title: Ventilator-integrated jet nebulization systems: tidal volume control and efficiency of synchronization.
abstract: BACKGROUND
  Jet nebulizers constitute the aerosolization devices most frequently used during mechanical ventilation. Continuous nebulization can influence the delivered tidal volume (V(T)) and lead to significant medication loss during expiration. Ventilators thus provide integrated jet nebulization systems that are synchronized during inspiration and ostensibly keep VT constant.
  
  
  METHODS
  This was a bench study of systems integrated in the Evita XL, Avea, Galileo, and G5 ventilators. The VT delivered with and without nebulization, the inspiratory synchronization of nebulization, and the aerosol deposition were measured with 2 locations of the nebulizer.
  
  
  RESULTS
  Changes in V(T) with the nebulizer were below 20 mL and below 10% of set V(T) for all ventilators. Synchronization was good at the beginning of insufflation, but prolonged nebulization was observed with all ventilators at the end of insufflation, until up to 1 s during expiration: 5-80% of nebulization occurred during expiration with significant aerosol loss in the expiratory limb. Synchrony could be improved by (1) reducing gas compression/decompression phenomena proximal to the jet nebulizer and (2) increasing inspiratory time, which reduced the amount of nebulization occurring during expiration. Placing the nebulizer upstream in the inspiratory limb did not affect inspiratory synchrony but allowed reduction of the amount of aerosol lost in the expiratory limb.
  
  
  CONCLUSIONS
  Jet nebulizer systems integrated in the tested ventilators are reliable in terms of V(T) control. Gas compression in tubing driving gas to the nebulizer delays synchronization and reduces nebulization yield if the nebulizer is placed close to the Y-piece. Increasing inspiratory time with no end-inspiratory pause reduces the expiratory loss of medication if placement of the nebulizer upstream in the inspiratory limb is not feasible.
authors.affiliation: Institut National de la Santé et de la Recherche Médicale, U955, Équipe Biomécanique Cellulaire et Respiratoire, and the Centre National de la Recherche Scientifique, équipe de recherche labellisée 7240, Créteil, France. Université Paris-Est Créteil, Unité Mixte de Recherche S955, Créteil, France. Service de Réanimation Polyvalente, Centre Hospitalier Régional Universitaire de Tours, Tours, France. Centre d'Étude des Pathologies Respiratoires, Institut National de la Santé et de la Recherche Médicale, UMR 1100/EA6305 F-37032 Tours, France, and the Faculté de Médecine de Tours, UMR 1100 Université François Rabelais, F-37032 Tours, France. stephanehrmann@gmail.com.
authors.forename: Stephan
authors.initials: S
authors.lastname: Ehrmann
authors.affiliation: Service des Soins Intensifs, Hôpitaux Universitaires de Genève, Geneva, Switzerland and Institut supérieur des sciences de la santé, Université Hassan ler, Settat, Morocco.
authors.forename: Aissam
authors.initials: A
authors.lastname: Lyazidi
authors.affiliation: Institut National de la Santé et de la Recherche Médicale, U955, Équipe Biomécanique Cellulaire et Respiratoire, and the Centre National de la Recherche Scientifique, équipe de recherche labellisée 7240, Créteil, France. Université Paris-Est Créteil, Unité Mixte de Recherche S955, Créteil, France.
authors.forename: Bruno
authors.initials: B
authors.lastname: Louis
authors.affiliation: Institut National de la Santé et de la Recherche Médicale, U955, Équipe Biomécanique Cellulaire et Respiratoire, and the Centre National de la Recherche Scientifique, équipe de recherche labellisée 7240, Créteil, France. Université Paris-Est Créteil, Unité Mixte de Recherche S955, Créteil, France.
authors.forename: Daniel
authors.initials: D
authors.lastname: Isabey
authors.affiliation: Centre d'Étude des Pathologies Respiratoires, Institut National de la Santé et de la Recherche Médicale, UMR 1100/EA6305 F-37032 Tours, France, and the Faculté de Médecine de Tours, UMR 1100 Université François Rabelais, F-37032 Tours, France.
authors.forename: Déborah
authors.initials: D
authors.lastname: Le Pennec
authors.affiliation: Institut National de la Santé et de la Recherche Médicale, U955, Équipe Biomécanique Cellulaire et Respiratoire, and the Centre National de la Recherche Scientifique, équipe de recherche labellisée 7240, Créteil, France. Department of Critical Care, St Michael's Hospital, the Keenan Research Centre and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
authors.forename: Laurent
authors.initials: L
authors.lastname: Brochard
authors.affiliation: Institut National de la Santé et de la Recherche Médicale, U955, Équipe Biomécanique Cellulaire et Respiratoire, and the Centre National de la Recherche Scientifique, équipe de recherche labellisée 7240, Créteil, France. Université Paris-Est Créteil, Unité Mixte de Recherche S955, Créteil, France. Wellman Center for Photomedicine, Massachusetts General Hospital, and the Department of Dermatology, Harvard Medical School, Boston, Massachusetts.
authors.forename: Gabriela
authors.initials: G
authors.lastname: Apiou-Sbirlea
mesh_terms: D000280:Administration, Inhalation; D000336:Aerosols / Q000008:administration & dosage; D004867:Equipment Design; D006611:High-Frequency Jet Ventilation; D006801:Humans; D066298:In Vitro Techniques; D007362:Intensive Care Units; D009330:Nebulizers and Vaporizers; D013990:Tidal Volume
chemical_list: D000336:Aerosols
keywords: administration, inhalation [MeSH]; nebulizers and vaporizers [MeSH]; respiration, artificial [MeSH]