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Hou J, Ji Q, Tang T, Xue Y, Gao L, Dai L, Xie J. CT-sensitized nanoprobe for effective early diagnosis and treatment of pulmonary fibrosis. J Nanobiotechnology 2025; 23:60. [PMID: 39881299 PMCID: PMC11776250 DOI: 10.1186/s12951-025-03128-0] [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: 10/15/2024] [Accepted: 01/15/2025] [Indexed: 01/31/2025] Open
Abstract
Early diagnosis is critical for providing a timely window for effective therapy in pulmonary fibrosis (PF); however, achieving this remains a significant challenge. The distinct honeycombing patterns observed in computed tomography (CT) for the primary diagnosis of PF are typically only visible in patients with moderate to severe disease, often leading to missed opportunities for early intervention. In this study, we developed a nanoprobe designed to accumulate at fibroblastic foci and loaded with the CT sensitizer iodide to enable effective early diagnosis of PF. An antibody fragment (Fab') targeting the platelet-derived growth factor receptor-α, which specifically binds to (myo)fibroblasts, was conjugated to the nanoprobe surface to enhance targeting of fibroblastic foci. Additionally, collagenase was employed to facilitate nanoprobe penetration by degrading the local collagen fibers within these foci. This approach led to significant accumulation of the CT sensitizer iodide in fibrotic lung tissues, resulting in enhanced CT imaging for the detection of fibroblastic foci and enabling early diagnosis of PF. Moreover, a dual-drug combination of oltipraz and rosiglitazone was co-loaded into the nanoparticles for the treatment of early-diagnosed PF. Remarkable therapeutic efficacy was observed in model mice with early PF using these nanoparticles. Our findings present a promising strategy for the early diagnosis of PF, potentially offering a valuable time window for effective treatment of this life-threatening disease.
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Affiliation(s)
- Jiwei Hou
- School of Medicine, Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Immunology and Reproduction Biology Laboratory & State Key Laboratory of Analytical Chemistry for Life Science, Medical School, Nanjing University, Nanjing, 210093, China
| | - Qijian Ji
- Department of Critical Care Medicine, Xuyi People's Hospital, 28 Hongwu Road, Xuyi, 211700, Jiangsu, China.
- Department of Emergency Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, PR China.
| | - Tianyu Tang
- Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology; Basic Medicine Research and Innovation Center of Ministry of Education, Medical School of Southeast University, 87 Dingjiaqiao, Nanjing, 210009, China
| | - Yonger Xue
- Center for BioDelivery Sciences, School of Pharmacy, Shanghai Jiao Tong University, Shanghai, 200240, China.
| | - Lin Gao
- Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology; Basic Medicine Research and Innovation Center of Ministry of Education, Medical School of Southeast University, 87 Dingjiaqiao, Nanjing, 210009, China
| | - Li Dai
- Department of cariol & endodont, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, 210008, China
| | - Jinbing Xie
- Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology; Basic Medicine Research and Innovation Center of Ministry of Education, Medical School of Southeast University, 87 Dingjiaqiao, Nanjing, 210009, China.
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Rogerson C, AbuSultaneh S, Sanchez‐Pinto LN, Gaston B, Wiehe S, Schleyer T, Tu W, Mendonca E. A matched analysis of the use of high flow nasal cannula for pediatric severe acute asthma. Pediatr Pulmonol 2024; 59:3457-3466. [PMID: 39212235 PMCID: PMC11601001 DOI: 10.1002/ppul.27233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 08/15/2024] [Accepted: 08/17/2024] [Indexed: 09/04/2024]
Abstract
RATIONALE The high-flow nasal cannula (HFNC) device is commonly used to treat pediatric severe acute asthma. However, there is little evidence regarding its effectiveness in real-world practice. OBJECTIVES We sought to compare the physiologic effects and clinical outcomes for children treated for severe acute asthma with HFNC versus matched controls. METHODS This was a single-center retrospective matched cohort study at a quaternary care children's hospital. Children ages 2-18 hospitalized for severe acute asthma from 2015 to 2022 were included. Encounters receiving treatment with HFNC within the first 24 h of hospitalization were included as cases. Controls were primarily treated with oxygen facemask. Logistic regression 1:1 propensity score matching was done using demographics, initial vital signs, and medications. The primary outcome was an improvement in clinical asthma symptoms in the first 24 h of hospitalization measured as percent change from initial. MEASUREMENTS AND MAIN RESULTS Of 693 eligible cases, 443 were matched to eligible controls. Propensity scores were closely aligned between the cohorts, with the only significant difference in clinical characteristics being a higher percentage of patients of Black race in the control group (54.3% vs. 46.6%; p = 0.02). Compared to the matched controls, the HFNC cohort had smaller improvements in heart rate (-11.5% [-20.9; -0.9] vs. -14.7% [-22.6;-5.7]; p < 0.01), respiratory rate (-14.3% [-27.9;5.4] vs. -16.7% [-31.5;0.0]; p = 0.03), and pediatric asthma severity score (-14.3% [-28.6;0.0] vs. -20.0% [-33.3;0.0]; p < 0.01) after 24 h of hospitalization. The HFNC cohort also had longer pediatric intensive care unit (PICU) length of stay (LOS) (1.5 days [1.1;2.1] vs. 1.2 days [0.9;1.8]; p < 0.01) and hospital LOS (2.8 days [2.1;3.8] vs. 2.5 days [1.9;3.4]; p < 0.01). When subgrouping to younger patients (2-3 years old), or those with the highest severity scores (PASS > 9), those treated with HFNC had no difference in clinical symptom improvements but maintained a longer PICU LOS. CONCLUSIONS Encounters using HFNC for severe acute pediatric asthma had decreased clinical improvement in 24 h of hospitalization compared to matched controls and increased LOS. Specific subgroups of younger patients and those with the highest severity scores showed no differences in clinical symptom improvement suggesting differential effects in specific patient populations.
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Affiliation(s)
- Colin Rogerson
- Department of Pediatrics, Division of Critical CareIndiana University School of MedicineIndianaUSA
- Regenstrief Institute Center for Biomedical InformaticsIndianaUSA
| | - Samer AbuSultaneh
- Department of Pediatrics, Division of Critical CareIndiana University School of MedicineIndianaUSA
| | | | - Benjamin Gaston
- Department of Pediatrics, Division of Critical CareIndiana University School of MedicineIndianaUSA
| | - Sarah Wiehe
- Department of Pediatrics, Division of Critical CareIndiana University School of MedicineIndianaUSA
- Regenstrief Institute Center for Health Services ResearchIndianaUSA
| | - Titus Schleyer
- Department of Pediatrics, Division of Critical CareIndiana University School of MedicineIndianaUSA
- Regenstrief Institute Center for Biomedical InformaticsIndianaUSA
| | - Wanzhu Tu
- Department of BiostatisticsIndiana UniversityIndianaUSA
| | - Eneida Mendonca
- Department of Pediatrics, Division of Critical CareIndiana University School of MedicineIndianaUSA
- Department of Pediatrics, Division of Critical CareCincinnati Children's Hospital and Medical CenterOhioUSA
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Ari A, Hoops JA, Koyuncu A, Fink JB. Dos and don'ts to optimize transnasal aerosol drug delivery in clinical practice. Expert Opin Drug Deliv 2024; 21:1103-1114. [PMID: 39104360 DOI: 10.1080/17425247.2024.2388838] [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: 03/05/2024] [Revised: 07/10/2024] [Accepted: 08/01/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Transnasal aerosol drug delivery has become widely accepted for treating acutely ill infants, children, and adults. More recently aerosol administration to wider populations receiving high and low-flow nasal oxygen has become common practice. AREAS COVERED Skepticism of insufficient aerosol delivery to the lungs has been tempered by multiple in vitro explorations of variables to optimize delivery efficiency. Additionally, clinical studies demonstrated comparable clinical responses to orally inhaled aerosols. This paper provides essential clinical guidance on how to improve transnasal aerosol delivery based on device-, settings-, and drug-related optimization to serve as a resource for educational initiatives and quality enhancement endeavors at healthcare institutions. EXPERT OPINION Transnasal aerosol delivery is proliferating worldwide, but indiscriminate use of excessive-high flows, poor selection and placement of aerosol devices and circuits can greatly reduce aerosol delivery and efficacy, potentially compromising treatment to acute and critically ill patients. Attention to these details can improve inhaled dose by an order of magnitude, making the difference between effective treatment and the progression to more invasive ventilatory support, with greater inherent risk and cost. These revelations have prompted specific recommendations for optimal delivery, driving advancements in aerosol generators, formulations, and future device designs to administer aerosols and maximize treatment effectiveness.
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Affiliation(s)
- Arzu Ari
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Jordan A Hoops
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Ayfer Koyuncu
- Bioengineering Division, College of Engineering, Hacettepe University, Ankara, Turkey
| | - James B Fink
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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Ari A, Raghavan N, Diaz M, Rubin BK, Fink JB. Individualized aerosol medicine: Integrating device into the patient. Paediatr Respir Rev 2024; 49:14-23. [PMID: 37739833 DOI: 10.1016/j.prrv.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 09/24/2023]
Abstract
Pulmonary drug delivery is complex due to several challenges including disease-, patient-, and clinicians-related factors. Although many inhaled medications are available in aerosol medicine, delivering aerosolized medications to patients requires effective disease management. There is a large gap in the knowledge of clinicians who select and provide instructions for the correct use of aerosol devices. Since improper device selection, incorrect inhaler technique, and poor patient adherence to prescribed medications may result in inadequate disease control, individualized aerosol medicine is essential for effective disease management and control. The components of individualized aerosol medicine include: (1) Selecting the right device, (2) Selecting the right interface, (3) Educating the patient effectively, and (4) Increasing patient adherence to therapy. This paper reviews each of these components and provides recommendations to integrate the device and interface into the patient for better clinical outcomes.
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Affiliation(s)
- Arzu Ari
- Texas State University, Department of Respiratory Care, USA.
| | | | - Martha Diaz
- Latin American Board of Certification in Respiratory Therapy, Colombia
| | - Bruce K Rubin
- Virginia Commonwealth University School of Medicine, USA.
| | - James B Fink
- Texas State University, Department of Respiratory Care, USA; Aerogen Pharma, USA.
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Koyuncu A, Ari A. Filling the gaps in the evaluation and selection of mobile health technologies in respiratory medicine. Expert Rev Respir Med 2024; 18:159-174. [PMID: 38795074 DOI: 10.1080/17476348.2024.2361048] [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: 01/08/2024] [Accepted: 05/24/2024] [Indexed: 05/27/2024]
Abstract
INTRODUCTION Mobile health (mHealth) technology in respiratory medicine is a fast-growing and promising digital technology that is popular among patients and healthcare providers (HCPs). They provide reminders and step-by-step instructions for the correct inhalation technique, monitor patients' adherence to treatment, and facilitate communication between patients and HCPs. AREAS COVERED While numerous mHealth apps have been developed over the years, most applications do not have supporting evidence. Selecting the best mHealth app in respiratory medicine is challenging due to limited studies carrying out mHealth app selection. Although mHealth technologies play an important part in the future of respiratory medicine, there is no single guide on the evaluation and selection of mHealth technologies for patients with pulmonary diseases. This paper aims to provide an overview of mHealth technologies, particularly emphasizing digital inhalers and standalone applications used in asthma. Additionally, it offers insights into the evaluation, selection, and pertinent considerations surrounding mHealth applications in respiratory medicine. EXPERT OPINION Evaluating mHealth apps will take time, resources, and collaboration between stakeholders such as governmental regulatory bodies, subject-matter experts, and industry representatives. Filling the gaps in the evaluation and selection of the mHealth app will improve clinical decision-making, personalized treatments, self-management and disease monitoring in respiratory medicine.
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Affiliation(s)
- Ayfer Koyuncu
- Graduate School of Science and Engineering, Bioengineering Department, Hacettepe University, Ankara, Turkey
| | - Arzu Ari
- College of Health Professions Department of Respiratory Care, Regent's Professor and Associate Dean for Research, Texas State University, Round Rock, TX, USA
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Miller AG, Rehder KJ, Rotta AT. High-flow nasal cannula in critical asthma: Time for the respiratory therapists to drive care! Pediatr Pulmonol 2023; 58:3369-3371. [PMID: 37642278 DOI: 10.1002/ppul.26661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Affiliation(s)
| | - Kyle J Rehder
- Duke University Medical Center, Durham, North Carolina, USA
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Rogerson C, Owora A, He T, Carroll A, Schleyer T, AbuSultaneh S, Tu W, Mendonca E. High flow nasal cannula use is associated with increased hospital length of stay for pediatric asthma. Pediatr Pulmonol 2023; 58:3046-3053. [PMID: 37530483 DOI: 10.1002/ppul.26617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/22/2023] [Accepted: 07/17/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND High flow nasal cannula (HFNC) is a respiratory device increasingly used to treat asthma. Recent mechanistic studies have shown that nebulized medications may have reduced delivery with HFNC, which may impair asthma treatment. This study evaluated the association between HFNC use for pediatric asthma and hospital length of stay (LOS). METHODS This was a retrospective matched cohort study. Cases included patients aged 2-18 years hospitalized between January 2010 and December 2021 with asthma and received HFNC treatment. Controls were selected using logistic regression propensity score matching based on demographics, vital signs, medications, imaging, and social and environmental determinants of health. The primary outcome was hospital LOS. RESULTS A total of 23,659 encounters met eligibility criteria, and of these 1766 cases included HFNC treatment with a suitable matched control. Cases were well-matched in demographics, social and environmental determinants of health, and clinical characteristics including use of adjunctive asthma therapies. The median hospital LOS for study cases was significantly higher at 87 h (interquartile range [IQR]: 61-145) compared to 66 h (IQR: 43-105) in the matched controls (p < 0.01). There was no significant difference in the rate of intubation and mechanical ventilation (8.9% vs. 7.6%, p = .18); however, the use of NIV was significantly higher in the cases than the control group (21.3% vs. 6.7%, p < .01). CONCLUSION In this study of children hospitalized for asthma, HFNC use was associated with increased hospital LOS compared to matched controls. Further research using more granular data and additional relevant variables is needed to validate these findings.
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Affiliation(s)
- Colin Rogerson
- Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Biostatistics, Indiana University-Purdue University, Indianapolis, Indiana, USA
| | - Arthur Owora
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tian He
- Regenstrief Institute, Center for Biomedical Informatics, Indianapolis, Indiana, USA
| | - Aaron Carroll
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Titus Schleyer
- Department of Biostatistics, Indiana University-Purdue University, Indianapolis, Indiana, USA
| | | | - Wanzhu Tu
- Regenstrief Institute, Center for Biomedical Informatics, Indianapolis, Indiana, USA
| | - Eneida Mendonca
- Indiana University School of Medicine, Indianapolis, Indiana, USA
- Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio, USA
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Huang Y, Zhao J, Hua X, Luo K, Shi Y, Lin Z, Tang J, Feng Z, Mu D. Guidelines for high-flow nasal cannula oxygen therapy in neonates (2022). J Evid Based Med 2023; 16:394-413. [PMID: 37674304 DOI: 10.1111/jebm.12546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
High-flow nasal cannula (HFNC) oxygen therapy, which is important in noninvasive respiratory support, is increasingly being used in critically ill neonates with respiratory failure because it is comfortable, easy to setup, and has a low incidence of nasal trauma. The advantages, indications, and risks of HFNC have been the focus of research in recent years, resulting in the development of the application. Based on current evidence, we developed guidelines for HFNC in neonates using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The guidelines were formulated after extensive consultations with neonatologists, respiratory therapists, nurse specialists, and evidence-based medicine experts. We have proposed 24 recommendations for 9 key questions. The guidelines aim to be a source of evidence and reference of HFNC oxygen therapy in clinical practice, and so that more neonates and their families will benefit from HFNC.
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Affiliation(s)
- Yi Huang
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
| | - Jing Zhao
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Xintian Hua
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Keren Luo
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Zhenlang Lin
- Department of Neonatology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, P.R. China
| | - Jun Tang
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Zhichun Feng
- Department of Neonatology, Faculty of Pediatrics, Chinese PLA General Hospital, Beijing, P.R. China
| | - Dezhi Mu
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
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Lenders V, Koutsoumpou X, Phan P, Soenen SJ, Allegaert K, de Vleeschouwer S, Toelen J, Zhao Z, Manshian BB. Modulation of engineered nanomaterial interactions with organ barriers for enhanced drug transport. Chem Soc Rev 2023; 52:4672-4724. [PMID: 37338993 DOI: 10.1039/d1cs00574j] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
The biomedical use of nanoparticles (NPs) has been the focus of intense research for over a decade. As most NPs are explored as carriers to alter the biodistribution, pharmacokinetics and bioavailability of associated drugs, the delivery of these NPs to the tissues of interest remains an important topic. To date, the majority of NP delivery studies have used tumor models as their tool of interest, and the limitations concerning tumor targeting of systemically administered NPs have been well studied. In recent years, the focus has also shifted to other organs, each presenting their own unique delivery challenges to overcome. In this review, we discuss the recent advances in leveraging NPs to overcome four major biological barriers including the lung mucus, the gastrointestinal mucus, the placental barrier, and the blood-brain barrier. We define the specific properties of these biological barriers, discuss the challenges related to NP transport across them, and provide an overview of recent advances in the field. We discuss the strengths and shortcomings of different strategies to facilitate NP transport across the barriers and highlight some key findings that can stimulate further advances in this field.
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Affiliation(s)
- Vincent Lenders
- Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium.
| | - Xanthippi Koutsoumpou
- Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium.
| | - Philana Phan
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Stefaan J Soenen
- Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium.
- NanoHealth and Optical Imaging Group, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, CN Rotterdam, 3015, The Netherlands
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B3000 Leuven, Belgium
- Leuven Child and Youth Institute, KU Leuven, 3000 Leuven, Belgium
- Woman and Child, Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Steven de Vleeschouwer
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Leuven, Belgium
- Leuven Brain Institute (LBI), KU Leuven, Leuven, Belgium
| | - Jaan Toelen
- Leuven Child and Youth Institute, KU Leuven, 3000 Leuven, Belgium
- Woman and Child, Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Zongmin Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Bella B Manshian
- Translational Cell and Tissue Research Unit, Department of Imaging and Pathology, KU Leuven, Herestraat 49, B3000 Leuven, Belgium.
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Montigaud Y, Georges Q, Leclerc L, Clotagatide A, Louf-Durier A, Pourchez J, Prévôt N, Périnel-Ragey S. Impact of gas humidification and nebulizer position under invasive ventilation: preclinical comparative study of regional aerosol deposition. Sci Rep 2023; 13:11056. [PMID: 37422519 PMCID: PMC10329710 DOI: 10.1038/s41598-023-38281-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/06/2023] [Indexed: 07/10/2023] Open
Abstract
Successful aerosol therapy in mechanically ventilated patients depends on multiple factors. Among these, position of nebulizer in ventilator circuit and humidification of inhaled gases can strongly influence the amount of drug deposited in airways. Indeed, the main objective was to preclinically evaluate impact of gas humidification and nebulizer position during invasive mechanical ventilation on whole lung and regional aerosol deposition and losses. Ex vivo porcine respiratory tracts were ventilated in controlled volumetric mode. Two conditions of relative humidity and temperature of inhaled gases were investigated. For each condition, four different positions of vibrating mesh nebulizer were studied: (i) next to the ventilator, (ii) right before humidifier, (iii) 15 cm to the Y-piece adapter and (iv) right after the Y-piece. Aerosol size distribution were calculated using cascade impactor. Nebulized dose, lung regional deposition and losses were assessed by scintigraphy using 99mtechnetium-labeled diethylene-triamine-penta-acetic acid. Mean nebulized dose was 95% ± 6%. For dry conditions, the mean respiratory tract deposited fractions reached 18% (± 4%) next to ventilator and 53% (± 4%) for proximal position. For humidified conditions, it reached 25% (± 3%) prior humidifier, 57% (± 8%) before Y-piece and 43% (± 11%) after this latter. Optimal nebulizer position is proximal before the Y-piece adapter showing a more than two-fold higher lung dose than positions next to the ventilator. Dry conditions are more likely to cause peripheral deposition of aerosols in the lungs. But gas humidification appears hard to interrupt efficiently and safely in clinical use. Considering the impact of optimized positioning, this study argues to maintain humidification.
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Affiliation(s)
- Yoann Montigaud
- Mines Saint-Etienne, Univ Jean Monnet, INSERM, U1059 Sainbiose; Centre CIS, 42023, Saint-Etienne, France
| | - Quentin Georges
- Intensive Care Unit G, CHU Saint-Etienne, 42055, Saint-Etienne, France
| | - Lara Leclerc
- Mines Saint-Etienne, Univ Jean Monnet, INSERM, U1059 Sainbiose; Centre CIS, 42023, Saint-Etienne, France
| | | | | | - Jérémie Pourchez
- Mines Saint-Etienne, Univ Jean Monnet, INSERM, U1059 Sainbiose; Centre CIS, 42023, Saint-Etienne, France
| | - Nathalie Prévôt
- Nuclear Medicine Unit, CHU Saint-Etienne, 42055, Saint-Etienne, France
- Université Jean Monnet, Mines Saint-Etienne, INSERM, U1059 Sainbiose, 42023, Saint-Etienne, France
| | - Sophie Périnel-Ragey
- Intensive Care Unit G, CHU Saint-Etienne, 42055, Saint-Etienne, France.
- Université Jean Monnet, Mines Saint-Etienne, INSERM, U1059 Sainbiose, 42023, Saint-Etienne, France.
- Intensive Care Unit G, Saint Etienne University Hospital, North Hospital, UMR INSERM U1059, Avenue Albert Raymond, 42270, Saint Priest en Jarez, France.
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O'Toole C, McGrath JA, Joyce M, O'Sullivan A, Thomas C, Murphy S, MacLoughlin R, Byrne MA. Effect of Nebuliser and Patient Interface Type on Fugitive Medical Aerosol Emissions in Adult and Paediatric Patients. Eur J Pharm Sci 2023; 187:106474. [PMID: 37225006 DOI: 10.1016/j.ejps.2023.106474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/19/2023] [Accepted: 05/21/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Open circuit aerosol therapy is associated with the potential for fugitive emissions of medical aerosol. Various nebulisers and interfaces are used in respiratory treatments, including the recent consideration of filtered interfaces. This study aims to quantify fugitive medical aerosols from various nebuliser types, in conjunction with different filtered and non-filtered interfaces. METHODS For both simulated adult and paediatric breathing, four nebuliser types were assessed including; a small volume jet nebuliser (SVN), a breath enhanced jet nebuliser (BEN), a breath actuated jet nebuliser (BAN) and a vibrating mesh nebuliser (VMN). A combination of different interfaces were used including filtered and unfiltered mouthpieces, as well as open, valved and filtered facemasks. Aerosol mass concentrations were measured using an Aerodynamic Particle Sizer at 0.8 m and 2.0 m. Additionally, inhaled dose was assessed. RESULTS Highest mass concentrations recorded were 214 (177, 262) µg m-3 at 0.8 m over 45-minute run. The highest and lowest fugitive emissions were observed for the adult SVN facemask combination, and the adult BAN filtered mouthpiece combination respectively. Fugitive emissions decreased when using breath-actuated (BA) mode compared to continuous (CN) mode on the BAN for the adult and paediatric mouthpiece combination. Lower fugitive emissions were observed when a filtered facemask or mouthpiece was used, compared to unfiltered scenarios. For the simulated adult, highest and lowest inhaled dose were 45.1 (42.6, 45.6)% and 11.0 (10.1,11.9)% for the VMN and SVN respectively. For the simulated paediatric, highest and lowest inhaled dose were 44.0 (42.4, 44.8)% and 6.1 (5.9, 7.0)% for the VMN and BAN CN respectively. Potential inhalation exposure of albuterol was calculated to be up to 0.11 µg and 0.12 µg for a bystander and healthcare worker respectively. CONCLUSION This work demonstrates the need for filtered interfaces in clinical and homecare settings to minimise fugitive emissions and to reduce the risk of secondary exposure to care givers.
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Affiliation(s)
- Ciarraí O'Toole
- Physics, School of Natural Sciences, Ryan Institute's Centre for Climate and Air Pollution Studies, College of Science & Engineering, University of Galway, H91 CF50, Galway, Ireland.
| | - James A McGrath
- Physics, School of Natural Sciences, Ryan Institute's Centre for Climate and Air Pollution Studies, College of Science & Engineering, University of Galway, H91 CF50, Galway, Ireland; Department of Experimental Physics, Maynooth University, Maynooth, Co. Kildare, Ireland.
| | - Mary Joyce
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland.
| | - Andrew O'Sullivan
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland.
| | - Ciara Thomas
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland.
| | - Sarah Murphy
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland.
| | - Ronan MacLoughlin
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland; School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland.
| | - Miriam A Byrne
- Physics, School of Natural Sciences, Ryan Institute's Centre for Climate and Air Pollution Studies, College of Science & Engineering, University of Galway, H91 CF50, Galway, Ireland.
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12
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Gelbart B, McSharry B, Delzoppo C, Erickson S, Lee K, Butt W, Rea M, Wang X, Beca J, Kazemi A, Shann F. Pragmatic Randomized Trial of Corticosteroids and Inhaled Epinephrine for Bronchiolitis in Children in Intensive Care. J Pediatr 2022; 244:17-23.e1. [PMID: 35093318 DOI: 10.1016/j.jpeds.2022.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/22/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether the combination of systemic corticosteroids and nebulized epinephrine, compared with standard care, reduces the duration of positive pressure support in children with bronchiolitis admitted to intensive care. STUDY DESIGN We performed a pragmatic, multicenter, open-label, randomized trial between July 2013 and November 2019 in children younger than 18 months old with a clinical diagnosis of bronchiolitis. The intervention group received the equivalent of 13 mg/kg prednisolone over 3 days, then 1 mg/kg daily for 3 days, plus 0.05 mL/kg of nebulized 1% epinephrine made up to 6 ml with 0.9% saline via jet nebulizer and mask using oxygen at 12 l/min every 30 minutes for 5 doses, then 1-4 hourly for 3 days, then as required for 3 days. The primary outcome was clinician-managed duration of positive pressure support in intensive care defined as high-flow nasal-prong oxygen, nasopharyngeal continuous positive airway pressure, or mechanical ventilation. RESULTS In total, 210 children received positive pressure support. In the corticosteroid-epinephrine group, 107 children received positive pressure support for a geometric mean of 26 (95% CI, 22-32) hours compared with 40 (95% CI 34-47) hours in 103 controls, adjusted ratio 0.66 (95% CI 0.51-0.84), P = .001. In the intervention group, 41 (38%) children experienced at least 1 adverse event, compared with 39 (38%) in the control group. CONCLUSIONS In children with severe bronchiolitis, the duration of clinician-managed pressure support was reduced by regular treatment with systemic corticosteroids and inhaled epinephrine compared with standard care. CLINICAL TRIAL REGISTRATION Australian Clinical Trials Research Network: ACTRN12613000316707.
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Affiliation(s)
- Ben Gelbart
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia.
| | - Brent McSharry
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, Australia
| | - Carmel Delzoppo
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Simon Erickson
- Paediatric Critical Care Unit, Perth Children's Hospital, Perth, Australia
| | - Katherine Lee
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - Warwick Butt
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Miriam Rea
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, Australia
| | - Xiaofang Wang
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, Australia
| | - Alex Kazemi
- Intensive Care Unit, Middlemore Hospital, Auckland, Australia
| | - Frank Shann
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
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13
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Khursheed R, Paudel KR, Gulati M, Vishwas S, Jha NK, Hansbro PM, Oliver BG, Dua K, Singh SK. Expanding the arsenal against pulmonary diseases using surface-functionalized polymeric micelles: breakthroughs and bottlenecks. Nanomedicine (Lond) 2022; 17:881-911. [PMID: 35332783 DOI: 10.2217/nnm-2021-0451] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pulmonary diseases such as lung cancer, asthma and tuberculosis have remained one of the common challenges globally. Polymeric micelles (PMs) have emerged as an effective technique for achieving targeted drug delivery for a local as well as a systemic effect. These PMs encapsulate and protect hydrophobic drugs, increase pulmonary targeting, decrease side effects and enhance drug efficacy through the inhalation route. In the current review, emphasis has been placed on the different barriers encountered by the drugs given via the pulmonary route and the mechanism of PMs in achieving drug targeting. The applications of PMs in different pulmonary diseases have also been discussed in detail.
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Affiliation(s)
- Rubiya Khursheed
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, 144411, India
| | - Keshav R Paudel
- Centre of Inflammation, Centenary Institute and University of Technology Sydney, Faculty of Science, School of Life Sciences, Sydney, 2007, Australia
| | - Monica Gulati
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, 144411, India.,Faculty of Health, Australian Research Centre in Complementary & Integrative Medicine, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Sukriti Vishwas
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, 144411, India
| | - Niraj Kumar Jha
- Department of Biotechnology, School of Engineering & Technology (SET), Sharda University, Plot No. 32-34 Knowledge Park III Greater Noida, Uttar Pradesh, 201310, India
| | - Philip M Hansbro
- Centre of Inflammation, Centenary Institute and University of Technology Sydney, Faculty of Science, School of Life Sciences, Sydney, 2007, Australia
| | - Brian G Oliver
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, 2007, Australia.,School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney 2007, Australia
| | - Kamal Dua
- Faculty of Health, Australian Research Centre in Complementary & Integrative Medicine, University of Technology Sydney, Ultimo, NSW, 2007, Australia.,Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Sachin Kumar Singh
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, 144411, India.,Faculty of Health, Australian Research Centre in Complementary & Integrative Medicine, University of Technology Sydney, Ultimo, NSW, 2007, Australia
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14
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Gallagher L, Joyce M, Murphy B, Mac Giolla Eain M, MacLoughlin R. The Impact of Head Model Choice on the In Vitro Evaluation of Aerosol Drug Delivery. Pharmaceutics 2021; 14:pharmaceutics14010024. [PMID: 35056920 PMCID: PMC8777612 DOI: 10.3390/pharmaceutics14010024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
There are variations in the values reported for aerosol drug delivery across in vitro experiments throughout the published literature, and often with the same devices or similar experimental setups. Factors contributing to this variability include, but are not limited to device type, equipment settings, drug type and quantification methods. This study assessed the impact of head model choice on aerosol drug delivery using six different adults and three different paediatric head models in combination with a facemask, mouthpiece, and high-flow nasal cannula. Under controlled test conditions, the quantity of drug collected varied depending on the choice of head model. Head models vary depending on a combination of structural design differences, facial features (size and structure), internal volume measurements and airway geometries and these variations result in the differences in aerosol delivery. Of the widely available head models used in this study, only three were seen to closely predict in vivo aerosol delivery performance in adults compared with published scintigraphy data. Further, this testing identified the limited utility of some head models under certain test conditions, for example, the range reported across head models was aerosol drug delivery of 2.62 ± 2.86% to 37.79 ± 1.55% when used with a facemask. For the first time, this study highlights the impact of head model choice on reported aerosol drug delivery within a laboratory setting and contributes to explaining the differences in values reported within the literature.
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Affiliation(s)
- Lauren Gallagher
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Mary Joyce
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Barry Murphy
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Marc Mac Giolla Eain
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Ronan MacLoughlin
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
- Correspondence:
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15
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Seif SM, Ma E, Rabea H, Saeed H, Abdelrahim MEA. Aerosol delivery of inhalation devices with different add-on connections to invasively ventilated COPD subjects: An in-vivo study. Eur J Pharm Sci 2021; 167:105988. [PMID: 34492291 DOI: 10.1016/j.ejps.2021.105988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/06/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022]
Abstract
Aerosol delivery to mechanically ventilated patients requires add-on connections to place the inhalation device within the ventilation circuit. The study aimed to evaluate the performance of Combihaler in dual limb invasive mechanical ventilation (IMV). A ventilator with a humidified dual limb circuit was adjusted to volume-controlled mode to imitate the adult breathing parameters. 24 (12 females) intubated chronic obstructive pulmonary disease (COPD) subjects had undergone the study. All patients were prescribed inhaled salbutamol dose delivered by either a metered-dose inhaler (pMDI) or vibrating mesh nebulizer (VMN). Each subject received salbutamol in four different inhalation device/connection conditions; pMDI+VMN+Combihaler, VMN+Combihaler, VMN+T-piece, and pMDI+T-piece. They were individually placed in the inspiratory limb at Y-piece. 5mg salbutamol was delivered by VMN with and without 2 pMDI puffs of salbutamol (100 µg), and 500µg was delivered by pMDI+T-piece. After aerosol delivery, two urine samples were collected from the patient; 30 min post-inhalation (USAL0.5) and cumulatively 24 h post-inhalation (USAL24) as indexes of lung deposition and systemic absorption, respectively. For the ex-vivo study, a collecting filter was placed before an endotracheal tube (ETT) to collect the delivered inhalable dose. In-vitro aerodynamic characteristics were also investigated. pMDI+VMN+Combihaler delivered more salbutamol to the lung and the ex-vivo filter than VMN+T-piece (p˂0.05, p≤0.01, respectively). VMN delivered a higher salbutamol amount to the lung, systemically, and the ex-vivo filter than pMDI+T-piece (p˂0.001). pMDI+VMN+Combihaler and VMN+Combihaler delivered aerosols with a less mass median aerodynamic diameter (MMAD) and higher fine particle fraction (FPF) compared to VMN+T-piece (p≤0.01 for MMAD, p˂0.01 for FPF) and pMDI+T-piece (p˂0.01 for both MMAD and FPF). Results of the study showed that pMDI+VMN+ Combihaler delivered more salbutamol than VMN+T-piece in IMV and demonstrate that 5 puffs (500-µg) of salbutamol with pMDI+T-piece has a lower aerosol delivering power at the level of USAL0.5, USAL24, and the ex-vivo inhalable dose than 5 mg nebulized salbutamol by VMNs in IMV.
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Affiliation(s)
- Salah M Seif
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Elnady Ma
- Chest Diseases Department, Kasr Al Einy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hoda Rabea
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt.
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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16
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Ari A, Blain K, Soubra S, Hanania NA. Treating COPD Patients with Inhaled Medications in the Era of COVID-19 and Beyond: Options and Rationales for Patients at Home. Int J Chron Obstruct Pulmon Dis 2021; 16:2687-2695. [PMID: 34611397 PMCID: PMC8487292 DOI: 10.2147/copd.s332021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/13/2021] [Indexed: 01/29/2023] Open
Abstract
COVID-19 has affected millions of patients, caregivers, and clinicians around the world. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads via droplets and close contact from person to person, and there has been an increased concern regarding aerosol drug delivery due to the potential aerosolizing of viral particles. To date, little focus has been given to aerosol drug delivery to patients with COVID-19 treated at home to minimize their hospital utilization. Since most hospitals were stressed with multiple admissions and experienced restricted healthcare resources in the era of COVID-19 pandemic, treating patients with COPD at home became essential to minimize their hospital utilization. However, guidance on how to deliver aerosolized medications safely and effectively to this patient population treated at home is still lacking. In this paper, we provide some strategies and rationales for device and interface selection, delivery technique, and infection control for patients with COPD who are being treated at home in the era of COVID-19 and beyond.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Karen Blain
- Department of Respiratory Therapy, University of North Carolina Wilmington, Wilmington, NC, USA
| | - Said Soubra
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Nicola A Hanania
- Airways Clinical Research Center, Baylor College of Medicine, Houston, TX, USA
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17
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Barber AT, Loughlin CE. Pediatric pulmonology 2019 year in review: Asthma. Pediatr Pulmonol 2021; 56:2449-2454. [PMID: 34081841 DOI: 10.1002/ppul.25507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 05/16/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Andrew T Barber
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ceila E Loughlin
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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18
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Ari A, Fink JB. Quantifying Delivered Dose with Jet and Mesh Nebulizers during Spontaneous Breathing, Noninvasive Ventilation, and Mechanical Ventilation in a Simulated Pediatric Lung Model with Exhaled Humidity. Pharmaceutics 2021; 13:pharmaceutics13081179. [PMID: 34452139 PMCID: PMC8400423 DOI: 10.3390/pharmaceutics13081179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 11/21/2022] Open
Abstract
Acutely ill children may transition between spontaneous breathing (SB), noninvasive ventilation (NIV), and mechanical ventilation (MV), and commonly receive the same drug dosage with each type of ventilatory support and interface. This study aims to determine the aerosol deposition with jet (JN) and mesh nebulizers (MN) during SB, NIV, and MV using a pediatric lung model. Drug delivery with JN (Mistymax10) and MN (Aerogen Solo) was compared during SB, NIV, and MV using three different lung models set to simulate the same breathing parameters (Vt 250 mL, RR 20 bpm, I:E ratio 1:3). A heated humidifier was placed between the filter and test lung to simulate exhaled humidity (35 ± 2 °C, 100% RH) with all lung models. Albuterol sulfate (2.5 mg/3 mL) was delivered, and the drug deposited on an absolute filter was eluted and analyzed with spectrophotometry. Aerosol delivery with JN was not significantly different during MV, NIV, and SB (p = 0.075), while inhaled dose obtained with MN during MV was greater than NIV and SB (p = 0.001). The delivery efficiency of MN was up to 3-fold more than JN during MV (p = 0.008), NIV (p = 0.005), and SB (p = 0.009). Delivered dose with JN was similar during MV, NIV, and SB, although the delivery efficiency of MN differs with different modes of ventilation.
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Affiliation(s)
- Arzu Ari
- Correspondence: ; Tel.: +1-512-716-2691
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19
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Ari A, Fink JB. Delivered dose with jet and mesh nebulisers during spontaneous breathing, noninvasive ventilation and mechanical ventilation using adult lung models. ERJ Open Res 2021; 7:00027-2021. [PMID: 34262965 PMCID: PMC8273293 DOI: 10.1183/23120541.00027-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/20/2021] [Indexed: 11/05/2022] Open
Abstract
What is the delivered dose with jet and mesh nebulisers during spontaneous breathing (SB), noninvasive ventilation (NIV), and mechanical ventilation (MV) using an adult lung model with exhaled humidity (EH)? The delivery of salbutamol sulfate (2.5 mg per 3 mL) with jet (Mistymax10) and mesh nebulisers (Aerogen Solo) was compared during SB, NIV, and MV using breathing parameters (tidal volume 450 mL, respiratory rate 20 breaths per min, inspiratory:expiratory ratio 1:3) with three lung models simulating exhaled humidity. A manikin was attached to a sinusoidal pump via a filter at the bronchi to simulate an adult with SB. A ventilator (V60) was attached via a facemask to a manikin with a filter at the bronchi connected to a test lung to simulate an adult receiving NIV. A ventilator-dependent adult was simulated through a ventilator (Servo-i) operated with a heated humidifier (Fisher & Paykel) attached to an endotracheal tube (ETT) with a heated-wire circuit. The ETT was inserted into a filter (Respirgard II). A heated humidifier was placed between the filter and test lung to simulate exhaled humidity (35±2°C, 100% relative humidity). Nebulisers were placed at the Y-piece of the inspiratory limb during MV and positioned between the facemask and the leak-port during NIV. A mouthpiece was used during SB. The delivered dose was collected in an absolute filter that was attached to the bronchi of the mannequin during each aerosol treatment and measured with spectrophotometry. Drug delivery during MV was significantly greater than during NIV and SB with a mesh nebuliser (p=0.0001) but not with a jet nebuliser (p=0.384). Delivery efficiency of the mesh nebuliser was greater than the jet nebuliser during MV (p=0.0001), NIV (p=0.0001), and SB (p=0.0001). Aerosol deposition obtained with a mesh nebuliser was greater and differed between MV, NIV, and SB, while deposition was low with a jet nebuliser and similar between the modes of ventilation tested.
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Affiliation(s)
- Arzu Ari
- Dept of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - James B Fink
- Dept of Respiratory Care, Texas State University, Round Rock, TX, USA
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20
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Li J, Fink JB. Narrative review of practical aspects of aerosol delivery via high-flow nasal cannula. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:590. [PMID: 33987288 DOI: 10.21037/atm-20-7383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Using high-flow nasal cannula (HFNC) as a "vehicle" to administer aerosolized medication has attracted clinicians' interest in recent years. In this paper, we summarize the current evidence to answer the common questions raised by clinicians about this new aerosol delivery route and best practices of administration. Benefits of trans-nasal aerosol delivery include increased comfort, ability to speak, eat, and drink for patients while meeting a range of oxygen requirements, particularly for those who need to inhale aerosolized medication for long periods. Aerosol administration via HFNC has been shown to be well tolerated by children and adults, with comparable or better delivery efficacy than other interfaces, ranging from 2-20%. In vitro and in vivo scintigraphy studies among pediatric and adult populations reported that the inhaled dose delivered via a vibrating mesh nebulizer is 2 to 3 fold greater than that via a jet nebulizer. For adults, placement of nebulizer at the inlet of humidifier increases inhaled dose while reducing rainout obstructing nasal prongs. When HFNC gas flow is set below patient inspiratory flow, aerosol deposition is higher than when the gas flow exceeds patient inspiratory flow; thus, if tolerated, titrating down HFNC gas flow during trans-nasal aerosol delivery, with close monitoring and the use of unit dose with high concentration are recommended. Trans-nasal pulmonary aerosol delivery has not been shown to increase bioaerosols generated by patients, but gas flow may disperse aerosols. Placement of a surgical or procedure mask over HFNC might reduce aerosol dispersion.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
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21
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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: 1.8] [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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22
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Ari A, Moody GB. How to deliver aerosolized medications through high flow nasal cannula safely and effectively in the era of COVID-19 and beyond: A narrative review. ACTA ACUST UNITED AC 2021; 57:22-25. [PMID: 33688576 PMCID: PMC7932031 DOI: 10.29390/cjrt-2020-041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The treatments of COVID-19 involve some degree of uncertainty. Current evidence also shows mixed findings with regards to bioaerosol dispersion and airborne transmission of COVID-19 during high flow nasal cannula (HFNC) therapy. While coping with this global pandemic created hot debates on the use of HFNC, it is important to bring detached opinions and current evidence to the attention of health care professionals (HCPs) who may need to use HFNC in patients with COVID-19. Aim The purpose of this paper is to provide a framework on the selection, placement, and use of nebulizers as well as HFNC prongs, gas flow, and delivery technique via HFNC to help clinicians deliver aerosolized medications through HFNC safely and effectively in the era of COVID-19 and beyond. Methods We searched PubMed, Medline, CINAHL, and Science Direct to identify studies on aerosol drug delivery through HFNC using the following keywords: (“aerosols,” OR “nebulizers”) AND (“high flow nasal cannula” OR “high flow oxygen therapy” OR “HFNC”) AND (“COVID-19,” OR “SARS-CoV-2”). Twenty-eight articles including in vitro studies, randomized clinical trials, scintigraphy studies, review articles, prospective and retrospective research were included in this review. Discussion and results It is not clear if the findings of the previous studies on bacterial contamination could be applied to viral transmission because they do not provide data that could be extrapolated to the risk of SARS-CoV-2 transmission. In the face of the unknown risk with the transmission of COVID-19 during HFNC therapy, the benefits of HFNC must be weighed against the risk of infection to HCPs and other patients. Due to the limited number of ventilators available in hospitals and the confirmed effectiveness of HFNC in treating hypoxemic respiratory failure, HFNC may prevent early intubation, and prolonged intensive care unit stays in patients with COVID-19. Conclusion Clinicians should review the magnitude of this risk based on current evidence and use the suggested strategies of this paper for safe and effective delivery of aerosolized medications through HFNC in the era of COVID-19 and beyond.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Therapy, Texas State University, Round Rock, TX, USA
| | - Gerald B Moody
- Children's Health - Children's Medical Center, Department of Respiratory Care, Dallas, TX, USA
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23
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Li J, Fink JB, MacLoughlin R, Dhand R. A narrative review on trans-nasal pulmonary aerosol delivery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:506. [PMID: 32807226 PMCID: PMC7430014 DOI: 10.1186/s13054-020-03206-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/27/2020] [Indexed: 01/21/2023]
Abstract
The use of trans-nasal pulmonary aerosol delivery via high-flow nasal cannula (HFNC) has expanded in recent years. However, various factors influencing aerosol delivery in this setting have not been precisely defined, and no consensus has emerged regarding the optimal techniques for aerosol delivery with HFNC. Based on a comprehensive literature search, we reviewed studies that assessed trans-nasal pulmonary aerosol delivery with HFNC by in vitro experiments, and in vivo, by radiolabeled, pharmacokinetic and pharmacodynamic studies. In these investigations, the type of nebulizer employed and its placement, carrier gas, the relationship between gas flow and patient’s inspiratory flow, aerosol delivery strategies (intermittent unit dose vs continuous administration by infusion pump), and open vs closed mouth breathing influenced aerosol delivery. The objective of this review was to provide rational recommendations for optimizing aerosol delivery with HFNC in various clinical settings.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
| | | | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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Li J, Wei W, Fink JB. In vitro comparison of unit dose vs infusion pump administration of albuterol via high-flow nasal cannula in toddlers. Pediatr Pulmonol 2020; 55:322-329. [PMID: 31782914 DOI: 10.1002/ppul.24589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/10/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Transnasal pulmonary aerosol delivery using high-flow nasal cannula (HFNC) devices has become a popular route of aerosol administration in toddlers. Clinically, albuterol is administered using an infusion pump or unit doses. However, little evidence is available to compare the two administration strategies. METHODS A toddler manikin (15 kg) with appropriate anatomic airway was connected with collecting filter to a simulator of distressed breathing. HFNC device with mesh nebulizer placed at the inlet of a humidifier at 37°C, with the gas flow set at 25 and 3.75 L/min. Five milligrams of albuterol was delivered in all experiments. With infusion pump administration, albuterol concentrations of 5 and 1 mg/mL were delivered at 4 and 20 mL/hr for 15 minutes. With unit dose administration, 1 mL (5 mg/mL) and 2 mL (2.5 mg/mL) of albuterol were nebulized. Additional tests with mouth open and nebulizers via mask were using 5 mg/1 mL for mesh nebulizer and 5 mg/3 mL for jet nebulizer (n = 3). The drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). RESULTS The inhaled dose was higher with unit dose than infusion pump administration with gas flows of 25 L/min (2.66 ± 0.38 vs 1.16 ± 0.28%; P = .004) and 3.75 L/min (10.51 ± 1.29 vs 8.58 ± 0.68%; P = .025). During unit dose administration, compared with closed-mouth breathing, open-mouth breathing generated a higher inhaled dose at 3.75 L/min and lower inhaled dose at 25 L/min. Compared to the nebulizers via mask with both open and closed-mouth breathing, nebulization via HFNC at 3.75 L/min generated greater inhaled dose, while HFNC at 25 L/min generated lower inhaled dose. CONCLUSIONS During transnasal aerosol delivery, the inhaled dose was higher with medication administrated using unit dose than using an infusion pump.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois
| | - Wu Wei
- Department of Critical Care Medicine, Shanghai Zhongshan Hospital, Fu Dan University, Shanghai, China
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois.,Aerogen Pharma Corp, San Mateo, California
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