Résumé
La ventilation mécanique (VM) était historiquement considérée comme une barrière à l’administration de médicaments sous forme d’aérosols inhalés. En détaillant les différents éléments de l’interaction complexe entre l’aérosol et la VM, nous verrons que l’administration d’aérosols médicamenteux au travers du circuit de VM est tout à fait pertinente à l’heure actuelle. La disponibilité de bêta-2-mimétiques et de corticoïdes sous forme d’aérosolsdoseurs rend leur administration simple, moyennant l’utilisation de chambres d’inhalation dédiées à la VM. L’administration d’autres molécules, comme les antibiotiques, nécessite le recours à des nébuliseurs: le choix entre nébuliseurs pneumatiques, ultrasoniques et à grille perforée sera discuté. Un certain nombre de moyens permettent d’optimiser le rendement de nébulisation: placement des nébuliseurs continus 15 à 40 cm en amont de la pièce en Y, réduction du débit inspiratoire et utilisation de nébuliseurs synchronisés sur l’inspiration. L’ensemble de ces moyens d’optimisation de l’aérosolthérapie au cours de la VM a permis d’obtenir des résultats cliniques significatifs. Nous ferons le point sur les données expérimentales et cliniques concernant l’efficacité des bêta-2-mimétiques, corticoïdes et antibiotiques inhalés au cours de la VM. En particulier, le traitement par voie inhalée des pneumonies acquises sous VM offre des perspectives cliniques intéressantes. Enfin, nous terminerons avec des recommandations concrètes pour la mise en oeuvre pratique de l’aérosolthérapie au cours de la VM.
Abstract
Mechanical ventilation was historically considered as a barrier to administer inhaled aerosolized drugs. Nowadays, inhaled aerosolized drug administration during mechanical ventilation is quite relevant, thanks to the understanding of the key factors ruling the complex interaction between the aerosol and mechanical ventilation. Availability of beta-2-mimetics and corticosteroids as metered-dose inhalers makes their delivery simple when using inhalation chambers dedicated to mechanical ventilation. Administration of other molecules like antibiotics requires the use of a nebulizer. The choice between pneumatic, ultra-sonic, and mesh nebulizers will be discussed. Several means allow optimizing nebulization performance, including the placement of continuous nebulizer 15–40 cm before the Y piece, the reduction in inspiratory flow, and the use of inspiration-synchronized nebulizers. When performed during mechanical ventilation, they led to significant clinical results. Here, experimental and clinical data regarding beta-2-agonists, corticosteroids, and antibiotics efficiency when delivered as inhaled aerosols during mechanical ventilation, will be high-lightened. Consistently, inhaled treatment of ventilator associated pneumonia appears promising. Finally, recommendations for implementation of aerosol therapy during mechanical ventilation will be presented for the clinical practice.
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Ehrmann, S., Guillon, A., Mercier, E. et al. Administration d’aérosols médicamenteux au cours de la ventilation mécanique. Réanimation 21, 42–54 (2012). https://doi.org/10.1007/s13546-011-0338-8
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DOI: https://doi.org/10.1007/s13546-011-0338-8