Precision medicine and aerosolization in mechanically ventilated adults

The use of nebulized drugs in critically ill patients is increasing, but little is known about the safety and efficacy of this strategy. Modern medicine implements strategies based on evidence, and the highest levels of evidence are obtained in randomized clinical trials. Therefore, van Meenen et al. (1) should be congratulated for their design of a multicentre randomized clinical trial to compare two different strategies of management: on-demand nebulization (that is, nebulization based on the physician’s clinical judgment) with N-acetylcysteine (a mucolytic) or salbutamol (a β-agonist), versus routine nebulization scheduled four times per day, regardless of patients’ clinical situation. The lack of masking was inherent in the protocol itself and although it may represent a limitation, it could not be obviated. The study was designed as a non-inferiority study. The primary outcome was the number of ventilation-free days within 28 days of inclusion; secondary outcomes were ICU and hospital length of stay and mortality, pulmonary complications (among them ventilator-associated pneumonia) and nebulization-related adverse events. The results can be summarized as follows: the on-demand nebulization strategy achieved similar results to routine nebulization, and adverse events were notably higher in the routine nebulization group. Another interesting finding was that nearly two-thirds of subjects in the elective arm did not have a condition requiring aerosolization