Effect of routine vs on-demand nebulization of acetylcysteine with salbutamol on accumulation of airway secretions in endotracheal tubes: substudy of a randomized clinical trial

Sophia van der Hoeven, Lorenzo Ball, Federico Constantino, David M van Meenen, Paolo Pelosi, Ludo F Beenen, Marcus J Schultz, Frederique Paulus, NEBULAE-investigators, Sophia van der Hoeven, Lorenzo Ball, Federico Constantino, David M van Meenen, Paolo Pelosi, Ludo F Beenen, Marcus J Schultz, Frederique Paulus, NEBULAE-investigators

Abstract

Background: Accumulated airway secretions in the endotracheal tube increase work of breathing and may favor airway colonization eventually leading to pneumonia. The aim of this preplanned substudy of the 'Preventive Nebulization of Mucolytic Agents and Bronchodilating Drugs in Intubated and Ventilated Intensive Care Unit Patients trial' (NEBULAE) was to compare the effect of routine vs on-demand nebulization of acetylcysteine with salbutamol on accumulation of secretions in endotracheal tubes in critically ill patients.

Results: In this single-center substudy of a national multicenter trial, patients were randomized to a strategy of routine nebulizations of acetylcysteine with salbutamol every 6 h until end of invasive ventilation, or to a strategy with on-demand nebulizations of acetylcysteine or salbutamol applied on strict clinical indications only. The primary endpoint, the maximum reduction in cross-sectional area (CSA) of the endotracheal tube was assessed with high-resolution computed tomography. Endotracheal tubes were collected from 72 patients, 36 from patients randomized to the routine nebulization strategy and 36 of patients randomized to the on-demand nebulization strategy. The maximum cross-sectional area (CSA) of the endotracheal tube was median 12 [6 to 15]% in tubes obtained from patients in the routine nebulization group, not different from median 9 [6 to 14]% in tubes obtained from patients in the on-demand nebulization group (P = 0.33).

Conclusion: In adult critically ill patients under invasive ventilation, routine nebulization of mucolytics and bronchodilators did not affect accumulation of airway secretions in the endotracheal tube. Trial registration Clinicaltrials.gov Identifier: NCT02159196.

Keywords: Acetylcysteine; Airway secretions; Endotracheal tube; Intensive care unit; Invasive ventilation; Nebulization; Salbutamol.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Tube mold used for image acquisition (a) and corresponding computed tomography image (b) of a partially obstructed tube (left) and the control tube (right). Bland–Altman analysis between CT-estimated and scale-measured mucus weight using a threshold of − 770 HU (c). CT, computed tomography.
Fig. 2
Fig. 2
Flow of patients in the effect of on-demand vs routine nebulization of acetylcysteine with salbutamol on endotracheal tube occlusion assessed with computed tomography a substudy of the NEBULAE randomized trial. ICU, intensive care unit; ETT, endotracheal tube
Fig. 3
Fig. 3
Endotracheal tube percent cross-sectional area reduction of each 1-mm section as function of the distance from the tube tip in patients receiving on-demand nebulizations (black) and patients receiving routine nebulizations (red). Values are plotted as median; error bands represent interquartile ranges. This plot represents the average mucus distribution in the two randomization arms, which is lower compared to the maximum cross-sectional area reduction of each patient. P-values are calculated with a two-way ANOVA using the distance from the tube tip and the randomization arm as factors. mm, millimeter

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Source: PubMed

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