Patients in the intensive care unit (ICU) who receive on-demand nebulization of acetylcysteine with salbutamol may not experience more ventilator-free days compared with patients who receive routine nebulization, according to a study published by the Journal of the American Medical Association.

Researchers identified 944 individuals at 7 ICUs in The Netherlands and randomly assigned them 1:1 to receive either on-demand (n=471) nebulization of acetylcysteine with salbutamol or scheduled nebulized acetylcysteine with salbutamol (n=473). The purpose of the study (ClinicalTrials.gov Identifier: NCT02159196) was to determine whether one of those methods resulted in an increased number of ventilator-free days and decreased mortality at day 28. A total of 455 patients receiving on-demand nebulization and 467 patients receiving routine nebulization were included in the primary analysis. Patients were included if they were not expected to be extubated within 24 hours of randomization.

At the end of 28 days, individuals in the on-demand group experienced an average of 21 ventilator-free days (interquartile range [IQR], 0-26), while those in the routine group experienced a median of 20 ventilator-free days (IQR, 0-26; 1-sided 95% CI, –0.00003-∞), resulting in an insignificant difference between the 2 groups (P =.78).


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The mortality rates at 28 days, time of discharge, and 90 days were not different between the groups, and the average ICU and hospital lengths of stays were also similar. Pulmonary complications also were not significantly different between the 2 groups (44.8% vs 48.8% difference, –4.0%; 95% CI, –10.4%-2.4%; P =.24)

Patients treated with routine nebulized treatments experienced a greater number of adverse events (13.8 vs 29.3%; difference, –15.5; 95% CI, –20.7% to –10.3%; P <.001), with most events attributed to tachyarrhythmia (12.5% vs 25.9%; difference, –13.4; 95% CI, –18.4% to –8.4%; P <.001) and agitation (0.2% vs 4.3%; difference, –4.1%; 95% CI, –5.9% to –2.2%; P <.001). However, there were no observed adverse events directly related to nebulization of either acetylcysteine or salbutamol.

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Researchers concluded that clinicians should consider the use of on-demand nebulization of acetylcysteine with salbutamol as a reasonable alternative to routine nebulization in patients in the ICU who receive invasive ventilation and who are not expected to be extubated within 24 hours.

Reference

Van Meenen DMP, van der Hoeven SM, Binnekade JM, et al. Effect of on-demand vs routine nebulization of acetylcysteine with salbutamol on ventilator-free days in intensive care unit patients receiving invasive ventilation. JAMA. 2018;319:993-1001.