Why do medical nebulizers differ in their output and particle size characteristics?

Nebulizers

Nebulizers generate aerosols from liquid-based solutions and suspensions. Nebulizers are particularly well suited to delivering larger doses of medication than is practical with inhalers and are used with a broad range of liquid formulations. When the same drug is available in liquid or inhaler form, nebulizers are applicable for use with patients who will not or cannot reliably use a pressurized metered-dosed inhaler (pMDI) or dry powder inhaler (DPI) due to poor lung function, hand-breath coordination, cognitive abilities (e.g., infants, elderly) or device preference. In a nebulizer, liquid medication is placed in a reservoir and fed to an aerosol generator to produce the droplets. A series of tubes and channels direct the aerosol to the patient via an interface such as mouthpiece, mask, tent, nasal prongs or artificial airway. All nebulizers contain these basic parts, although the technology and design used can vary widely and can result in significant difference in ergonomics, directions for use, and performance. While many types of nebulizers have been described, the three categories of modern clinical nebulizers include: (1) pneumatic jet nebulizers (JN); (2) ultrasonic nebulizers (USN); and (3) vibrating mesh nebulizers (VMN). Nebulizers are also described in terms of their reservoir size. Small volume nebulizers (SVNs), most commonly used for medical aerosol therapy, can hold 5 to 20 mL of medication and may be jet, ultrasonic, or mesh nebulizers. Large volume nebulizers, typically jet or ultrasonic nebulizers, hold up to 200 mL and may be used for either bland aerosol therapy or continuous drug administration.

Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus

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.

The History of Therapeutic Aerosols: A Chronological Review

In 1956, Riker Laboratories, Inc., (now 3 M Drug Delivery Systems) introduced the first pressurized metered dose inhaler (MDI). In many respects, the introduction of the MDI marked the beginning of the modern pharmaceutical aerosol industry. The MDI was the first truly portable and convenient inhaler that effectively delivered drug to the lung and quickly gained widespread acceptance. Since 1956, the pharmaceutical aerosol industry has experienced dramatic growth. The signing of the Montreal Protocol in 1987 led to a surge in innovation that resulted in the diversification of inhaler technologies with significantly enhanced delivery efficiency, including modern MDIs, dry powder inhalers, and nebulizer systems. The innovative inhalers and drugs discovered by the pharmaceutical aerosol industry, particularly since 1956, have improved the quality of life of literally hundreds of millions of people. Yet, the delivery of therapeutic aerosols has a surprisingly rich history dating back more than 3500 years to ancient Egypt. The delivery of atropine and related compounds has been a crucial inhalation therapy throughout this period and the delivery of associated structural analogs remains an important therapy today. Over the centuries, discoveries from many cultures have advanced the delivery of therapeutic aerosols. For thousands of years, therapeutic aerosols were prepared by the patient or a physician with direct oversight of the patient using custom-made delivery systems. However, starting with the Industrial Revolution, advancements in manufacturing resulted in the bulk production of therapeutic aerosol delivery systems produced by people completely disconnected from contact with the patient. This trend continued and accelerated in the 20th century with the mass commercialization of modern pharmaceutical inhaler products. In this article, we will provide a summary of therapeutic aerosol delivery from ancient times to the present along with a look to the future. We hope that you will find this chronological summary intriguing and informative.

The effects of suspension particle size on the performance of air-jet, ultrasonic and vibrating-mesh nebulisers

Using latex microspheres as model suspensions, the influence of suspension particle size (1, 4.5 and 10 μm) on the properties of aerosols produced using Pari LC Sprint (air-jet), Polygreen (ultrasonic), Aeroneb Pro (actively vibrating-mesh) and Omron MicroAir NE-U22 (passively vibrating-mesh) nebulisers was investigated. The performance of the Pari nebuliser was independent of latex spheres particle size. For both Polygreen and Aeroneb Pro nebulizers, total aerosol output increased when the size of latex spheres increased, with highest fine particle fraction (FPF) values being recorded. However, following nebulisation of 1 or 4.5 μm suspensions with the Polygreen device, no particles were detected in the aerosols deposited in a two-stage impinger, suggesting that the aerosols generated from this device consisted mainly of the continuous phase while the dispersed microspheres were excluded and remained in the nebuliser. The Omron nebuliser efficiently nebulised the 1 μm latex spheres, with high output rate and no particle aggregation. However, this device functioned inefficiently when delivering 4.5 or 10 μm suspensions, which was attributed to the mild vibrations of its mesh and/or the blockage of the mesh apertures by the microspheres. The Aeroneb Pro fragmented latex spheres into smaller particles, but uncontrolled aggregation occurred upon nebulisation. This study has shown that the design of the nebuliser influenced the aerosol properties using latex spheres as model suspensions. Moreover, for the recently marketed mesh nebulisers, the performance of the Aeroneb Pro device was less dependent on particle size of the suspension compared with the Omron MicroAir nebuliser.

Aerosol generation using nanometer liposome suspensions for pulmonary drug delivery applications

Pulmonary lung targeting finds applications in drug delivery to the lung itself and to other body organs, via blood circulation following transfer across alveolar membranes. Understanding pulmonary drug delivery systems towards improving their efficacy needs identification of particle sizes of relevance and elucidation of links between suspension properties, techniques of atomisation and properties of the generated aerosols. This review article is focussed on understanding the elements of pulmonary drug delivery, specifically related to suspensions of small liposomes. Specific objectives of this review include (a) understanding aerosol particle deposition and absorption on pulmonary surface, (b) links between properties of aerosol generation and colloidal drug carriers used for drug encapsulation, and (c) investigation on the controlled properties of liposome aerosols generated using different atomisation techniques for efficacious aerosol therapy.

Ventilation scintigraphy with lipophilic cationic compounds

OBJECTIVE

On the basis of our hypothesis that lipophilic cations may be more suitable for ventilation lung scintigraphy than the conventional technetium-99m diethylenetriamine penta-acetic acid (Tc-DTPA), comparative studies were carried out.

BASIC METHODS

The nebulization potential of nine routine radiopharmaceuticals was compared on medical and scintigraphy-specific nebulizers. This was followed by ventilation scintigraphy in 14 patients with chronic obstructive airway disease (n=13) or pulmonary embolism (n=1) where either 99mTc-methoxyisobutylisonitrile (n=10) or Tc-tetrofosmin (n=4) was used. Same-patient comparison with 99mTc-DTPA ventilation scan was available in six patients using the same acquisition protocol. Comparison with 99mTc-DTPA was made with respect to the nebulization rates, radioactivity delivered per unit of radioactivity available for inhalation, and regional distribution of inhaled counts.

RESULTS

Lipophilic cation solutions had a significantly higher nebulization rate compared with 99mTc-DTPA using the medical nebulizer (235%, P<0.01) and 370% on scintigraphy-specific nebulizer (P<0.01). More than three times the counts of 99mTc-methoxyisobutylisonitrile or 99mTc-tetrofosmin was deposited in the body compared with Tc-DTPA aerosol per megabecquerel activity inhaled (1.5 vs. 0.4 kcounts/MBq) (P<0.001), preferentially in the lungs (75.2 vs. 65.2%), at the expense of oropharynx and stomach. Within the lungs, about 50% more counts were deposited in the outer one-third lung with lipophilic cations. Overall, therefore, more than 12 times the radioactivity deposition was achieved in the peripheral one-third of the lungs with the lipophilic cations.

CONCLUSION

Ventilation lung scanning with lipophilic cations is a viable substitute of nanoparticle scintigraphy (technegas and pertechnegas, which are expensive and technically far more demanding).

The nanoscale in pulmonary delivery. Part 2: formulation platforms

This article is the second part of a review on the nanoscale in pulmonary drug delivery. Specifically it summarises and analyses the potential of the different inhalation delivery routes: nebulisers, dry powder inhalers, pressurised metered-dose inhalers, for the delivery of nanoparticles or nanodroplets. Few products and experimental studies have managed to fully exploit the nanoscale in inhalation delivery, although some may unknowingly benefit from it. Nebulisers are the most advanced in using the nanoscale, pressurised metered-dose inhalers require further developments to realise its full potential, and dry powder inhalers are specifically in need of a dry solid nanoparticle generation technique to make it a reality.

Laser Diffractometry as a Technique for the Rapid Assessment of Aerosol Particle Size from Inhalers

The rapid assessment of aerosols produced by medicinal inhalers is highly desirable from several standpoints, including the assurance of product quality, the development of new delivery systems, and the need to meet an increasing requirement by regulatory bodies for reliable in vitro performance data. Particle size analysis has traditionally been undertaken by cascade impactor on account of the direct assessment of active pharmaceutical ingredient(s) (APIs) that is possible by this method. However, laser diffractometry is less labor-intensive, more rapid, and can be a less invasive procedure. The technique provides meaningful results; as long as precautions are taken to validate that the measurements are an accurate reflection of the distribution of API mass as a function of particle or droplet size. We begin the review by examining the underlying theory of the laser diffraction method. After a brief description of current laser diffractometers used in inhaler measurements, we continue by examining the range of applications by inhaler class. We then examine the basis upon which inhaler measurements made by laser-diffractometry can be compared with equivalent particle size distribution data from compendial techniques. We conclude the assessment of the technique by developing guidelines for its valid application as a component of the range of in vitro methods that are available for inhaler performance assessment.

Aerosolised antibiotics: a critical appraisal of their use

Aerosolised antimicrobial agents have been used in clinical practice since the 1950s. The main advantage of this route of administration is the targeted drug delivery to the site of infection in the lung. Exploitation of this targeted delivery can yield high concentrations at the site of infection/colonisation while minimising systemic toxicities. It is important to note that the ability of a drug to reach the target area in the lung effectively is dependent on a number of variables, including the nebuliser, patient technique, host anatomy and disease-specific factors. The most convincing data to support the use of aerosolised antimicrobials has been generated with tobramycin solution for inhalation (TOBI, Chiron Corp.) for maintenance treatment in patients with cystic fibrosis. In addition to cystic fibrosis, the use of aerosolised antimicrobials has also been studied for the treatment or prevention of a number of additional disease states including non-cystic fibrosis bronchiectasis, ventilator-associated pneumonia and prophylaxis against pulmonary fungal infections. Key studies evaluating the benefits and shortcomings of aerosolised antimicrobial agents in these areas are reviewed. Although the theory behind aerosolised administration of antibiotics seems to be sound, there are limited data available to support the routine use of this modality. Owing to the gaps still existing in our knowledge base regarding the routine use of aerosolised antibiotics, caution should be exercised when attempting to administer antimicrobials via this route in situations falling outside clearly established indications such as the treatment of patients with cystic fibrosis or Pneumocystis pneumonia.

In vitro evaluation of bronchodilator drug delivery by jet nebulization during pediatric mechanical ventilation

OBJECTIVE

To determine the influence of jet nebulizer brands and nebulization mode on albuterol delivery in a mechanically ventilated pediatric lung model.

DESIGN

In vitro, laboratory study.

SETTING

Research laboratory of a university hospital.

INTERVENTIONS

Using albuterol as a marker, six jet nebulizers (Microneb NA420, Sidestream, Acorn II, Cirrus, Upmist, Micro Mist) were tested in four nebulization modes in a bench model mimicking the ventilatory pattern of a 10-kg infant (Galileo ventilator, Hamilton Medical). The amounts of albuterol deposited on the inspiratory filters at the end of the endotracheal tube were determined, as well as the pressure, flow profiles, and particle size distribution of the jet nebulizers.

MEASUREMENTS AND MAIN RESULTS

Pooling the data of the six jet nebulizer brands (n = 30) indicated that intermittent nebulization during the expiratory phase was more efficient (6.5 +/- 2.5% of the initial dose, p < .001) than intermittent nebulization during the inspiratory phase (1.9 +/- 1.2%) and continuous nebulization with air from the ventilator (4.0 +/- 1.5%) or from an external source (4.2 +/- 1.4%). The particle size distribution at 6 L x min(-1) was between 2.81 and 3.30 microm.

CONCLUSIONS

In our in vitro pediatric lung model, the quantity of inhaled drug was low. Jet nebulizer brands and nebulization modes significantly affected drug delivery, and in vitro models designed for adults cannot be extrapolated to infants.

Perfluorocarbon species and nebulizer type influence aerosolization rate and particle size of perfluorocarbon aerosol

PURPOSE

Aerosolization of perfluorocarbons (PFC) has been proven beneficial in vivo. The present in vitro study was performed to investigate, how PFC-aerosolization is affected by type of nebulizer and PFC properties.

MATERIALS AND METHODS

Aerosolization rate was studied of 4 different PFC that were nebulized using 3 different jet nebulizers (operating at different flows: 4.1; 7.1; 13 l/min) and one ultrasonic nebulizer. Distribution of aerosol particle size was determined with a laser diffraction device.

RESULTS

Between the studied nebulizers, considerable differences in the aerosolization rate were found. Aerosolization rate was significantly lower for PFOB (0.48-1.24 mL/min), when compared with PF 5080, RM 101 and FC 77 (1.33-4.75 mL/min). The ultrasonic nebulizer did not generate an aerosol but rather PFC vapor. Lowest mass median diameter (MMD) was found for PFOB and varied between the jet nebulizers from 2.2 and 3.7 microm, with a small range in particle size (maximum of 7.3 microm). FC 77 had highest MMD (3.5 to 9.2 microm) and greatest range of particle size of up to 13 microm.

CONCLUSIONS

Our in vitro data show that aerosolization rate depends mainly on density of PFC and the flow of nebulizer. Particle size distribution is affected by PFC properties. Our result may explain controversial results of published in vivo studies.

Nebulized antibiotics in cystic fibrosis

Nebulization is a useful administration route in cystic fibrosis (CF) as it delivers antibiotics directly to the endobronchial site of infection and is associated with decreased toxicity because of limited systemic absorption. It is assumed that the concentration of antibiotics in bronchial secretions should be as high as 10 times the minimum inhibiting concentration to allow penetration of antibiotics into biofilms, suppress inhibitory factors and promote bactericidal effectiveness. However, effective aerosol delivery is compromised by nebulizers with limited capacity to produce particles of a size in the respirable range. Three antibiotics are commonly used for inhalation: tobramycin, amikacin and colistin (colomycin). Placebo-controlled studies evaluating antibiotic aerosol maintenance in stable patients chronically infected with Pseudomonas aeruginosa indicate a significant improvement of lung function and a reduction of the number of hospital admissions for an acute exacerbation of CF. TOBI is a recently marketed preservative- and sulfate-free formula of tobramycin, specially designed for diffusion in the bronchioles and optimal tolerance. A wide-scope study involving 520 patients compared TOBI (300 mg twice daily; n = 258) with placebo (n = 262) for three 28-day cycles with each cycle separated by a 28-day period of no treatment. Respiratory function was significantly improved as early as in the second week and remained so for the rest of the trial even during periods without aerosol treatment. There was also a parallel decrease in the relative risk of hospitalization, the number of days of hospitalization and the number of days on intravenous antipyocyanic treatment. Toxicity studies carried out so far have shown no renal or ototoxicity with nebulized tobramycin. Introduction or selection of resistant bacteria is relatively rare but remains a matter of concern. Aerosol maintenance treatment with an appropriate antibiotic in a high enough dosage can be recommended for patients with CF who are chronically infected with P. aeruginosa.

Validation of laser diffraction method as a substitute for cascade impaction in the European Project for a Nebulizer Standard

The project for a European standard testing procedure to characterize nebulizers in terms of particle size distribution has been based on using the Andersen-Marple personal cascade impactor model 298 (A-MPCI) with a sodium fluoride reference solution. In the present study methods based on laser diffraction (Mastersizer-X) and time-of-flight (TOF)(APS) and another cascade impactor (GS1-CI) were compared with the A-MPCI. Two types of nebulizer (Pari LC+ and Microneb) were tested with all apparatuses, and a third type of nebulizer (NL9) was tested with the A-MPCI and Mastersizer-X. Nebulizers were charged with a solution of sodium fluoride in conditions reproducing the European Committee for Normalization (CEN) protocol. There was no difference between the Mastersizer-X and the A-MPCI or between the GS1-CI and the A-MPCI in terms of mass median aerodynamic diameter (MMAD). Comparison between the APS and the A-MPCI showed a significant difference with the Microneb. The geometric standard deviations (GSD) obtained with the A-MPCI were on average 10% greater than GSD obtained with the other apparatuses, but the differences were not statistically significant. We conclude that laser diffraction can be used for particle size distribution in the context of the European standard, and that the Mastersizer-X is particularly interesting for industrial practice in view of its simplicity and robustness.

Time-of-flight aerodynamic particle size analyzers: their use and limitations for the evaluation of medical aerosols

Time-of-flight (TOF) aerosol analyzers are a class of instruments that measure the aerodynamic diameter of individual particles following a controlled acceleration in a well-defined flow field. Two instruments have been used to analyze the size of medical aerosols: Aerosizer particle size analyzer (TSI Particle Instruments/Amherst, Amherst, MA), Aerodynamic Particle Sizer (APS) aerosol spectrometer (TSI) Both instruments are capable of sizing several thousand particles a second, making it possible to obtain aerodynamic particle size distributions in a few seconds compared with up to 1 hour per measurement using compendial methods that are based on either the multistage liquid impinger or cascade impactor. This rapidity makes TOF analysis attractive for product development, as many different variables can potentially be investigated during a short period of time. The data thus obtained should be used with caution, however. Several issues, most notably the lack of a direct relationship with the mass of drug substance present and the vulnerability of the measurements to coincidence effects when sampling concentrated aerosols, may severely limit the value of data from many aerosol delivery systems, especially pressurized metered dose inhalers (pMDIs). A review of the literature illustrating the issues that are involved and providing guidance on the most appropriate uses of these analyzers is presented.

The salt output of a nebulizer--a comparison between two nebulizer types

The output of a nebulizer is generally defined as its weight loss during 1 min of nebulization. This mass output includes the weight loss due to evaporation of the solution required to moisten the dry air that is fed through the nebulizer. In order to compare results obtained from studies using different nebulizers we introduce the salt output as the amount of the solution that actually leaves the liquid phase as droplets and not by evaporation. The performance characteristics of a standard jet nebulizer (MA2) and a Sidestream jet neublizer were compared. Mass output was determined at different methacholine concentrations. Salt output was assessed by analysing the remaining salt in the nebulizers after 1 min of nebulization. Overall system performance in terms of forced expiratory volume in 1 sec (FEV1) reduction after 1 min of exposure to individually selected concentrations of methacholine were studied in 15 healthy, non-smoking subjects. Both nebulizer types showed a moderate linear increase of mass output with methacholine concentration. The efficiency coefficient, the quotient between salt output and mass output, was found to be 0.93 and 0.75 for the MA2 and Sidestream nebulizer respectively. These findings were explained by differences in airflow through, and temperature inside, the nebulizers. The salt output of the nebulizers proved to be better correlated to the FEV1-reduction following methacholine inhalation than did the mass output. The relative amount of the salt output that adhered to the acrylic walls of the Sidestream nebulizer drying tower was found to be 9%. We conclude that it is more appropriate to use salt output than mass output as a nebulizer performance descriptor. The study also shows the importance of determining nebulizer system performance under conditions as similar to true provocations as possible.

Regional deposition of inhaled Evans blue dye in mechanically ventilated rabbits with air or helium oxygen mixture

An animal model has been used and further developed to examine and evaluate differences in regional deposition patterns of an Evans Blue dye (EB) tracer aerosol. This was done by using different carrier gas composition of either He-O2 (80% helium, 20% oxygen) or air (79% nitrogen, 21% oxygen) in histamine-provoked and nonprovoked rabbits. The ratio of peripheral deposition to total deposition (central + peripheral), in relation to percentage increase in intratracheal pressure (ITP delta %), was used as an evaluation tool. The animals were tracheostomized, cannulated, and ventilated in a volume-controlled mode until they were stable. Saline or histamine was then administrated for 2 min before the tracer aerosol EB was given. The percentage increase in intratracheal pressure before and after provocation was calculated (ITP delta %) and was, on average, 51 +/- 20% for air and 51 +/- 20% for He-O2. EB was extracted from lung tissues and measured with a spectrophotometer. The absorbance in different lung regions was used as a measure of the distribution of aerosol. Bronchial provocation gave a central deposition 0.55 +/- 0.11 (mean +/- SD, ratio = peripheral deposition/central + peripheral deposition) compared to 0.80 +/- 0.09 in the control group. He-O2-ventilated rabbits showed significantly higher peripheral deposition ratio (0.67 +/- 0.12) compared with air-ventilated rabbits (0.55 +/- 0.11). The latter finding may be due to the difference in the degree of turbulent flow. There were significant correlations between intratracheal peak pressure and peripheral deposition, r = -.60 and r = -.71 for air and He-O2, respectively. This study demonstrates the possibility of using a rabbit model and different carrier gases for evaluation of effects of bronchial provocation.

Development and evaluation of a pulsed nebulizer with predictable dosing characteristics

A metered dose nebulizer assembly with the capability for repeatable doses is described, comprising a commercial disposable nebulizer and a timing circuit to control the duration of air supply. Data on performance of the nebulizer apparatus under typical operating conditions are presented, using cromolyn sodium as a model compound. Repeat doses from the apparatus typically show less than 10% relative standard deviation.