Abstract
BackgroundInhalation of nebulised medications is performed in upright sitting to maximise lung volumes. The pattern of deposition is poor for inhaled medications in people with Cystic Fibrosis. The pattern tends to be non-uniform and typically the upper lobes receive a reduced dose compared to the rest of the lung. One strategy that has been proposed as having the potential to improve homogeneity of deposition is to adopt an alternate side lying position for the inhalation procedure. This study sought to determine whether, among adults with Cystic Fibrosis, there is any disadvantage to delivery time of nebulised medications with a strategy of alternate side lying, compared to upright sitting.MethodsA randomised crossover trial with concealed allocation, intention-to-treat analysis and blinded assessors was undertaken. The participants were 24 adults with stable Cystic Fibrosis. They inhaled 4 mL of normal saline via an LC Star™ nebuliser twice within 24 h. In random order, participants sat upright throughout nebulisation, or alternated between left and right side lying at each minute during the nebulisation period. The nebuliser was stopped and weighed each minute until the residual volume was reached. The primary outcome was the time required for 3.5 mL to be delivered. The secondary outcomes were: respiratory rate; ratio of the volume delivered on right and left sides; and calculation of how long the periods in side lying can be extended without causing greater than 20% discrepancy in dose delivered in the two positions.ResultsThe delivery time did not significantly differ between sitting and side lying (mean difference 0.58 min, 95% confidence interval (CI) -1.40 to 0.24). There was no significant correlation between delivery time, lung function or subject height (all R2 < 0.4). Increasing side lying duration from 1 to 2 min did not significantly impact the dose delivered on each side. Turning each 3 min however, significantly worsened the disparity (mean ratio 1.32, 95% CI 1.24 to 1.40).ConclusionSide lying during inhalation therapy does not prolong nebulisation time. 2-min periods should provide an equal dose in the two side lying positions.Trial registrationProspectively registered on 4 July 2011; ACTRN12611000672954.
Highlights
Inhalation of nebulised medications is performed in upright sitting to maximise lung volumes
We considered that a minimum difference of 5 min in delivery time for the 3.5 mL dose would be large enough to contribute to clinical decision-making about which positioning regimen to use
Flow of participants through the study Twenty-four participants with Cystic Fibrosis were recruited and all completed the study. These participants had characteristics that were representative of the characteristics of patients attending the adult Cystic Fibrosis Clinic at Royal Prince Alfred Hospital in regards to age and lung function (FEV1)
Summary
Inhalation of nebulised medications is performed in upright sitting to maximise lung volumes. This study sought to determine whether, among adults with Cystic Fibrosis, there is any disadvantage to delivery time of nebulised medications with a strategy of alternate side lying, compared to upright sitting. Over the past few decades, research has established many nebulised therapies that improve the clinical status and quality of life of people with Cystic Fibrosis, including inhaled tobramycin [1] recombinant human deoxyribonuclease [2] and hypertonic saline [3]. These therapies, along with nebulised bronchodilators and other nebulised antibiotics, add considerably to the duration of a patient’s treatment regimen. Poor deposition in the upper lobes has been identified in people with Cystic Fibrosis [7, 14,15,16,17], people with HIV [8, 18, 19], and other populations, including healthy people [9, 20, 21]
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