Nebulization of mucolytic agents and bronchodilating drugs for ICU patients receiving invasive ventilation

Artificial ventilation and the presence of an endotracheal tube or trachea cannula are associated with increased mucus production and impaired airway clearance. Accumulation of airway secretions can lead to mucus plugging in the airway, and consequently cause atelectasis and airway colonization. The first can lead to oxygenation problems, the second may cause respiratory infections.
Preventive routine nebulization of mucolytics, often combined with a bronchodilator, has been suggested to prevent these problems, though this was never tested in a robust study. The national multicenter randomized clinical non-inferiority trial, named NEBULAE, showed an on-demand nebulization strategy to be non-inferior to a preventive routine nebulization strategy with respect to the duration of invasive ventilation, and the proportion of endotracheal tube obstructions. Preventive routine nebulizations, however, led to more adverse events. And were more expensive then on-demand nebulizations. A national survey showed that the preventive nebulization strategy was practiced in many Dutch ICU’s. In a before and after study, successful and sustained de-implementation of preventive routine nebulizations was achieved in one center.