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Sadeghi T, Fatehi P, Pakzad L. Effect of Nasal Inhalation on Drug Particle Deposition and Size Distribution in the Upper Airway: With Soft Mist Inhalers. Ann Biomed Eng 2024; 52:1195-1212. [PMID: 38509413 DOI: 10.1007/s10439-023-03423-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/10/2023] [Indexed: 03/22/2024]
Abstract
Delivery of drugs to the lungs is commonly achieved using nasal and/or oral breathing-assisted techniques. The route of inhalation can substantially change the fate of inhaled droplets. The Respimat® Soft Mist™ Inhaler (SMI) is a commercially available efficient inhaler with 40-60% effectiveness. In the present study, we used computational fluid dynamics (CFD) with a custom setup to investigate the effect of a combined oral/nasal inhalation route on the SMI's regional droplet deposition, size distribution, and flow field. Our setup used a modified induction port (MIP) to mimic nasal inhalation inside the human respiratory tract. Six different oral/nasal flow rate ratios inside the MIP were applied (total flow rate of 30 l/min). An overall good agreement was achieved between simulation outcomes and in vitro results. Our results confirmed that the combined inhalation route affects the flow field, altering the MIP's droplet deposition and size distribution. The lowest depositional loss, mainly in the mouth area, was observed at oral/nasal flow rate ratios of O/N = 1 and O/N = 2 with 3% and 7.7% values, respectively. Droplets with a 2-5 µm diameter range showed the highest droplet mass inside the MIP at all combined flow rates. We observed less intense vortexes followed by a lower level of turbulent kinetic energy at the oral/nasal ratio of 1. Increasing the relative humidity (RH) at oral/nasal flow rate ratios of 0.07, 1, and 14 led to an increase in droplet deposition at the outlet of the MIP.
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Affiliation(s)
- Taha Sadeghi
- Department of Chemical Engineering, Lakehead University, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada
| | - Pedram Fatehi
- Department of Chemical Engineering, Lakehead University, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada
| | - Leila Pakzad
- Department of Chemical Engineering, Lakehead University, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada.
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2
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Prinz F, Pokorný J, Elcner J, Lízal F, Mišík O, Malý M, Bělka M, Hafen N, Kummerländer A, Krause MJ, Jedelský J, Jícha M. Comprehensive experimental and numerical validation of Lattice Boltzmann fluid flow and particle simulations in a child respiratory tract. Comput Biol Med 2024; 170:107994. [PMID: 38308867 DOI: 10.1016/j.compbiomed.2024.107994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 01/03/2024] [Accepted: 01/13/2024] [Indexed: 02/05/2024]
Abstract
The numerical simulation of inhaled aerosols in medical research starts to play a crucial role in understanding local deposition within the respiratory tract, a feat often unattainable experimentally. Research on children is particularly challenging due to the limited availability of in vivo data and the inherent morphological intricacies. CFD solvers based on Finite Volume Methods (FVM) have been widely employed to solve the flow field in such studies. Recently, Lattice Boltzmann Methods (LBM), a mesoscopic approach, have gained prominence, especially for their scalability on High-Performance Computers. This study endeavours to compare the effectiveness of LBM and FVM in simulating particulate flows within a child's respiratory tract, supporting research related to particle deposition and medication delivery using LBM. Considering a 5-year-old child's airway model at a steady inspiratory flow, the results are compared with in vitro experiments. Notably, both LBM and FVM exhibit favourable agreement with experimental data for the mean velocity field and the turbulence intensity. For particle deposition, both numerical methods yield comparable results, aligning well with in vitro experiments across a particle size range of 0.1-20 µm. Discrepancies are identified in the upper airways and trachea, indicating a lower deposition fraction than in the experiment. Nonetheless, both LBM and FVM offer invaluable insights into particle behaviour for different sizes, which are not easily achievable experimentally. In terms of practical implications, the findings of this study hold significance for respiratory medicine and drug delivery systems - potential health impacts, targeted drug delivery strategies or optimisation of respiratory therapies.
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Affiliation(s)
- František Prinz
- Brno University of Technology, Technicka 2896, Brno, 616 69, Czech Republic.
| | - Jan Pokorný
- Brno University of Technology, Technicka 2896, Brno, 616 69, Czech Republic
| | - Jakub Elcner
- Brno University of Technology, Technicka 2896, Brno, 616 69, Czech Republic
| | - František Lízal
- Brno University of Technology, Technicka 2896, Brno, 616 69, Czech Republic
| | - Ondrej Mišík
- Brno University of Technology, Technicka 2896, Brno, 616 69, Czech Republic
| | - Milan Malý
- Brno University of Technology, Technicka 2896, Brno, 616 69, Czech Republic
| | - Miloslav Bělka
- Brno University of Technology, Technicka 2896, Brno, 616 69, Czech Republic
| | - Nicolas Hafen
- Karlsruhe Institute of Technology, Kaiserstraße 12, Karlsruhe, 76131, Germany
| | - Adrian Kummerländer
- Karlsruhe Institute of Technology, Kaiserstraße 12, Karlsruhe, 76131, Germany
| | - Mathias J Krause
- Karlsruhe Institute of Technology, Kaiserstraße 12, Karlsruhe, 76131, Germany
| | - Jan Jedelský
- Brno University of Technology, Technicka 2896, Brno, 616 69, Czech Republic
| | - Miroslav Jícha
- Brno University of Technology, Technicka 2896, Brno, 616 69, Czech Republic
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3
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Leclerc L, Prévôt N, Hodin S, Delavenne X, Mentzel H, Schuschnig U, Pourchez J. Acoustic Aerosol Delivery: Assessing of Various Nasal Delivery Techniques and Medical Devices on Intrasinus Drug Deposition. Pharmaceuticals (Basel) 2023; 16:135. [PMID: 37259287 PMCID: PMC9962259 DOI: 10.3390/ph16020135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 07/31/2023] Open
Abstract
This study aims to evaluate the impact of the nasal delivery technique and nebulizing technologies (using different frequencies of oscillating airflow) for acoustic aerosol targeting of maxillary sinuses. Sodium fluoride (chemical used as a marker), tobramycin (drug used as a marker) and 99mTc-DTPA (radiolabel aerosol) were used to assess the intrasinus aerosol deposition on a nasal cast. Two commercial medical devices (PARI SINUS nebulizer and NL11SN ATOMISOR nebulizer) and various nasal delivery techniques (one or two nostrils connected to the aerosol inlet, the patient with the soft palate closed or open during the acoustic administration of the drug, the presence or not of flow resistance in the nostril opposite to the one allowing the aerosol to be administered) were evaluated. The closed soft palate condition showed a significant increase in drug deposition even though no significant difference in the rest of the nasal fossae was noticed. Our results clearly demonstrated a higher intrasinus aerosol deposition (by a factor 2-3; respectively 0.03 ± 0.007% vs. 0.003 ± 0.0002% in the right maxillary sinus and 0.027 ± 0.006% vs. 0.013 ± 0.004% in the left maxillary sinus) using the acoustic airflow generated by the PARI SINUS compared to the NL11SN ATOMISOR. The results clearly demonstrated that the optimal conditions for aerosol deposition in the maxillary sinuses were obtained with a closed soft palate. Thus, the choice of the nebulizing technology (and mainly the frequency of the pulsating aerosol generated) and also the recommendation of the best nasal delivery technique are key factors to improve intrasinus aerosol deposition.
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Affiliation(s)
- Lara Leclerc
- Mines Saint-Etienne, Université Jean Monnet Saint-Etienne, INSERM, Sainbiose U1059, Centre CIS, F-42023 Saint-Etienne, France
| | - Nathalie Prévôt
- Université Jean Monnet Saint-Étienne, Mines Saint-Etienne, INSERM, Sainbiose U1059, F-42023 Saint-Etienne, France
- Nuclear Medicine Unit, CHU Saint-Etienne, F-42055 Saint-Etienne, France
| | - Sophie Hodin
- Université Jean Monnet Saint-Étienne, Mines Saint-Etienne, INSERM, Sainbiose U1059, F-42023 Saint-Etienne, France
| | - Xavier Delavenne
- Université Jean Monnet Saint-Étienne, Mines Saint-Etienne, INSERM, Sainbiose U1059, F-42023 Saint-Etienne, France
| | | | | | - Jérémie Pourchez
- Mines Saint-Etienne, Université Jean Monnet Saint-Etienne, INSERM, Sainbiose U1059, Centre CIS, F-42023 Saint-Etienne, France
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4
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Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, Khilnani GC, Chaudhary D, Singla R, Koul PA, Mahashur AA, Ghoshal AG, Behera D, Christopher DJ, Talwar D, Ganguly D, Paramesh H, Gupta KB, Kumar T M, Motiani PD, Shankar PS, Chawla R, Guleria R, Jindal SK, Luhadia SK, Arora VK, Vijayan VK, Faye A, Jindal A, Murar AK, Jaiswal A, M A, Janmeja AK, Prajapat B, Ravindran C, Bhattacharyya D, D'Souza G, Sehgal IS, Samaria JK, Sarma J, Singh L, Sen MK, Bainara MK, Gupta M, Awad NT, Mishra N, Shah NN, Jain N, Mohapatra PR, Mrigpuri P, Tiwari P, Narasimhan R, Kumar RV, Prasad R, Swarnakar R, Chawla RK, Kumar R, Chakrabarti S, Katiyar S, Mittal S, Spalgais S, Saha S, Kant S, Singh VK, Hadda V, Kumar V, Singh V, Chopra V, B V. Indian Guidelines on Nebulization Therapy. Indian J Tuberc 2022; 69 Suppl 1:S1-S191. [PMID: 36372542 DOI: 10.1016/j.ijtb.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/16/2023]
Abstract
Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.
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Affiliation(s)
- S K Katiyar
- Department of Tuberculosis & Respiratory Diseases, G.S.V.M. Medical College & C.S.J.M. University, Kanpur, Uttar Pradesh, India.
| | - S N Gaur
- Vallabhbhai Patel Chest Institute, University of Delhi, Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater NOIDA, Uttar Pradesh, India
| | - R N Solanki
- Department of Tuberculosis & Chest Diseases, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Raj Kumar
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, National Centre of Allergy, Asthma & Immunology; University of Delhi, Delhi, India
| | - G C Khilnani
- PSRI Institute of Pulmonary, Critical Care, & Sleep Medicine, PSRI Hospital, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhary
- Department of Pulmonary & Critical Care Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rupak Singla
- Department of Tuberculosis & Respiratory Diseases, National Institute of Tuberculosis & Respiratory Diseases (formerly L.R.S. Institute), Delhi, India
| | - Parvaiz A Koul
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Ashok A Mahashur
- Department of Respiratory Medicine, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
| | - A G Ghoshal
- National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
| | - D Behera
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepak Talwar
- Metro Centre for Respiratory Diseases, Noida, Uttar Pradesh, India
| | | | - H Paramesh
- Paediatric Pulmonologist & Environmentalist, Lakeside Hospital & Education Trust, Bengaluru, Karnataka, India
| | - K B Gupta
- Department of Tuberculosis & Respiratory Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India
| | - Mohan Kumar T
- Department of Pulmonary, Critical Care & Sleep Medicine, One Care Medical Centre, Coimbatore, Tamil Nadu, India
| | - P D Motiani
- Department of Pulmonary Diseases, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - P S Shankar
- SCEO, KBN Hospital, Kalaburagi, Karnataka, India
| | - Rajesh Chawla
- Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Department of Pulmonary Medicine & Sleep Disorders, AIIMS, New Delhi, India
| | - S K Jindal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Luhadia
- Department of Tuberculosis and Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - V K Arora
- Indian Journal of Tuberculosis, Santosh University, NCR Delhi, National Institute of TB & Respiratory Diseases Delhi, India; JIPMER, Puducherry, India
| | - V K Vijayan
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, University of Delhi, Delhi, India
| | - Abhishek Faye
- Centre for Lung and Sleep Disorders, Nagpur, Maharashtra, India
| | | | - Amit K Murar
- Respiratory Medicine, Cronus Multi-Specialty Hospital, New Delhi, India
| | - Anand Jaiswal
- Respiratory & Sleep Medicine, Medanta Medicity, Gurugram, Haryana, India
| | - Arunachalam M
- All India Institute of Medical Sciences, New Delhi, India
| | - A K Janmeja
- Department of Respiratory Medicine, Government Medical College, Chandigarh, India
| | - Brijesh Prajapat
- Pulmonary and Critical Care Medicine, Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
| | - C Ravindran
- Department of TB & Chest, Government Medical College, Kozhikode, Kerala, India
| | - Debajyoti Bhattacharyya
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, Army Hospital (Research & Referral), New Delhi, India
| | | | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Centre for Research and Treatment of Allergy, Asthma & Bronchitis, Department of Chest Diseases, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Jogesh Sarma
- Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Lalit Singh
- Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - M K Sen
- Department of Respiratory Medicine, ESIC Medical College, NIT Faridabad, Haryana, India; Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mahendra K Bainara
- Department of Pulmonary Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nilkanth T Awad
- Department of Pulmonary Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, M.K.C.G. Medical College, Berhampur, Orissa, India
| | - Naveed N Shah
- Department of Pulmonary Medicine, Chest Diseases Hospital, Government Medical College, Srinagar, Jammu & Kashmir, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care & Sleep Medicine, PSRI, New Delhi, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Parul Mrigpuri
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pawan Tiwari
- School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - R Narasimhan
- Department of EBUS and Bronchial Thermoplasty Services at Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Vijai Kumar
- Department of Pulmonary Medicine, MediCiti Medical College, Hyderabad, Telangana, India
| | - Rajendra Prasad
- Vallabhbhai Patel Chest Institute, University of Delhi and U.P. Rural Institute of Medical Sciences & Research, Safai, Uttar Pradesh, India
| | - Rajesh Swarnakar
- Department of Respiratory, Critical Care, Sleep Medicine and Interventional Pulmonology, Getwell Hospital & Research Institute, Nagpur, Maharashtra, India
| | - Rakesh K Chawla
- Department of, Respiratory Medicine, Critical Care, Sleep & Interventional Pulmonology, Saroj Super Speciality Hospital, Jaipur Golden Hospital, Rajiv Gandhi Cancer Hospital, Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - S Chakrabarti
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sonam Spalgais
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | | | - Surya Kant
- Department of Respiratory (Pulmonary) Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - V K Singh
- Centre for Visceral Mechanisms, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Virendra Singh
- Mahavir Jaipuria Rajasthan Hospital, Jaipur, Rajasthan, India
| | - Vishal Chopra
- Department of Chest & Tuberculosis, Government Medical College, Patiala, Punjab, India
| | - Visweswaran B
- Interventional Pulmonology, Yashoda Hospitals, Hyderabad, Telangana, India
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Nolasco S, Manti S, Leonardi S, Vancheri C, Spicuzza L. High-Flow Nasal Cannula Oxygen Therapy: Physiological Mechanisms and Clinical Applications in Children. Front Med (Lausanne) 2022; 9:920549. [PMID: 35721052 PMCID: PMC9203852 DOI: 10.3389/fmed.2022.920549] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
High-flow nasal cannula (HFNC) oxygen therapy has rapidly become a popular modality of respiratory support in pediatric care. This is undoubtedly due to its ease of use and safety, which allows it to be used in a wide variety of settings, ranging from pediatric intensive care to patients' homes. HFNC devices make it possible to regulate gas flow and temperature, as well as allowing some nebulized drugs to be administered, features very useful in children, in which the balance between therapeutic effectiveness and adherence to treatment is pivotal. Although the physiological effects of HFNC are still under investigation, their mechanisms of action include delivery of fixed concentration of oxygen, generation of positive end-expiratory pressure, reduction of the work of breathing and clearance of the nasopharyngeal dead space, while providing optimal gas conditioning. Nevertheless, current evidence supports the use of HFNC mainly in moderate-to-severe bronchiolitis, whereas for asthma exacerbations and breath sleeping disorders there is a lack of randomized controlled trials comparing HFNC to continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV), which are essentials for the identification of response and non-response predictors. In this regard, the development of clinical guidelines for HFNC, including flow settings, indications, and contraindications is urgently needed.
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Affiliation(s)
- Santi Nolasco
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- *Correspondence: Santi Nolasco
| | - Sara Manti
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Salvatore Leonardi
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Carlo Vancheri
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Lucia Spicuzza
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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6
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Golshahi L, Finlay WH, Wachtel H. Use of Airway Replicas in Lung Delivery Applications. J Aerosol Med Pulm Drug Deliv 2022; 35:61-72. [PMID: 35262408 DOI: 10.1089/jamp.2021.29057.lg] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The use of extrathoracic airway replicas in optimization of drug delivery to the lungs with nebulizers, dry powder inhalers (DPIs) and pressurized metered-dose inhalers (pMDIs) is discussed. Such airway replicas have been useful in evaluating new pulmonary drug delivery platforms mainly based on the comparison of the total lung dose (TLD) and the aerodynamic particle size distribution (APSD) of the aerosol distal to the physical models. The ability of these in vitro methods to replicate in vivo results has allowed advancements in respiratory drug delivery and in the accuracy and utility of in vitro-in vivo correlations (IVIVCs).
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Affiliation(s)
- Laleh Golshahi
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Warren H Finlay
- Department of Mechanical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Herbert Wachtel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
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7
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Ben Porat S, Gelman D, Yerushalmy O, Alkalay-Oren S, Coppenhagen-Glazer S, Cohen-Cymberknoh M, Kerem E, Amirav I, Nir-Paz R, Hazan R. Expanding clinical phage microbiology: simulating phage inhalation for respiratory tract infections. ERJ Open Res 2021; 7:00367-2021. [PMID: 34760998 PMCID: PMC8573233 DOI: 10.1183/23120541.00367-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/05/2021] [Indexed: 11/12/2022] Open
Abstract
Phage therapy is a promising antibacterial strategy for resistant respiratory tract infections. Phage inhalation may serve this goal; however, it requires a careful assessment of their delivery by this approach. Here we present an in vitro model to evaluate phage inhalation. Eight phages, most of which target pathogens common in cystic fibrosis, were aerosolised by jet nebuliser and administered to a real-scale computed tomography-derived 3D airways model with a breathing simulator. Viable phage loads reaching the output of the nebuliser and the tracheal level of the model were determined and compared to the loaded amount. Phage inhalation resulted in a diverse range of titre reduction, primarily associated with the nebulisation process. No correlation was found between phage delivery to the phage physical or genomic dimensions. These findings highlight the need for tailored simulations of phage delivery, ideally by a patient-specific model in addition to proper phage matching, to increase the potential of phage therapy success.
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Affiliation(s)
- Shira Ben Porat
- Institute of Biomedical and Oral Research, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- Dept of Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- These authors contributed equally
| | - Daniel Gelman
- Institute of Biomedical and Oral Research, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- Dept of Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- Dept of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- These authors contributed equally
| | - Ortal Yerushalmy
- Institute of Biomedical and Oral Research, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sivan Alkalay-Oren
- Institute of Biomedical and Oral Research, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shunit Coppenhagen-Glazer
- Institute of Biomedical and Oral Research, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Malena Cohen-Cymberknoh
- Pediatric Pulmonology Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eitan Kerem
- Pediatric Pulmonology Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Israel Amirav
- Pediatric Pulmonary Unit, Dana-Dwek Children's Hospital, Tel Aviv, Israel
| | - Ran Nir-Paz
- Dept of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- These authors contributed equally
| | - Ronen Hazan
- Institute of Biomedical and Oral Research, Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- These authors contributed equally
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Ari A. A path to successful patient outcomes through aerosol drug delivery to children: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:593. [PMID: 33987291 PMCID: PMC8105845 DOI: 10.21037/atm-20-1682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/03/2020] [Indexed: 11/06/2022]
Abstract
Although using aerosolized medications is a mainstay of treatment in children with asthma and other respiratory diseases, there are many issues in terms of device and interface selection, delivery technique and dosing, as well as patient and parental education that have not changed for half a century. Also, due to many aerosol devices and interfaces available on the market and the broad range of patient characteristics and requirements, providing effective aerosol therapy to children becomes a challenge. While aerosol delivery devices are equally effective, if they are age-appropriate and used correctly, the majority of aerosol devices require multiple steps to be used efficiently. Unfortunately, many children with pulmonary diseases have problems with the correct delivery technique and do not gain therapeutic benefits from therapy that result in poor disease management and increased healthcare costs. Therefore, the purpose of this paper is to review the current knowledge on aerosol delivery devices used in children and guide clinicians on the optimum device- and interface-selection, delivery technique, and dosing in this patient population. Strategies on how to deliver aerosolized medications in crying and distressed children and how to educate parents on aerosol therapy and promote patient adherence to prescribed medications are also provided. Future directions of aerosol therapy in children should focus on these issues and implement policies and clinical practices that highlight the potential solutions to these problems.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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Wilkins JV, Golshahi L, Rahman N, Li L. Evaluation of Intranasal Vaccine Delivery Using Anatomical Replicas of Infant Nasal Airways. Pharm Res 2021; 38:141-153. [PMID: 33449250 DOI: 10.1007/s11095-020-02976-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Nasal delivery is a favorable route for vaccination against most respiratory infections, as antigen deposited in the nasal turbinate and Waldeyer's ring areas induce mucosal and systemic immune responses. However, little is known about the nasal distribution of the vaccines, specifically for infants. METHODS Anatomical nasal replicas of five subjects, 3-24 months, were developed to assess local intranasal vaccine delivery using MAD Nasal™ device, and understand impact of breathing conditions and administration parameters. High performance liquid chromatography was used to quantify the deposition pattern and determine the delivery efficiency. RESULTS The delivery efficiency on average for all models was found to be 86.57±14.23%. There were no significant differences in the total delivery efficiency between the models in all cases. However, the regional deposition pattern was altered based on the model and subsequent administration. Furthermore, removing the foam tip from the MAD Nasal™ device, to study the impact of insertion length, did not significantly increase the efficiency within the two models tested, 5- and 16-month. CONCLUSION Incorporating nasal replicas in testing provided a benchmark to determine the efficiency of a common intranasal vaccine delivery combination product. This proposed platform would allow comparing other potential nasal vaccine delivery devices.
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Affiliation(s)
- John V Wilkins
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 800 E. Leigh St, Richmond, Virginia, 23298, USA
| | - Laleh Golshahi
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 800 E. Leigh St, Richmond, Virginia, 23298, USA.
| | - Nausheen Rahman
- Bioprocess Research and Development, Sanofi Pasteur Ltd., Building 95, 1755 Steeles Avenue West, Toronto, Ontario, M2R 3T4, Canada
| | - Lillian Li
- Bioprocess Research and Development, Sanofi Pasteur Ltd., Building 95, 1755 Steeles Avenue West, Toronto, Ontario, M2R 3T4, Canada.
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10
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Lizal F, Elcner J, Jedelsky J, Maly M, Jicha M, Farkas Á, Belka M, Rehak Z, Adam J, Brinek A, Laznovsky J, Zikmund T, Kaiser J. The effect of oral and nasal breathing on the deposition of inhaled particles in upper and tracheobronchial airways. JOURNAL OF AEROSOL SCIENCE 2020; 150:105649. [PMID: 32904428 PMCID: PMC7455204 DOI: 10.1016/j.jaerosci.2020.105649] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 08/05/2020] [Accepted: 08/13/2020] [Indexed: 05/21/2023]
Abstract
The inhalation route has a substantial influence on the fate of inhaled particles. An outbreak of infectious diseases such as COVID-19, influenza or tuberculosis depends on the site of deposition of the inhaled pathogens. But the knowledge of respiratory deposition is important also for occupational safety or targeted delivery of inhaled pharmaceuticals. Simulations utilizing computational fluid dynamics are becoming available to a wide spectrum of users and they can undoubtedly bring detailed predictions of regional deposition of particles. However, if those simulations are to be trusted, they must be validated by experimental data. This article presents simulations and experiments performed on a geometry of airways which is available to other users and thus those results can be used for intercomparison between different research groups. In particular, three hypotheses were tested. First: Oral breathing and combined breathing are equivalent in terms of particle deposition in TB airways, as the pressure resistance of the nasal cavity is so high that the inhaled aerosol flows mostly through the oral cavity in both cases. Second: The influence of the inhalation route (nasal, oral or combined) on the regional distribution of the deposited particles downstream of the trachea is negligible. Third: Simulations can accurately and credibly predict deposition hotspots. The maximum spatial resolution of predicted deposition achievable by current methods was searched for. The simulations were performed using large-eddy simulation, the flow measurements were done by laser Doppler anemometry and the deposition has been measured by positron emission tomography in a realistic replica of human airways. Limitations and sources of uncertainties of the experimental methods were identified. The results confirmed that the high-pressure resistance of the nasal cavity leads to practically identical velocity profiles, even above the glottis for the mouth, and combined mouth and nose breathing. The distribution of deposited particles downstream of the trachea was not influenced by the inhalation route. The carina of the first bifurcation was not among the main deposition hotspots regardless of the inhalation route or flow rate. On the other hand, the deposition hotspots were identified by both CFD and experiments in the second bifurcation in both lungs, and to a lesser extent also in both the third bifurcations in the left lung.
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Affiliation(s)
- Frantisek Lizal
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Jakub Elcner
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Jan Jedelsky
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Milan Maly
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Miroslav Jicha
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Árpád Farkas
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
- Centre for Energy Research, Konkoly-Thege Miklós u. 29-33, 1121, Budapest, Hungary
| | - Miloslav Belka
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Zdenek Rehak
- Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 602 00, Czech Republic
| | - Jan Adam
- Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 602 00, Czech Republic
- ÚJV Řež, a.s., Hlavni 130, Husinec-Rez, Rez 250 68, Czech Republic
| | - Adam Brinek
- CEITEC - Central European Institute of Technology, Brno University of Technology, Purkynova 123, Brno, 612 00, Czech Republic
| | - Jakub Laznovsky
- CEITEC - Central European Institute of Technology, Brno University of Technology, Purkynova 123, Brno, 612 00, Czech Republic
| | - Tomas Zikmund
- CEITEC - Central European Institute of Technology, Brno University of Technology, Purkynova 123, Brno, 612 00, Czech Republic
| | - Jozef Kaiser
- CEITEC - Central European Institute of Technology, Brno University of Technology, Purkynova 123, Brno, 612 00, Czech Republic
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Variation in Practice Related to the Use of High Flow Nasal Cannula in Critically Ill Children. Pediatr Crit Care Med 2020; 21:e228-e235. [PMID: 32106187 DOI: 10.1097/pcc.0000000000002258] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine current management of critically ill children and gather views regarding high flow nasal cannula therapy and to evaluate research priorities for a large prospective randomized controlled trial of noninvasive respiratory support in children. DESIGN Multinational cross-sectional questionnaire survey conducted in 2018. SETTING The sample included pediatric intensive care physicians in North and South America, Asia, Europe, and Australia/New Zealand. MEASUREMENT Questions consisted of: 1) characteristics of intensivists and hospital, 2) practice of high flow nasal cannula, 3) supportive treatment, and 4) research of high flow nasal cannula. INTERVENTIONS None. MAIN RESULTS We collected data from 1,031 respondents; 919 (North America, 215; Australia/New Zealand, 34; Asia, 203; South America, 186; Europe, 281) were analyzed. Sixty-nine percent of the respondents used high flow nasal cannula in non-PICU settings in their institutions. For a case of bronchiolitis/pneumonia infant, 2 L/kg/min of initial flow rate was the most commonly used. For a scenario of pneumonia with 30 kg weight, more than 60% of the respondents initiated flow based on patient body weight; while, 18% applied a fixed flow rate. Noninvasive ventilation was considered as a next step in more than 85% of respondents when the patient is failing with high flow nasal cannula. Significant practice variations were observed in clinical practice markers used, flow weaning strategy, and supportive practices. Views comparing high flow nasal cannula to continuous positive airway pressure also noticeably varied across the respondents. CONCLUSIONS Significant practice variations including views of high flow nasal cannula compared to continuous positive airway pressure was found among pediatric intensive care physicians. To expedite establishment and standardization of high flow nasal cannula practice, research aimed at understanding the heterogeneity found in this study should be undertaken.
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12
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Madney YM, Laz NI, Elberry AA, Rabea H, Abdelrahim ME. The influence of changing interfaces on aerosol delivery within high flow oxygen setting in adults: An in-vitro study. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2019.101365] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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13
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Dugernier J, Reychler G, Vecellio L, Ehrmann S. Nasal High-Flow Nebulization for Lung Drug Delivery: Theoretical, Experimental, and Clinical Application. J Aerosol Med Pulm Drug Deliv 2019; 32:341-351. [DOI: 10.1089/jamp.2019.1524] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Jonathan Dugernier
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Soins Intensifs, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Médecine Physique, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Grégory Reychler
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Service de pneumologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Laurent Vecellio
- Centre d'études des pathologies respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Stephan Ehrmann
- Centre d'études des pathologies respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
- Médecine intensive réanimation, Centre d'investigation clinique CIC INSERM 1415, CHRU de Tours, Tours, France
- CRICS-TriggerSep Research Network
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Herbes C, Gonçalves AM, Motta GC, Ventura DADS, Colvero M, Amantéa SL. Metered-dose inhaler therapy with spacers: Are newborns capable of using this system correctly? Pediatr Pulmonol 2019; 54:1417-1421. [PMID: 31286689 DOI: 10.1002/ppul.24436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/15/2019] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Aerosol therapy using a metered-dose inhaler (MDI) coupled to a spacer chamber is the most widely used long-term treatment modality for chronic lung disease of prematurity. However, its use in neonates is based on data obtained from other age groups. Proper use of maintenance treatment is essential for the long-term stability of these patients. OBJECTIVE To ascertain whether newborns are capable of generating negative pressure during the use of a spacer with face mask for aerosol therapy. PATIENTS AND METHODS Total of 117 low-risk newborns (age 12-48 hours), with no congenital malformations or any detectable clinical symptoms, were included. Inspiratory pressure was measured with a respiratory pressure meter, at each respiratory cycle, during a 10-second period, for three sequential measurements. The meter was connected to the inner chamber of the spacer through a noncollapsible silicone tube. Suitably sized masks were used. RESULTS Only 43 participants (36.8%) generated a negative pressure capable of opening the spacer valve, as verified by the respiratory pressure meter. In 25 patients, all three measurements were within the expected range. Weight, gestational age, and mode of delivery were in no way associated with the ability to generate a detectable negative pressure. CONCLUSION In neonates, the MDI therapy with a spacer chamber and face mask is susceptible to failure due to the inability of most patients in this age range to generate a negative inspiratory pressure sufficient to open the spacer valve.
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Affiliation(s)
- Carolina Herbes
- Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Amanda Machado Gonçalves
- Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Gabriela Cantori Motta
- Department of Neonatology, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Maurício Colvero
- Department of Neonatology, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.,Department of Pediatrics, UFCSPA, Porto Alegre, RS, Brazil
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Sood BG, Cortez J, Kolli M, Sharma A, Delaney-Black V, Chen X. Aerosolized surfactant in neonatal respiratory distress syndrome: Phase I study. Early Hum Dev 2019; 134:19-25. [PMID: 31121339 DOI: 10.1016/j.earlhumdev.2019.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/03/2019] [Accepted: 05/07/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Treating respiratory distress syndrome (RDS) with intratracheal surfactant requires endotracheal intubation and mechanical ventilation, (MV) with their attendant risks. Use of non-invasive respiratory support in the delivery room averts the need for MV but delays surfactant administration. OBJECTIVE We hypothesized that aerosolized surfactant is feasible and safe in infants 240/7-366/7 weeks gestational age (GA) with RDS, receiving non-invasive respiratory support. DESIGN/METHODS In an unblinded Phase I study, sequentially enrolled infants with RDS stratified by GA received increasing doses (100 or 200 mg/kg of phospholipid) and dilutions (12.5 or 8.3 mg/ml) of surfactant using a jet nebulizer. Infants were monitored clinically and with cerebral oximetry. RESULTS Seventeen infants were enrolled. Age at start of first dose and dose duration were 4.9 (3.4-10.1) and 2.1 (1.0-2.8) hours respectively. Two infants in the lowest GA stratum (240/7-286/7) required intubation within 2 h after the first dose. Fifteen infants completed the study; 13 received two doses. Infants tolerated the aerosol treatment well. No other significant adverse events were identified. Parental permission for cerebral oximetry was obtained in 16 infants. In the two infants who later exited the study, values prior to start of aerosolized surfactant were lower compared to 14 infants who completed the study (p = 0.0835), increased after start of study intervention (p = 0.0105) and decreased after intubation (p = 0.0003). CONCLUSIONS We have demonstrated the feasibility and safety of aerosolized surfactant in preterm infants receiving non-invasive respiratory support. The treatment was well tolerated by infants and clinical caregivers.
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Affiliation(s)
- Beena G Sood
- Children's Hospital of Michigan, 3901 Beaubien Blvd., Suite 3N027, Detroit, MI 48201, USA; Hutzel Women's Hospital, 3990 John R St, Detroit, MI 48201, USA; Department of Pediatrics, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA.
| | - Josef Cortez
- Department of Pediatrics, University of Florida College of Medicine, 665 W 8th Street, Jacksonville, FL 32209, USA.
| | - Madhuri Kolli
- Department of Pediatrics, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA
| | - Amit Sharma
- Children's Hospital of Michigan, 3901 Beaubien Blvd., Suite 3N027, Detroit, MI 48201, USA; Hutzel Women's Hospital, 3990 John R St, Detroit, MI 48201, USA; Department of Pediatrics, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA.
| | - Virginia Delaney-Black
- Department of Pediatrics, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA.
| | - Xinguang Chen
- University of Florida College of Medicine, College of Public Health, 2004 Mowray Road, Gainesville, FL 32610, USA.
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Valencia-Ramos J, Arnaez J, Benito JM, Mirás A, Ochoa C, Beltrán S. A comparative in vitro study of standard facemask jet nebulization and high-flow nebulization in bronchiolitis. Exp Lung Res 2019; 45:13-21. [PMID: 31007091 DOI: 10.1080/01902148.2019.1599084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Aim of Study: The use of a nebulizer paired with high-flow nasal cannulas (HFNC) has been proposed for drug delivery in bronchiolitis. Particle size nebulized is a relevant factor determining the efficacy of the nebulization. We replicated in vitro the theoretical parameters most widely used in bronchiolitis and we compared the size of the droplet nebulized with a standard nebulizer and a nebulizer integrated into HFNC. Materials and Methods: We used laser diffraction to analyze the particle size nebulized (volume median diameter Dv50). The standard system was a jet nebulizer connected to a facemask with a flow rate of 8 L/min (JN). Three designs were used as nebulizers integrated into HFNC: a vibrating mesh nebulizer set 1) before (HFNC-BH) and 2) after (HFNC-AH) the humidifier, and 3) a jet nebulizer connected before the nasal cannula (HFNC-BNC). HFNC was used with neonatal (3-8 L/min) and infant cannulas (8-15 L/min). Results: Droplet size was similar among the three drugs studied. A lower particle size was obtained when using the nebulization system integrated into HFNC compared to the standard nebulizer, regardless of the flow rate and the nasal cannula used when the position of the nebulizer was before the nasal cannula (p < 0.05): 6.89 µm (JN), 2.49 µm (HFNC-BNC 3 L/min), 2.59 µm (HFNC-BNC 5 L/min), 2.44 µm (HFNC-BNC 8 L/min), 3.22 µm (HFNC-BNC 10 L/min), 3.23 µm (HFNC-BNC 13 L/min), 3.16 µm (HFNC-BNC 15 L/min). The particle size was lower in HFNC-BF compared to the HFNC-AH using neonatal nasal cannula (3-8 L/min) (p < 0.05). Conclusion: The use of a nebulizer integrated with HFNC has shown promising results in an experimental scenario of bronchiolitis. The particle size achieved with the nebulizer placed before the humidifier is equivalent to the one obtained via conventional nebulization, and it is even smaller when the integrated nebulizer is placed before the nasal cannulas.
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Affiliation(s)
- Juan Valencia-Ramos
- a Paediatric Intensive Care Unit , Hospital Universitario de Burgos , Burgos , Spain
| | - Juan Arnaez
- b Department of Neonatology , Hospital Universitario de Burgos , Burgos , Spain
| | - José Manuel Benito
- c Chemical Engineering Division, Department of Biotechnology and Food Science , Universidad de Burgos , Burgos , Spain
| | - Alicia Mirás
- a Paediatric Intensive Care Unit , Hospital Universitario de Burgos , Burgos , Spain
| | - Carlos Ochoa
- d Department of Investigation Unit , Hospital Virgen de la Concha, Escuela Universitaria de Enfermería de Zamora , Zamora , Spain
| | - Sagrario Beltrán
- c Chemical Engineering Division, Department of Biotechnology and Food Science , Universidad de Burgos , Burgos , Spain
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Bass K, Boc S, Hindle M, Dodson K, Longest W. High-Efficiency Nose-to-Lung Aerosol Delivery in an Infant: Development of a Validated Computational Fluid Dynamics Method. J Aerosol Med Pulm Drug Deliv 2018; 32:132-148. [PMID: 30556777 DOI: 10.1089/jamp.2018.1490] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Computational fluid dynamics (CFD) provides a powerful tool for developing new high-efficiency aerosol delivery strategies, such as nose-to-lung (N2L) aerosol administration to infants and children using correctly sized aerosols. The objective of this study was to establish numerically efficient CFD solution methods and guidelines for simulating N2L aerosol administration to an infant based on comparisons with concurrent in vitro experiments. Materials and Methods: N2L administration of a micrometer-sized aerosol (mass median aerodynamic diameter [MMAD] = 1.4 μm) was evaluated using concurrent CFD simulations and in vitro experiments. Aerosol transport and deposition was assessed in a new nasal airway geometry of a 6-month-old infant with a streamlined nasal cannula interface, which was constructed as a CFD mesh and three-dimensionally printed to form an identical physical prototype. CFD meshes explored were a conventional tetrahedral approach with near-wall (NW) prism elements and a new polyhedral mesh style with an equally refined NW layer. The presence of turbulence in the model was evaluated using a highly efficient low-Reynolds number (LRN) k-ω turbulence model, with previously established NW corrections that accounted for anisotropic wall-normal turbulence as well as improved NW velocity interpolations and hydrodynamic particle damping. Results: Use of the new polyhedral mesh was found to improve numerical efficiency by providing more rapid convergence and requiring fewer control volumes. Turbulent flow was found in the nasal geometry, generated by the inlet jets from the nasal cannula interface. However, due to the small particle size, turbulent dispersion was shown to have little effect on deposition. Good agreement was established between the CFD predictions using the numerically efficient LRN k-ω model with appropriate NW corrections and in vitro deposition data. Aerosol transmission efficiencies through the delivery tube, nasal cannula, and infant nasal model, based on experimental and CFD predictions, were 93.0% and 91.5%, respectively. Conclusions: A numerically efficient CFD approach was established to develop transnasal aerosol administration to infants and children. Small particle aerosols with aerodynamic diameters of ∼1.5 μm were confirmed to have low inertial depositional loss, and have low deposition from turbulent dispersion, making them ideal for high-efficiency lung delivery through an infant nasal cannula interface.
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Affiliation(s)
- Karl Bass
- 1 Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia
| | - Susan Boc
- 2 Department of Pharmaceutics, and Virginia Commonwealth University, Richmond, Virginia
| | - Michael Hindle
- 2 Department of Pharmaceutics, and Virginia Commonwealth University, Richmond, Virginia
| | - Kelley Dodson
- 3 Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Worth Longest
- 1 Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia.,2 Department of Pharmaceutics, and Virginia Commonwealth University, Richmond, Virginia
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Golshahi L, Hosseini S. Intranasal Filtration of Inhaled Aerosol in Human Subjects as a Function of Nasal Pressure Drop. J Aerosol Med Pulm Drug Deliv 2018; 32:13-23. [PMID: 30199315 DOI: 10.1089/jamp.2018.1476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Intersubject variability in nasal deposition of inhaled aerosol is significant because of the differences in nasal anatomy and breathing rate. The notable limitation of the majority of previously developed predictive correlations is including a limited number of subjects. A few recent studies have considered a wide age range of subjects, but the resulting correlations require the knowledge of the dimensions of the nasal airways and the properties of inhaled gas. In this study empirical correlations are proposed to predict aerosol deposition in nasal airways of subjects of different age as a function of intranasal pressure drop and the particle aerodynamic diameter. METHODS The experimental nasal deposition and pressure drop data in anatomically correct nasal replicas of 5 adults, 13 children aged 4-14 years, and 11 infants aged 3-18 months were reanalyzed. The range of aerodynamic diameter was 0.5-5.3 μm and physiological breathing at different activity levels was considered. Correlations between nasal deposition and a deposition parameter including the aerodynamic size of inhaled aerosol and nasal pressure drop were developed with nonlinear least-square algorithms. The general coefficient of determination r2 was used to evaluate the fitting accuracy for each correlation. RESULTS New correlations were developed to predict the intranasal deposition of particles as a function of intranasal pressure drop and particle size for pediatric and adult subjects. The intranasal deposition fraction in adults and children can be calculated using the same correlation, whereas the intranasal deposition in infants followed a different trend line because of higher intranasal pressure drop in infants. CONCLUSION This study was the first offering correlations to predict intranasal deposition in multiple age groups using only the aerodynamic size of inhaled aerosol and nasal pressure drop. These correlations include the effects of intersubject variability in nasal deposition within each age group and among different age groups.
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Affiliation(s)
- Laleh Golshahi
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia
| | - Sana Hosseini
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia
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19
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Bräunlich J, Wirtz H. Oral Versus Nasal High-Flow Bronchodilator Inhalation in Chronic Obstructive Pulmonary Disease. J Aerosol Med Pulm Drug Deliv 2017; 31:248-254. [PMID: 29261402 DOI: 10.1089/jamp.2017.1432] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nasal high flow (NHF) alters breathing patterns, stabilizes fraction of inspired oxygen (FiO2) during respiratory distress, helps to keep up hemostasis in the airways, and washes out the upper airways. Particularly the support of inspiratory flow and decrease in functional dead space are interesting mechanisms of action with regard to aerosol delivery. Several laboratory investigations have studied aerosol delivery via the nasal route by using NHF, whereas clinical benefits are poorly evaluated. METHODS Thirty patients with stable chronic obstructive pulmonary disease Gold D were recruited. In a randomized order, they inhaled a salbutamol 2.5 mg/ipratropium bromide 500 μg solution oral or NHF adapted on the second study day. A jet nebulizer was used as aerosol delivery device. The chosen flow rate was 35 L/min. RESULTS Four patients refused to repeat the procedure, for example, for inconvenience or fear of delayed discharge, and were not included in the intention-to-treat analysis. All remaining patients tolerated both inhalation systems well. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), airway resistance (Rtot), and residual volume (RV) were significantly altered after bronchodilator inhalation with each of the both devices. The two different ways of combined bronchodilator inhalation resulted in very comparable changes in FVC, FEV1, relative 1 second-capacity (FEV1%FVC), Rtot, total lung capacity (TLC), RV, and residual volume expressed as percent of TLC (RV%TLC). However, in between devices, no difference was observed on comparing the postinhalational measurements of FVC, FEV1, Rtot, and RV. CONCLUSIONS We conclude from this proof-of-principle kind of study that inhalation of combined bronchodilators adapted to an NHF device is similarly effective to inhalation with a standard oral aerosol nebulizer. (Clinical Trails NCT02885103).
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Affiliation(s)
- Jens Bräunlich
- Department of Respiratory Medicine, University of Leipzig , Leipzig, Germany
| | - Hubert Wirtz
- Department of Respiratory Medicine, University of Leipzig , Leipzig, Germany
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Réminiac F, Vecellio L, Loughlin RM, Le Pennec D, Cabrera M, Vourc'h NH, Fink JB, Ehrmann S. Nasal high flow nebulization in infants and toddlers: An in vitro and in vivo scintigraphic study. Pediatr Pulmonol 2017; 52:337-344. [PMID: 27392199 DOI: 10.1002/ppul.23509] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/20/2016] [Accepted: 06/08/2016] [Indexed: 12/15/2022]
Abstract
Aerosol therapy in infants and toddlers is challenging. Nebulization within a nasal high flow (NHF) circuit is attractive. The aim of this study was to quantify aerosol lung deposition when combined with NHF as compared with standard practice. Lung doses were measured scintigraphically after nebulization with jet and mesh nebulizer placed within a NHF circuit in a spontaneously breathing non-human primate model (macaque) and in the anatomical bench SAINT model, respectively representing a full-term newborn and a 9-month-old toddler. In the SAINT model, lung depositions observed with the mesh nebulizer placed in the NHF circuit set at 2 and 4 L/min were 3.3% and 4.2% of the nebulizer charge, respectively, and similar to the 1.70% observed with the control standard facemask jet nebulization (6 L/min flow). In the macaque model, the depositions observed with the mesh nebulizer in the NHF circuit set at 2 and 4 L/min were 0.49% and 0.85%, respectively, also similar to the control measurement (0.71%). Mesh nebulization within a NHF circuit set at 8 L/min and jet nebulization either within a NHF circuit or placed on top of the cannula (NHF set at 2 L/min; total flow of 8 L/min), resulted in a significantly lower lung depositions. Mesh nebulization within a NHF circuit delivering up to 4 L/min gas is likely to be at least as effective than jet nebulization with a facemask in infants and toddlers. Aerosol facemask placement on top of cannulas or jet nebulization within the NHF circuit may be less effective. Pediatr Pulmonol. 2017;52:337-344. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- François Réminiac
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France.,CHRU de Tours, Anesthésie-réanimation, Tours, France.,CHRU de Tours, Réanimation polyvalente, Tours, France
| | - Laurent Vecellio
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France.,Faculté de médecine, Aerodrug, DTF Medical, Tours, France
| | | | - Deborah Le Pennec
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France
| | - Maria Cabrera
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France
| | - Nathalie Heuzé Vourc'h
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France
| | | | - Stephan Ehrmann
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France.,CHRU de Tours, Réanimation polyvalente, Tours, France
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21
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Ari A. Drug delivery interfaces: A way to optimize inhalation therapy in spontaneously breathing children. World J Clin Pediatr 2016; 5:281-287. [PMID: 27610343 PMCID: PMC4978620 DOI: 10.5409/wjcp.v5.i3.281] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/03/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
There are several different types of drug delivery interfaces available on the market. Using the right interface for aerosol drug delivery to children is essential for effective inhalation therapy. However, clinicians usually focus on selecting the right drug-device combination and often overlook the importance of interface selection that lead to suboptimal drug delivery and therapeutic response in neonates and pediatrics. Therefore, it is necessary to critically assess each interface and understand its advantage and disadvantages in aerosol drug delivery to this patient population. The purpose of this paper is to provide a critical assessment of drug delivery interfaces used for the treatment of children with pulmonary diseases by emphasizing advantages and problems associated with their use during inhalation therapy.
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Pourchez J, Leclerc L, Sarry G, Vergnon JM, Dubus JC. [Bench-test evaluation of spacer devices for fluticasone delivery to infants]. Rev Mal Respir 2016; 34:29-35. [PMID: 27155896 DOI: 10.1016/j.rmr.2016.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 02/26/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Use of a spacer device to optimize the delivery of fluticasone to infants with asthma is an important issue and clinicians require guidance around the choice of device. This in vitro study characterizes the particle size and the fluticasone delivery via 9 spacers. METHODS We used an in vitro infant nasal cast with two different inspiratory flow rates (50 and 100mL/s). Fluticasone particle size in the aerosol was evaluated by laser diffractometry and tracheal deposition by spectrophotometric assay. RESULTS Significant differences in particle size were observed between the 9 spacers (similar D50 but D90 from 5.65±0.65 to 8.80±1.35μm). A 75 % or higher respirable fraction was obtained for only 5 spacers. The 50mL/s flow rate lead to the best drug delivery. At this flow, OptiChamber® (62±3 %) and Vortex® (91±8.5 %) had a tracheal deposition over 50 % of the initial dose of fluticasone, although the 7 other spacers exhibited a fluticasone deposition less than 25 %. DISCUSSION This study shows a wide variation of drug delivery between the 9 spacers studied. We demonstrate that a low inspiratory flow and a spacer showing antistatic properties facilitate drug delivery.
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Affiliation(s)
- J Pourchez
- École nationale supérieure des Mines de Saint-Étienne, CIS-EMSE, Sainbiose, 42023 Saint-Étienne, France; Inserm, U1059, Sainbiose, 42023 Saint-Étienne, France; Université de Lyon, 42023 Saint-Étienne, France.
| | - L Leclerc
- École nationale supérieure des Mines de Saint-Étienne, CIS-EMSE, Sainbiose, 42023 Saint-Étienne, France; Inserm, U1059, Sainbiose, 42023 Saint-Étienne, France; Université de Lyon, 42023 Saint-Étienne, France
| | - G Sarry
- École nationale supérieure des Mines de Saint-Étienne, CIS-EMSE, Sainbiose, 42023 Saint-Étienne, France; Inserm, U1059, Sainbiose, 42023 Saint-Étienne, France; Université de Lyon, 42023 Saint-Étienne, France
| | - J-M Vergnon
- Inserm, U1059, Sainbiose, 42023 Saint-Étienne, France; Université de Lyon, 42023 Saint-Étienne, France; Service de pneumologie, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - J C Dubus
- Unité de pneumopédiatrie, CHU Timone-Enfants, 13385 Marseille cedex 5, France
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Abstract
INTRODUCTION Nebulizers are the oldest modern method of delivering aerosols to the lungs for the purpose of respiratory drug delivery. While use of nebulizers remains widespread in the hospital and home setting, certain newer nebulization technologies have enabled more portable use. Varied fundamental processes of droplet formation and breakup are used in modern nebulizers, and these processes impact device performance and suitability for nebulization of various formulations. AREAS COVERED This review first describes basic aspects of nebulization technologies, including jet nebulizers, various high-frequency vibration techniques, and the use of colliding liquid jets. Nebulizer use in hospital and home settings is discussed next. Complications in aerosol droplet size measurement owing to the changes in nebulized droplet diameters due to evaporation or condensation are discussed, as is nebulization during mechanical ventilation. EXPERT OPINION While the limelight may often appear to be focused on other delivery devices, such as pressurized metered dose and dry powder inhalers, the ease of formulating many drugs in water and delivering them as aqueous aerosols ensures that nebulizers will remain as a viable and relevant method of respiratory drug delivery. This is particularly true given recent improvements in nebulizer droplet production technology.
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Affiliation(s)
- Andrew R Martin
- University of Alberta, Department of Mechanical Engineering , Edmonton, Alberta, T6G 2G8 , Canada
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