Objective: To compare the postoperative outcomes of inspiratory muscle training and aerobic exercise, along with standard care, on lung cancer patients undergoing video-assisted thoracoscopic surgery (VATS). Design: A parallel-group, single-blind randomized clinical trial Setting: Thoracic surgery ward and outpatient clinic in a teaching hospital Subjects: Overall 63 patients underwent VATS were randomly assigned to a triaging (TG, n = 32) or control group (CG, n = 31). A total of 54 patients (TG, n = 26; CG, n = 28) completed the study. Intervention: TG: six-week threshold inspiratory muscle training and aerobic exercise. CG: standard care. Main measures: Maximum inspiratory pressure (PImax), maximum expiratory pressure (PEmax) lung expansion volume, and 6-min walking test (6MWT) were performed on the day of chest tube removal (baseline), and 2, 6, and 12 weeks postoperatively. Results: The TG showed significant improvement in PImax at week 6 (71.6 ± 34.9 vs. 94.3 ± 32.8 cmH₂O, P = 0.018), PEmax at week 2 (70.9 ± 24.3 vs. 90.9 ± 28.2 cmH₂O, P = 0.015) and week 12 (76.1 ± 20.2 vs. 98.6 ± 35.3 cmH₂O, P = 0.012), the lung expansion volume at week 2 (1080 ± 433 vs 1457 ± 624 mL, P = 0.02) and week 12 (1200 ± 387 vs 1885 ± 678 mL, P < 0.001), in addition to the 6MWT at week 2 (332 ± 78 vs 412 ± 74 m, P = 0.002), week 6 (360 ± 70 vs 419 ± 60 m, P = 0.007) and week 12 (360 ± 58 vs 402 ± 65 m, P = 0.036). Conclusion: A six weeks of inspiratory muscle training and aerobic exercise had improved respiratory muscle strength and aerobic exercise postoperatively in lung cancer patients after VATS as early as 2 weeks.

Caring for prolonged mechanical ventilation (PMV) patients imposes heavy psychological, physical, social, and financial burdens on caregivers. Currently, studies regarding the burden on caregivers of PMV patients are scant; therefore, the present study investigated the burden on caregivers of PMV patients. This cross-sectional study was approved by the Institutional Review Board of Zuoying Armed Forces General Hospital. A survey was conducted among the caregivers of PMV patients who were admitted to a chronic respiratory care ward (RCW) or were receiving home care from June to December 2010. The survey included basic demographic information of PMV patients and their caregivers and the Burden Assessment Scale scores for 4 domains comprising a total of 21 questions (physical burden, n = 5; psychological burden, n = 6; social burden, n = 6; financial burden, n = 4). Statistical analyses were conducted using the t test, 1-way analysis of variance with the Scheffé post hoc test, and the chi-square test, and P < .05 was considered statistically significant. A total of 160 caregivers (age, 50–53 years) were recruited (n = 80 each in the home care and RCW groups), and most of these caregivers were married women. Due to insufficient sleep, physical exhaustion, back pain, and caregiving, home caregivers had significantly higher physical burden levels than RCW caregivers (P < .01). Home caregivers experienced higher physical burden levels than RCW caregivers. Therefore, clinical and professional support must be provided to home caregivers of PMV patients.

In comparison with spontaneously breathing non-intubated subjects, intubated, mechanically ventilated patients encounter various challenges, barriers, and opportunities in receiving medical aerosols. Since the introduction of mechanical ventilation as a part of modern critical care medicine during the middle of the last century, aerosolized drug delivery by jet nebulizers has become a common practice. However, early evidence suggested that aerosol generators differed in their efficacies, and the introduction of newer aerosol technology (metered dose inhalers, ultrasonic nebulizer, vibrating mesh nebulizers, and soft moist inhaler) into the ventilator circuit opened up the possibility of optimizing inhaled aerosol delivery during mechanical ventilation that could meet or exceed the delivery of the same aerosols in spontaneously breathing patients. This narrative review will catalogue the primary variables associated with this process and provide evidence to guide optimal aerosol delivery and dosing during mechanical ventilation. While gaps exist in relation to the appropriate aerosol drug dose, discrepancies in practice, and cost-effectiveness of the administered aerosol drugs, we also present areas for future research and practice. Clinical practice should expand to incorporate these techniques to improve the consistency of drug delivery and provide safer and more effective care for patients.

BACKGROUND: The performance of nebulizers varies with the design type as well as the breathing patterns of various age groups. The present study quantified aerosol delivery using spontaneously breathing parameters of a small child (2–4 years) by a lung simulator to determine the influence of nebulizer type, actuation mechanisms, and pediatric aerosol masks. METHODS: Three types of nebulizer (constant-output, breath-enhanced, and breath-actuated nebulizer) and 3 masks (standard pediatric mask, the Fish mask, and a valved mask) were chosen for the testing. The actuation mechanism of the breath-actuated nebulizer was tested by manual synchronization with inspiration, breath actuation, and continuous nebulization. The nebulizer performance was determined by determining mass median aerodynamic diameter and analyzing drug deposition distal to the trachea (inhaled mass), on the face, on the mask, residual drug in the nebulizer, and the time of nebulization. The quantity of salbutamol deposited was determined by spectrophotometry (276 nm). RESULTS: Mass median aerodynamic diameter was similar across nebulizers. Breath-actuated nebulization generated a lower inhaled dose and higher nebulization time than continuous nebulization ( P = .001). Breath synchronized aerosol generation, whether breath-actuated or manually actuated, yielded 10–20 times lower inhaled mass than continuous nebulization (0.1–0.6% vs 5–11%, respectively). The AeroEclipse, operated continuously, delivered greater inhaled dose than the LC Plus ( P = .025). Higher inhaled dose was achieved with the Fish mask than standard or valved mask, with all nebulizers tested ( P = .001). CONCLUSIONS: In this model using ventilatory parameters associated with a 2–4-year-old child, breath-actuated nebulization was not as effective as continuous nebulization. Aerosol mask design can impact inhaled drug dose across the range of nebulizers tested.

BACKGROUND: Aerosol delivery through mechanical ventilation is influenced by the type of aerosol generator, pattern of nebulization, and a patient's breathing pattern. This study compares the efficiency of pneumatic nebulization modes provided by a ventilator with adult and pediatric in vitro lung models. METHODS: Three pneumatic nebulization modes (inspiratory intermittent [IIM], continuous [CM], and expiratory intermittent [EIM]) provided by the Galileo Gold ventilator delivered medical aerosol to collection filters distal to an endotracheal tube with adult and pediatric test lungs. A unit dose of 5 mg/2.5 mL albuterol was diluted into 4 mL with distilled water and added to a jet nebulizer. The nebulizer was placed proximal to the ventilator, 15 cm from the inlet of the heated humidifier chamber with a T-piece and corrugated aerosol tubing and powered by gas from the ventilator in each of the 3 modes. Time for nebulization was recorded in minutes. Albuterol samples collected in the inhalation filter, nebulizer, T-piece, and corrugated tubing were eluted with distilled water and analyzed with a spectrophotometer. RESULTS: The inhaled drug, as a percentage of total dose in both lung models, was 5.1–7.5%, without statistical significance among the 3 modes. Median nebulization times for IIM, CM, and EIM were 38.9, 14.3, and 17.7 min, respectively, and nebulization time for the 3 modes significantly differed ( P < .001). The inhaled drug mass for the 3 modes with the adult lung model was similar to that with the pediatric lung model (7.39 ± 0.76 vs 6.27 ± 0.69%, P = .77). CONCLUSIONS: Aerosol drug delivery with a jet nebulizer placed proximal to the ventilator was not dependent on nebulization mode during simulated pediatric and adult conventional mechanical ventilation. Use of expiratory intermittent mode and continuous nebulization should be considered to reduce treatment time.

Although aerosol delivery through mechanical ventilators has been used to administer various medications, little is known of administration with colistin. This in vitro evaluation aimed to evaluate size distribution of colistin delivery by different types of nebulizers and concentrations during mechanical ventilation. Colistin methanesulfonate (colistin) for injection was dissolved in 6 mL of distilled water to produce a low concentration (L; 156 mg) and a high concentration (H; 312 mg). A dose volume of 6 mL was placed in a vibrating mesh nebulizer (VMN) and a jet nebulizer (JN). The inhaled mass (mean ± SD) of the VMN-L (53.80 ± 14.79 mg) was greater than both the JN-L (19.82 ± 3.34 mg, P = 0.001) and JN-H (31.72 ± 4.48 mg, P = 0.017). The nebulization time of the VMN-L (42.35 ± 2.30 min) was two times longer than the JN-L (21.12 ± 0.8 min) or JN-H (21.65 ± 0.42 min; P < 0.001). The mass median aerodynamic distal to the endotracheal tube was within a similar range at 2.03 to 2.26 μm (P = 0.434), independent of neb or formulation concentration. In conclusion, the VMN-L yields greater inhaled mass than the JN with either concentration. Therefore, a standard nominal dose of colistin results in a higher delivered dose during mechanical ventilation with a VMN compared with a JN and may be considered the preferred device. If JN must be used, multiple doses of low concentration colistin may compensate for poor delivery performance.