The Effect of Breathing Pattern on Nebulizer Drug Delivery

Predicting Inhaled Drug Dose Generated by Mesh Nebulizers

Background: The lung dose of nebulized drugs for spontaneous breathing is influenced by breathing patterns and nebulizer performance. This study aimed to develop a system for measuring breath patterns and a formula for estimating inhaled drugs, and then to validate the hypothesized prediction formula. Methods: An in vitro model was first used to determine correlations among the delivered dose, breath patterns, and doses deposited on the accessories and reservoirs testing with a breathing simulator to generate 12 adult breathing patterns (n = 5). A pressure sensor was developed to measure breathing parameters and used along with a prediction formula that accounted for the initial charge dose, respiratory pattern, and dose on the accessory and reservoir of a nebulizer. Three brands of nebulizers were tested by placing salbutamol (5.0 mg/2.5 mL) in the drug holding chamber. Ten healthy individuals participated in the ex vivo study to validate the prediction formula. The agreement between the predicted and inhaled doses was analyzed using the Bland-Altman plot. Results: The in vitro model showed that the inspiratory time to total respiratory cycle time (Ti/Ttotal; %) was significantly directly correlated with the delivered dose among the respiratory factors, followed by inspiratory flow, respiratory rate, and tidal volume. The ex vivo model showed that Ti/Ttotal was significantly directly correlated with the delivered dose among the respiratory factors, in addition to the nebulization time and accessory dose. The Bland-Altman plots for the ex vivo model showed similar results between the two methods. Large differences in inhaled dose measured at the mouth were observed among the subjects, ranging from 12.68% to 21.68%; however, the difference between the predicted dose and inhaled dose was lower, at 3.98%-5.02%. Conclusions: The inhaled drug dose could be predicted with the hypothesized estimation formula, which was validated by the agreement between the inhaled and predicted doses of breathing patterns of healthy individuals.

Development and Characterization of a 96-Well Exposure System for Safety Assessment of Nanomaterials

In this study, a 96-well exposure system for safety assessment of nanomaterials is developed and characterized using an air-liquid interface lung epithelial model. This system is designed for sequential nebulization. Distribution studies verify the reproducible distribution over all 96 wells, with lower insert-to-insert variability compared to non-sequential application. With a first set of chemicals (TritonX), drugs (Bortezomib), and nanomaterials (silver nanoparticles and (non-)fluorescent crystalline nanocellulose), sequential exposure studies are performed with human lung epithelial cells followed by quantification of the deposited mass and of cell viability. The developed exposure system offers for the first time the possibility of exposing an air-liquid interface model in a 96-well format, resulting in high-throughput rates, combined with the feature for sequential dosing. This exposure system allows the possibility of creating dose-response curves resulting in the generation of more reliable cell-based assay data for many types of applications, such as safety analysis. In addition to chemicals and drugs, nanomaterials with spherical shapes, but also morphologically more complex nanostructures can be exposed sequentially with high efficiency. This allows new perspectives on in vivo-like and animal-free approaches for chemical and pharmaceutical safety assessment, in line with the 3R principle of replacing and reducing animal experiments.

Good Practices for the Laboratory Performance Testing of Aqueous Oral Inhaled Products (OIPs): an Assessment from the International Pharmaceutical Aerosol Consortium on Regulation and Science (IPAC-RS)

Multiple sources must be consulted to determine the most appropriate procedures for the laboratory-based performance evaluation of aqueous oral inhaled products (OIPs) for the primary measures, dose uniformity/delivery, and aerodynamic particle (droplet) size distribution (APSD). These sources have been developed at different times, mainly in Europe and North America, during the past 25 years by diverse organizations, including pharmacopeial chapter/monograph development committees, regulatory agencies, and national and international standards bodies. As a result, there is a lack of consistency across all the recommendations, with the potential to cause confusion to those developing performance test methods. We have reviewed key methodological aspects of source guidance documents identified by a survey of the pertinent literature and evaluated the underlying evidence supporting their recommendations for the evaluation of these performance measures. We have also subsequently developed a consistent series of solutions to guide those faced with the various associated challenges when developing OIP performance testing methods for oral aqueous inhaled products.

Inhaled Antifungal Agents for the Treatment and Prophylaxis of Pulmonary Mycoses

Pulmonary mycoses are associated with high morbidity and mortality. The current standard treatment by systemic administration is limited by inadequate local bioavailability and systemic toxic effects. Aerosolisation of antifungals is an attractive approach to overcome these problems, but no inhaled antifungal formulation is currently available for the treatment of pulmonary mycoses. Hence, the development of respirable antifungals formulations is of interest and in high demand. In this review, the recent advances in the development of antifungal formulations for pulmonary delivery are discussed, including both nebulised and dry powder formulations. Although the clinical practices of nebulised parenteral amphotericin B and voriconazole formulations (off-label use) are reported to show promising therapeutic effects with few adverse effects, there is no consensus about the dosage regimen (e.g. the dose, frequency, and whether they are used as single or combination therapy). To maximise the benefits of nebulised antifungal therapy, it is important to establish standardised protocol that clearly defines the dose and specifies the device and the administration conditions. Dry powder formulations of antifungal agents such as itraconazole and voriconazole with favourable physicochemical and aerosol properties are developed using various powder engineering technologies, but it is important to consider their suitability for use in patients with compromised lung functions. In addition, more biological studies on the therapeutic efficacy and pharmacokinetic profile are needed to demonstrate their clinical potential.

Feasibility study of a surface-coated lung model to quantify active agent deposition for preclinical studies

BACKGROUND

Multiple drug resistance of a growing number of bacterial pathogens represents an increasing challenge in conventional curative treatments of infectious diseases. However, the development and testing of new antibiotics is associated with a high number of animal experiments.

METHODS

A symmetrical parametrized lung test rig allowing the exposure of air-passage surfaces to antibiotics was designed and tested to demonstrate proof-of-principle with aerosols containing allicin, which is an antimicrobial natural product from garlic. An artificial lung surface is coated with bacteria embedded in a hydrogel and growth inhibition is visualized by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide, that is reduced from colourless to the dark blue formazan in the presence of metabolically active, living cells. A nebulizer is used to generate the aerosols.

FINDINGS

The results show that allicin has an antibiotic effect as an aerosol and that the deposition pattern of the active agent occurred mainly around the carinal regions.

INTERPRETATION

The model represents an integral system for continuous, spatial detection of aerosol deposition and allows the analysis of bacterial behaviour and the toxicity of the active agent. Thus, the deposition of antimicrobial aerosols on the bronchial surfaces is characterized in preliminary tests without any animal experiments.

Polymer-coated aperture plates for tailored atomization processes

There is a significant industrial demand for minimizing the size of droplets for various technical applications. Herein, conformal polymer coatings were used to decrease the orifice dimensions of aperture plates to almost any desired dimension. The generated droplet size revealed a relevant impact on the final dried particle size in a spray-drying process. Likewise, the smaller droplets generated resulted in an improved lung deposition following inhalation. Overall, the current results help increase the understanding on how to manipulate the size distribution of droplets produced by actuated aperture plates, especially in the sub-10 μm range.

In Vitro Study of the Effect of Breathing Pattern on Aerosol Delivery During High-Flow Nasal Therapy

Introduction

The use of concurrent aerosol delivery during high-flow nasal therapy (HFNT) may be exploited to facilitate delivery of a variety of prescribed medications for inhalation. The study assessed the effect of tidal volume, breath rate, and inspiratory:expiratory (I:E) ratio on the quantity of aerosol captured at the level of the trachea during simulated HFNT.

Methods

Testing was completed according to a factorial statistical design of experiments (DOE) approach. Tracheal dose was characterized with a vibrating mesh nebulizer (Aerogen Solo, Aerogen Ltd) using simulated adult, small child, and infant HFNT models. Furthermore, aerosol delivery was evaluated across a range of adult patient profiles with clinically representative test setups.

Results

Aerosol delivery increased with a large tidal volume, a rapid breath rate, and a long inspiratory time. Tidal volume, breath rate, and I:E ratio each had a significant effect on tracheal dose across simulated adult, small child, and infant breathing.

Conclusion

The main trends that were identified in the statistical DOE predicted aerosol delivery across adult patient breathing profiles, in terms of tidal volume, breath rate, and I:E ratio. Therefore, patients with distressed breathing profiles may be expected to receive a larger aerosol dose than those with normal breathing rates.

Funding

Aerogen Limited.

3D printed drug delivery and testing systems - a passing fad or the future?

The US Food and Drug Administration approval of the first 3D printed tablet in 2015 has ignited growing interest in 3D printing, or additive manufacturing (AM), for drug delivery and testing systems. Beyond just a novel method for rapid prototyping, AM provides key advantages over traditional manufacturing of drug delivery and testing systems. These includes the ability to fabricate complex geometries to achieve variable drug release kinetics; ease of personalising pharmacotherapy for patient and lowering the cost for fabricating personalised dosages. Furthermore, AM allows fabrication of complex and micron-sized tissue scaffolds and models for drug testing systems that closely resemble in vivo conditions. However, there are several limitations such as regulatory concerns that may impede the progression to market. Here, we provide an overview of the advantages of AM drug delivery and testing, as compared to traditional manufacturing techniques. Also, we discuss the key challenges and future directions for AM enabled pharmaceutical applications.

Model Calculations of Regional Deposition and Disposition for Single Doses of Inhaled Liposomal and Dry Powder Ciprofloxacin

BACKGROUND

Model predictions of regional deposition in the respiratory tract are useful in assessing factors that influence the effectiveness of aerosol delivery. Regional deposition models have previously been coupled with models of mucous production and clearance to estimate initial concentrations of drug deposited in the airway surface liquid (ASL) lining tracheobronchial airways.

METHODS

Established models of regional deposition and ASL volumes were used to provide input to a new model evaluating the disposition of drug resulting from dissolution or release, absorption, and mucociliary clearance. Additional modeling of oral absorption, distribution, and elimination allowed prediction of systemic exposure. Herein, predicted ASL and plasma concentrations of free (dissolved or unencapsulated) ciprofloxacin over time are reported for a healthy, adult lung model following inhalation of single doses of nebulized liposomal (6 mL of liposomal ciprofloxacin for inhalation, 50 mg/mL, or 6 mL of Pulmaquin, 210 mg; Aradigm) and dry powder (32.5 and 65 mg doses; Bayer) formulations.

RESULTS

Over a range of mucous production rates and tracheal clearance velocities, peak ASL concentrations of free ciprofloxacin were consistently greater for Pulmaquin than for other formulations investigated, owing to the presence of free drug in the nebulized Pulmaquin formulation. The time that ASL concentrations of free drug remained above the minimum inhibitory concentration for Pseudomonas aeruginosa was similar for all four formulations. Predicted plasma ciprofloxacin concentration profiles were in good agreement with available data from Phase I trials in healthy volunteers.

CONCLUSIONS

Predictions of ASL drug concentrations over time are valuable in elucidating the roles of deposition, drug release or dissolution, and disposition on the effectiveness of inhaled aerosol therapies. For inhaled ciprofloxacin, the present results predict similar ASL concentrations of free drug over time following single doses of inhaled liposomal and dry powder formulations. The impact of multiple doses and airway disease warrants further consideration.

Aerosol Production by Vibrating Membrane Technology: Analysis of the Electrolyte Effect on Generated Droplet Size and Nebulizer Output Rate

The performance of vibrating membrane technology (i.e., aerosol droplet size and output rate) depends on the specific electrolyte concentration. However, the underlying factors, which determine nebulizer performance, are currently only poorly understood. This study compared the charge of aerosol droplets (Dekati^® BOLAR^™) nebulized with the eFlow^® rapid and the streaming potential (SurPASS^®) forming at the liquid/metal interface. Nebulization of 0.01 mM sodium chloride resulted in a rather large droplet size of >8 μm and an output rate of only ∼0.4 g/min. Increasing the sodium chloride content to 10 mM led to a droplet size of <5 μm and an output rate of ∼1.0 g/min. No significant difference was detected when comparing the net charge-to-mass ratios of generated aerosols. In contrast, the streaming potential (i.e., adversary of droplet detachment) differed remarkably between the 2 electrolyte solutions. The higher salt concentration compensated the electrical potential difference formed at the liquid/metal interface and, thus, caused an increased output rate (and a delivery of smaller aerosol droplets). Overall, this study identified the streaming potential as a significant parameter with impact on vibrating membrane nebulizer performance. The presented results will promote progress in this specific subfield of aerosol drug delivery.

Generation of tailored aerosols for inhalative drug delivery employing recent vibrating-mesh nebulizer systems

Direct drug delivery to the lungs is considered the gold standard for the treatment of a variety of respiratory diseases, owing to the increased therapeutic selectivity of the inhalative approach. Airborne formulations with defined size characteristics are required to improve the deposition pattern within the airways. In this respect, different nebulizer systems have been conceived, which has enabled the generation of respirable medicament mists. Here, vibrating-mesh technology revealed significant potential to overcome the main shortcomings associated with ‘traditional’ devices. Tailored orifice dimensions and defined formulation characteristics are of special interest for the generation of suitable aerosol droplets for inhalative purposes. Ongoing developments in device and formulation design will optimize the clinical outcome of inhalative drug delivery under application of vibrating-mesh technology.

Reconciliation of Cascade Impaction during Wet Nebulization

Cascade impaction is an important tool for measuring aerosol distributions from wet nebulizers; however, results vary depending on laboratory and technique. The focus of this study was to reconcile the contribution of particle evaporation to these reported differences. To measure the effect of evaporation, we compared aerosol distributions from circuits ventilated with humidified air, ambient air, and a nonventilated, standing cloud circuit using low-flow cascade impaction (1.0 L/min). Aerosol distributions were similar for the humidified/ventilated and standing cloud models [mass median aerodynamic diameter (MMAD) 3.4 microm, and 3.6 microm Aero-Eclipse, 5.8 and 5.1 microm Misty-Neb, 3.8 and 3.2 microm Pari LC Plus]. In the ventilated/ambient air model, smaller particle sizes were measured (2.2 microm AeroEclipse, 2.4 microm Misty-Neb, 2.1 microm Pari LC Plus). Techniques of cascade impaction significantly affected measured aerosol distributions. MMAD were defined by nebulizer type and conditions of particle evaporation not by impactor. Aerosol mixing with ambient air caused evaporation and shrinkage of particles, and accounts for differences between laboratories. Patients breathing from nebulizers may entrain ambient air possibly affecting deposition.

Toward modern inhalational bacteriophage therapy: nebulization of bacteriophages of Burkholderia cepacia complex

Antibiotic-resistant bacterial infections have renewed interest in finding substitute methods of treatment. The purpose of the present in vitro study was to investigate the possibility of respiratory delivery of a Burkholderia cepacia complex (BCC) bacteriophage by nebulized aerosol administration. Bacteriophages in isotonic saline were aerosolized with Pari LC star and eFlow nebulizers, at titers with mean value (standard deviation) of 2.15 x 10(8) (1.63 x 10(8)) plaque-forming unit (PFU)/mL in 2.5-mL nebulizer fills. The breathing pattern of an adult was simulated using a pulmonary waveform generator. During breath simulation, the size distributions of the nebulized aerosol were measured using phase doppler anemometry (PDA). Efficiency of nebulizer delivery was subsequently determined by collection of aerosol on low resistance filters and measurement of bacteriophage titers. These filter titers were used as input data to a mathematical lung deposition model to predict regional deposition of bacteriophages in the lung and initial bacteriophage titers in the liquid surface layer of each conducting airway generation. The results suggest that BCC bacteriophages can be nebulized successfully within a reasonable delivery time and predicted titers in the lung indicate that this method may hold potential for treatment of bacterial lung infections common among cystic fibrosis patients.

Current therapies and technological advances in aqueous aerosol drug delivery

Recent advances in aerosolization technology have led to renewed interest in pulmonary delivery of a variety of drugs. Pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) have experienced success in recent years; however, many limitations are presented by formulation difficulties, inefficient delivery, and complex device designs. Simplification of the formulation process as well as adaptability of new devices has led many in the pharmaceutical industry to reconsider aerosolization in an aqueous carrier. In the acute care setting, breath-enhanced air-jet nebulizers are controlling and minimizing the amount of wasted medication, while producing a high percentage of respirable droplets. Vibrating mesh nebulizers offer advantages in higher respirable fractions (RFs) and slower velocity aerosols when compared with air-jet nebulizers. Vibrating mesh nebulizers incorporating formulation and patient adaptive components provide improvements to continuous nebulization technology by generating aerosol only when it is most likely to reach the deep lung. Novel innovations in generation of liquid aerosols are now being adapted for propellant-free pulmonary drug delivery to achieve unprecedented control over dose delivered and are leading the way for the adaptation of systemic drugs for delivery via the pulmonary route. Devices designed for the metered dose delivery of insulin, morphine, sildenafil, triptans, and various peptides are all currently under investigation for pulmonary delivery to treat nonrespiratory diseases. Although these devices are currently still in clinical testing (with the exception of the Respimat), metered dose liquid inhalers (MDLIs) have already shown superior outcomes to current pulmonary and systemic delivery methods.

Development of the premature infant nose throat-model (PrINT-Model): an upper airway replica of a premature neonate for the study of aerosol delivery

Clinical efficacy of aerosol therapy in premature newborns depends on the efficiency of delivery of aerosolized drug to the bronchial tree. To study the influence of various anatomical, physical, and physiological factors on aerosol delivery in preterm newborns, it is crucial to have appropriate in vitro models, which are currently not available. We therefore constructed the premature infant nose throat-model (PrINT-Model), an upper airway model corresponding to a premature infant of 32-wk gestational age by three-dimensional (3D) reconstruction of a three-planar magnetic resonance imaging scan and subsequent 3D-printing. Validation was realized by visual comparison and comparison of total airway volume. To study the feasibility of measuring aerosol deposition, budesonide was aerosolized through the cast and lung dose was expressed as percentage of nominal dose. The airway volumes of the initial magnetic resonance imaging and validation computed tomography scan showed a relative deviation of 0.94%. Lung dose at low flow (1 L/min) was 61.84% and 9.00% at high flow (10 L/min), p < 0.0001. 3D-reconstruction provided an anatomically accurate surrogate of the upper airways of a 32-wk-old premature infant, making the model suitable for future in vitro testing.

Evaluation of an in vitro in vivo correlation for nebulizer delivery using artificial neural networks

The ability to generate predictive models linking the in vitro assessment of pharmaceutical products with in vivo performance has the potential to enable greater control of clinical quality whilst minimizing the number of in vivo studies in drug development. Artificial neural networks (ANNs) provide a means of generating predictive models correlating critical product characteristics to key performance attributes. In this regard, ANNs have been used to model historical data exploring the relative lung bioavailability of salbutamol from several different nebulizers. The generated ANN model was shown to relate urinary salbutamol excretion at 30 min post-inhalation, which is the index of relative lung bioavailability of salbutamol, to specific fractions of the particle size distribution, to subject body surface area and to the methods of nebulization. This model was validated using unseen data and gave good agreement with pharmacokinetic outcomes for 17 data records. The model gave improved predictions of urinary salbutamol excretion for individual subjects compared to the published linear correlation generated using the same data. It is therefore concluded that ANN models have the potential to provide reliable estimates of pharmacokinetic performance that relate to lung deposition, for nebulized medicines in individual subjects.

Evaluation of in vitro in vivo correlations for dry powder inhaler delivery using artificial neural networks

The aim of these experiments was to investigate the use of artificial neural networks (ANNs) for generating models able to predict the relative lung bioavailability and clinical effect of salbutamol when delivered to healthy volunteers and asthmatic patients from dry powder inhalers (DPIs). ANN software was used to model in vitro, demographic and in vivo data from human subjects for four different DPI formulations containing salbutamol sulfate. In 12 volunteers, a model linking the in vitro aerodynamic characteristics of the emitted dose and volunteer body surface area with the urinary excretion of drug and its metabolite in the 24h period after inhalation was established. In 11 mild asthmatics, a predictive model correlating in vitro data, baseline lung function, body surface area and age with post-treatment improvements in forced expiratory volume in 1s (FEV1) was also generated. Models validated using unseen data from individual subjects receiving the different DPI formulations were shown to give predictions of in vivo performance. The squared correlation coefficients (R2) for plots comparing predicted and observed in vivo outcomes were 0.83 and 0.84 for urinary excretion and lung function data, respectively. It can therefore be concluded that ANN models have the potential to predict the in vivo performance of DPIs in individual subjects.

Modeling of aerosol deposition with interface devices

Various approaches can be used to mathematically model the performance of different masks, mouthpieces, and aerosol delivery devices. The sophistication of such models can vary widely, from the use of simple algebraic empirical correlations to advanced computational fluid dynamics simulations. Bench-top testing is also often used to model aspects of devices, since it is difficult to capture certain aspects of device behavior with mathematical models. These various approaches to modeling differ in their limitations. Empirical correlations exist for predicting the effects of varying mouthpiece diameter and mouth-throat dimensions on extrathoracic losses, but are restricted to stable, nonballistic aerosols in certain flow rate ranges. Computational fluid dynamics (CFD) simulations that solve the Reynolds-averaged Navier-Stokes (RANS) equations typically require near-wall turbulence corrections in order to adequately model mouth-throat deposition, while Large Eddy Simulation (LES) removes this deficiency. Bench-top models that use replicas of the extrathoracic airways vary in their accuracy and generality in replicating the filtering properties of these airways. Choosing and using these various modeling approaches for evaluating patient-device interfaces requires knowledge of their merits and pitfalls, a brief discussion of which is given here.

Tolerability and pharmacokinetics of inhaled bimosiamose disodium in healthy males

AIMS

The aim of these first-in-human studies was to investigate the tolerability and the pharmacokinetics of bimosiamose disodium (TBC1269Z) administered by inhalation.

METHODS

Two randomized, double-blind, placebo-controlled Phase I trials were performed in healthy males. In a single-dose escalating study 48 subjects received doses of 2-140 mg bimosiamose disodium by inhalation and in a multiple-dose study 32 subjects received 8-70 mg bimosiamose disodium twice daily. In both studies 4 ml of the drug solution was administered via nebulizer over 15 min. Adverse events, vital signs, ECG, clinical laboratory parameters and forced expiratory volume in 1 s (FEV(1)) data were recorded and nasopharyngeal examinations were performed to address the safety and tolerability. Blood was collected for the determination of plasma concentrations of bimosiamose.

RESULTS

All subjects completed the study. No deaths or severe adverse events occurred. Eleven mild adverse events occurred in the dose-escalation study and 34 in the multiple-dose study after inhalation of bimosiamose disodium. Adverse events were more frequent at the highest dose (140 mg) of the dose-escalation study. For placebo treatment one moderate adverse event was observed in the dose-escalation study after placebo treatment, eight mild and three moderate adverse events occurred in the multiple-dose study. Bimosiamose was detected in plasma (maximum concentration 64 ng ml(-1)) only at doses > or =50 mg given twice daily and 105 mg once daily. For the highest dose a median value of 5746 h ng ml(-1) was determined for the AUC over the entire period of treatment of the multiple-dose study.

CONCLUSION

The results suggest that single and multiple inhalation of bimosiamose disodium up to 70 mg is well tolerated in healthy males. Systemic bioavailability after inhalation is low.

Liquid Atomizing: Nebulizing and Other Methods of Producing Aerosols

Liquid atomization (or nebulization) is the most traditional method of drug delivery to the lung. Although other methods seem to often be preferred for the delivery of new drugs, nebulizers are experiencing a revival, with new devices based on different atomization techniques, and the more traditional jet nebulizers evolving to become "smart nebulizers." These smart devices synchronize delivery with the patient's breath, estimate or measure delivered dose, provide feedback and data storage, and in some cases control breathing maneuvers. Besides adding new features, new nebulizers are also addressing traditional shortcomings, namely, reducing size, bulkiness, and power consumption. But in the longer term, nebulizers are expected to offer even more important features. Following the trend toward individually optimized therapy, nebulizers will be able to estimate deposited dosage and concentrations in the lung. In addition, as progress in nanotechnology allows the development of smart drug carrying particles, advanced liquid nebulization is expected to be the delivery mode of choice for these smart particle aerosols.

In VitroEstimations ofIn VivoJet Nebulizer Efficiency Using Actual and Simulated Tidal Breathing Patterns

In vivo aerosol delivery efficiency was estimated in vitro for two jet nebulizers using a breath monitor (Breathe!; Pari GmbH, Germany) and breath simulator (COMPAS; Pari GmbH) to reproduce subject tidal breathing patterns. The AeroEclipse (Trudell Medical International, Canada), a breath-actuated nebulizer, and the LC Star (Pari GmbH), a breath-enhanced nebulizer, were filled with levalbuterol HCl solution (Sepracor, USA) and operated with compressed O(2) at 8 lpm. Tidal breathing patterns of 20 adult subjects were digitally recorded with the Breathe! Breath Monitor. Subjects then breathed tidally from each nebulizer separately for 1 minute and to nebulizer dryness. Levalbuterol aerosol collected on filters placed between the nebulizer and mouth was chemically assayed to determine the inspired mass (IM), wasted mass (WM) and total emitted mass (TM). Measurements were repeated using the COMPAS Breath Simulator to simulate each subject's tidal breathing pattern. IM, WM, and TM measurements using actual versus simulated tidal breathing were highly comparable for each nebulizer, except the IM (p < 0.05) from LC Star measured at nebulizer dryness. Breath simulation was an inaccurate tool for estimating the time to nebulizer dryness as simulated measurements to nebulizer dryness took significantly longer than measurements preformed with actual tidal breathing (p < 0.001). While breath simulation provides an accurate in vitro tool for estimating in vivo aerosol delivery, it should not completely replace in vivo measurements until inherent limitations in simulator operation can be overcome to provide a more clinically realistic simulation.

A simple method of bronchoprovocation using a valved holding chamber

This study was undertaken to ascertain whether the use of a valved holding chamber (VHC) during bronchial provocation testing might increase lung deposition and repeatability of the test relative to the tidal breathing method. The 2-min tidal breathing results were compared to five inhalations from a VHC device in patients using the Pari-provoII nebulizer (MMD = 2.1mkm). Lung and mouth deposition, losses though the exhaled air and losses before aerosol delivery to the patient's mouth were measured in patients using a radiolabeled 99Tc-DTPA solution and gamma camera. The study revealed that lung deposition was 67% with the VHC method, and losses with exhaled air were 29% of the inhaled amount. The tidal breathing method resulted in lung deposition of 20.9 +/- 3.4%, and losses with exhaled air were 77.5 +/-3.5%. Mouth deposition did not differ significantly between methods. Variability in lung deposition was 15.3% for the VHC and 32.0% for the tidal breathing method. In addition to greater lung deposition and reproducibility, the VHC method allows easier calculation of the inhaled dose.