Effects of an external nasal dilator strip (ENDS) compared to xylometazolin nasal spray

Safety and Efficacy of External Nasal Dilator Strips with N95 Respirator Masks by Emergency Department Personnel

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has prompted increased use of personal protective equipment (PPE) to maintain the health and safety of caregivers. This study was conducted in 2020 to evaluate the safety and efficacy of external nasal dilator strips (ENDS) coupled with N95 respirators in a sample of community hospital emergency department personnel.

METHODS

After obtaining written consent, the authors tested participants' response to exercise (i.e., walking up 10 flights of stairs) while wearing an N95 respirator, both with and without an ENDS. The authors measured participants' heart rate and respiratory effort responses over four minutes following their exercise trial. A convenience sample of these personnel also repeated their respirator fit testing while wearing an ENDS with the N95 style they had previously been fitted for.

RESULTS

A total of N = 50 participants were enrolled. Peak heart rate while wearing an ENDS was 125 beats per minute (BPM) with the ENDS versus 130 BPM without (p = 0.21). The Borg Exertion Score while wearing an ENDS peaked at 13 with the ENDS versus 14 without (p = 0.08). However, when subjects were surveyed before and after the trial upon whether they would consider using an ENDS beneath their N95 using a scale of 1-5, their interest in this significantly increased (p = 0.004). Four of the 13 (31%) participants who completed repeated fit testing while wearing the ENDS beneath their N95 respirator failed the repeat testing.

CONCLUSIONS

These results first suggest that a sizable proportion of ED personnel may fail N95 fit testing while wearing an ENDS beneath the N95 mask for which they had been previously fitted. Although providers' subjective interest in use of ENDS increased, these results also demonstrate that use of an ENDS beneath an N95 respirator may not significantly increase exercise tolerance.

[External and internal nasal valve. Diagnostic and treatment methods for dysfunction]

The purpose of the work is the analysis of diagnostic methods of nasal valve dysfunction according to Pubmed database and national medical journals during the period from 1997 to 2019. A brief analysis of the definition of the zones of the external and internal nasal valve, diagnostic methods, including external nasal dilators, spiral computed tomography, assessment of the degree of displacement of the nasal wing using various aspirators is given. Various methods for treating nasal valve dysfunction, such as external and internal dilators, strengthening the nasal wings, suture techniques, expanding the edge of the pear-shaped hole, implantation of absorbable polymers into the side wall of the nose are critically evaluated. Our own original correction method is described for dysfunction of the external nasal valve caused by the vertically located legs of the inferior lateral cartilage.

Sleep Quality and Congestion with Breathe Right Nasal Strips: Two Randomized Controlled Trials

Introduction

Two multicenter, double-blind, randomized controlled trials assessed the effect of Breathe Right Nasal Strips (BRNS) on sleep-related quality of life in otherwise healthy subjects with chronic nocturnal nasal congestion who reported trouble sleeping.

Methods

Subjects were randomized to BRNS or a placebo strip for approximately 8 h each night for 14 days. Efficacy was assessed in the clinic using the Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire (NRQLQ).

Results

A total of 140 subjects were randomized in Study 1, and 130 in Study 2. There was no significant difference between BRNS and placebo on either the NRQLQ “Sleep Problems” domain or the “Feel Tired and Unrefreshed” item of the “Symptoms on Waking in the Morning” domain at day 7 or 14. There was, however, a significant change in the least squares mean difference from baseline to days 7 and 14 in both the BRNS and placebo arms for each of these endpoints. BRNS were well tolerated.

Conclusions

BRNS did not significantly improve subjective measures of sleep quality and nasal congestion compared with placebo strips in this population of chronic nocturnal congestion sufferers with self-reported sleep impairment, possibly due to a strong placebo effect.

Funding

GlaxoSmithKline Consumer Healthcare.

ClinicalTrials.gov Registration Numbers

Study 1: NCT03549117; Study 2: NCT03549130.

Objective and Subjective Effects of a Prototype Nasal Dilator Strip on Sleep in Subjects with Chronic Nocturnal Nasal Congestion

Introduction

This exploratory study characterized the performance of a nasal dilator strip with improved spring forces in lowering nasal resistance during sleep and reducing sleep-disordered breathing in subjects with difficulty sleeping due to chronic nocturnal nasal congestion.

Methods

Subjects applied the strip at bedtime for 28 days (active phase; n = 70). Objective assessments included snoring variables, breathing route during sleep, and polysomnography measures compared with baseline. Nasal breathing, congestion, and sleep were measured subjectively using rating scales and questionnaires. During a crossover nasal resistance phase (n = 55), nasal resistance was measured using posterior rhinomanometry with the strip applied on one of two nights.

Results

In the active phase, breathing and sleep were perceived to improve, with less daytime sleepiness (P < 0.04) and increased ease of breathing, sleep quality, staying asleep, and feeling refreshed in the morning (all P < 0.0001). However, while objective polysomnography metrics were generally similar with and without the strip, median wake after sleep onset time was numerically reduced by ~ 11 min, and the spontaneous arousal rate fell by ~ 37%. In the nasal resistance phase (n = 55), median resistance (at 0.2–0.25 l/s) while asleep was 39.1% lower with (n = 37) versus without (n = 36) the strip (1.34 vs. 2.20 cmH₂O/l/s; P = 0.048).

Conclusions

This exploratory study supports a role for the improved spring force nasal dilator strip in alleviating sleep-related symptoms in subjects with chronic nasal congestion, potentially via lowering nasal resistance and reducing nocturnal awakenings. A larger study is indicated to confirm these preliminary data.

ClinicalTrials.gov identifier

NCT03105297.

Funding

GlaxoSmithKline Consumer Healthcare.

Plain Language Summary

Plain language summary available for this article.

Electronic supplementary material

The online version of this article (10.1007/s12325-019-00980-z) contains supplementary material, which is available to authorized users.

Randomized Trials of Nasal Patency and Dermal Tolerability With External Nasal Dilators in Healthy Volunteers

Background

External nasal dilator strips are used as nonpharmacological therapy to reduce snoring and daytime sleepiness. In a product improvement initiative, a marketed strip (BRNS) and 2 prototype nasal strips were evaluated.

Objective

To compare the nasal patency and multiple-use dermal tolerability of the BRNS and prototype nasal strips using both objective and subject-reported outcome measures.

Methods

Two studies were conducted separately in healthy volunteers ≥18 years of age. A single-day nasal patency randomized crossover study assessed minimal cross-sectional area (MCA; second restriction) and nasal volume (using acoustic rhinometry); nasal inspiratory flow and resistance (using posterior rhinomanometry); and subject-reported evaluations of the BRNS compared with the butterfly strip and teardrop strip prototypes. A single-center, randomized, controlled, parallel-group, evaluator-blinded study assessed dermal tolerability of the BRNS and the butterfly strip over 7 consecutive nights of use, using the Dermal Response Scale (DRS) and subject-reported comfort and ease of removal.

Results

In the Patency study (N = 50), all 3 strips demonstrated significant improvement from baseline in MCA, nasal volume, and nasal flow parameters (resistance and peak flow). The prototype strips demonstrated significantly more improvement in nasal volume than the BRNS, and the butterfly strip showed significantly more improvement in MCA than the BRNS; all strips were similar with respect to nasal flow and subject-reported nasal breathing outcomes. In the Dermal Tolerability study (N = 82), all subjects scored 0 (no evidence of irritation) on the DRS at all 7 morning assessments; the BRNS was numerically, but not significantly, superior to the butterfly strip on subject-reported outcomes.

Conclusion

The Patency study demonstrated significant improvement from baseline in nasal dimensions and flow for all 3 evaluated strips; between-strip differences were confined to nasal dimensions. Both the BRNS and butterfly strip were generally well tolerated, with no evidence of dermal response over 7 consecutive nights of use.

ClinicalTrials.gov identifiers: NCT01105949 and NCT01495494

Effects of nasal dilator strips on subjective measures of sleep in subjects with chronic nocturnal nasal congestion: a randomized, placebo-controlled trial

Background

This exploratory study investigated effects of a new asymmetric butterfly-shaped prototype nasal dilator strip and the currently marketed clear Breathe Right Nasal Strip (BRNS) on subjective measures of nasal congestion and sleep quality.

Methods

In this randomized, double-blind study, subjects with chronic nasal congestion and sleep difficulties were assigned a BRNS clear strip, an asymmetric butterfly prototype, or an asymmetric butterfly placebo strip without springs, to use nightly for 2 weeks. The main outcomes included change from baseline to days 7 and 14 on the Pittsburgh Insomnia Rating Scale (PIRS), Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire (NRQLQ), and Congestion Quantifier Seven-Item Test (CQ7).

Results

The intent-to-treat population included 59 subjects. The butterfly and BRNS strips showed significant (P < 0.05) improvement versus placebo on PIRS satisfaction with sleep at day 7 [least square (LS) mean changes: − 0.7, − 0.6, and − 0.2, respectively], and the butterfly strip also showed significant improvement from baseline on this outcome versus placebo at day 14 (− 1.0 vs − 0.5). On the NRQLQ, both the butterfly prototype and BRNS clear were more effective than placebo in improving symptoms on waking at day 7 (LS mean changes: − 7.9, − 7.2, and − 4.1, respectively); the BRNS clear was significantly more effective than placebo in improving sleep problems at day 7 (− 7.4 vs − 4.2). There were no between-treatment differences on the CQ7. All strips were well tolerated.

Conclusions

The asymmetric butterfly prototype and BRNS clear strip significantly improved some subjective measures of nasal congestion and sleep compared with placebo in subjects with nasal congestion and sleep difficulties.

Trial registration This study is registered at ClinicalTrials.gov (identifier: NCT01122849)

Electronic supplementary material

The online version of this article (10.1186/s13223-018-0258-5) contains supplementary material, which is available to authorized users.

Evidence and evidence gaps in therapies of nasal obstruction and rhinosinusitis

Therapeutic decisions in otorhinolaryngology are based on clinical experience, surgical skills, and scientific evidence. Recently, evidence-based therapies have gained increased attention and importance due to their potential to improve the individual patient's treatment and their potential at the same time to reduce treatment costs. In clinical practice, it is almost impossible to stay ahead of the increasing mass of literature and on the other hand critically assess the presented data. A solid scientific and statistical knowledge as well as a significant amount of spare time are required to detect systematic bias and other errors in study designs, also with respect to assessing whether or not a study should be part of an individual therapeutic decision. Meta-analyses, reviews, and clinical guidelines are, therefore, of increasing importance for evidence-based therapy in clinical practice. This review is an update of the availability of external evidence for the treatment of nasal obstruction and rhinosinusitis. It becomes evident that both groups of diseases differ significantly in the availability of external evidence. Furthermore, it becomes obvious that surgical treatment options are normally based on evidence of significantly lower quality than medical treatment options.

Does the Airmax® internal nasal dilator increase peak nasal inspiratory flow (PNIF) in adolescent athletes?

OBJECTIVES

Nasal dilators are being developed for the purpose of increasing air flow in the nasal valve. The aim of this study is to evaluate the use of the internal nasal dilator (IND) by adolescent athletes.

METHODS

A double-blind, crossover clinical trial in which we evaluated 54 adolescents using experimental and placebo INDs, submitted to a cardio-respiratory test in randomized order. The predicted values for the peak nasal inspiratory flow (PNIF) were obtained and the intensity of dyspnea was evaluated using the visual analog scale method after the race.

RESULTS

In relation to PNIF (% predicted), when participants used the experimental IND, significantly higher means were found in comparison with the placebo (104.27±24.67L/min and 97.73±25.61L/min, respectively) (p=0.010). There were no significant differences observed in terms of heart rate (HR), pulse oximetry (SpO2) and maximal oxygen uptake (VO2max), before and after the cardio-respiratory test. There was also no significant difference (p>0.05) between the use of experimental and placebo INDs on dyspnea scale measurements after completion of the cardio-respiratory test.

CONCLUSION

Results suggested that the Airmax® IND improves nasal patency, as measured by PNIF, in healthy adolescent athletes. There was no statistically significant difference in the values for heart rate and SpO2. There was also no difference between the conditions tested for the mean VO2max. Further studies should be conducted to evaluate the effect of IND in adolescent athletes with chronic diseases, such as asthma and allergic rhinitis, and also using other cardio-respiratory assessment methods.

Magnetic resonance imaging reveals the complementary effects of decongestant and Breathe Right Nasal Strips on internal nasal anatomy

OBJECTIVES/HYPOTHESIS

This magnetic resonance imaging (MRI) study of 26 subjects with nasal congestion was performed to assess in the complete nasal passage both the anatomical effect of the marketed Breathe Right Nasal Strip (BRNS) relative to placebo and the potential adjunctive effect of using a decongestant in combination with the BRNS.

STUDY DESIGN

Randomized, crossover study.

METHODS

The study consisted of two parts, the first involving application of either the BRNS or the placebo strip in a randomized, crossover design with evaluator blinding, and repeated MRI scanning; and the second a sequential process of decongestant administration, MRI scanning, application of the BRNS, and repeated MRI. The same anatomical MRI protocol was used throughout. Nasal patency was assessed in the whole nasal passage and eight subregions (by inferior-superior, anterior-posterior division). Numerical response scores representing subjective nasal congestion were also obtained.

RESULTS

Results demonstrate significant anatomical enlargement with the BRNS relative to placebo (P < .001), as well as an additive effect of using a decongestant in combination with the BRNS; both supported by a strong and significant negative correlation with the subjective nasal response measures of nasal congestion (r = -0.98, P = .002). Furthermore, analysis of the nasal subregions indicates that this adjunctive effect arises from a partially localized action of the complementary products: the BRNS acting primarily anteriorly in the nose and the decongestant mainly posteriorly.

CONCLUSIONS

The BRNS alone significantly increases nasal patency and alleviates perceived nasal congestion, and additional relief of symptoms can be obtained with simultaneous use of a decongestant.

LEVEL OF EVIDENCE

1b. Laryngoscope, 126:2205-2211, 2016.

External nasal dilators: definition, background, and current uses

Our goal was to revise the literature about external nasal dilators (ENDs) as to their definition, history, and current uses. We reviewed journals in the PubMed and MEDLINE databases. The current uses hereby presented and discussed are physical exercise, nasal congestion and sleep, snoring, pregnancy, cancer, and healthy individuals. Numerous studies have shown that ENDs increase the cross-sectional area of the nasal valve, reducing nasal resistance and transnasal inspiratory pressure and stabilizing the lateral nasal vestibule, avoiding its collapse during final inspiration. These effects also facilitate breathing and are beneficial to patients with nasal obstruction. Furthermore, END use is simple, noninvasive, painless, affordable, and bears minimum risk to the user. Most studies have limited sample size and are mainly focused on physical exercise. In conclusion, ENDs seem useful, so further studies involving potential effects on the performance of physical tests and improvements in sleep quality are necessary, especially in children and teenagers.

Relationship between nasal valve changes and nasalance of the voice

OBJECTIVE

It is well known that the nasal cavity and paranasal sinuses affect the acoustic characteristics of the voice as resonators. Any expansion in nasal valve area, the narrowest segment of the nasal cavity, affects the nasal resistance and therefore has the potential to alter the nasalance. The aim of this study was to investigate the effect of nasal valve changes on nasalance of the voice by using an external nasal dilator strip that widens the nasal valve area.

STUDY DESIGN

Before-and-after study.

SETTING

Tertiary university hospital.

SUBJECTS AND METHODS

Healthy volunteer subjects who had no nasal or voice-related complaints were enrolled in the study. All subjects underwent acoustic rhinometry and nasometry before and while wearing a commercially available external nasal dilator strip. The data with and without the nasal strip were compared.

RESULTS

Twenty-five subjects were enrolled in the study. After the application of nasal strips, statistically significant increases were observed in the minimal cross-sectional area of the nasal valve. However, there were no significant changes in the nasalance measurements.

CONCLUSION

Despite increasing the nasal valve area, application of the nasal strips did not cause any significant change in nasalance scores in healthy subjects, showing no relationship between the nasal valve and nasalance of the voice.

A systematic review to assess the anatomical correlates of the notches in acoustic rhinometry

BACKGROUND

The graph obtained by Acoustic Rhinometry in most studies of normal adult Caucasian individuals clearly shows two notches at the beginning of the rhinogram. However, we found different opinions in the literature regarding the anatomical correlation of the anterior notches.

OBJECTIVE OF REVIEW

The aim of this study was to identify and to discuss papers providing objective evidence of anatomic correlation of two anterior notches.

TYPE OF REVIEW

A systematic review of the literature using a defined search strategy. Papers were included based on pre-defined criteria, which included standardization of techniques.

SEARCH STRATEGY

Systematic literature searches of MEDLINE and SCIELO (1989-2008).

EVALUATION METHOD

Review of all randomized controlled trials by two authors and grading of articles for quality. A meta-analysis of data was attempted.

RESULTS

21 articles were identified. Five of which were prospective studies with randomized controlled trials.

CONCLUSIONS

The majority of Acoustic Rhinometry studies affirm that the first notch is the nasal valve and the second is the anterior end of the inferior turbinate. These findings were based on papers that had not studied the anatomical correlation of these notches. Other studies claim that the first notch is the nostril and the second is the nasal valve as a whole. The conclusion that can be drawn concerning anatomic correlation of the first two notches is that there are conflicting opinions about this correlation in the literature and that more studies are needed to provide more convincing data.