachycardia, and elevated airway pressures have been reported following intraosseous gelatin administration.[3] Drug capsules, suppositories, plasma expanders, and vaccine stabilizers including diphtheria-tetanus-pertussis, measles, mumps, rubella, varicella, yellow fever, rabies, and some influenza vaccines contain bovine and porcine gelatins as heat stabilizers. Since gelatin is contained in various vaccines given in children, then vaccination is regarded as a primary route of

Figure 1: Improvized arrangement

improvized arrangement, a T-adaptor with jet nebulizer assembly is attached to the above mentioned connection port [Figure 1]. A one-way valve [Direction, Figure 1] is attached to the free end of the T-adaptor to prevent aerosol loss and direct airflow to the bag inlet when it is re-expanding. Presence of resuscitation bag next to the jet nebulizer and addition of 3-4 mL of normal saline to the drug can help in effective delivery of aerosol. The tidal and minute volumes can be controlled manually to deliver aerosol safely to the ventilator dependent patients where compatible aerosol device is not available.

Ashish Saraogi

Department of Anaesthesiology, NIMS Hospital and Medical College, Jaipur, Rajasthan, India

Correspondence: Dr. Ashish Saraogi, B6, Faculty B Block, NIMS University Campus, Shobha Nagar, Jaipur-Delhi Highway, Jaipur - 303 121, Rajasthan, India. E-mail: [email protected]

References 1. 2.

3. 4.

Rubin BK. Air and soul: The science and application of aerosol therapy. Respir Care 2010;55:911-21. Guerin C, Fassier T, Bayle F, Lemasson S, Richard JC. Inhaled bronchodilator administration during mechanical ventilation: How to optimize it, and for which clinical benefit? J Aerosol Med Pulm Drug Deliv 2008;21:85-96. Dhand R. Aerosol delivery during mechanical ventilation: From basic techniques to new devices. J Aerosol Med Pulm Drug Deliv 2008;21:45-60. Dorsch JA, Dorsch SA. Manual resuscitators. In: Understanding Anaesthesia Equipments. 5th ed. New Delhi: Lippincott William’s and Wilkins; 2008. p. 282-93. Access this article online Quick Response Code: Website:

DOI: 10.4103/0972-5229.133955



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