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DiBlasi RM, Engberg RJ, Poli J, Carlin KE, Kontoudios N, Longest PW, Kajimoto M. Aerosol Delivery Efficiency With High-Flow Nasal Cannula Therapy in Neonatal, Pediatric, and Adult Nasal Upper-Airway and Lung Models. Respir Care 2024; 69:1146-1160. [PMID: 38981652 PMCID: PMC11349594 DOI: 10.4187/respcare.11400] [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] [Indexed: 07/11/2024]
Abstract
BACKGROUND High-flow nasal cannula (HFNC) systems employ different methods to provide aerosol to patients. This study compared delivery efficiency, particle size, and regional deposition of aerosolized bronchodilators during HFNC in neonatal, pediatric, and adult upper-airway and lung models between a proximal aerosol adapter and distal aerosol circuit chamber. METHODS A filter was connected to the upper airway to a spontaneously breathing lung model. Albuterol was nebulized using the aerosol adapter and circuit at different clinical flow settings. The aerosol mass deposited in the upper airway and lung was quantified. Particle size was measured with a laser diffractometer. Regional deposition was assessed with a gamma camera at each nebulizer location and patient model with minimum flow settings. RESULTS Inhaled lung doses ranged from 0.2-0.8% for neonates, 0.2-2.2% for the small child, and 0.5-5.2% for the adult models. Neonatal inhaled lung doses were not different between the aerosol circuit and adapter, but the aerosol circuit showed marginally greater lung doses in the pediatric and adult patient models. Impacted aerosols and condensation in the non-heated HFNC and aerosol delivery components contributed to the dispersion of coarse liquid droplets, high deposition (11-44%), and occlusion of the supine neonatal upper airway. In contrast, the upright pediatric and adult upper-airway models had minimal deposition (0.3-7.0%) and high fugitive losses (∼24%) from liquid droplets leaking out of the nose. The high impactive losses in the aerosol adapter (56%) were better contained than in the aerosol circuit, resulting in less cannula sputter (5% vs 22%), fewer fugitive losses (18% vs 24%), and smaller inhaled aerosols (5 µm vs 13 µm). CONCLUSIONS The inhaled lung dose was low (1-5%) during HFNC. Approaches that streamline aerosol delivery are needed to provide safe and effective therapy to patients receiving aerosolized medications with this HFNC system.
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Affiliation(s)
- Robert M DiBlasi
- Respiratory Therapy Department, Seattle Children's Hospital, Seattle, Washington; and Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, Washington
| | - Rebecca J Engberg
- Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, Washington; and Pediatric Intensive Care Unit, Seattle Children's Hospital, Seattle, Washington
| | - Jonathan Poli
- Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, Washington
| | - Kristen E Carlin
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Niko Kontoudios
- Respiratory Therapy Department, Seattle Children's Hospital, Seattle, Washington; and Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, Washington
| | - P Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia
| | - Masaki Kajimoto
- Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, Washington
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2
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Nemcova N, Kosutova P, Kolomaznik M, Mateffy S, Turianikova Z, Calkovska A, Mikolka P. The effect of budesonide delivered by high-frequency oscillatory ventilation on acute inflammatory response in severe lung injury in adult rabbits. Physiol Res 2023; 72:S509-S521. [PMID: 38165755 PMCID: PMC10861260 DOI: 10.33549/physiolres.935232] [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: 03/30/2023] [Accepted: 09/15/2023] [Indexed: 02/01/2024] Open
Abstract
The inflammation present in acute respiratory distress syndrome (ARDS) and thereby associated injury to the alveolar-capillary membrane and pulmonary surfactant can potentiate respiratory failure. Even considering the high mortality rate of severe ARDS, glucocorticoids appear to be a reasonable treatment option along with an appropriate route of delivery to the distal lung. This study aimed to investigate the effect of budesonide therapy delivered intratracheally by high-frequency oscillatory ventilation (HFOV) on lung function and inflammation in severe ARDS. Adult New Zealand rabbits with respiratory failure (P/F<13.3 kPa) induced by intratracheal instillation of hydrochloric acid (HCl, 3 ml/kg, pH 1.5) followed by high tidal ventilation (VT 20 ml/kg) to mimic ventilator-induced lung injury (VILI) were treated with intratracheal bolus of budesonide (0.25 mg/kg, Pulmicort) delivered by HFOV (frequency 8 Hz, MAP 1 kPa, deltaP 0.9 kPa). Saline instead of HCl without VILI with HFOV delivered air bolus instead of therapy served as healthy control. All animals were subjected to lung-protective ventilation for 4 h, and respiratory parameters were monitored regularly. Postmortem, lung injury, wet-to-dry weight ratio, leukocyte shifts, and levels of cytokines in plasma and lung were evaluated. Budesonide therapy improved the lung function (P/F ratio, oxygenation index, and compliance), decreased the cytokine levels, reduced lung edema and neutrophils influx into the lung, and improved lung architecture in interstitial congestion, hyaline membrane, and atelectasis formation compared to untreated animals. This study indicates that HFOV delivered budesonide effectively ameliorated respiratory function, and attenuated acid-induced lung injury in a rabbit model of severe ARDS.
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Affiliation(s)
- N Nemcova
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic.
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3
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Colglazier E, Ng AJ, Parker C, Woolsey D, Holmes R, Dsouza A, Becerra J, Stevens L, Nawaytou H, Keller RL, Fineman JR. Safety and tolerability of continuous inhaled iloprost in critically ill pediatric pulmonary hypertension patients: A retrospective case series. Pulm Circ 2023; 13:e12289. [PMID: 37731624 PMCID: PMC10507570 DOI: 10.1002/pul2.12289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/19/2023] [Accepted: 09/06/2023] [Indexed: 09/22/2023] Open
Abstract
Inhaled iloprost (iILO) has shown efficacy in treating patients with hypoxic lung disease and pulmonary hypertension, inducing selective pulmonary vasodilation and improvement in oxygenation. However, its short elimination half-life of 20-30 min necessitates frequent intermittent dosing (6-9 times per day). Thus, the administration of iILO via continuous nebulization represents an appealing method of drug delivery in the hospital setting. The objectives are: (1) describe our continuous iILO delivery methodology and safety profile in mechanically ventilated pediatric pulmonary hypertension patients; and (2) characterize the initial response of iILO in these pediatric patients currently receiving iNO. Continuous iILO was delivered and well tolerated (median 6 days; range 1-94) via tracheostomy or endotracheal tube using the Aerogen® mesh nebulizer system coupled with a Medfusion® 400 syringe pump. No adverse events or delivery malfunctions were reported. Initiation of iILO resulted in an increase in oxygen saturation from 81.4 ± 8.6 to 90.8 ± 4.1%, p < 0.05. Interestingly, prior iNO therapy for >1 day resulted in a higher response rate to iILO (as defined as a ≥ 4% increase in saturations) compared to those receiving iNO <1 day (85% vs. 50%, p = 0.06). When the use of iILO is considered, continuous delivery represents a safe, less laborious alternative and concurrent treatment with iNO should not be considered a contraindication. However, given the retrospective design and small sample size, this study does not allow the evaluation of the efficacy of continuous iILO on outcomes beyond the initial response. Thus, a prospective study designed to evaluate the efficacy of continuous iILO is necessary.
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Affiliation(s)
- Elizabeth Colglazier
- Department of NursingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Angelica J. Ng
- Department of Pharmaceutical ServicesUniversity of California, San FrancsicoSan FranciscoCAUSA
- Merck Sharp & Dohme LLCRahwayNew JerseyUSA
| | - Claire Parker
- Department of NursingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - David Woolsey
- Department of Respiratory TherapyUniversity of California San Francisco Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Raymond Holmes
- Department of Respiratory TherapyUniversity of California San Francisco Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Allison Dsouza
- Department of NursingUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Jasmine Becerra
- Department of PediatricsUniversity of California San Francisco Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Leah Stevens
- Department of PediatricsUniversity of California San Francisco Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Hythem Nawaytou
- Department of PediatricsUniversity of California San Francisco Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Roberta L. Keller
- Department of PediatricsUniversity of California San Francisco Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | - Jeffrey R. Fineman
- Department of PediatricsUniversity of California San Francisco Benioff Children's HospitalSan FranciscoCaliforniaUSA
- Cardiovascular Research InstituteUniversity of California San Francisco Benioff Children's HospitalSan FranciscoCaliforniaUSA
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4
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Abstract
Inhaled nitric oxide (iNO) therapy had a transformational impact on the management of infants with persistent pulmonary hypertension of the newborn (PPHN). iNO remains the only approved pulmonary vasodilator for PPHN; yet 30% to 40% of patients do not respond or have incomplete response to iNO. Lung recruitment strategies with early surfactant administration and high-frequency ventilation can optimize the response to iNO in the presence of parenchymal lung diseases. Alternate pulmonary vasodilators are used commonly as rescue, life-saving measures, though there is a lack of high-quality evidence supporting their efficacy and safety. This article reviews the available evidence and future directions for research in PPHN.
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5
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Abstract
Noninvasive high-frequency oscillatory (NHFOV) and percussive (NHFPV) ventilation represent 2 nonconventional techniques that may be useful in selected neonatal patients. We offer here a comprehensive review of physiology, mechanics, and biology for both techniques. As NHFOV is the technique with the wider experience, we also provided a meta-analysis of available clinical trials, suggested ventilatory parameters boundaries, and proposed a physiology-based clinical protocol to use NHFOV.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A.Beclere" Medical Center, Paris Saclay University Hospitals, APHP, Paris - France; Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris - France.
| | - Roberta Centorrino
- Division of Pediatrics and Neonatal Critical Care, "A.Beclere" Medical Center, Paris Saclay University Hospitals, APHP, Paris - France; Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris - France
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6
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Alharbi AS, Yousef AA, Alharbi SA, Al-Shamrani A, Alqwaiee MM, Almeziny M, Said YS, Alshehri SA, Alotaibi FN, Mosalli R, Alawam KA, Alsaadi MM. Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus. Ann Thorac Med 2021; 16:188-218. [PMID: 34012486 PMCID: PMC8109687 DOI: 10.4103/atm.atm_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022] Open
Abstract
The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.
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Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahd Hospital of the University, Khobar, Saudi Arabia
| | - Saleh A. Alharbi
- Department of Pediatrics, Umm Al-Qura University, Mecca, Saudi Arabia
- Department of Pediatrics, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mansour M. Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mohammed Almeziny
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Yazan S. Said
- Department of Pediatrics, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Saleh Ali Alshehri
- Department of Emergency, Pediatric Emergency Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Faisal N. Alotaibi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura University, Makkah, Saudi Arabia
- Department of Pediatrics, International Medical Center, Jeddah, Saudi Arabia
| | - Khaled Ali Alawam
- Department of Respiratory Therapy Sciences, Inaya Medical College, Riyadh, Saudi Arabia
| | - Muslim M. Alsaadi
- Department of Pediatrics, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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7
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Lin HL, Fink JB, Ge H. Aerosol delivery via invasive ventilation: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:588. [PMID: 33987286 DOI: 10.21037/atm-20-5665] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In comparison with spontaneously breathing non-intubated subjects, intubated, mechanically ventilated patients encounter various challenges, barriers, and opportunities in receiving medical aerosols. Since the introduction of mechanical ventilation as a part of modern critical care medicine during the middle of the last century, aerosolized drug delivery by jet nebulizers has become a common practice. However, early evidence suggested that aerosol generators differed in their efficacies, and the introduction of newer aerosol technology (metered dose inhalers, ultrasonic nebulizer, vibrating mesh nebulizers, and soft moist inhaler) into the ventilator circuit opened up the possibility of optimizing inhaled aerosol delivery during mechanical ventilation that could meet or exceed the delivery of the same aerosols in spontaneously breathing patients. This narrative review will catalogue the primary variables associated with this process and provide evidence to guide optimal aerosol delivery and dosing during mechanical ventilation. While gaps exist in relation to the appropriate aerosol drug dose, discrepancies in practice, and cost-effectiveness of the administered aerosol drugs, we also present areas for future research and practice. Clinical practice should expand to incorporate these techniques to improve the consistency of drug delivery and provide safer and more effective care for patients.
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Affiliation(s)
- Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan.,Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi.,Department of Respiratory Therapy, Chiayi Chang Gung Memorial Hospital, Chiayi
| | - James B Fink
- Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA.,Aerogen Pharma Corp., San Mateo, California, USA
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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8
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Kam CW, Ruiz FE. Opportunities and challenges of pharmacotherapy for pulmonary arterial hypertension in children. Pediatr Pulmonol 2021; 56:593-613. [PMID: 33002306 DOI: 10.1002/ppul.25101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/15/2020] [Accepted: 09/27/2020] [Indexed: 12/13/2022]
Abstract
Pediatric pulmonary hypertension (PAH) is a rare disease that carries a poor prognosis if left untreated. Although there are published guidelines for the treatment of children with pulmonary hypertension, due to the limited number of robust pediatric clinical trials, recommendations are often based on limited data or clinical experience. Furthermore, many practical aspects of care, particularly for the pediatric patient, are learned through experience and best navigated with a multidisciplinary team. While newer PAH therapies have been approved for adults, there is still limited but expanding experience in pediatrics. This new information will help improve the targets of goal-oriented therapy. Lastly, this review highlights practical aspects in the use of the different therapies available for the treatment of pediatric pulmonary hypertension.
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Affiliation(s)
- Charissa W Kam
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas, USA
| | - Fadel E Ruiz
- Department of Pulmonology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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9
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Life-threatening PPHN refractory to nitric oxide: proposal for a rational therapeutic algorithm. Eur J Pediatr 2021; 180:2379-2387. [PMID: 34091748 PMCID: PMC8179956 DOI: 10.1007/s00431-021-04138-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/19/2021] [Accepted: 05/31/2021] [Indexed: 01/11/2023]
Abstract
Persistent pulmonary hypertension of the neonate (PPHN) refractory to inhaled nitric oxide still represents a frequent clinical challenge with negative outcomes in neonatal critical care. Several pulmonary vasodilators have become available thanks to improved understanding of pulmonary hypertension pathobiology. These drugs are commonly used in adults and there are numerous case series and small studies describing their potential usefulness in neonates, as well. New vasodilators act on different pathways, some of them can have additive effects and all have different pharmacology features. This information has never been summarized so far and no comprehensive pathobiology-driven algorithm is available to guide the treatment of refractory PPHN.Conclusion: We offer a rational clinical algorithm to guide the treatment of refractory PPHN based on expert advice and the more recent pathobiology and pharmacology knowledge. What is Known: • Refractory PPHN occurs in 30-40% of iNO-treated neonates and represents a significant clinical problem. Several pulmonary vasodilators have become available thanks to a better understanding of pulmonary hypertension pathobiology. What is New: • Available vasodilators have different pharmacology, mechanisms of action and may provide additive effect. We provide a rational clinical algorithm to guide the treatment of refractory PPHN based on expert advice and the more recent pathobiology and pharmacology knowledge.
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10
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Esmaeilizand R, Rocha T, Harrison A, Gray S, Fusch G, Dolovich M, Mukerji A. Efficiency of budesonide delivery via a mesh nebulizer in an in-vitro neonatal ventilator model. Pediatr Pulmonol 2020; 55:2283-2288. [PMID: 32519801 DOI: 10.1002/ppul.24897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine the delivery efficiency of budesonide aerosol via a mesh nebulizer in a neonatal ventilator model. DESIGN/METHOD In an in-vitro ventilated neonatal model, budesonide suspension was administered using a mesh nebulizer. A collection filter was placed distal to the endotracheal tube and budesonide captured by the filter was measured using UV spectroscopy. The ventilator was, in turn, either on high frequency or conventional ventilation mode and the nebulizer was placed either proximal (close to the endotracheal tube) or distal (between the wet side of humidifier and the inspiratory circuit). Each combination (nebulizer position and ventilation mode) to assess budesonide delivery was tested five times. RESULTS Overall delivery of budesonide to the distal end of the endotracheal tube a small percentage of the total dose administered. The deposition with conventional ventilation was 2.12% (±1.06) and 1.26% (±0.27), with proximal and distal placement of the nebulizer, respectively. With high-frequency ventilation, the deposition percentages were 1.82% (±0.82) and 1.69% (±0.23), with proximal and distal nebulizer placement, respectively. CONCLUSION Only a small percentage of administered budesonide is delivered to the distal endotracheal tube, irrespective of ventilation mode, and nebulizer placement.
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Affiliation(s)
| | - Taciano Rocha
- Department of Physiotherapy, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Ava Harrison
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shari Gray
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Gerhard Fusch
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Myrna Dolovich
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
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11
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Xi J, Talaat M, Si XA, Han P, Dong H, Zheng S. Alveolar size effects on nanoparticle deposition in rhythmically expanding-contracting terminal alveolar models. Comput Biol Med 2020; 121:103791. [PMID: 32568674 DOI: 10.1016/j.compbiomed.2020.103791] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 10/24/2022]
Abstract
Significant differences in alveolar size exist in humans of different ages, gender, health, and among different species. The effects of alveolar sizes, as well as the accompanying breathing frequencies, on regional and local dosimetry of inhaled nanoparticles have not been sufficiently studied. Despite a well-accepted qualitative understanding of the advection-diffusion-sedimentation mechanism in the acinar region, a quantitative picture of the interactions among these factors remains inchoate. The objective of this study is to quantify the effects of alveolar size on the regional and local deposition of inhaled nanoparticles in alveolar models of varying complexities and to understand the dynamic interactions among different deposition mechanisms. Three different models were considered that retained 1, 4, and 45 alveoli, respectively. For each model, the baseline geometry was scaled by ¼, ½, 2, 4, and 8 times by volume. Temporal evolution and spatial distribution of particle deposition were tracked using a discrete-phase Lagrangian model. Lower retentions of inhaled nanoparticles were observed in the larger alveoli under the same respiration frequency, while similar retentions were found among different geometrical scales if breathing frequencies allometrically matched the alveolar size. Dimensional analysis reveals a manifold deposition mechanism with tantamount contributions from advection, diffusion, and gravitational sedimentation, each of which can become dominant depending on the location in the alveoli. Results of this study indicate that empirical correlations obtained from one sub-population cannot be directly applied to others, nor can they be simply scaled as a function of the alveolar size or respiration frequency due to the regime-transiting deposition mechanism that is both localized and dynamic.
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Affiliation(s)
- Jinxiang Xi
- Department of Biomedical Engineering, University of Massachusetts, Lowell, MA, USA.
| | - Mohamed Talaat
- Department of Biomedical Engineering, University of Massachusetts, Lowell, MA, USA
| | - Xiuhua April Si
- Department of Aerospace, Industrial, and Mechanical Engineering California Baptist University, Riverside, CA, USA
| | - Pan Han
- Department of Mechanical and Aerospace Engineering University of Virginia, Charlottesville, VA, USA
| | - Haibo Dong
- Department of Mechanical and Aerospace Engineering University of Virginia, Charlottesville, VA, USA
| | - Shaokuan Zheng
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
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12
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Li J, Gong L, Ari A, Fink JB. Decrease the flow setting to improve trans-nasal pulmonary aerosol delivery via "high-flow nasal cannula" to infants and toddlers. Pediatr Pulmonol 2019; 54:914-921. [PMID: 30920155 DOI: 10.1002/ppul.24274] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/16/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Trans-nasal pulmonary aerosol delivery for infants and toddlers has recently gained popularity, however, the reported lung deposition is low. We aimed to investigate the influential factors to improve the delivery. METHODS Anatomic airway manikins simulating infant (5 kg) and toddler (15 kg) with collecting filter connected the trachea and breath simulator, were set to represent quiet and distressed breathing. Nasal cannula flow was set at 0.125, 0.25, 0.5, 1, and 2 L/kg/min. A mesh nebulizer (Aerogen) was placed at the inlet of humidifier (Fisher & Paykel) and proximal to patient. Albuterol (5 mg in 1 mL) was nebulized for each condition (n = 3). Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). RESULTS Inhaled dose was higher with nebulizer placed at the inlet of humidifier than proximal to patient in all settings, except the infant model at low gas flow settings (0.125 and 0.25 L/kg/min). When nebulizer was placed at the inlet of humidifier, inhaled dose was higher when gas flow was below patient's inspiratory flow than when gas flow exceeded patient's inspiratory flow (8.77 ± 3.84 vs 2.16 ± 1.29%, P < 0.001); aerosol deposition increased as gas flow decreased, with greatest deposition at gas flow of 0.25 L/kg/min (11.29 ± 2.15%). A multiple linear regression identified gas flow as the primary predictor of aerosol delivery. CONCLUSIONS Trans-nasal pulmonary aerosol delivery was significantly improved when gas flow was below patient's inspiratory flow, aerosol deposition increased with decreased nasal cannula flow, with greatest deposition at 0.25 L/kg/min.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - Lingyue Gong
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - Arzu Ari
- Department of Respiratory Care, College of Health Professions, Texas State University, Round Rock, Texas
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
- Aerogen Pharma Corp, San Mateo, California
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13
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Berkelhamer SK, Mestan KK, Steinhorn R. An update on the diagnosis and management of bronchopulmonary dysplasia (BPD)-associated pulmonary hypertension. Semin Perinatol 2018; 42:432-443. [PMID: 30384985 DOI: 10.1053/j.semperi.2018.09.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The past decade of neonatal care has been highlighted by increased survival rates in smaller and more premature infants. Despite reduction in mortality associated with extreme prematurity, long term pulmonary morbidities remain a concern, with growing recognition of the clinical burden attributable to infants with bronchopulmonary dysplasia (BPD)-associated pulmonary hypertension (PH). Recent publications shed light on the critical contributions of maternal placental pathology and compromised intrauterine growth to fetal pulmonary vascular development. A body of literature has further clarified postnatal risk factors for PH, most notably the severity of BPD but surprisingly the additional presence of non-pulmonary morbidities including necrotizing enterocolitis (NEC). Limitations of current diagnostics persist with growing consideration of novel echocardiographic approaches as well as complementary non-invasive biomarkers to better identify infants at risk. In 2015, a joint report published by the American Heart Association and American Thoracic Society provided the first guidelines for the care of children with PH with limited content to address BPD-associated PH. These guidelines were expanded upon in an expert consensus report produced by the Pediatric Pulmonary Hypertension Network (PPHNet). These recommendations encouraged the use of standardized screening protocols and emphasized the importance of evaluation and treatment of comorbidities when PH is identified. Cardiac catheterization was recommended prior to initiation of therapy for more accurate quantification of pulmonary pressures, clarification of anatomy and guidance in the use of pharmacotherapy. Despite these guidelines, significant practice variation persists and gaps remain with respect to optimal evaluation and management of BPD-associated PH.
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Affiliation(s)
| | - Karen K Mestan
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Lin HL, Fang TP, Cho HS, Wan GH, Hsieh MJ, Fink JB. Aerosol delivery during spontaneous breathing with different types of nebulizers- in vitro/ex vivo models evaluation. Pulm Pharmacol Ther 2017; 48:225-231. [PMID: 29277689 DOI: 10.1016/j.pupt.2017.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 12/15/2017] [Accepted: 12/16/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nebulizers for spontaneous breathing have been evaluated through different study designs. There are limitations in simulated bench models related to patient and nebulizer factors. The aim of this study was to determine the correlation of inhaled drug mass between in vitro and ex vivo studies by testing aerosol deposition of various types of nebulizers. METHODS Ten healthy subjects were recruited to receive aerosol therapy with five nebulizers in random order: 1) a jet nebulizer (JN); 2) a breath-enhanced nebulizer (BEN); 3) a manually triggered nebulizer (MTN), 4) a breath-actuated nebulizer (BAN), and 5) a vibrating mesh nebulizer (VMN) with valved-adapter. A unit dose of salbutamol containing 5 mg in 2.5 mL was placed into the nebulizer and administered for 10 min. For the ex vivo study, minute ventilation of healthy subjects was recorded for 1 min. For the in vitro study a breathing simulator was utilized with adult breathing patterns. Aerosolized drug from the nebulizers and the accessory tubes was captured using inspiratory and expiratory collecting filters. Captured drug was eluted, measured and expressed as inhaled and exhaled mass using spectrophotometry at a wavelength of 276 nm. RESULTS 10 healthy subjects were recruited, aged 20.8 ± 0.7 years old, with a mean height of 166.2 ± 9.2 cm and weight of 64.7 ± 12.4 kg. There was no significant difference in the inhaled drug dose between the JN and BEN (15.0 ± 1.94% and 17.74 ± 2.65%, respectively, p = .763), yet the inhaled doses were lower than the other three nebulizers (p < .001). The VMN delivered greater inhaled dose than the other four nebulizers (p < .01). The respiratory rate of the cohorts was significantly correlated with the inhaled drug dose. For the in vitro model, the JN delivered a lower inhaled dose (11.6 ± 1.6, p < .001) than the other nebulizers, whereas the MTN and BAN deposited significantly lower exhaled doses (1.7 ± 0.4 and 2.7 ± 0.2, respectively, p < .001). The VMN demonstrated a greater drug dose with the in vitro study than the ex vivo model (44.0 ± 0.9% and 35.5 ± 6.3% respectively, p = .003), whereas the JN in the ex vivo model resulted in a greater inhaled drug dose (15.0 ± 1.9% for ex vivo vs 11.6 ± 1.6% for in vitro, p = .008). CONCLUSIONS These in vitro/ex vivo model comparisons of nebulizers performance indicated that breath-related nebulizers can be estimated using an in vitro model; however, the JN and VMN delivered inhaled drug mass differed between models. There was a significant correlation between respiratory rate and inhaled mass, and the inhaled drug dose generated by VMN correlated with minute ventilation. This study demonstrated that the VMN produced greater inhaled drug dose and lowest residual dose, whereas the BEN, BAN, and MTN produced lower exhaled drug dose in both in vitro and ex vivo models.
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Affiliation(s)
- Hui-Ling Lin
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Respiratory Therapy, Chang Gung University of Science and Technology, Chiayi, Taiwan.
| | - Tien-Pei Fang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Respiratory Therapy, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Hui-Sun Cho
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Respiratory Therapy, Yuan's General Hospital, Kaohsiung, Taiwan
| | - Gwo-Hwa Wan
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Respiratory Therapy, Chang Gung University of Science and Technology, Chiayi, Taiwan; Department of Neurosurgery, Chang Gung Memorial Hospital-Linko, Taoyuan, Taiwan
| | - Meng-Jer Hsieh
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Medicine, Chang Gung Memorial Hospital, ChiYi, Taiwan
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Inhaled Treprostinil Drug Delivery During Mechanical Ventilation and Spontaneous Breathing Using Two Different Nebulizers. Pediatr Crit Care Med 2017; 18:e253-e260. [PMID: 28441181 PMCID: PMC5478389 DOI: 10.1097/pcc.0000000000001188] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To determine the feasibility of delivering inhaled treprostinil during mechanical ventilation and spontaneous unassisted ventilation using the Tyvaso Inhalation System and the vibrating mesh nebulizer. We sought to compare differences in fine particle fraction, and absolute inhaled treprostinil mass delivered to neonatal, pediatric, and adult models affixed with a face mask, conventional, and high-frequency ventilation between Tyvaso Inhalation System and with different nebulizer locations between Tyvaso Inhalation System and vibrating mesh nebulizer. DESIGN Fine particle fraction was first determined via impaction with both the Tyvaso Inhalation System and vibrating mesh nebulizer. Next, a test lung configured with neonatal, pediatric, and adult mechanics and a filter to capture medication was attached to a realistic face model during spontaneous breathing or an endotracheal tube during conventional ventilation and high-frequency oscillator ventilator. Inhaled treprostinil was then nebulized with both the Tyvaso Inhalation System and vibrating mesh nebulizer, and the filter was analyzed via high-performance liquid chromatography. Testing was done in triplicate. Independent two-sample t tests were used to compare mean fine particle fraction and inhaled mass between devices. Analysis of variance with Tukey post hoc tests were used to compare within device differences. SETTING Academic children's hospital aerosol research laboratory. MEASUREMENTS AND MAIN RESULTS Fine particle fraction was not different between the Tyvaso Inhalation System and vibrating mesh nebulizer (0.78 ± 0.04 vs 0.77 ± 0.08, respectively; p = 0.79). The vibrating mesh nebulizer delivered the same or greater inhaled treprostinil than the Tyvaso Inhalation System in every simulated model and condition. When using the vibrating mesh nebulizer, delivery was highest when using high-frequency oscillator ventilator in the neonatal and pediatric models, and with the nebulizer in the distal position in the adult model. CONCLUSIONS The vibrating mesh nebulizer is a suitable alternative to the Tyvaso Inhalation System for inhaled treprostinil delivery. Fine particle fraction is similar between devices, and vibrating mesh nebulizer delivery meets or exceeds delivery of the Tyvaso Inhalation System. Delivery for infants and children during high-frequency oscillator ventilator with the vibrating mesh nebulizer may result in higher than expected dosages.
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Luecke C, McPherson C. Treatment of Persistent Pulmonary Hypertension of the Newborn: Use of Pulmonary Vasodilators in Term Neonates. Neonatal Netw 2017; 36:160-168. [PMID: 28494828 DOI: 10.1891/0730-0832.36.3.160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) represents a challenging condition associated with significant morbidity. A successful transition from intrauterine to extrauterine life is contingent on adequate pulmonary vasodilation. Several pathophysiologies contribute to the failure of this cascade and may result in life-threatening hypoxia and acidosis in the newborn. Management includes optimal respiratory support, adequate sedation and analgesia, and support of vascular tone and cardiac function. Pulmonary vasodilation has the potential to overcome the cycle of hypoxia and acidosis, improving outcome in these infants. Oxygen and inhaled nitric oxide represent the foundation of therapy. Tertiary pulmonary vasodilators represent a greater challenge, selecting between therapies that include prostanoids, sildenafil, and milrinone. Variable levels of evidence exist for each agent. Thorough review of available data informing efficacy and adverse effects contributes to the development of an informed approach to neonates with refractory PPHN.
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Sharma M, Callan E, Konduri GG. Pulmonary vasodilator therapy in persistent pulmonary hypertension of the newborn. Clin Perinatol 1984; 11:693-701. [PMID: 6488673 PMCID: PMC8885147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A review of the physiology of persistent pulmonary hypertension of the newborn is provided, followed by a critical review of many of the agents that have been employed to treat this condition. In addition, the authors speculate on what type of pharmacologic therapy may prove useful in the future.
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Affiliation(s)
- Megha Sharma
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Emily Callan
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Wauwatosa, WI
| | - G. Ganesh Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Wisconsin, Wauwatosa, WI
- Corresponding author: G. Ganesh Konduri, MD., 999 N 92 St, CCC Ste C410, Wauwatosa, WI, 53226.
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