Inhalation Therapy In Patients Research Articles

Efficacy and safety of inhaled molecular hydrogen therapy in patients with respiratory failure due to chronic obstructive pulmonary disease exacerbation in post-COVID period

Molecular hydrogen (H2) is a powerful antioxidant and anti-apoptotic agent. H2 has been studied in a number of clinical studies in the recent years.The aim of this research was to investigate the efficacy and safety of H2 inhalation therapy in patients with hypoxemic and hypercapnic respiratory failure (RF) against exacerbation of chronic obstructive pulmonary disease (COPD) in the post-COVID (Corona Virus Disease 2019) period.Methods. The randomized prospective parallel comparative study included patients (n = 60: 40 men aged 71.2 ± 1.8 years, 20 women aged 70.9 ± 2.8 years) with a post-COVID-19 exacerbation of COPD complicated by hypoxemic/hypercapnic RF. The patients were divided into 2 groups: group 1 (main) (n = 30: 18 men, 12 women), group 2 (control) (n = 30: 18 men, 12 women). To maintain arterial blood saturation ≥ 90 %, patients in both groups received respiratory support (non-invasive ventilation) using the Prisma 25ST device (Lowenstein Medical, Germany) in the BiPAP S/T mode (BiLevel Positive Airway Pressure Spontaneous/Time spontaneous/forced mode 20–24/4–6 cm H2O and O2, respectively; the fractional oxygen concentration in the inhaled gas mixture was ≥ 24%). In addition to standard treatment, patients in the main group received additional H2 therapy (Suisonia device, Japan) through a nasal cannula for 90 minutes daily for 14 days.Results. In patients of the main group, a decrease in the stiffness index was detected from 14.6 ± 1.2 to 6.2 ± 0.6 m/s, and the arterial blood lactate level – from 2.84 ± 0.1 to 0.02 ± 0.1 mmol/l (p < 0.001), the calculated shunt fraction Qs/Qt (venous admixture) – from 27.21 ± 3.4 to 7.14 ± 1.23 (p < 0.01) and an increase in the following parameters: reflection index – from 42.2 ± 2.0 to 66.2 ± 4.9% (p < 0.05), virus-specific IgG level – from 134 ± 125 to 669 ± 164 (p < 0. 05), blood flow velocity in arterioles – from 473 ± 108 to 868 ± 64 μm/s (p < 0.05), blood flow velocity in venules – from 299 ± 56 to 862 ± 69 μm/s (p < 0.05), the 6-minute walk distance – from 57.1 ± 4.4 to 328.9 ± 33.7 m (p < 0.05).Conclusion. H2 inhalations were safe and increased the therapeutic effect when added to standard therapy for patients with hypoxemic and hypercapnic RF during exacerbation of COPD in the post-COVID period.

H2 inhalation therapy in patients with moderate COVID-19 (H2COVID): a prospective ascending-dose phase I clinical trial.

This study is registered with ClinicalTrials.gov as NCT04633980.

Adherence, Disease Control, and Misconceptions Related to the Use of Inhalation Therapy in Patients with Obstructive Pulmonary Diseases: A Cross-Sectional Study.

Background and Objectives: Inadequate treatment of asthma and chronic obstructive pulmonary disease (COPD) might have a negative impact on their progression. Inhalation therapy is the cornerstone of pharmacotherapy for these conditions. However, challenges such as low adherence, negative attitudes, and misconceptions about inhaled medications still persist, impeding effective disease management. This study aimed to evaluate adherence, ascertain the level of disease control in asthma and COPD, explore potential misconceptions surrounding inhalation therapy among patients with obstructive lung diseases and the general population in Vojvodina, and evaluate the reliability of newly developed questionnaires employed in the study. Materials and Methods: This cross-sectional study utilized a battery of questionnaires encompassing sociodemographic data, the Asthma Control Test (ACT), the COPD Assessment Test (CAT), along with two novel questionnaires-one for assessing adherence and another for analyzing attitudes toward inhalation therapy. Statistical analyses were conducted using SPSS software, version 25.0. Results: The average ACT score among patients with asthma was 17.31, while it was 19.09 for the CAT questionnaire among COPD patients. The composite score on the newly developed adherence assessment questionnaire was 2.27, exhibiting a reliability coefficient lower than recommended (α = 0.468). Significant statistical differences emerged among sample subgroups regarding attitudes and misconceptions toward inhalation therapy. The reliability coefficient for this questionnaire was deemed satisfactory (α = 0.767). Conclusions: Adherence rates were notably suboptimal in both subgroups of the studied population. The disease control levels were higher among asthma patients, while they exhibited less prevalent misconceptions regarding inhalation therapy compared to COPD patients and the healthy population.

Assessing the effectiveness of inhalation therapy in patients with chronic airway diseases: A new digital measurement

BackgroundThis study aimed to evaluate the effectiveness of inhalation therapy in patients with chronic airway diseases via the use of a new multiparametric inhalation assessment device. MethodsA multiparametric inhalation evaluation device (PF810, UBREATH, Zhejiang, China) that could simulate common inhalation devices with 6 different levels (0-V) of resistance was used in this study. The device was considered suitable if the three parameters of peak inspiratory flow rate (PIFR), effective inspiratory time (EIT), and breath-hold time (BHT) after inspiration met the minimum requirements. ResultsA total of 4,559 tests were performed. The qualification rates of 0-V resistance gear from low to high were 3.38 % (I), 8.42 % (0), 15.31 % (II), 16.71 % (III), 20.27 % (IV), and 46.91 % (V). The COPD patients in the 3 experimental groups had the lowest percentages of isolates classified as resistant 0, III, and V, which were 5.65 %, 11.93 %, and 40.43 %, respectively. The lowest percentage was 39.67 % (V) for insufficient EIT and 18.40 % (V) for BHT less than 5 s after inspiration. The results of 149 subjects who had used the inhalation device showed that the VIE and EIT at 0 levels were significantly greater than those before training (Z= -5.651, -5.646, P < 0.001). The VIE and EIT at I-III and V significantly increased after training (all P < 0.05). ConclusionsPatients using portable inhaler devices do not always inhale with adequate flow patterns. The multiparametric inhalation assessment device may be useful in outpatient settings.

Penerapan Terapi Inhalasi Nebulizer pada Pasein dengan Bersihan Jalan Napas Tidak Efektif Akibat Community-Acquired Pneumonia

Community acquired Pneumonia is a type of Pneumonia that is acquired in the community. The incidence of Pneumonia in Indonesia in 2013 ranged from 23%-27% and mortality was 1.19%. From 2015-2018 confirmed cases of Pneumonia in children under 5 years were recorded at 505,331 patients with 425 patients dying. The prevalence of Pneumonia in Bali Province in 2018 there were 20,560 cases found based on a history of diagnosis by health workers and / or symptoms that had been felt by respondents / patients. Analyze the effect of the application of Nebulizer inhalation therapy in patients with ineffective airway clearance problems due to Community acquired Pneumonia (CAP). Using case study design with the implementation of nursing care from assessment, diagnosis, intervention, implementation, and evaluation. This study was conducted at RSUP Prof. Dr. I.G.N.G NGOERAH, Denpasar Bali, in July 2023. The results of the analysis showed changes in the patient's respiratory status after administration of Nebulizer inhalation therapy. The result is clear white mucus discharge and not viscous; respiratory rate decreased, ronchi sounds decreased, and SPO2 status: 98%, patients appeared calmer. Nebulizer inhalation therapy is effective in overcoming airway clearance problems is not effective in Pneumonia patients, especially CAP.

The role of peak inspiratory flow in the selection of inhalation therapy in patients with chronic obstructive pulmonary disease

Pharmacotherapy for chronic obstructive pulmonary disease (COPD) primarily relies on inhalation therapy. The choice of an appropriate inhalation device is of particular importance as it impacts the frequency of device use errors, patient adherence to treatment, and overall treatment effectiveness. Peak inspiratory flow (PIF) represents the maximum air flow rate generated by a patient during inhalation and is measured in liters per minute. Dry powder inhalers (DPIs) possess internal device resistance that patients must overcome to activate the device. Measuring PIF is an integral component of optimizing COPD therapy when utilizing dry powder inhalers (DPIs). For most DPIs, an optimal PIF value is considered to be no less than 60 L/min, while with a PIF of less than 30 L/min, the medication can’t reach the lower airways. At the same time, the clinical effectiveness of the use of DPI at values of PIF from 30 L/min to 60 L/min may be insufficient, therefore, it is necessary to take into account the value of PIF for the selection of basic COPD therapy. Given the lack of portable fluometers among doctors in real clinical practice, it is important to identify risk factors for suboptimal PIF in patients with COPD. Patients with emphysema, pulmonary hyperinflation, elderly, female, short height, obesity and comorbidity are at risk for insufficient PIF value for further effective use of DPI.This review provides essential information about the role of inspiratory flow for the effective use of DPIs, presents methods for its measurement, discusses predictors of suboptimal PIF, and offers recommendations for selecting inhalation devices for COPD patients based on PIF values.

An electrochemical nitric oxide generator for in-home inhalation therapy in pulmonary artery hypertension

BackgroundInhaled NO is a selective pulmonary vasodilator proven to be therapeutic for patients with pulmonary artery hypertension (PAH). The most common NO delivery system in clinical practice is cylinder-based, but unfortunately limited by its high costs, complicated delivery, and the requirement of an extensive supply chain, leaving vast unmet medical needs globally.MethodsTo address the need for rapid, affordable, and safe production of nitric oxide (NO) for in-home inhalation therapy in patients with PAH. We developed a novel portable device to derive NO from a nitrite complex solution with a copper(II)-ligand catalyst, and further examined its effectiveness in a porcine model of PAH. This model was established by using female Bama miniature pig and induced by monocrotaline (MCT) administration.ResultsThis generator could rapidly and safely produce therapeutic NO at concentrations ranging from 0 to 100 parts per million (ppm) with the least disproportionated nitrogen dioxide (NO2) and byproducts. It could effectively alleviate pulmonary arterial pressure (PAP) and pulmonary vascular resistance (PVR) in piglets with PAH, without causing major physiologic disruptions.ConclusionsOur electrochemical NO generator is able to produce the desired NO doses for pulmonary vasodilation in a safe and sustainable way, with low costs, which paves the way for its subsequent clinical trials in the patient with PAH and other common cardiopulmonary conditions with a high disease burden around the world.

Acinetobacter baumannii among Patients Receiving Glucocorticoid Aerosol Therapy during Invasive Mechanical Ventilation, China.

Acinetobacter baumannii is a nosocomial pathogen associated with severe illness and death. Glucocorticoid aerosol is a common inhalation therapy in patients receiving invasive mechanical ventilation. We conducted a prospective cohort study to analyze the association between glucocorticoid aerosol therapy and A. baumannii isolation from ventilator patients in China. Of 497 enrolled patients, 262 (52.7%) received glucocorticoid aerosol, and A. baumannii was isolated from 159 (32.0%). Glucocorticoid aerosol therapy was an independent risk factor for A. baumannii isolation (hazard ratio 1.5, 95% CI 1.02-2.28; p = 0.038). Patients receiving glucocorticoid aerosol had a higher cumulative hazard for A. baumannii isolation and analysis showed that glucocorticoid aerosol therapy increased A. baumannii isolation in most subpopulations. Glucocorticoid aerosol was not a direct risk factor for 30-day mortality, but A. baumannii isolation was independently associated with 30-day mortality in ventilator patients. Physicians should consider potential A. baumannii infection when prescribing glucocorticoid aerosol therapy.

Polymyxin Induces Significant Transcriptomic Perturbations of Cellular Signalling Networks in Human Lung Epithelial Cells.

Inhaled polymyxins are increasingly used to treat pulmonary infections caused by multidrug-resistant Gram-negative pathogens. We have previously shown that apoptotic pathways, autophagy and oxidative stress are involved in polymyxin-induced toxicity in human lung epithelial cells. In the present study, we employed human lung epithelial cells A549 treated with polymyxin B as a model to elucidate the complex interplay of multiple signalling networks underpinning cellular responses to polymyxin toxicity. Polymyxin B induced toxicity (1.0 mM, 24 h) in A549 cells was assessed by flow cytometry and transcriptomics was performed using microarray. Polymyxin B induced cell death was 19.0 ± 4.2% at 24 h. Differentially expressed genes (DEGs) between the control and polymyxin B treated cells were identified with Student’s t-test. Pathway analysis was conducted with KEGG and Reactome and key hub genes related to polymyxin B induced toxicity were examined using the STRING database. In total we identified 899 DEGs (FDR < 0.01), KEGG and Reactome pathway analyses revealed significantly up-regulated genes related to cell cycle, DNA repair and DNA replication. NF-κB and nucleotide-binding oligomerization domain-like receptor (NOD) signalling pathways were identified as markedly down-regulated genes. Network analysis revealed the top 5 hub genes (i.e., degree) affected by polymyxin B treatment were PLK1 (48), CDK20 (46), CCNA2 (42), BUB1 (40) and BUB1B (37). Overall, perturbations of cell cycle, DNA damage and pro-inflammatory NF-κB and NOD-like receptor signalling pathways play key roles in polymyxin-induced toxicity in human lung epithelial cells. Noting that NOD-like receptor signalling represents a group of key sensors for microorganisms and damage in the lung, understanding the mechanism of polymyxin-induced pulmonary toxicity will facilitate the optimisation of polymyxin inhalation therapy in patients.

Repeated inhaler technique assessment by pharmacists improves inhalation therapy in patients with chronic obstructive pulmonary disease and bronchial asthma

Repeated inhaler technique assessment by pharmacists improves inhalation therapy in patients with chronic obstructive pulmonary disease and bronchial asthma

Impact of inhalation therapy on occurrence of oral manifestations in patients with bronchial asthma, in Jeddah, Saudi Arabia

Background: Inhalation therapy for asthma includes cortisol and bronchodilators. High dosage and long duration of inhalation therapy has been linked with several adverse effects on the oral tissues. Objectives: To explore the oral manifestations associated with the use of inhalation therapy among patients with asthma in Jeddah city. Method: This was a cross sectional study; the non-probability convenient sampling method was used to select 215 subjects (99 with Doctor diagnosed asthma and 116 without asthma), from the outpatient clinics of two private hospitals. Data were collected using interview questionnaire, the standard 5th ed. WHO survey on oral manifestations, measurement of vital signs and anthropometric parameters, as well as clinical oral examination. Data were analyzed using SPSS version 22, and Logistic multinomial regression was used to study the Odds ratio and its 95% confidence interval between the variables. Level of significance for the study was 0.05. Results: The majority of patients with asthma (95%) used inhalation therapy, without use of spacers. Ulceration, pigmentation and candidiasis of the tongue, buccal mucosa and palate weresignificantly more encountered among patients with asthma compared to those without asthma (p &lt; 0.001, 0.002 and 0.046 respectively). Xerostomia and salivary gland affection, also, were significantly more encountered among patients with asthma compared to those without asthma (p &lt; 0.000, and 0.002 respectively). Patients with asthma were 7.7 times more likely to develop tongue disorders (OR: 7.7, p &lt; 0.013), 3 times more likely to develop buccal mucosal disorders (OR: 3, p &lt; 0.039), and 15 times more likely to develop palate disorders (OR: 15, p &lt; 0.004) compared to subjects without bronchial asthma. Conclusion: Use of inhalation therapy in patients with asthma was significantly associated with increased occurrence of oral health problems. Health education programs about proper use of inhalers and oral hygiene should be implemented by primary health care personnel. Key words: Inhalation therapy, Asthma, Oral manifestations, Jeddah.

Digital Inhalers for Asthma or Chronic Obstructive Pulmonary Disease: AScientific Perspective.

Impressive advances in inhalation therapy for patients with asthma and chronic obstructive pulmonary disease (COPD) have occurred in recent years. However, important gaps in care remain, particularly relating to poor adherence to inhaled therapies. Digital inhaler health platforms which incorporate digital inhalers to monitor time and date of dosing are an effective disease and medication management tool, promoting collaborative care between clinicians and patients, and providing more in-depth understanding of actual inhaler use. With advances in technology, nearly all inhalers can be digitalized with add-on or embedded sensors to record and transmit data quantitating inhaler actuations, and some have additional capabilities to evaluate inhaler technique. In addition to providing an objective and readily available measure of adherence, they allow patients to interact with the device directly or through their self-management smartphone application such as via alerts and recording of health status. Clinicians can access these data remotely and during patient encounters, to better inform them about disease status and medication adherence and inhaler technique. The ability for remote patient monitoring is accelerating interest in and the use of these devices in clinical practice and research settings. More than 20 clinical studies of digital inhalers in asthma or COPD collectively show improvement in medication adherence, exacerbation risk, and patient outcomes with digital inhalers. These studies support previous findings about patient inhaler use and behaviors, but with greater granularity, and reveal some new findings about patient medication-taking behaviors. Digital devices that record inspiratory flows with inhaler use can guide proper inhaler technique and may prove to be a clinically useful lung function measure. Adoption of digital inhalers into practice is still early, and additional research is needed to determine patient and clinician acceptability, the appropriate place of these devices in the therapeutic regimen, and their cost effectiveness. Video: Digital Inhalers for Asthma or Chronic Obstructive Pulmonary Disease: A Scientific Perspective (MP4 74535 kb)Supplementary InformationThe online version supplementary material available at 10.1007/s41030-021-00167-4.

Peak-Inspiratory-Flow-Rate Guided Inhalation Therapy Reduce Severe Exacerbation of COPD.

Optimal peak inspiratory flow rate (PIFR) is crucial for inhalation therapy in patients with chronic obstructive pulmonary disease (COPD). However, little is known about the impact of PIFR-guided inhalation therapy on the clinical outcomes among patients with varying severities of COPD. A PIFR-guided inhalation therapy, including PIFR assessment and PIFR-guided inhaler education, was introduced in a pay-for-performance COPD management program in National Taiwan University Hospital. Among 383 COPD patients, there was significant reduction in incidence of severe acute exacerbation in the PIFR-guided inhalation therapy (PIFR group) than conventional inhaler education (control group) (11.9 vs. 21.1%, p = 0.019) during one-year follow-up. A multivariable Cox’s proportional-hazards analysis revealed that the PIFR-guided inhalation therapy was a significant, independent factor associated with the reduced risk of severe exacerbation (adjusted hazard ratio = 0.49, 95% confidence interval, 0.28–0.84, p = 0.011). Subgroup analysis found PIFR-guided inhalation therapy was more beneficial to patients with older age, short body stature, COPD stage 1&2, group C&D (frequent exacerbation phenotype), and using multiple inhalers. This study showed the PIFR-guided inhalation therapy significantly reduced the incidence of severe acute exacerbation than conventional inhaler education in patients with COPD. Careful PIFR-assessment and education would be crucial in the management of COPD.

ВЕНТИЛЯЦІЙНІ ТА ДИФУЗІЙНІ ПОРУШЕННЯ У ОСІБ, ЩО ПЕРЕНЕСЛИ НЕГОСПІТАЛЬНУ ПНЕВМОНІЮ, АСОЦІЙОВАНУ З КОРОНАВІРУСНОЮ ХВОРОБОЮ (COVID-19). МОЖЛИВОСТІ ІНГАЛЯЦІЙНОЇ ТЕРАПІЇ

VENTILATION AND DIFFUSIONAL DISORDERS IN PERSONS AFTER COMMUNITYACQUIRED PNEUMONIA, ASSOCIATED WITH CORONAVIRUS DISEASE (COVID-19). POSSIBILITIES OF INHALATION THERAPY T. O. Pertseva, L. I. Konopkina, K. O. Bielosludtseva, O. O. Shchudro, K. V. Fuhol Dnipro State Medical University, Dnipro, Ukraine Abstract. The aim of the study was to evaluate the results of our own observations of persons after communityacquired pneumonia associated with coronavirus disease (COVID-19), to determine options of functional disorders that may be observed in the post COVID-19 period, and to justify the possibility of inhalation therapy in patients with certain clinical symptoms in the post COVID-19 period, and demonstrate its effectiveness. Materials and methods. The results of our own observations are presented in the form of descriptions of ten clinical cases of functional state of the respiratory system in persons after community-acquired pneumonia associated with COVID-19. Conclusions. At the end of the acute period of COVID-19, the ventilatory function of the lungs in patients may be different: normal, with restrictive disorders (varying degrees of severity), with obstructive disorders (usually mild), with mixed disorders (without prevalence of certain types of changes, or with prevalence, most often, restrictive disorders). In this case, impaired diffusion capacity of the lungs is an extremely common phenomenon. Most likely, in COVID-19 in a certain category of patients, not only interstitial lung tissue but also bronchial tree tissue (mucous membrane, submucosal layer, muscles, vessels) may be involved in the pathological process. It is possible that this process may be of autoimmune origin. If there are bronchoobstructive disorders in the post COVID-19 period, patients should be prescribed bronchodilator therapy; long-acting β2 -agonists, in particular formoterol, may be the drugs of choice. If there is a long-term recovery of lung tissue structure, given that coronavirus disease is an autoimmune disease, the use of inhaled corticosteroids should be considered individually. The combined drug Bufomix Easyhailer® , prescribed according to the indications, has shown good efficacy and safety in the management of the patient in the post COVID-19 period. Key words: coronavirus disease; COVID-19; pneumonia, associated with COVID-19; post COVID-19 period; spirometry; diffusion lung capacity of carbon monoxide; DLCO.

Effect of PIFR-based optimised inhalation therapy in patients recovering from acute exacerbation of chronic obstructive pulmonary disease: protocol of a prospective, multicentre, superiority, randomised controlled trial

IntroductionAcute exacerbation (AE) is a major cause of disease progression and death in patients with chronic obstructive pulmonary disease (COPD), accounting for majority of medical expenditures. Correct inhalation therapy is...

PIFRr-based Inhalation Therapy in Patients Recovering From AECOPD

PIFRr-based Inhalation Therapy in Patients Recovering From AECOPD

Sleep Disorders and Adherence to Inhalation Therapy in Patients with Chronic Obstructive Pulmonary Disease.

Sleep disorders are common in patients with chronic obstructive pulmonary disease (COPD) and are associated with greater disease severity, more frequent exacerbations, greater use of emergency health care, and higher mortality. They may contribute to worsening of COPD course by reducing patients' adherence to treatment. The aim of this study was to evaluate quality of sleep in COPD patients and to assess the relationship between impaired sleep and adherence to inhalation therapy. The study included 106 COPD patients who were asked to answer the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Adherence to Refills and Medications Scale (ARMS). Clinical and demographic data were also collected. We found that over 60% of patients presented with sleep disorders (PSQI ≥5) and 75% with daytime sleepiness. None of the patients presented with optimal adherence to pharmacotherapy. Worse adherence was correlated with greater sleep disorders (r=0.56; p<0.001). ARMS questionnaire proved to be of high overall internal consistency (Cronbach's alpha=0.85). In conclusion, poor quality of sleep coexists with poor adherence to treatment among COPD patients. ARMS was proved to be a reliable tool for the assessment of adherence. Interventions aimed at improving sleep quality may be helpful to improve adherence to inhalation therapy in COPD patients.

PRS33 - Cost-Effectiveness of Roflumilast As Add-On To Triple Inhaled Therapy Vs Triple Inhaled Therapy In Patients with Severe And Very Severe COPD Associated with Chronic Bronchitis In Sweden

PRS33 - Cost-Effectiveness of Roflumilast As Add-On To Triple Inhaled Therapy Vs Triple Inhaled Therapy In Patients with Severe And Very Severe COPD Associated with Chronic Bronchitis In Sweden

Erratum to “Compliance with inhalation therapy in patients with chronic obstructive pulmonary disease”

Erratum to “Compliance with inhalation therapy in patients with chronic obstructive pulmonary disease”

Inhalation Therapy in Patients Receiving Mechanical Ventilation: An Update

Incremental gains in understanding the influence of various factors on aerosol delivery in concert with technological advancements over the past 2 decades have fueled an ever burgeoning literature on aerosol therapy during mechanical ventilation. In-line use of pressurized metered-dose inhalers (pMDIs) and nebulizers is influenced by a host of factors, some of which are unique to ventilator-supported patients. This article reviews the impact of various factors on aerosol delivery with pMDIs and nebulizers, and elucidates the correlation between in-vitro estimates and in-vivo measurement of aerosol deposition in the lung. Aerosolized bronchodilator therapy with pMDIs and nebulizers is commonly employed in intensive care units (ICUs), and bronchodilators are among the most frequently used therapies in mechanically ventilated patients. The use of inhaled bronchodilators is not restricted to mechanically ventilated patients with chronic obstructive pulmonary disease (COPD) and asthma, as they are routinely employed in other ventilator-dependent patients without confirmed airflow obstruction. The efficacy and safety of bronchodilator therapy has generated a great deal of interest in employing other inhaled therapies, such as surfactant, antibiotics, prostacyclins, diuretics, anticoagulants and mucoactive agents, among others, in attempts to improve outcomes in critically ill ICU patients receiving mechanical ventilation.