Purpose of review: Although drug therapy is most commonly delivered via the intravenous route, novel inhaled agents have been introduced for use in the ICU. Additionally, drugs previously delivered intravenously are now being delivered via the respiratory tract in an effort to reduce systemic toxicity and maximize effectiveness.
Recent findings: Aerosolized antibiotics have seen increased use in an effort to reduce systemic effects, reduce ventilator-associated pneumonia, and direct high drug concentrations at the site of infection. Drug-resistant pneumonia has also been effectively treated with aerosolized antibiotics. Secretion management includes a host of devices, therapies, and drugs, but the evidence for these is scant. Cardiac drugs via the endotracheal route should be used only when intravenous access is delayed. Inhaled nitric oxide has a defined role in care of infants, although new indications have limited and conflicting data. The use of helium-oxygen mixtures provides symptom relief in a wide variety of scenarios associated with turbulent flow in large airways.
Summary: Inhaled nitric oxide has an established role in neonatal intensive care and a limited role in adult intensive care. Heliox provides symptom relief, but at present cannot be considered routine as a consequence of the multiple technological challenges. Inhaled antimicrobials appear to provide a therapeutic advantage in select individuals with pneumonia. Secretion management is best achieved by adequate humidification and as needed suctioning. The role of inhaled carbon monoxide in critical care holds significant promise, but is currently in early clinical trials.