Report of the UK Cystic Fibrosis Trust Antibiotic Working Group

5.16 Nebuliser/compressor systems for antibiotics5.16.1 Characteristics of available devicesDelivery devices for antibiotics are divided into the traditional conventional nebuliser/compressorsystems and the more recent devices which utilise vibrating mesh technology. Conventional systemsconsist of a jet nebuliser and electrical air compressor.The new generation of nebulisers has advanced from jet nebulisation to vibrating mesh technologywhich produces a fine, dense aerosol cloud of low velocity e.g. eFlow® rapid and I-neb® Theyprovide shorter treatment times with improved efficiency and efficacy of deposition. These devices aresmall, light weight, silent and battery driven.The I-neb® has the additional features of AAD® and ‘target inhalation mode’ (TIM). AAD® adaptsto the individual's breathing pattern and targets antibiotic delivery to the first part of inspiration. Apredetermined dose is delivered with audible feed back on successful completion. Drug delivery istherefore precise and reproducible with each administration. No drug is delivered during expirationand environmental contamination is eliminated. (1% of exhaled fraction during tidal breathing modeand 0.2% during TIM). 73 TIM promotes a slow deep inhalation which is controlled by restricting theinspiratory flow to 15 L/min. Sensory feedback to the lip indicates the expiratory phase. This modeof inhalation results in high peripheral deposition 74 and is acceptable to patients. 75An RCT of an earlier device, utilising AAD® (Halolite®), compared the use of the AAD andconventional high output nebuliser system in 259 patients with CF in a multicentre trial. The AADwas preferred by patients, increased their adherence to treatment and resulted in more doses beingtaken to an acceptable level. It was suggested that the increased chest tightness observed afterinhalation of colistin using the AAD might have been due to more successful delivery to thelungs. 76;77 The use of bronchodilator solution in patients using AAD with colistin had a positive effecton maintaining both short and long-term FEV1, as opposed to bronchodilator via a metered doseinhaler or dry powder inhaler. 76 In another study, using the AAD system, colistin in doses up to 2MUdissolved in 2 ml of 0.9% sodium chloride was well tolerated. 78Studies evaluating AAD® and I-neb® have demonstrated increased pulmonary deposition comparedto conventional systems. 78-80 Whilst it is recognised that conventional systems may under-dosepatients, clinicians should be attentive to the potential for over-dosing with the new devices.Individual patient monitoring and follow up is recommendedThe eFlow® rapid delivers continuous nebulisation with exhaled antibiotic into the environment.Any requirement for filtering would apply to this device. Audible cut out occurs at the end oftreatment based on the remaining residual volume of the nebuliser. Drug delivery is angle dependentand accounts for variability of dose deliveredI-neb® is only available with a prescription of Promixin® and is supplied at no cost by the company.The eFlow® rapid is available for purchase.5.16.2 Recommendations for nebuliser devices• For conventional systems use an active venturi nebuliser (breath assisted) e.g. Ventstream(Respironics, Chichester, UK) or Pari LC Sprint or Pari LC Sprint Star (Pari Medical, WestByfleet UK) with a compressor producing a flow rate of 6 litres per minute. If unacceptably long,the nebulisation time can be reduced for patients with low inspiratory flow [D].Cystic Fibrosis Trust 5.16March 2009