title: Key considerations on nebulization of antimicrobial agents to mechanically ventilated patients.
abstract: Nebulized antibiotics have an established role in patients with cystic fibrosis or bronchiectasis. Their potential benefit to treat respiratory infections in mechanically ventilated patients is receiving increasing interest. In this consensus statement of the European Society of Clinical Microbiology and Infectious Diseases, the body of evidence of the therapeutic utility of aerosolized antibiotics in mechanically ventilated patients was reviewed and resulted in the following recommendations: Vibrating-mesh nebulizers should be preferred to jet or ultrasonic nebulizers. To decrease turbulence and limit circuit and tracheobronchial deposition, we recommend: (a) the use of specifically designed respiratory circuits avoiding sharp angles and characterized by smooth inner surfaces, (b) the use of specific ventilator settings during nebulization including use of a volume controlled mode using constant inspiratory flow, tidal volume 8 mL/kg, respiratory frequency 12 to 15 bpm, inspiratory:expiratory ratio 50%, inspiratory pause 20% and positive end-expiratory pressure 5 to 10 cm H2O and (c) the administration of a short-acting sedative agent if coordination between the patient and the ventilator is not obtained, to avoid patient's flow triggering and episodes of peak decelerating inspiratory flow. A filter should be inserted on the expiratory limb to protect the ventilator flow device and changed between each nebulization to avoid expiratory flow obstruction. A heat and moisture exchanger and/or conventional heated humidifier should be stopped during the nebulization period to avoid a massive loss of aerosolized particles through trapping and condensation. If these technical requirements are not followed, there is a high risk of treatment failure and adverse events in mechanically ventilated patients receiving nebulized antibiotics for pneumonia.
authors.affiliation: European Study Group for Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain. Electronic address: jrello@crips.es.
authors.forename: J
authors.initials: J
authors.lastname: Rello
authors.affiliation: Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie (UPMC) of Paris 6, Paris, France.
authors.forename: J J
authors.initials: JJ
authors.lastname: Rouby
authors.affiliation: Critical Care Department, CHUV, Lausanne, Switzerland.
authors.forename: C
authors.initials: C
authors.lastname: Sole-Lleonart
authors.affiliation: Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie (UPMC) of Paris 6, Paris, France.
authors.forename: J
authors.initials: J
authors.lastname: Chastre
authors.affiliation: Department of Internal Medicine, Faculty of Medicine & Health Science, Ghent University, European Study Group for Infections in Critically Ill Patients (ESGCIP), Ghent, Belgium.
authors.forename: S
authors.initials: S
authors.lastname: Blot
authors.affiliation: Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie (UPMC) of Paris 6, Paris, France.
authors.forename: C E
authors.initials: CE
authors.lastname: Luyt
authors.affiliation: Critical Care Department, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Institut of Research, Barcelona, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Riera
authors.affiliation: Department of Medical Microbiology and Infectious Diseases, European Study Group of Nosocomial Infections (ESGNI), Rotterdam, The Netherlands.
authors.forename: M C
authors.initials: MC
authors.lastname: Vos
authors.affiliation: Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie (UPMC) of Paris 6, Paris, France.
authors.forename: A
authors.initials: A
authors.lastname: Monsel
authors.affiliation: Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Dhanani
authors.affiliation: Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia.
authors.forename: J A
authors.initials: JA
authors.lastname: Roberts
mesh_terms: D000890:Anti-Infective Agents / Q000008:administration & dosage / Q000627:therapeutic use; D032921:Consensus; D006801:Humans; D009330:Nebulizers and Vaporizers; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy / Q000517:prevention & control; D012121:Respiration, Artificial
chemical_list: D000890:Anti-Infective Agents
keywords: Aminoglycosides; Antibiotic aerosolization; Colistin; Multidrug-resistant organisms; Nebulizers; Ventilator-associated pneumonia; Ventilator-associated tracheobronchitis