title: The delivery of aerosolized steroids from MDIs with nozzle extensions: quantitative laboratory evaluation of a method to improve aerosol delivery to intubated patients.
abstract: OBJECTIVE
  Pulmonary deposition of aerosolized drug from a metered dose inhaler (MDI) is low with intubated patients. In the laboratory, extension of the MDI nozzle to the endotracheal tube tip has been shown to increase the delivered dose of albuterol. The objectives of this study were to determine the dose of aerosolized steroid (beclomethasone and triamcinolone) delivered through a MDI nozzle extension, the effect of nozzle extension length and number of actuations on the delivered dose, and particle size delivered through the nozzle extension.
  
  
  METHODS
  A 19-G catheter was used as the MDI nozzle extension. The nozzle extension was attached to a 60-ml syringe via the Luer-Lok connection, and the distal end was directed through a hole drilled into a 15-ml capped tube. The MDI was placed into the syringe and actuated by pressing the syringe plunger. Drug delivered through the nozzle extension into the tube was dissolved in methanol (beclomethasone) or ethanol (triamcinolone). Nozzle extension lengths of 10 cm, 20 cm and 30 cm were studied. For each nozzle extension length, delivery was assessed using one, two, three and five actuations of each drug. Drug remaining in the nozzle extension was recovered by rinsing with the appropriate solvent. Aerosol particle size leaving the nozzle extension was determined using a seven-stage cascade impactor. Beclomethasone and triamcinolone concentrations were determined by spectrophotometry at 239 nm.
  
  
  METHODS
  Respiratory care laboratory of a university teaching hospital.
  
  
  RESULTS
  For the pooled results, 70.2 +/- 14.1% of the dose was delivered through the nozzle extension, with no difference between beclomethasone and triamcinolone (p = 0.838). The proportion of drug delivered through the 10-cm extension (76.7 +/- 8.4%) was greater than that from the 20-cm (66.1 +/- 16.5%) and 30-cm (67.7 +/- 13.9%) extensions (p = 0.001). Less drug was delivered through the extension with one actuation (54.1 +/- 17.7%) than with two (71.2 +/- 7.7%), three (77.2 +/- 5.5%), or five actuations (78.2 +/- 4.3%) (p < 0.001). There was a decrease in MMAD with increasing nozzle extension length (3.14 +/- 0.61 microns for 10 cm, 2.97 +/- 0.28 microns for 20 cm, 2.37 +/- 0.27 microns for 30 cm; p = 0.005).
  
  
  CONCLUSIONS
  A high proportion of aerosolized steroid was delivered with a MDI actuated through a nozzle extension. The proportion delivered through the nozzle extension was significantly less with longer nozzle extensions and with fewer actuations, but this may not be clinically important. Although particle sizes were smaller from longer nozzle extensions, all were within the respirable range. These results suggest that steroids can be delivered efficiently using a MDI nozzle extension.
authors.affiliation: Respiratory Care Laboratory, Massachusetts General Hospital, Boston 02114, USA.
authors.forename: D
authors.initials: D
authors.lastname: Hess
authors.forename: D
authors.initials: D
authors.lastname: Fisher
authors.forename: R A
authors.initials: RA
authors.lastname: Peterfreund
authors.forename: R M
authors.initials: RM
authors.lastname: Kacmarek
mesh_terms: D000336:Aerosols; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage*; D001507:Beclomethasone / Q000008:administration & dosage*; D004867:Equipment Design; D006801:Humans; D008422:Materials Testing; D009330:Nebulizers and Vaporizers / Q000592:standards*; D010316:Particle Size; D012121:Respiration, Artificial; D013053:Spectrophotometry; D014018:Tissue Distribution; D014221:Triamcinolone / Q000008:administration & dosage*
chemical_list: D000336:Aerosols; D000893:Anti-Inflammatory Agents; D014221:Triamcinolone; D001507:Beclomethasone