RESUMEN

Desde hace más de 30 años los medicamentos inhalados y los dispositivos para su administración son una opción segura y eficaz en el manejo de múltiples enfermedades respiratorias. Existen indicaciones plenamente demostradas para algunos fármacos v.gr., los broncodilatadores y corticosteroides inhalados son particulares a enfermedades como asma y EPOC; el uso de antibióticos en fibrosis quística, los vasodilatadores pulmonares en hipertensión arterial pulmonar. No obstante, existen padecimientos agudos caracterizados por inflamación en la vía aérea y producción de secreciones que representan un reto para que el clínico pueda aplicar las opciones terapéuticas y el mejor dispositivo para su entrega. El objetivo del presente documento es proporcionar un panorama basado en la información disponible sobre los fármacos que son administrados de forma inhalada; asimismo, describir los dispositivos apropiados para lograr el objetivo propiamente mencionado.

PALABRAS CLAVE

Propelentes de aerosoles, broncodilatadores, corticosteroides, antibióticos, mucolíticos, nebulizadores.

REFERENCIAS

1. Dhand R. Basic techniques for aerosol delivery during mechanical ventilation. Respir Care 2004;49:611-622.

2. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College Of Asthma, Allergy, And Immunology. Chest 2005;127:335-371.

3. Luyt CE, Combes A, Nieszkowska A, Trouillet JL, Chastre J. Aerosolized antibiotics to treat ventilator-associated pneumonia. Curr Opin Infect Dis 2009;22:154-158.

4. Newman SP, Pavia D, Morén F, Sheahan NF, Clarke SW. Deposition of pressurized aerosols in the human respiratory tract. Thorax 1981;36:52-55.

5. Fernández Tena A, Casan Clarà P. Deposition of inhaled particles in the lungs. Arch Bronconeumol 2012;48:240-246.

6. Kondili E, Georgopoulos D. Aerosol medications. Respir Care Clin N Am 2002;8:309-334.

7. Dhand R. Inhalation therapy in invasive and noninvasive mechanical ventilation. Curr Opin Crit Care 2007;13:27-38.

8. Geller DE. Comparing clinical features of the nebulizer, metered-dose inhaler, and dry powder inhaler. Respir Care 2005;50:1313-1321.

9. Mouloudi E, Georgopoulos D. Treatment with aerosols in mechanically ventilated patients: is it worthwhile? Curr Opin Anaesthesiol 2002;15:103-109.

10. Balsamo R, Lanata L, Egan CG. Mucoactive drugs. Eur Respir Rev 2010;19:127-133.

11. Witek TJ Jr. The fate of inhaled drugs: the pharmacokinetics and pharmacodynamics of drugs administered by aerosol. Respir Care 2000;45:826-830.

12. Colice GL. Comparing inhaled corticosteroids. Respir Care 2000;45:846-853.

13. Calverley P, Pauwels R, Vestbo J, et al. Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: a randomized controlled trial Lancet 2003;361:449-456.

14. Jones PW, Willits LR, Burge PS, Calverley PM. Disease severity and the effect of fluticasone propionate on chronic obstructive pulmonary disease exacerbations. Eur Respir J 2003;21:68-73.

15. Nava S, Compagnoni ML. Controlled short-term trial of fluticasone propionate in ventilator-dependent patients with COPD. Chest 2000;118:990-999.

16. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.

17. Pérez-Pedrero MJ, Sánchez-Casado M, Rodríguez-Villar S. Nebulized colistin treatment of multi-resistant Acinetobacter baumannii pulmonary infection in critical ill patients. Med Intensiva 2011;35:226-231.

18. Linden PK, Paterson DL. Parenteral and inhaled colistin for treatment of ventilator-associated pneumonia. Clin Infect Dis 2006;43:S89-94.

19. Palmer LB. Aerosolized antibiotics in critically ill ventilated patients. Curr Opin Crit Care 2009;15:413-418.

20. Palmer LB, Smaldone GC, Chen JJ, et al. Aerosolized antibiotics and ventilator-associated tracheobronchitis in the intensive care unit. Crit Care Med 2008;36:2008-2013.

21. Badia JR, Soy D, Adrover M, et al. Disposition of instilled versus nebulized tobramycin and imipenem in ventilated intensive care unit (ICU) patients. J Antimicrob Chemother 2004;54:508-514.

22. Miller DD, Amin MM, Palmer LB, Shah AR, Smaldone GC. Aerosol delivery and modern mechanical ventilation: in vitro/in vivo evaluation. Am J Respir Crit Care Med 2003;168:1205-1209.

23. Palmer LB, Smaldone GC, Simon SR, O’Riordan TG, Cuccia A. Aerosolized antibiotics in mechanically ventilated patients: delivery and response. Crit Care Med 1998;26:31-39.

24. Goldstein I, Wallet F, Robert J, Becquemin MH, Marquette CH, Rouby JJ. Lung tissue concentrations of nebulized amikacin during mechanical ventilation in piglets with healthy lungs. Am J Respir Crit Care Med 2002;165:171-175.

25. Luyt CE, Clavel M, Guntupalli K, et al. Pharmacokinetics and lung delivery of PDDS-aerosolized amikacin (NKTR-061) in intubated and mechanically ventilated patients with nosocomial pneumonia. Crit Care 2009;13:R200.

26. Geller DE. Aerosol antibiotics in cystic fibrosis. Respir Care 2009;54:658-670.

27. Konstan MW, Flume PA, Kappler M, et al. Safety, efficacy and convenience of tobramycin inhalation powder in cystic fibrosis patients: The EAGER trial. J Cyst Fibros 2011;10:54-61.

28. Michalopoulos A, Fotakis D, Virtzili S, et al. Aerosolized colistin as adjunctive treatment of ventilator-associated pneumonia due to multidrug-resistant Gram-negative bacteria: a prospective study. Respir Med 2008;102:407-412.

29. Dhand R. The role of aerosolized antimicrobials in the treatment of ventilator-associated pneumonia. Respir Care 2007;52:866-884.

30. Gomberg-Maitland M, Olschewski H. Prostacyclin therapies for the treatment of pulmonary arterial hypertension. Eur Respir J 2008;31:891-901.

31. van Heerden PV, Barden A, Michalopoulos N, Bulsara MK, Roberts BL. Dose-response to inhaled aerosolized prostacyclin for hypoxemia due to ARDS. Chest 2000;117:819-827.

32. Siobal MS, Hess DR. Are inhaled vasodilators useful in acute lung injury and acute respiratory distress syndrome? Respir Care 2010;55:144-157.

33. Hoeper MM, Schwarze M, Ehlerding S, et al. Long-term treatment of primary pulmonary hypertension with aerosolized iloprost, a prostacyclin analogue. N Engl J Med 2000;342:1866-1870.

34. Voswinckel R, Enke B, Reichenberger F, et al. Favorable effects of inhaled treprostinil in severe pulmonary hypertension: results from randomized controlled pilot studies. J Am Coll Cardiol 2006;48:1672-1681.

35. Stevens TP, Harrington EW, Blennow M, Soll RF. Early surfactant administration with brief ventilation vs selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev 2007:CD003063.

36. Anzueto A, Baughman RP, Guntupalli KK, et al. Aerosolized surfactant in adults with sepsis-induced acute respiratory distress syndrome. Exosurf Acute Respiratory Distress Syndrome Sepsis Study Group. N Engl J Med 1996;334:1417-1421.

37. Rogers DF. Mucoactive agents for airway mucus hypersecretory diseases. Respir Care 2007;52:1176-1193.

38. Rubin BK. Mucolytics, expectorants, and mucokinetic medications. Respir Care 2007;52:859-865.

39. Fuloria M, Rubin BK. Evaluating the efficacy of mucoactive aerosol therapy. Respir Care 2000;45:868-873.

40. Gentile MA. Inhaled medical gases: more to breathe than oxygen. Respir Care 2011;56:1341-1357.

41. Frazier MD, Cheifetz IM. The role of heliox in paediatric respiratory disease. Paediatr Respir Rev 2010;11:46-53.

42. Moga AM, de Marchie M, Saey D, Spahija J. Mechanisms of non-pharmacologic adjunct therapies used during exercise in COPD. Respir Med 2012;106:614-626.

43. Goode ML, Fink JB, Dhand R, Tobin MJ. Improvement in aerosol delivery with helium-oxygen mixtures during mechanical ventilation. Am J Respir Crit Care Med 2001;163:109-114.

44. Cavaliere F, Masieri S. Furosemide protective effect against airway obstruction. Curr Drug Targets 2002;3:197-201.

45. Dolovich MA, MacIntyre NR, Anderson PJ, et al. Consensus statement: aerosols and delivery devices. American Association for Respiratory Care. Respir Care 2000;45:589-596.

46. Duarte AG, Fink JB, Dhand R. Inhalation therapy during mechanical ventilation. Respir Care Clin N Am 2001;7:233-260.

47. Laube BL, Janssens HM, de Jongh FH, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J 2011;37:1308-1331.

48. Newman SP. Aerosol generators and delivery systems. Respir Care 1991;36:939-951.

49. Hess DR. Nebulizers: principles and performance. Respir Care 2000;45:609-622.

50. Nebulizer therapy. Guidelines. British thoracic society nebulizer project group. Thorax 1997;52:S4-24.

51. Hess D, Fisher D, Williams P, Pooler S, Kacmarek RM. Medication nebulizer performance. Effects of diluent volume, nebulizer flow, and nebulizer brand. Chest 1996;110:498-505.

52. Everard ML, Evans M, Milner AD. Is tapping jet nebulizers worthwhile? Arch Dis Child 1994;70:538-539.

53. Fink JB. Aerosol device selection: evidence to practice. Respir Care 2000;45:874-885.

54. Dhand R, Guntur VP. How best to deliver aerosol medications to mechanically ventilated patients. Clin Chest Med 2008;29:277-296.

55. Coates AL, Denk O, Leung K, et al. Higher tobramycin concentration and vibrating mesh technology can shorten antibiotic treatment time in cystic fibrosis. Pediatr Pulmonol 2011;46:401-408.

56. Newman SP. Principles of metered-dose inhaler design. Respir Care 2005;50:1177-1190.

57. Smyth HD. The influence of formulation variables on the performance of alternative propellant-driven metered dose inhalers. Adv Drug Deliv Rev 2003;55:807-828.

58. Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulizers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2006:CD000052.

59. Wieshammer S, Dreyhaupt J. Dry powder inhalers: which factors determine the frequency of handling errors? Respiration 2008;75:18-25.

60. Lavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med 2008;102:593-604.

61. Dahl R, Backer V, Ollgaard B, Gerken F, Kesten S. Assessment of patient performance of the HandiHaler compared with the metered dose inhaler four weeks after instruction. Respir Med 2003;97:1126-1133.