Pulmonary Drug Delivery in the Prehospital Setting

1
Pulmonary Drug Delivery in the Prehospital Setting
2
ACLS 2002

• If a tracheal tube has been placed before venous
  access is achieved, epinephrine, lidocaine, and
  atropine can be administered via the tracheal
  tube. Administer all tracheal medications at 2 to
  2.5 times the recommended IV dose, diluted in 10
  ml of normal saline or distilled water. .

3
ACLS 2002

• Pass a catheter beyond the tip of the tracheal
  tube, stop chest compressions, spray the drug
  solution quickly down the tracheal tube, follow
  immediately with several quick insufflations to
  create a rapidly absorbed aerosol, then resume
  chest compressions.

4
Stop chest compressions

• Why stop chest compressions?
• To prevent splash-back of medications into your
  face.
• To protect you from eye and mucous membrane
  contamination with patient secretions that may
  contain HIV, hepatitis, tuberculosis and other
  bad lung bugs.

5
Pass a catheter

• Why Pass a catheter?
• Reduces drug loss
• Doesn't stick to the ET tube wall.
• Doesnt splash back out the unattached ETT.
• Increases volume of drug delivered to the source
  tissue - lungs

6
Spray the drug... to create a rapidly absorbed
aerosol

• Why an aerosol?
• Aerosolized medication will deposit more distally
  in the lung tissue covering a larger absorptive
  surface.
• Larger surface coverage better drug absorption
  into the blood stream.

7
Literature Support

• Mazkereth Crit Care Med 1992
• Design Compared plasma epinephrine
  concentrations after direct ETT administration
  versus catheter delivery into the bronchus.
• Results
• Catheter delivery resulted in twice the blood
  epinephrine level in half the time (1.2 minutes)

8
Literature Support

• Paret Resuscitation 1999
• Design Compared plasma atropine concentrations
  and cardiac responses after direct ETT
  administration versus catheter delivery into the
  bronchus.
• Results
• Catheter delivery resulted in twice the atropine
  blood level, longer half-life and higher heart
  rate.

9
Pulmonary Drug Delivery in ACLS Ideal Delivery
system

• No need to stop ventilation
• No need to stop CPR
• No risk of splash-back into the face
• Catheter delivery into the lung to reduce drug
  losses
• Aerosolized mist to improve absorptive surface
  coverage

10
Pulmonary Drug Delivery in ACLS Ideal Delivery
system
MADett - Mucosal Atomization Device
11
MADett - Mucosal Atomization Device

• No need to stop ventilation
• No need to stop CPR
• No risk of splash-back into the face
• Catheter delivery into the lung to avoid
  adherence to the ETT wall
• Aerosolized mist to improve absorptive surface
  coverage

12
MADett - Instructions for use

• Step 1 Attach the MADett adapter to the
  endotracheal tube and resume ventilation.

13
MADett - Instructions for use

• Step 2 Slide the MADett catheter into the ETT
  until the black mark lines up with the 26 cm mark
  on the ETT.

14
MADett - Instructions for use

• Step 3 Once the mark is aligned, tighten the
  lock nut to hold the tube in place.

Lock nut
15
MADett - Instructions for use

• Step 4 Attach ampule of medication to the
  MADett via the luer lock attachment.

16
MADett - Instructions for use

• Step 5 Briskly compress syringe while
  simultaneously bagging the patient to drive
  atomized mist deeply into the lungs

17
MADett - Frequently asked questions

• What dose of ACLS medications should be used?
• ACLS doses are only estimates.
• Use the current dose recommended for ETT delivery
  (2 to 2.5 times IV dose).
• Do not use 10 cc saline chaser since the ETT
  does not need to be washed out into the lungs.

18
MADett - Frequently asked questions

• What other medications can be used with the
  MADett ?
• Most pulmonary medications (including ACLS drugs)
  are off label and require medical director
  approval.
• Consider
• ACLS drugs
• Bronchodilators such as albuterol and Atrovent

19
MADett - Frequently asked questions

• Why not just nebulize drugs wont that improve
  pulmonary drug delivery over atomizing with the
  MADett?
• Nebulization is time consuming and not reasonable
  in cardiac arrest.
• Nebulization results in less drug delivery to the
  lungs than catheter delivery via ETT.
• See literature support next slide

20
Literature support Nebs vs ETT catheter

• Crogan, Anesthesiology 1989
• 3 of MDI delivered drug exits tip of 6.0 tube
• 6.5 of MDI delivered drug exits tip of 9.0 tube
• Coleman, Ann Pharmacotherapy 1996
• 5-15 of nebulized drug gets to the trachea
• Bressolle, Antimicrob Agents Chemother 1993
• Nebulized drug 8 bioavailable
• ETT Catheter Delivery 47 bioavailability

21
MADett - Frequently asked questions

• What sized endotracheal tube can the MADett be
  used with?
• The MADett is currently designed to adapt to any
  standard single lumen endotracheal tube that is
  size 7.0 or larger.
• Do not use the MADett with endotracheal tubes
  that are smaller than 7.0

22
MADett - Frequently asked questions

• When you place the MADett into the lumen of the
  endotracheal tube, does this not cause a severe
  restriction in airflow?
• Placing the MADett within the ETT results in a
  narrowing of internal tube diameter equivalent to
  a tube that is 2 sizes smaller.
• Clinically the airflow restriction is barely
  noticeable while bagging a patient.

23
Using the MADett

• Practice!!
• Everyone should familiarize him/herself with the
  MADett before using it in the field.
• Using the device - general
• 1st Draw up water into a syringe
• 2nd Expel air from syringe.
• 3rd Attach syringe to the MADett device via
  luer lock.
• 4th Briskly compress the syringe plunger.
• Brisk brief compression results in controlled
  atomization.
• Gently pushing the plunger will not result in
  atomization.

24
Using the MADett

• Now practice on a manikin
• Intubate a manikin
• Attach the MADett? adapter to the ETT and begin
  ventilation.
• Slide the MADett catheter in until the 26 cm
  mark is aligned properly. Tighten the lock nut.
• Attach the medication syringe.
• Inject medication and ventilate simultaneously.

25
MADett Mucosal Atomization Device -
Endotracheal Tube

• Device designed to allow emergency personnel to
  delivery pulmonary medications as an atomized
  spray.
• Broad 30-micron spray ensures excellent pulmonary
  surface coverage.