Continuous infusion aerosol delivery of prostacyclins during mechanical ventilation: challenges, limitations, and recent advances

Introduction Critically ill mechanically ventilated patients routinely receive aerosol delivery of epoprostenol by continuous infusion of the nebulizer by syringe pump. This procedure is 'off-label' as no FDA approved drug presently exists. Without standardized protocols, therapy is based on prior experience with bronchodilators, limited studies of delivery systems and anecdotal clinical trials. Current protocols based upon patient body weight and drug concentration determines the infusion rate of drug dose delivered to the nebulizer , which is only distantly related to dose delivered to the lung and may be altered by many factors. Areas covered This paper reviews the background of this technique as well as current methods of managing drug delivery, technical challenges, and limitations. A recent advance in aerosol laboratory bench testing, using radiolabeled aerosols, is presented to reveal important factors defining delivery. Expert opinion Off-label use of continuously nebulized prostacyclin in the ICU lacks the support of large clinical trials needed for FDA clearance. However, comprehensive bench studies afford the potential for clinicians to better understand and manage therapy at a level above simple dosing of the nebulizer by body weight. New research techniques are enhancing our basic comprehension of the interaction between aerosol devices and the mechanical ventilator.

Automated summary

This paper reviews the background, current methods, challenges, and limitations of aerosol delivery of epoprostenol in critically ill mechanically ventilated patients. A recent advance in bench testing using radiolabeled aerosols is presented to reveal important factors defining delivery. The off-label use of continuously nebulized prostacyclin in the ICU lacks support from large clinical trials, but bench studies can provide insight for better therapy management.