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Koyuncu A, Ari A. Filling the gaps in the evaluation and selection of mobile health technologies in respiratory medicine. Expert Rev Respir Med 2024; 18:159-174. [PMID: 38795074 DOI: 10.1080/17476348.2024.2361048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/24/2024] [Indexed: 05/27/2024]
Abstract
INTRODUCTION Mobile health (mHealth) technology in respiratory medicine is a fast-growing and promising digital technology that is popular among patients and healthcare providers (HCPs). They provide reminders and step-by-step instructions for the correct inhalation technique, monitor patients' adherence to treatment, and facilitate communication between patients and HCPs. AREAS COVERED While numerous mHealth apps have been developed over the years, most applications do not have supporting evidence. Selecting the best mHealth app in respiratory medicine is challenging due to limited studies carrying out mHealth app selection. Although mHealth technologies play an important part in the future of respiratory medicine, there is no single guide on the evaluation and selection of mHealth technologies for patients with pulmonary diseases. This paper aims to provide an overview of mHealth technologies, particularly emphasizing digital inhalers and standalone applications used in asthma. Additionally, it offers insights into the evaluation, selection, and pertinent considerations surrounding mHealth applications in respiratory medicine. EXPERT OPINION Evaluating mHealth apps will take time, resources, and collaboration between stakeholders such as governmental regulatory bodies, subject-matter experts, and industry representatives. Filling the gaps in the evaluation and selection of the mHealth app will improve clinical decision-making, personalized treatments, self-management and disease monitoring in respiratory medicine.
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Affiliation(s)
- Ayfer Koyuncu
- Graduate School of Science and Engineering, Bioengineering Department, Hacettepe University, Ankara, Turkey
| | - Arzu Ari
- College of Health Professions Department of Respiratory Care, Regent's Professor and Associate Dean for Research, Texas State University, Round Rock, TX, USA
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2
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Weant KA, Baum RA, Hile GB, Humphries RL, Metts EL, Miller AR, Woolum JA, Bailey AM. Nebulized medications in the emergency department: A narrative review of nontraditional agents. Am J Health Syst Pharm 2024; 81:88-105. [PMID: 37879862 DOI: 10.1093/ajhp/zxad273] [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: 10/24/2023] [Indexed: 10/27/2023] Open
Abstract
PURPOSE This article summarizes emerging nontraditional therapies administered via the nebulization route for use in the emergency department (ED). SUMMARY Although traditional routes of medication administration (eg, intravenous) have been the mainstay of administration modalities for decades, these routes may not be appropriate for all patients. Nowhere is this more readily apparent than in the ED setting, where patients with a variety of presentations receive care. One unique route for medication administration that has increasingly gained popularity in the ED is that of aerosolized drug delivery. This route holds promise as direct delivery of medications to the site of action could yield a more rapid and effective therapeutic response while also minimizing systemic adverse effects by utilizing a fraction of the systemic dose. Medication administration via nebulization also provides an alternative that is conducive to rapid, less invasive access, which is advantageous in the emergent setting of the ED. This review is intended to analyze the existing literature regarding this route of administration, including the nuances that can impact drug efficacy, as well as the available literature regarding novel, noncommercial nebulized medication therapy given in the ED. CONCLUSION Multiple medications have been investigated for administration via this route, and when implementing any of these therapies several practical considerations must be taken into account, from medication preparation to administration, to ensure optimal efficacy while minimizing adverse effects. The pharmacist is an essential bedside team member in these scenarios to assist with navigating unique and complex nuances of this therapy as they develop.
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Affiliation(s)
- Kyle A Weant
- Department of Clinical Pharmacy and Outcome Sciences, University of South Carolina College of Pharmacy, Columbia, SC, USA
| | - Regan A Baum
- University of Kentucky HealthCare, Lexington, KY, and University of Kentucky College of Pharmacy, Lexington, KY, USA
| | | | - Roger L Humphries
- Department of Emergency Medicine, University of Kentucky HealthCare, Lexington, KY, USA
| | - Elise L Metts
- University of Kentucky HealthCare, Lexington, KY, and University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Amy R Miller
- University of South Carolina College of Pharmacy, Columbia, SC, USA
| | - Jordan A Woolum
- University of Kentucky HealthCare, Lexington, KY, and University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Abby M Bailey
- University of Kentucky HealthCare, Lexington, KY, and University of Kentucky College of Pharmacy, Lexington, KY, USA
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3
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Hermet P, Delache B, Herate C, Wolf E, Kivi G, Juronen E, Mumm K, Žusinaite E, Kainov D, Sankovski E, Virumäe K, Planken A, Merits A, Besaw JE, Yee AW, Morizumi T, Kim K, Kuo A, Berriche A, Dereuddre-Bosquet N, Sconosciuti Q, Naninck T, Relouzat F, Cavarelli M, Ustav M, Wilson D, Ernst OP, Männik A, LeGrand R, Ustav M. Broadly neutralizing humanized SARS-CoV-2 antibody binds to a conserved epitope on Spike and provides antiviral protection through inhalation-based delivery in non-human primates. PLoS Pathog 2023; 19:e1011532. [PMID: 37531329 PMCID: PMC10395824 DOI: 10.1371/journal.ppat.1011532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
The COVID-19 pandemic represents a global challenge that has impacted and is expected to continue to impact the lives and health of people across the world for the foreseeable future. The rollout of vaccines has provided highly anticipated relief, but effective therapeutics are required to further reduce the risk and severity of infections. Monoclonal antibodies have been shown to be effective as therapeutics for SARS-CoV-2, but as new variants of concern (VoC) continue to emerge, their utility and use have waned due to limited or no efficacy against these variants. Furthermore, cumbersome systemic administration limits easy and broad access to such drugs. As well, concentrations of systemically administered antibodies in the mucosal epithelium, a primary site of initial infection, are dependent on neonatal Fc receptor mediated transport and require high drug concentrations. To reduce the viral load more effectively in the lung, we developed an inhalable formulation of a SARS-CoV-2 neutralizing antibody binding to a conserved epitope on the Spike protein, ensuring pan-neutralizing properties. Administration of this antibody via a vibrating mesh nebulization device retained antibody integrity and resulted in effective distribution of the antibody in the upper and lower respiratory tract of non-human primates (NHP). In comparison with intravenous administration, significantly higher antibody concentrations can be obtained in the lung, resulting in highly effective reduction in viral load post SARS-CoV-2 challenge. This approach may reduce the barriers of access and uptake of antibody therapeutics in real-world clinical settings and provide a more effective blueprint for targeting existing and potentially emerging respiratory tract viruses.
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Affiliation(s)
| | - Benoît Delache
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT); Fontenay-aux-Roses, France
| | - Cecile Herate
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT); Fontenay-aux-Roses, France
| | | | - Gaily Kivi
- Icosagen Cell Factory OÜ; Tartu, Estonia
| | | | - Karl Mumm
- Icosagen Cell Factory OÜ; Tartu, Estonia
| | | | | | | | | | | | | | - Jessica E Besaw
- Department of Biochemistry, University of Toronto; Toronto, Canada
| | - Ai Woon Yee
- Department of Biochemistry, University of Toronto; Toronto, Canada
| | | | - Kyumhyuk Kim
- Department of Biochemistry, University of Toronto; Toronto, Canada
| | - Anling Kuo
- Department of Biochemistry, University of Toronto; Toronto, Canada
| | - Asma Berriche
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT); Fontenay-aux-Roses, France
| | - Nathalie Dereuddre-Bosquet
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT); Fontenay-aux-Roses, France
| | - Quentin Sconosciuti
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT); Fontenay-aux-Roses, France
| | - Thibaut Naninck
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT); Fontenay-aux-Roses, France
| | - Francis Relouzat
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT); Fontenay-aux-Roses, France
| | - Mariangela Cavarelli
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT); Fontenay-aux-Roses, France
| | - Mart Ustav
- Icosagen Cell Factory OÜ; Tartu, Estonia
| | | | - Oliver P Ernst
- Department of Biochemistry, University of Toronto; Toronto, Canada
- Department of Molecular Genetics, University of Toronto; Toronto, Canada
| | | | - Roger LeGrand
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT); Fontenay-aux-Roses, France
| | - Mart Ustav
- Icosagen Cell Factory OÜ; Tartu, Estonia
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Mitchell JP, Carter I, Christopher JD, Copley M, Doub WH, Goodey A, Gruenloh CJ, Larson BB, Lyapustina S, Patel RB, Stein SW, Suman JD. 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). AAPS PharmSciTech 2023; 24:73. [PMID: 36869256 DOI: 10.1208/s12249-023-02528-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
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.
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Affiliation(s)
- Jolyon P Mitchell
- Jolyon Mitchell Inhaler Consulting Services Inc., 1154 St. Anthony Road, London, Ontario, N6H2R1, Canada.
| | - I Carter
- PPD Inc., Part of Thermo Fisher Scientific, Athlone, Ireland
| | | | - M Copley
- Copley Scientific Ltd., Nottingham, UK
| | - W H Doub
- OINDP In Vitro Analysis, Kirkwood, Missouri, 63122, USA
| | - A Goodey
- Merck & Co. Inc., Kenilworth, New Jersey, 07033, USA
| | - C J Gruenloh
- PPD Inc., Part of Thermo Fisher Scientific, Middleton, Wisconsin, 53562-466, USA
| | - B B Larson
- PPD Inc., Part of Thermo Fisher Scientific, Middleton, Wisconsin, 53562-466, USA
| | - S Lyapustina
- Faegre Drinker Biddle & Reath LLP, Washington, District of Columbia, 20005, USA
| | - R B Patel
- Intellectual Designs LLC, Brookfield, Connecticut, 06804, USA
| | - S W Stein
- Kindeva Drug Delivery, Woodbury, Minnesota, 55129, USA
| | - J D Suman
- Next Breath LLC, a Division of Aptar Group, Halethorpe, Maryland, 21227, USA
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Amin MA, Taha HK, Hussein RRS, Sarhan RM, Abdelrahim MEA. Effect of oxygen flow on aerosol delivery from a vibrating mesh nebulizer with a holding chamber. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2022. [DOI: 10.1186/s43088-022-00338-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Abstract
Background
A holding chamber (HC) was created to work with a vibrating mesh nebulizer (VMN) to boost the total inhalable dose for patients. In addition to the optional supply of supplemental oxygen, it facilitates intermittent and continuous nebulization. Our goal was to see how well a VMN coupled to a HC with a mouthpiece or valved facemask performed at varied oxygen flows starting at 0–6 L/min. In this study, we used a breathing simulator to simulate adults' spontaneous breathing patterns with a tidal volume of 500 mL and a 1:1 inhalation–exhalation ratio. For the combination of nebulizer and HC adapter with a valved facemask or mouthpiece, five determinations were made. Salbutamol was recovered and evaluated using high-performance liquid chromatography from the inhalation filter connected to the breathing simulator, the nebulizer reservoir chamber, and the HC.
Results
The amount of salbutamol in the nebulizer reservoir chamber and within the HC did not differ significantly when using a mouthpiece or a valved facemask. However, the supplied dose to the inhalation filter was increased until oxygen flow reached 2 and 3 L/min using the mouthpiece and valved facemask as interfaces, respectively. The supplied salbutamol was much higher at this flow than at the other oxygen flows. This was followed by a progressive reduction in the supplied salbutamol until the lowest given dose was reached at 6 L/min oxygen flow, p < 0.005.
Conclusions
The supplied doses of salbutamol to the inhalation filter were variable with the VMN connected to the HC and mouthpiece or valved facemask, with significant improvements until an oxygen flow of 2 L/min with a mouthpiece and 3 L/min with a valved facemask, followed by gradual decreases to lower values at an oxygen flow of 6 L/min. An in vivo investigation is required to further validate the findings.
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Spence BM, Longest W, Dutta R, Momin MAM, Strickler S, Hindle M. In Vitro Evaluation of Nebulized Pharmaceutical Aerosol Delivery to the Lungs Using a New Heated Dryer System (HDS). AAPS PharmSciTech 2022; 24:10. [PMID: 36451052 PMCID: PMC9994751 DOI: 10.1208/s12249-022-02460-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/04/2022] [Indexed: 12/02/2022] Open
Abstract
The objective of this study was to develop a new heated dryer system (HDS) for high efficiency lung delivery of nebulized aerosol and demonstrate performance with realistic in vitro testing for trans-nasal aerosol administration simultaneously with high-flow nasal cannula (HFNC) therapy and separately for direct oral inhalation (OI) of the aerosol. With the HDS-HFNC and HDS-OI platforms, new active synchronization control routines were developed to sense subject inhalation and coordinate drug aerosol delivery. In vitro experiments were conducted to predict regional drug loss and lung delivery efficiency in systems that included the HDS with various patient interfaces, realistic airway models, and simulated breathing waveforms. For the HDS-HFNC platform and a repeating breathing waveform, total system loss was < 10%, extrathoracic deposition was approximately 6%, and best-case lung delivery efficiency was 75-78% of nebulized dose. Inclusion of randomized breathing with the HFNC system decreased lung delivery efficiency by ~ 10% and had no impact on nasal depositional loss. For the HDS-OI platform and best-case mouthpiece, total system loss was < 8%, extrathoracic deposition was < 1%, and lung delivery efficiency was > 90% of nebulized dose. Normal vs. deep randomized oral inhalation had little impact on performance of the HDS-OI platform and environmental aerosol loss was negligible. In conclusion, both platforms demonstrated the potential for high efficiency lung delivery of the aerosol with the HDS-OI platform having the added advantages of nearly eliminating extrathoracic deposition, being insensitive to breathing waveform, and preventing environmental aerosol loss.
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Affiliation(s)
- Benjamin M Spence
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA.
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA.
| | - Rabijit Dutta
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mohammad A M Momin
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sarah Strickler
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
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7
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Otto M, Kropp Y, Kummer L, Thiel M, Tsagogiorgas C. [Can mesh nebulizers improve prehospital aerosol therapy? An in vitro study on simulated prehospital emergency patients suffering from respiratory distress]. DIE ANAESTHESIOLOGIE 2022; 71:758-766. [PMID: 35976418 PMCID: PMC9525251 DOI: 10.1007/s00101-022-01183-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 04/15/2022] [Accepted: 06/19/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nebulizers used to treat prehospital emergency patients should provide a high output efficiency to achieve a fast onset of therapeutic drug effects while remaining unaffected by the presence of supplementary oxygen flow or the patient's breathing pattern. On the other hand, nebulizer performance is directly influenced by differences in device design, gas flow and patients' breathing patterns. Several studies from emergency departments were able to demonstrate an improvement in patient outcome when using a mesh nebulizer instead of a jet nebulizer. Data or bench studies regarding prehospital care are non-existent. OBJECTIVE The aim of the present in vitro study was to evaluate which type of aerosol generator would best address the requirements of a prehospital adult emergency patient suffering from respiratory distress. MATERIAL AND METHODS We evaluated the performance of a jet nebulizer (Cirrus™ 2, Intersurgical®) and two mesh nebulizers (Aerogen Solo® with USB controller, Aerogen Limited and M‑Neb® mobile, NEBU-TEC International med. Produkte Eike Kern GmbH) with the possibility of portable operation in an in vitro model of a spontaneously breathing adult emergency patient. One physiological and three pathological breathing patterns (distressed breathing pattern as well as stable and acute exacerbated chronic obstructive pulmonary disease) were simulated. Nebulizer output and salbutamol lung deposition were measured at different oxygen flow rates using a face mask as the delivery interface. RESULTS The mesh nebulizers produced a significantly higher aerosol output when compared to the jet nebulizer. The M‑Neb® mobile was able to significantly exceed the output of the Aerogen Solo®. Oxygen flow had the largest influence on the output of the jet nebulizer but hardly affected the mesh nebulizers. After a nebulization time of 10 min the M‑Neb® mobile also achieved the highest total salbutamol lung deposition (P < 0.001). Aerosol drug deposition was therefore mainly determined by the nebulizer's drug output per unit time. The deposition could not be improved using a spacer but was strongly influenced by the simulated emergency patients' breathing pattern. CONCLUSION The use of mesh nebulizers might have the potential to improve the aerosol therapy of prehospital emergency patients. In general, mesh nebulizers seem to be superior to jet nebulizers regarding aerosol output per unit time and total lung deposition. The present data suggest that aerosol output and drug deposition to the collection filter in this simulated setting are closely connected and crucial for total salbutamol deposition, as the deposition could not be improved by adding a spacer. Aerosol drug deposition in simulated emergency patients' lungs is therefore mainly determined by the nebulizer's drug output per unit time. The level of oxygen flow used had the largest influence on the output of the jet nebulizer but hardly affected the output of the tested mesh nebulizers. Mesh nebulizers could therefore enable a demand-adapted oxygen therapy due to their consistent performance despite the presence of oxygen flow. A high respiratory rate was associated with a high drug deposition, which is clinically desirable in the treatment of patients in respiratory distress; however, drug underdosing must also be expected in the treatment of bradypneic patients. Further clinical studies must prove whether our findings also apply to the treatment of real prehospital emergency patients.
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Affiliation(s)
- M Otto
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Y Kropp
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - L Kummer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Thiel
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - C Tsagogiorgas
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
- Klinik für Anästhesie und Intensivmedizin, St. Elisabethenkrankenhaus Frankfurt, Frankfurt am Main, Deutschland.
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Bahlool AZ, Fattah S, O’Sullivan A, Cavanagh B, MacLoughlin R, Keane J, O’Sullivan MP, Cryan SA. Development of Inhalable ATRA-Loaded PLGA Nanoparticles as Host-Directed Immunotherapy against Tuberculosis. Pharmaceutics 2022; 14:pharmaceutics14081745. [PMID: 36015371 PMCID: PMC9415714 DOI: 10.3390/pharmaceutics14081745] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/11/2022] [Accepted: 08/20/2022] [Indexed: 11/16/2022] Open
Abstract
Developing new effective treatment strategies to overcome the rise in multi-drug resistant tuberculosis cases (MDR-TB) represents a global challenge. A host-directed therapy (HDT), acting on the host immune response rather than Mtb directly, could address these resistance issues. We developed an HDT for targeted TB treatment, using All Trans Retinoic Acid (ATRA)-loaded nanoparticles (NPs) that are suitable for nebulization. Efficacy studies conducted on THP-1 differentiated cells infected with the H37Ra avirulent Mycobacterium tuberculosis (Mtb) strain, have shown a dose-dependent reduction in H37Ra growth as determined by the BACT/ALERT® system. Confocal microscopy images showed efficient and extensive cellular delivery of ATRA-PLGA NPs into THP-1-derived macrophages. A commercially available vibrating mesh nebulizer was used to generate nanoparticle-loaded droplets with a mass median aerodynamic diameter of 2.13 μm as measured by cascade impaction, and a volumetric median diameter of 4.09 μm as measured by laser diffraction. In an adult breathing simulation experiment, 65.1% of the ATRA PLGA-NP dose was inhaled. This targeted inhaled HDT could offer a new adjunctive TB treatment option that could enhance current dosage regimens leading to better patient prognosis and a decreasing incidence of MDR-TB.
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Affiliation(s)
- Ahmad Z. Bahlool
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, D02 YN77 Dublin, Ireland
- Tissue Engineering Research Group, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, D02 YN77 Dublin, Ireland
- Department of Clinical Medicine, Trinity Translational Medicine Institute, St. James’s Hospital, Trinity College Dublin, The University of Dublin, D08 9WRT Dublin, Ireland
| | - Sarinj Fattah
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, D02 YN77 Dublin, Ireland
- Tissue Engineering Research Group, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, D02 YN77 Dublin, Ireland
| | - Andrew O’Sullivan
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, D02 YN77 Dublin, Ireland
- Research and Development, Science and Emerging Technologies, Aerogen Ltd., Galway Business Park, Dangan, H91 HE94 Galway, Ireland
| | - Brenton Cavanagh
- Cellular and Molecular Imaging Core, Royal College of Surgeons in Ireland RCSI, D02 YN77 Dublin, Ireland
| | - Ronan MacLoughlin
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, D02 YN77 Dublin, Ireland
- Research and Development, Science and Emerging Technologies, Aerogen Ltd., Galway Business Park, Dangan, H91 HE94 Galway, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
| | - Joseph Keane
- Department of Clinical Medicine, Trinity Translational Medicine Institute, St. James’s Hospital, Trinity College Dublin, The University of Dublin, D08 9WRT Dublin, Ireland
| | - Mary P. O’Sullivan
- Department of Clinical Medicine, Trinity Translational Medicine Institute, St. James’s Hospital, Trinity College Dublin, The University of Dublin, D08 9WRT Dublin, Ireland
| | - Sally-Ann Cryan
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, D02 YN77 Dublin, Ireland
- Tissue Engineering Research Group, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, D02 YN77 Dublin, Ireland
- SFI Advanced Materials and Bioengineering Research (AMBER) Centre, RCSI and Trinity College Dublin, D02 PN40 Dublin, Ireland
- SFI Centre for Research in Medical Devices (CÚRAM), NUIG & RCSI, H91 W2TY Galway, Ireland
- Correspondence:
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9
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Odziomek M, Ulatowski K, Dobrowolska K, Górniak I, Sobieszuk P, Sosnowski TR. Aqueous dispersions of oxygen nanobubbles for potential application in inhalation therapy. Sci Rep 2022; 12:12455. [PMID: 35864438 PMCID: PMC9302230 DOI: 10.1038/s41598-022-16720-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/14/2022] [Indexed: 11/22/2022] Open
Abstract
Inhalation is a non-invasive method of local drug delivery to the respiratory system. This study analyzed the potential use of aqueous dispersion of oxygen nanobubbles (ADON) as a drug carrier with the additional function of oxygen supplementation to diseased lungs. The suitability of the membrane-based method of ADON preparation and, next, the stability of ADON properties during storage and after aerosolization in nebulizers of various designs (jet, ultrasonic, and two vibrating mesh devices) was investigated. The increased oxygen content in the aerosol generated in two mesh nebulizers suggests that the proposed concept may be helpful in the oxygen supplementation during drug delivery by aerosol inhalation without using an additional oxygen source. This application can increase the overall effectiveness of lung disease treatment and pulmonary rehabilitation.
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Affiliation(s)
- Marcin Odziomek
- Faculty of Chemical and Process Engineering, Warsaw University of Technology, Waryńskiego 1 Street, 00-645, Warsaw, Poland.
| | - Karol Ulatowski
- Faculty of Chemical and Process Engineering, Warsaw University of Technology, Waryńskiego 1 Street, 00-645, Warsaw, Poland
| | - Katarzyna Dobrowolska
- Faculty of Chemical and Process Engineering, Warsaw University of Technology, Waryńskiego 1 Street, 00-645, Warsaw, Poland
| | - Izabela Górniak
- Faculty of Chemical and Process Engineering, Warsaw University of Technology, Waryńskiego 1 Street, 00-645, Warsaw, Poland
| | - Paweł Sobieszuk
- Faculty of Chemical and Process Engineering, Warsaw University of Technology, Waryńskiego 1 Street, 00-645, Warsaw, Poland
| | - Tomasz R Sosnowski
- Faculty of Chemical and Process Engineering, Warsaw University of Technology, Waryńskiego 1 Street, 00-645, Warsaw, Poland.
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Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, Khilnani GC, Chaudhary D, Singla R, Koul PA, Mahashur AA, Ghoshal AG, Behera D, Christopher DJ, Talwar D, Ganguly D, Paramesh H, Gupta KB, Kumar T M, Motiani PD, Shankar PS, Chawla R, Guleria R, Jindal SK, Luhadia SK, Arora VK, Vijayan VK, Faye A, Jindal A, Murar AK, Jaiswal A, M A, Janmeja AK, Prajapat B, Ravindran C, Bhattacharyya D, D'Souza G, Sehgal IS, Samaria JK, Sarma J, Singh L, Sen MK, Bainara MK, Gupta M, Awad NT, Mishra N, Shah NN, Jain N, Mohapatra PR, Mrigpuri P, Tiwari P, Narasimhan R, Kumar RV, Prasad R, Swarnakar R, Chawla RK, Kumar R, Chakrabarti S, Katiyar S, Mittal S, Spalgais S, Saha S, Kant S, Singh VK, Hadda V, Kumar V, Singh V, Chopra V, B V. Indian Guidelines on Nebulization Therapy. Indian J Tuberc 2022; 69 Suppl 1:S1-S191. [PMID: 36372542 DOI: 10.1016/j.ijtb.2022.06.004] [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: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/16/2023]
Abstract
Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.
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Affiliation(s)
- S K Katiyar
- Department of Tuberculosis & Respiratory Diseases, G.S.V.M. Medical College & C.S.J.M. University, Kanpur, Uttar Pradesh, India.
| | - S N Gaur
- Vallabhbhai Patel Chest Institute, University of Delhi, Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater NOIDA, Uttar Pradesh, India
| | - R N Solanki
- Department of Tuberculosis & Chest Diseases, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Raj Kumar
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, National Centre of Allergy, Asthma & Immunology; University of Delhi, Delhi, India
| | - G C Khilnani
- PSRI Institute of Pulmonary, Critical Care, & Sleep Medicine, PSRI Hospital, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhary
- Department of Pulmonary & Critical Care Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rupak Singla
- Department of Tuberculosis & Respiratory Diseases, National Institute of Tuberculosis & Respiratory Diseases (formerly L.R.S. Institute), Delhi, India
| | - Parvaiz A Koul
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Ashok A Mahashur
- Department of Respiratory Medicine, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
| | - A G Ghoshal
- National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
| | - D Behera
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepak Talwar
- Metro Centre for Respiratory Diseases, Noida, Uttar Pradesh, India
| | | | - H Paramesh
- Paediatric Pulmonologist & Environmentalist, Lakeside Hospital & Education Trust, Bengaluru, Karnataka, India
| | - K B Gupta
- Department of Tuberculosis & Respiratory Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India
| | - Mohan Kumar T
- Department of Pulmonary, Critical Care & Sleep Medicine, One Care Medical Centre, Coimbatore, Tamil Nadu, India
| | - P D Motiani
- Department of Pulmonary Diseases, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - P S Shankar
- SCEO, KBN Hospital, Kalaburagi, Karnataka, India
| | - Rajesh Chawla
- Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Department of Pulmonary Medicine & Sleep Disorders, AIIMS, New Delhi, India
| | - S K Jindal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Luhadia
- Department of Tuberculosis and Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - V K Arora
- Indian Journal of Tuberculosis, Santosh University, NCR Delhi, National Institute of TB & Respiratory Diseases Delhi, India; JIPMER, Puducherry, India
| | - V K Vijayan
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, University of Delhi, Delhi, India
| | - Abhishek Faye
- Centre for Lung and Sleep Disorders, Nagpur, Maharashtra, India
| | | | - Amit K Murar
- Respiratory Medicine, Cronus Multi-Specialty Hospital, New Delhi, India
| | - Anand Jaiswal
- Respiratory & Sleep Medicine, Medanta Medicity, Gurugram, Haryana, India
| | - Arunachalam M
- All India Institute of Medical Sciences, New Delhi, India
| | - A K Janmeja
- Department of Respiratory Medicine, Government Medical College, Chandigarh, India
| | - Brijesh Prajapat
- Pulmonary and Critical Care Medicine, Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
| | - C Ravindran
- Department of TB & Chest, Government Medical College, Kozhikode, Kerala, India
| | - Debajyoti Bhattacharyya
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, Army Hospital (Research & Referral), New Delhi, India
| | | | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Centre for Research and Treatment of Allergy, Asthma & Bronchitis, Department of Chest Diseases, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Jogesh Sarma
- Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Lalit Singh
- Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - M K Sen
- Department of Respiratory Medicine, ESIC Medical College, NIT Faridabad, Haryana, India; Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mahendra K Bainara
- Department of Pulmonary Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nilkanth T Awad
- Department of Pulmonary Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, M.K.C.G. Medical College, Berhampur, Orissa, India
| | - Naveed N Shah
- Department of Pulmonary Medicine, Chest Diseases Hospital, Government Medical College, Srinagar, Jammu & Kashmir, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care & Sleep Medicine, PSRI, New Delhi, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Parul Mrigpuri
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pawan Tiwari
- School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - R Narasimhan
- Department of EBUS and Bronchial Thermoplasty Services at Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Vijai Kumar
- Department of Pulmonary Medicine, MediCiti Medical College, Hyderabad, Telangana, India
| | - Rajendra Prasad
- Vallabhbhai Patel Chest Institute, University of Delhi and U.P. Rural Institute of Medical Sciences & Research, Safai, Uttar Pradesh, India
| | - Rajesh Swarnakar
- Department of Respiratory, Critical Care, Sleep Medicine and Interventional Pulmonology, Getwell Hospital & Research Institute, Nagpur, Maharashtra, India
| | - Rakesh K Chawla
- Department of, Respiratory Medicine, Critical Care, Sleep & Interventional Pulmonology, Saroj Super Speciality Hospital, Jaipur Golden Hospital, Rajiv Gandhi Cancer Hospital, Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - S Chakrabarti
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sonam Spalgais
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | | | - Surya Kant
- Department of Respiratory (Pulmonary) Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - V K Singh
- Centre for Visceral Mechanisms, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Virendra Singh
- Mahavir Jaipuria Rajasthan Hospital, Jaipur, Rajasthan, India
| | - Vishal Chopra
- Department of Chest & Tuberculosis, Government Medical College, Patiala, Punjab, India
| | - Visweswaran B
- Interventional Pulmonology, Yashoda Hospitals, Hyderabad, Telangana, India
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Antivirals and the Potential Benefits of Orally Inhaled Drug Administration in COVID-19 Treatment. J Pharm Sci 2022; 111:2652-2661. [PMID: 35691607 PMCID: PMC9181835 DOI: 10.1016/j.xphs.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/05/2022] [Accepted: 06/05/2022] [Indexed: 12/25/2022]
Abstract
Coronavirus Disease 2019 (COVID-19) pandemic has been on the agenda of humanity for more than 2 years. In the meantime, the pandemic has caused economic shutdowns, halt of daily lives and global mobility, overcrowding of the healthcare systems, panic, and worse, more than 6 million deaths. Today, there is still no specific therapy for COVID-19. Research focuses on repurposing of antiviral drugs that are licensed or currently in the research phase, with a known systemic safety profile. However, local safety profile should also be evaluated depending on the new indication, administration route and dosage form. Additionally, various vaccines have been developed. But the causative virus, Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), has undergone multiple variations, too. The premise that vaccines may suffice to eradicate new and all variants is unreliable, as they are based on earlier versions of the virus. Therefore, a specific medication therapy for COVID-19 is crucial and needed in order to prevent severe complications of the disease. Even though there is no specific drug that inhibits the replication of the disease-causing virus, among the current treatment options, systemic antivirals are the most medically appropriate. As SARS-CoV-2 directly targets the lungs and initiates lung damage, treating COVID-19 with inhalants can offer many advantages over the enteral/parenteral administration. Inhaled drug delivery provides higher drug concentration, specifically in the pulmonary system. This enables the reduction of systemic side effects and produces a rapid clinical response. In this article, the most frequently (systemically) used antiviral compounds are reviewed including Remdesivir, Favipiravir, Molnupiravir, Lopinavir-Ritonavir, Umifenovir, Chloroquine, Hydroxychloroquine and Heparin. A comprehensive literature search was conducted to provide insight into the potential inhaled use of these antiviral drugs and the current studies on inhalation therapy for COVID-19 was presented. A brief evaluation was also made on the use of inhaler devices in the treatment of COVID-19. Inhaled antivirals paired with suitable inhaler devices should be considered for COVID-19 treatment options.
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12
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Does Valved Holding Chamber Improve Aerosol Lung Deposition with a Jet Nebulizer? A Randomized Crossover Study. Pharmaceutics 2022; 14:pharmaceutics14030566. [PMID: 35335942 PMCID: PMC8956008 DOI: 10.3390/pharmaceutics14030566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/26/2022] [Indexed: 02/01/2023] Open
Abstract
Using valved holding chambers (VHC) during aerosol therapy has been reported to improve the inhaled dose with various aerosol devices, including vibrating mesh nebulizers. The aim of this study was to quantify the pulmonary deposition of a jet nebulizer (JN) with and without a VHC, and a mesh nebulizer (MN) with a VHC in a randomized cross-over trial with seven healthy consenting adults. Our hypothesis was that the use of a VHC would improve deposition with the JN. Diethylnitriaminopentacetic acid with technetium (DTPA-Tc99m), with the activity of 1 mC with 0.9% saline solution was nebulized. The radiolabeled aerosol was detected by 2D planar scintigraphy after administration. The pulmonary deposition was greater with a JN with a VHC (4.5%) than a JN alone (3.2%; p = 0.005. However, an MN with a VHC (30.0%) was six-fold greater than a JN or JN with a VHC (p < 0.001). The extrapulmonary deposition was higher in the JN group without a VHC than in the other two modalities (p < 0.001). Deposition in the device was greater with a JN + VHC than an MN+/VHC (p < 0.001). Lower residual drug at the end of the dose was detected with an MN than either JN configuration. The exhaled dose was greater with a JN alone than either an MN or JN with VHC (p < 0.001). In conclusion, the addition of the VHC did not substantially improve the efficiency of aerosol lung deposition over a JN alone.
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Madney YM, Harb HS, Porée T, Eckes M, Boules ME, Abdelrahim MEA. Preliminary bronchodilator dose effect on aerosol-delivery through different nebulizers in noninvasively ventilated COPD patients. Exp Lung Res 2022:1-9. [PMID: 35234097 DOI: 10.1080/01902148.2022.2047243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 11/04/2022]
Abstract
Objectives: This study aimed to evaluate the effect of a preliminary bronchodilator dose on the aerosol-d elivery by different nebulizers in noninvasively ventilated chronic obstructive pulmonary disease (COPD) patients. Method: COPD patients were randomized to receive study doses of 800 µg beclomethasone dipropionate (BPD) nebulized by either a vibrating mesh nebulizer (VMN) or a jet nebulizer (JN) connected to MinimHal spacer device. On a different day, the nebulized dose of beclomethasone was given to each patient by the same aerosol generator with and without preceded two puffs (100 µg each) of salbutamol delivered by a pressurized-metered dose inhaler. Urinary BPD and its metabolites in 30 min post-inhalation samples and pooled up to 24 h post-inhalation were measured. On day 2, ex-vivo studies were performed with BPD collected on filters before reaching patients which were eluted from filters and analyzed to estimate the total emitted dose.Results: The highest urinary excretion amounts of BPD and its metabolites 30 min and 24 h post-inhalation were identified with pMDI + VMN compared with other regimens(p < 0.001). The amounts of BPD and its metabolites excreted 30 min post inhalation had approximately doubled with pMDI + JN compared with JN delivery (p < 0.05). No significant effect was found in the ex-vivo study results except between VMN and JN with a significant superiority of the VMN (p < 0.001).Conclusion: Using a preliminary bronchodilator dose before drug nebulization significantly increased the effective lung dose of the nebulized drug with both VMNs and JNs. However, adding a preliminary bronchodilator dose increased the 24 hr cumulative urinary amount of the drug representing higher systemic delivery of the drug, which in turn could result in higher systemic side effects.
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Affiliation(s)
- Yasmin M Madney
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-suef, Egypt
| | - Hadeer S Harb
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-suef, Egypt
| | | | | | - Marina E Boules
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-suef, Egypt
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-suef, Egypt
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Pourmehran O, Cazzolato B, Tian Z, Arjomandi M. The effect of inlet flow profile and nozzle diameter on drug delivery to the maxillary sinus. Biomech Model Mechanobiol 2022; 21:849-870. [PMID: 35137283 PMCID: PMC9132880 DOI: 10.1007/s10237-022-01563-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 01/25/2022] [Indexed: 11/25/2022]
Abstract
In this paper, the effect of the turbulence and swirling of the inlet flow and the diameter of the nozzle on the flow characteristics and the particles' transport/deposition patterns in a realistic combination of the nasal cavity (NC) and the maxillary sinus (MS) were examined. A computational fluid dynamics (CFD) model was developed in ANSYS® Fluent using a hybrid Reynolds averaged Navier–Stokes–large-eddy simulation algorithm. For the validation of the CFD model, the pressure distribution in the NC was compared with the experimental data available in the literature. An Eulerian–Lagrangian approach was employed for the prediction of the particle trajectories using a discrete phase model. Different inlet flow conditions were investigated, with turbulence intensities of 0.15 and 0.3, and swirl numbers of 0.6 and 0.9 applied to the inlet flow at a flow rate of 7 L/min. Monodispersed particles with a diameter of 5 µm were released into the nostril for various nozzle diameters. The results demonstrate that the nasal valve plays a key role in nasal resistance, which damps the turbulence and swirl intensities of the inlet flow. Moreover, it was found that the effect of turbulence at the inlet of the NC on drug delivery to the MS is negligible. It was also demonstrated that increasing the flow swirl at the inlet and decreasing the nozzle diameter improves the total particle deposition more than threefold due to the generation of the centrifugal force, which acts on the particles in the nostril and vestibule. The results also suggest that the drug delivery efficiency to the MS can be increased by using a swirling flow with a moderate swirl number of 0.6. It was found that decreasing the nozzle diameter can increase drug delivery to the proximity of the ostium in the middle meatus by more than 45%, which subsequently increases the drug delivery to the MS. The results can help engineers design a nebulizer to improve the efficiency of drug delivery to the maxillary sinuses.
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Affiliation(s)
- Oveis Pourmehran
- School of Mechanical Engineering, The University of Adelaide, North Terrace, Adelaide, SA, 5005, Australia.
| | - Benjamin Cazzolato
- School of Mechanical Engineering, The University of Adelaide, North Terrace, Adelaide, SA, 5005, Australia
| | - Zhao Tian
- School of Mechanical Engineering, The University of Adelaide, North Terrace, Adelaide, SA, 5005, Australia
| | - Maziar Arjomandi
- School of Mechanical Engineering, The University of Adelaide, North Terrace, Adelaide, SA, 5005, Australia
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Anderson N, Clarke S, von Ungern-Sternberg BS. Aerosolized drug delivery in awake and anesthetized children to treat bronchospasm. Paediatr Anaesth 2022; 32:156-166. [PMID: 34862993 DOI: 10.1111/pan.14354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/25/2022]
Abstract
Bronchospasm is a common respiratory adverse event in pediatric anesthesia. First-line treatment commonly includes inhaled salbutamol. This review focuses on the current best practice to deliver aerosolized medications to awake as well as anesthetized pediatric patients and discusses the advantages and disadvantages of various administration techniques. Additionally, we detail the differences between various airway devices used in anesthesia. We highlight the unmet need for innovation of orally inhaled drug products to deliver aerosolized medications during pediatric respiratory critical events such as bronchospasm. It is therefore important that clinicians remain up to date with the best clinical practice for aerosolized drug delivery in order to prevent and efficiently treat pediatric patients experiencing life-threatening respiratory emergencies.
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Affiliation(s)
- Natalie Anderson
- Perioperative Medicine, Telethon Kids Institute, Nedlands, WA, Australia.,School of Population Health, Curtin University, Bentley, WA, Australia
| | - Sarah Clarke
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia
| | - Britta S von Ungern-Sternberg
- Perioperative Medicine, Telethon Kids Institute, Nedlands, WA, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
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Gallagher L, Joyce M, Murphy B, Mac Giolla Eain M, MacLoughlin R. The Impact of Head Model Choice on the In Vitro Evaluation of Aerosol Drug Delivery. Pharmaceutics 2021; 14:pharmaceutics14010024. [PMID: 35056920 PMCID: PMC8777612 DOI: 10.3390/pharmaceutics14010024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
There are variations in the values reported for aerosol drug delivery across in vitro experiments throughout the published literature, and often with the same devices or similar experimental setups. Factors contributing to this variability include, but are not limited to device type, equipment settings, drug type and quantification methods. This study assessed the impact of head model choice on aerosol drug delivery using six different adults and three different paediatric head models in combination with a facemask, mouthpiece, and high-flow nasal cannula. Under controlled test conditions, the quantity of drug collected varied depending on the choice of head model. Head models vary depending on a combination of structural design differences, facial features (size and structure), internal volume measurements and airway geometries and these variations result in the differences in aerosol delivery. Of the widely available head models used in this study, only three were seen to closely predict in vivo aerosol delivery performance in adults compared with published scintigraphy data. Further, this testing identified the limited utility of some head models under certain test conditions, for example, the range reported across head models was aerosol drug delivery of 2.62 ± 2.86% to 37.79 ± 1.55% when used with a facemask. For the first time, this study highlights the impact of head model choice on reported aerosol drug delivery within a laboratory setting and contributes to explaining the differences in values reported within the literature.
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Affiliation(s)
- Lauren Gallagher
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Mary Joyce
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Barry Murphy
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Marc Mac Giolla Eain
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Ronan MacLoughlin
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
- Correspondence:
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17
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Tseng HY, Lin HL, Chiang HS. In Vitro Evaluation of Aerosol Delivery by Hand-Held Mesh Nebulizers in an Adult Spontaneous Breathing Lung Model. J Aerosol Med Pulm Drug Deliv 2021; 35:83-90. [PMID: 34647814 DOI: 10.1089/jamp.2021.0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Drug inhalation is common mode of treatment for chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate the efficiency of aerosol devices in a simulated COPD adult lung model using five commercially available hand-held mesh nebulizers. Materials and Methods: Five nebulizers (PARI VELOX®, Omron NE-U22, Aeroneb® Go, APEX PY001, and Pocket Air®) were tested with a unit dose of 5.0 mg/2.5 mL salbutamol. An in vitro lung model (compliance: 0.06 L/cm H2O, resistance: 20 cm H2O/L/sec) was constructed to simulate parameters (tidal volume of 500 mL, respiratory rate of 15 breaths/min, inspiratory time of 1 second) of an adult patient with COPD. A bacterial filter was attached at the bronchi level for drug collection, referring as inhaled mass. After nebulization, the inhaled mass (%), dose remaining on each component (%), particle size characteristics, and nebulizer performances were analyzed. Particle size characteristics were analyzed using an 8-stage Anderson Cascade Impactor. The salbutamol particles deposited were eluted and analyzed using a spectrophotometer at 276 nm. The inhaled mass (%), dose remaining on each component (%), particle size distribution, and nebulizer performance were statistically analyzed using analysis of variance (ANOVA) with Sheffee post hoc tests. Results: Pocket Air and APEX PY001 showed the greatest inhaled mass and the lowest dose in the mouthpiece connection. The largest and smallest mass median aerodynamic diameters were found with Omron NE-U22 and PARI VELOX, respectively. In addition, the output rate and inhaled aerosol rate (IAR) of PARI VELOX were higher than those of other nebulizers. Conclusions: This study showed that the performance of commercially available mesh nebulizers varied. Aerosol particles deposited on different auxiliary equipment directly influenced the output rate and IAR of the mesh nebulizer. Clinical validation of the drug IAR is necessary to avoid overdose and reduce drug wastage.
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Affiliation(s)
- Hui-Yun Tseng
- Department of Chemistry, and Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City, Taiwan.,Department of Respiratory Therapy, Fu Jen Catholic University, New Taipei City, Taiwan.,Department of Respiratory Therapy, Collage of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Ling Lin
- Department of Respiratory Therapy, Collage of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Han-Sun Chiang
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City, Taiwan
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18
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Ari A, Blain K, Soubra S, Hanania NA. Treating COPD Patients with Inhaled Medications in the Era of COVID-19 and Beyond: Options and Rationales for Patients at Home. Int J Chron Obstruct Pulmon Dis 2021; 16:2687-2695. [PMID: 34611397 PMCID: PMC8487292 DOI: 10.2147/copd.s332021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/13/2021] [Indexed: 01/29/2023] Open
Abstract
COVID-19 has affected millions of patients, caregivers, and clinicians around the world. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads via droplets and close contact from person to person, and there has been an increased concern regarding aerosol drug delivery due to the potential aerosolizing of viral particles. To date, little focus has been given to aerosol drug delivery to patients with COVID-19 treated at home to minimize their hospital utilization. Since most hospitals were stressed with multiple admissions and experienced restricted healthcare resources in the era of COVID-19 pandemic, treating patients with COPD at home became essential to minimize their hospital utilization. However, guidance on how to deliver aerosolized medications safely and effectively to this patient population treated at home is still lacking. In this paper, we provide some strategies and rationales for device and interface selection, delivery technique, and infection control for patients with COPD who are being treated at home in the era of COVID-19 and beyond.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Karen Blain
- Department of Respiratory Therapy, University of North Carolina Wilmington, Wilmington, NC, USA
| | - Said Soubra
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Nicola A Hanania
- Airways Clinical Research Center, Baylor College of Medicine, Houston, TX, USA
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19
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Ari A, Fink JB. Quantifying Delivered Dose with Jet and Mesh Nebulizers during Spontaneous Breathing, Noninvasive Ventilation, and Mechanical Ventilation in a Simulated Pediatric Lung Model with Exhaled Humidity. Pharmaceutics 2021; 13:pharmaceutics13081179. [PMID: 34452139 PMCID: PMC8400423 DOI: 10.3390/pharmaceutics13081179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 11/21/2022] Open
Abstract
Acutely ill children may transition between spontaneous breathing (SB), noninvasive ventilation (NIV), and mechanical ventilation (MV), and commonly receive the same drug dosage with each type of ventilatory support and interface. This study aims to determine the aerosol deposition with jet (JN) and mesh nebulizers (MN) during SB, NIV, and MV using a pediatric lung model. Drug delivery with JN (Mistymax10) and MN (Aerogen Solo) was compared during SB, NIV, and MV using three different lung models set to simulate the same breathing parameters (Vt 250 mL, RR 20 bpm, I:E ratio 1:3). A heated humidifier was placed between the filter and test lung to simulate exhaled humidity (35 ± 2 °C, 100% RH) with all lung models. Albuterol sulfate (2.5 mg/3 mL) was delivered, and the drug deposited on an absolute filter was eluted and analyzed with spectrophotometry. Aerosol delivery with JN was not significantly different during MV, NIV, and SB (p = 0.075), while inhaled dose obtained with MN during MV was greater than NIV and SB (p = 0.001). The delivery efficiency of MN was up to 3-fold more than JN during MV (p = 0.008), NIV (p = 0.005), and SB (p = 0.009). Delivered dose with JN was similar during MV, NIV, and SB, although the delivery efficiency of MN differs with different modes of ventilation.
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Affiliation(s)
- Arzu Ari
- Correspondence: ; Tel.: +1-512-716-2691
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20
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Ari A, Fink JB. Delivered dose with jet and mesh nebulisers during spontaneous breathing, noninvasive ventilation and mechanical ventilation using adult lung models. ERJ Open Res 2021; 7:00027-2021. [PMID: 34262965 PMCID: PMC8273293 DOI: 10.1183/23120541.00027-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/20/2021] [Indexed: 11/05/2022] Open
Abstract
What is the delivered dose with jet and mesh nebulisers during spontaneous breathing (SB), noninvasive ventilation (NIV), and mechanical ventilation (MV) using an adult lung model with exhaled humidity (EH)? The delivery of salbutamol sulfate (2.5 mg per 3 mL) with jet (Mistymax10) and mesh nebulisers (Aerogen Solo) was compared during SB, NIV, and MV using breathing parameters (tidal volume 450 mL, respiratory rate 20 breaths per min, inspiratory:expiratory ratio 1:3) with three lung models simulating exhaled humidity. A manikin was attached to a sinusoidal pump via a filter at the bronchi to simulate an adult with SB. A ventilator (V60) was attached via a facemask to a manikin with a filter at the bronchi connected to a test lung to simulate an adult receiving NIV. A ventilator-dependent adult was simulated through a ventilator (Servo-i) operated with a heated humidifier (Fisher & Paykel) attached to an endotracheal tube (ETT) with a heated-wire circuit. The ETT was inserted into a filter (Respirgard II). A heated humidifier was placed between the filter and test lung to simulate exhaled humidity (35±2°C, 100% relative humidity). Nebulisers were placed at the Y-piece of the inspiratory limb during MV and positioned between the facemask and the leak-port during NIV. A mouthpiece was used during SB. The delivered dose was collected in an absolute filter that was attached to the bronchi of the mannequin during each aerosol treatment and measured with spectrophotometry. Drug delivery during MV was significantly greater than during NIV and SB with a mesh nebuliser (p=0.0001) but not with a jet nebuliser (p=0.384). Delivery efficiency of the mesh nebuliser was greater than the jet nebuliser during MV (p=0.0001), NIV (p=0.0001), and SB (p=0.0001). Aerosol deposition obtained with a mesh nebuliser was greater and differed between MV, NIV, and SB, while deposition was low with a jet nebuliser and similar between the modes of ventilation tested.
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Affiliation(s)
- Arzu Ari
- Dept of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - James B Fink
- Dept of Respiratory Care, Texas State University, Round Rock, TX, USA
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21
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Park HM, Chang KH, Moon SH, Park BJ, Yoo SK, Nam KC. In vitro delivery efficiencies of nebulizers for different breathing patterns. Biomed Eng Online 2021; 20:59. [PMID: 34112170 PMCID: PMC8194228 DOI: 10.1186/s12938-021-00895-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022] Open
Abstract
Background Nebulizers are medical devices that deliver aerosolized medication directly to lungs to treat a variety of respiratory diseases. However, breathing patterns, respiration rates, airway diameters, and amounts of drugs delivered by nebulizers may be respiratory disease dependent. Method In this study, we developed a respiratory simulator consisting of an airway model, an artificial lung, a flow sensor, and an aerosol collecting filter. Various breathing patterns were generated using a linear actuator and an air cylinder. We tested six home nebulizers (jet (2), static (2), and vibrating mesh nebulizers (2)). Nebulizers were evaluated under two conditions, that is, for the duration of nebulization and at a constant output 1.3 mL using four breathing patterns, namely, the breathing pattern specified in ISO 27427:2013, normal adult, asthmatic, and COPD. Results One of the vibrating mesh nebulizers had the highest dose delivery efficiency. The drug delivery efficiencies of nebulizers were found to depend on breathing patterns. Conclusion We suggest a quantitative drug delivery efficiency evaluation method and calculation parameters that include considerations of constant outputs and residual volumes. The study shows output rates and breathing patterns should be considered when the drug delivery efficiencies of nebulizers are evaluated.
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Affiliation(s)
- Hyun Mok Park
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang, South Korea.,Graduate Program of Biomedical Engineering, Yonsei University, Seoul, South Korea
| | - Kyung Hwa Chang
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang, South Korea
| | - Sang-Hyub Moon
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang, South Korea.,Graduate Program of Biomedical Engineering, Yonsei University, Seoul, South Korea
| | - Bong Joo Park
- Department of Electrical & Biological Physics, Kwangwoon University, Seoul, South Korea.,Institute of Biomaterials, Kwangwoon University, Seoul, South Korea
| | - Sun Kook Yoo
- Graduate Program of Biomedical Engineering, Yonsei University, Seoul, South Korea. .,Department of Medical Engineering, Yonsei University College of Medicine, Seoul, South Korea.
| | - Ki Chang Nam
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang, South Korea.
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22
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Fatima N, Kaushik V, Ayoub A. A Narrative Review of a Pulmonary Aerosolized Formulation or a Nasal Drop Using Sera Containing Neutralizing Antibodies Collected from COVID-19-Recovered Patients as a Probable Therapy for COVID-19. IRANIAN JOURNAL OF MEDICAL SCIENCES 2021; 46:151-168. [PMID: 34083848 PMCID: PMC8163704 DOI: 10.30476/ijms.2020.86417.1624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/29/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19) emerged as a new contagion during December 2019, since which time it has triggered a rampant spike in fatality rates worldwide due to insufficient medical treatments and a lack of counteragents and prompted the World Health Organization to declare COVID-19 a public health emergency. It is, therefore, vital to accelerate the screening of new molecules or vaccines to win the battle against this pandemic. Experiences from previous epidemiological data on coronaviruses guide investigators in designing and exploring new compounds for a safe and cost-effective treatment. Several reports on the severe acute respiratory syndrome (SARS) epidemic indicate that severe acute respiratory syndrome coronavirus (SARS-CoV) and the novel COVID-19 use angiotensin-converting enzyme 2 (ACE2) as a receptor for binding to the host cell in the lung epithelia through the spike protein on their virion surface. ACE2 is a mono-carboxypeptidase best known for cleaving major peptides and substrates. Its degree in human airway epithelia positively correlates with coronavirus infection. The treatment approach can be the neutralization of the virus entering lung epithelial cells by using sera containing antibodies collected from COVID-19-recovered patients. Hence, we herein propose a pulmonary aerosolized formulation or a nasal drop using sera, which contain antibodies to prevent, treat, or immunize against COVID-19 infection.
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Affiliation(s)
- Nishat Fatima
- School of Pharmacy, Al-Hawash Private University, Homs, Syria
| | | | - Amjad Ayoub
- School of Pharmacy, Al-Hawash Private University, Homs, Syria
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23
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Ari A. A path to successful patient outcomes through aerosol drug delivery to children: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:593. [PMID: 33987291 PMCID: PMC8105845 DOI: 10.21037/atm-20-1682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/03/2020] [Indexed: 11/06/2022]
Abstract
Although using aerosolized medications is a mainstay of treatment in children with asthma and other respiratory diseases, there are many issues in terms of device and interface selection, delivery technique and dosing, as well as patient and parental education that have not changed for half a century. Also, due to many aerosol devices and interfaces available on the market and the broad range of patient characteristics and requirements, providing effective aerosol therapy to children becomes a challenge. While aerosol delivery devices are equally effective, if they are age-appropriate and used correctly, the majority of aerosol devices require multiple steps to be used efficiently. Unfortunately, many children with pulmonary diseases have problems with the correct delivery technique and do not gain therapeutic benefits from therapy that result in poor disease management and increased healthcare costs. Therefore, the purpose of this paper is to review the current knowledge on aerosol delivery devices used in children and guide clinicians on the optimum device- and interface-selection, delivery technique, and dosing in this patient population. Strategies on how to deliver aerosolized medications in crying and distressed children and how to educate parents on aerosol therapy and promote patient adherence to prescribed medications are also provided. Future directions of aerosol therapy in children should focus on these issues and implement policies and clinical practices that highlight the potential solutions to these problems.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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24
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Sou T, Bergström CAS. Contemporary Formulation Development for Inhaled Pharmaceuticals. J Pharm Sci 2020; 110:66-86. [PMID: 32916138 DOI: 10.1016/j.xphs.2020.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/22/2022]
Abstract
Pulmonary delivery has gained increased interests over the past few decades. For respiratory conditions, targeted drug delivery directly to the site of action can achieve a high local concentration for efficacy with reduced systemic exposure and adverse effects. For systemic conditions, the unique physiology of the lung evolutionarily designed for rapid gaseous exchange presents an entry route for systemic drug delivery. Although the development of inhaled formulations has come a long way over the last few decades, many aspects of it remain to be elucidated. In particular, a reliable and well-understood method for in vitro-in vivo correlations remains to be established. With the rapid and ongoing advancement of technology, there is much potential to better utilise computational methods including different types of modelling and simulation approaches to support inhaled formulation development. This review intends to provide an introduction on some fundamental concepts in pulmonary drug delivery and inhaled formulation development followed by discussions on some challenges and opportunities in the translation of inhaled pharmaceuticals from preclinical studies to clinical development. The review concludes with some recent advancements in modelling and simulation approaches that could play an increasingly important role in modern formulation development of inhaled pharmaceuticals.
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Affiliation(s)
- Tomás Sou
- Drug Delivery, Department of Pharmacy, Uppsala University, Uppsala, Sweden; Pharmacometrics, Department of Pharmacy, Uppsala University, Uppsala, Sweden.
| | - Christel A S Bergström
- Drug Delivery, Department of Pharmacy, Uppsala University, Uppsala, Sweden; The Swedish Drug Delivery Center, Department of Pharmacy, Uppsala University, Uppsala, Sweden
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25
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Al-Shamrani A, Al-Harbi AS, Alhaider SA, Alharbi S, Al-Harbi NS, Alanazi A, Al Ahmadi TS. Approach to childhood asthma in the era of COVID-19: The official statement endorsed by the Saudi Pediatric Pulmonology Association (SPPA). Int J Pediatr Adolesc Med 2020; 7:103-106. [PMID: 32838011 PMCID: PMC7354375 DOI: 10.1016/j.ijpam.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Coronaviruses are a large family of viruses that infect humans, which may result in mild symptoms similar to those of the common cold. COVID-19 is most recent subtype similar or even worse than the two previous pandemic strains which were the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV). The first cases of COVID-19 emerged in December 2019. Since then, the virus causing the disease has infected more than four million people around the globe and led to hundreds of thousands deaths. We think addressing the management of asthma in the era of this pandemic is important for several reasons: high prevalence of asthma in Saudi Arabia, further, majorities were uncontrolled disease. The statement will provide special instructions and answers to common questions of physicians dealing with asthmatic children during this pandemic.
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Affiliation(s)
- Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Alfaisal University, Riyadh, Saudi Arabia
| | - Adel S Al-Harbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Alfaisal University, Riyadh, Saudi Arabia
| | - S A Alhaider
- King Faisal Specialist Hospital and Research Centre (KFSH&RC), Department of Pediatrics, Alfaisal University, Riyadh, Saudi Arabia
| | - Saleh Alharbi
- Department of Pediatrics, Umm Al Qura University, Makkah, Saudi Arabia
| | - Nasser S Al-Harbi
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alnashmi Alanazi
- Security Forces Hospital, Department of Pediatric, Riyadh, Saudi Arabia
| | - Turki S Al Ahmadi
- College of Medicine, Pediatric Department, King Abdulaziz University, Jeddah, Saudi Arabia
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26
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Ari A. Practical strategies for a safe and effective delivery of aerosolized medications to patients with COVID-19. Respir Med 2020; 167:105987. [PMID: 32421541 PMCID: PMC7172670 DOI: 10.1016/j.rmed.2020.105987] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/19/2020] [Indexed: 01/08/2023]
Abstract
The COVID-19, the disease caused by a novel coronavirus and named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread rapidly across the globe. It has caused outbreaks of illness due to person-to-person transmission of the virus mainly via close contacts and droplets produced by an infected person's cough or sneeze. Exhaled droplets from infected patients with COVID-19 can be inhaled into the lungs and leads to respiratory illness such as pneumonia and acute respiratory distress syndrome. Although aerosol therapy is a mainstay procedure used to treat pulmonary diseases at home and healthcare settings, it has a potential for fugitive emissions during therapy due to the generation of aerosols and droplets as a source of respiratory pathogens. Delivering aerosolized medications to patients with COVID-19 can aggravate the spread of the novel coronavirus. This has been a real concern for caregivers and healthcare professionals who are susceptible to unintended inhalation of fugitive emissions during therapy. Due to a scarcity of information in this area of clinical practice, the purpose of this paper is to explain how to deliver aerosolized medications to mild-, sub-intensive, and intensive-care patients with COVID-19 and how to protect staff from exposure to exhaled droplets during aerosol therapy.
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Affiliation(s)
- Arzu Ari
- Texas State University, College of Health Professions, Department of Respiratory Care, 200 Bobcat Way, Willow Hall, Suite# 214, Round Rock, TX, 78665, USA.
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27
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Madney YM, Laz NI, Elberry AA, Rabea H, Abdelrahim ME. The influence of changing interfaces on aerosol delivery within high flow oxygen setting in adults: An in-vitro study. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2019.101365] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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28
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Hu J, Chen X, Li S, Zheng X, Zhang R, Tan W. Comparison of the performance of inhalation nebulizer solution and suspension delivered with active and passive vibrating-mesh device. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2019.101353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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29
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Ari A, Fink JB. Recent advances in aerosol devices for the delivery of inhaled medications. Expert Opin Drug Deliv 2020; 17:133-144. [PMID: 31959028 DOI: 10.1080/17425247.2020.1712356] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Aerosolized medications are commonly prescribed for the treatment of patients with pulmonary diseases, and there has been an increased interest in the development of aerosol delivery devices over the years. Technical innovations have advanced device design, novel features such as breath actuation, dose tracking, portability, and feedback mechanism during treatment that improved the performance of aerosol devices, and effectiveness of inhalation therapy.Areas covered: The purpose of this paper is to review recent advances in aerosol devices for delivery of inhaled medications.Expert opinion: Drug formulations and device designs are rapidly evolving to make more consistent dosing across a broad range of inspiratory efforts, to maximize dose and target specific areas of the diseased lung.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, College of Health Professions, Round Rock, TX, USA
| | - James B Fink
- Department of Respiratory Care, Texas State University, College of Health Professions, Round Rock, TX, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
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30
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Ullmann N, Di Marco A, Columbu F, Negro V, Chiarini Testa MB, Panetta V, Tripodi S, Potapova E, Allegorico A, Matricardi PM, Cutrera R. A Novel, Portable MESH Nebulizer-An Alternative to Metered Dose Inhaler: Efficacy and Usability in Preschool Wheezers. Front Pediatr 2020; 8:598690. [PMID: 33363063 PMCID: PMC7758231 DOI: 10.3389/fped.2020.598690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/10/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction and Objectives: Wheezing episodes are the first causes of doctor's consultation in preschool age. Treatment is usually administered with a metered dose inhaler (MDI) spacer. At variance, many parents and doctors prefer to use a compressor nebulizer, which cannot be easily carried. The study is aimed at testing whether a pocket mesh nebulizer has similar efficacy and acceptability than a standard MDI device. Materials and Methods: The IPAC study was a randomized, controlled, non-inferiority trial (number: 1616/2018, Ospedale Pediatrico Bambino Gesu'-IRCCS). The study had two arms: cases, using MicroAIR U100, and controls, using MDI+spacer device. Both devices were adopted for long-term treatment and for exacerbations. Follow-up was organized with clinical visits and a daily e-diary connected to an application for mobile phone. Results: One hundred patients were enrolled. The frequency of asthmatic symptoms showed a non-inferiority for MicroAIR U100 group vs. MDI. Accordingly, no significant difference was found in the average % of days with cough, wheezing, breathlessness after exercise, days lost at school, and not-programmed visits. Considering only patients with >1 day with symptoms, no significant sdifferences were found in the number of exacerbations nor in the cumulative days with symptoms. The acceptance and usability of both devices have been favorable. However, the MDI+AeroChamber® device showed better acceptability. Conclusions: Our study shows that MicroAIR U-100, a mesh nebulizer, has similar clinical efficacy but lower acceptance and usability than an MDI plus Aerochamber® in delivering therapy in preschool wheezers. Therefore, MicroAIR U-100 might be a valuable second choice, when the delivery of medication with an MDI plus Aerochamber® is not accepted, or wrongly used by the parents.
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Affiliation(s)
- Nicola Ullmann
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics, Research Institute, Bambino Gesù Children Hospital, Rome, Italy
| | - Antonio Di Marco
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics, Research Institute, Bambino Gesù Children Hospital, Rome, Italy
| | - Fabiana Columbu
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics, Research Institute, Bambino Gesù Children Hospital, Rome, Italy
| | - Valentina Negro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics, Research Institute, Bambino Gesù Children Hospital, Rome, Italy
| | - Maria Beatrice Chiarini Testa
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics, Research Institute, Bambino Gesù Children Hospital, Rome, Italy
| | - Valentina Panetta
- L'altrastatistica srl, Consultancy & Training, Biostatistics, Rome, Italy
| | | | - Ekaterina Potapova
- Department of Pediatric Pneumology & Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Annalisa Allegorico
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics, Research Institute, Bambino Gesù Children Hospital, Rome, Italy
| | - Paolo Maria Matricardi
- Department of Pediatric Pneumology & Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics, Research Institute, Bambino Gesù Children Hospital, Rome, Italy
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31
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McCarthy SD, Horgan E, Ali A, Masterson C, Laffey JG, MacLoughlin R, O'Toole D. Nebulized Mesenchymal Stem Cell Derived Conditioned Medium Retains Antibacterial Properties Against Clinical Pathogen Isolates. J Aerosol Med Pulm Drug Deliv 2019; 33:140-152. [PMID: 31730399 DOI: 10.1089/jamp.2019.1542] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: Mesenchymal stem/stromal cells (MSCs) have demonstrated promise in pathogenic acute respiratory distress syndrome models and are advancing to clinical efficacy testing. Besides immunomodulatory effects, MSC derived conditioned medium (CM) has direct antibacterial effects, possibly through LL-37 and related secreted peptide activity. We investigated MSC-CM compatibility with vibrating mesh technology, allowing direct delivery to the infected lung. Methods: MSC-CM from bone marrow (BM) and umbilical cord (UC) MSCs were passed through the commercially available Aerogen Solo nebulizer. Known colony forming units of Escherichia coli, Staphylococcus aureus, and multidrug resistant Klebsiella pneumoniae clinical isolates were added to MSC-CM in an orbital shaker and antibacterial capacity assessed through OD600 spectrophotometry. To exclude the possible effects of medium depletion on bacteria proliferation, MSC-CM was concentrated with a 3000 Da cutoff filter, diluted with fresh media, and retested against inoculum. Enzyme-linked immunosorbent assay was used to quantify levels of antimicrobial peptides (AMPs) and IL-8 present at pre- and postnebulization. Results: Both BM and UC MSC-CM inhibited proliferation of all pathogens, and this ability was retained after nebulization. Concentrating and reconstituting CM did not affect antibacterial properties. Interestingly, LL-37 protein did not appear to survive nebulization, although other secreted AMPs and an unrelated protein, IL-8, were largely intact. Conclusion: MSC-CM is a potent antimicrobial agent and is compatible with vibrating mesh nebulization delivery. The mechanism is through a secreted factor that is over 3000 Da in size, although it does not appear to rely solely on previously identified peptides such as LL-37, hepcidin, or lipocalin-2.
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Affiliation(s)
- Sean D McCarthy
- Anaesthesia, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Elizabeth Horgan
- Microbiology, School of Natural Sciences, National University of Ireland Galway, Galway, Ireland
| | - Areeba Ali
- Microbiology, School of Natural Sciences, National University of Ireland Galway, Galway, Ireland
| | - Claire Masterson
- Anaesthesia, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - John G Laffey
- Anaesthesia, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Ronan MacLoughlin
- Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Aerogen Ltd., Dangan, Galway.,School of Pharmacy, Royal College of Surgeons, Dublin, Ireland.,School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
| | - Daniel O'Toole
- Anaesthesia, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
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Chung S, Baumlin N, Dennis JS, Moore R, Salathe SF, Whitney PL, Sabater J, Abraham WM, Kim MD, Salathe M. Electronic Cigarette Vapor with Nicotine Causes Airway Mucociliary Dysfunction Preferentially via TRPA1 Receptors. Am J Respir Crit Care Med 2019; 200:1134-1145. [PMID: 31170808 PMCID: PMC6888648 DOI: 10.1164/rccm.201811-2087oc] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 06/05/2019] [Indexed: 12/11/2022] Open
Abstract
Rationale: Electronic cigarette (e-cig) use has been widely adopted under the perception of safety. However, possibly adverse effects of e-cig vapor in never-smokers are not well understood.Objectives: To test the effects of nicotine-containing e-cig vapors on airway mucociliary function in differentiated human bronchial epithelial cells isolated from never-smokers and in the airways of a novel, ovine large animal model.Methods: Mucociliary parameters were measured in human bronchial epithelial cells and in sheep. Systemic nicotine delivery to sheep was quantified using plasma cotinine levels, measured by ELISA.Measurements and Main Results:In vitro, exposure to e-cig vapor reduced airway surface liquid hydration and increased mucus viscosity of human bronchial epithelial cells in a nicotine-dependent manner. Acute nicotine exposure increased intracellular calcium levels, an effect primarily dependent on TRPA1 (transient receptor potential ankyrin 1). TRPA1 inhibition with A967079 restored nicotine-mediated impairment of mucociliary parameters including mucus transport in vitro. Sheep tracheal mucus velocity, an in vivo measure of mucociliary clearance, was also reduced by e-cig vapor. Nebulized e-cig liquid containing nicotine also reduced tracheal mucus velocity in a dose-dependent manner and elevated plasma cotinine levels. Importantly, nebulized A967079 reversed the effects of e-cig liquid on sheep tracheal mucus velocity.Conclusions: Our findings show that inhalation of e-cig vapor causes airway mucociliary dysfunction in vitro and in vivo. Furthermore, they suggest that the main nicotine effect on mucociliary function is mediated by TRPA1 and not nicotinic acetylcholine receptors.
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Affiliation(s)
- Samuel Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, Florida; and
| | - Nathalie Baumlin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, Florida; and
| | - John S. Dennis
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, Florida; and
| | - Robert Moore
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, Florida; and
| | - Sebastian F. Salathe
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, Florida; and
| | - Phillip L. Whitney
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, Florida; and
| | - Juan Sabater
- Department of Research, Mount Sinai Medical Center, Miami Beach, Florida
| | - William M. Abraham
- Department of Research, Mount Sinai Medical Center, Miami Beach, Florida
| | - Michael D. Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, Florida; and
| | - Matthias Salathe
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, Florida; and
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Ari A. Effect of nebulizer type, delivery interface, and flow rate on aerosol drug delivery to spontaneously breathing pediatric and infant lung models. Pediatr Pulmonol 2019; 54:1735-1741. [PMID: 31313534 DOI: 10.1002/ppul.24449] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/08/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Different types of nebulizers, interfaces, and flow rates are used to deliver aerosolized medications to children. The purpose of this study was to determine the effect of nebulizer type, delivery interface, and flow rate on aerosol drug delivery to spontaneously breathing pediatric and infant lung models. METHODOLOGY A teaching mannequin was attached to a sinusoidal pump via a collecting filter at the bronchi to simulate a spontaneously breathing child (Vt: 250 mL, RR: 20 bpm and Ti: 1 second) and infant (Vt = 100 mL, RR = 30 bpm, Ti: 0.7 seconds). Albuterol sulfate was nebulized with jet (Misty Max 10; Cardinal Health) and mesh (Aerogen Solo; Aerogen) nebulizers using a low-flow nasal cannula (LFNC; Hudson), a high-flow nasal cannula (HFNC; Fisher & Paykel), face mask (FM; Hudson), and mouthpiece (MP; Cardinal Health). While all interfaces were used in the pediatric study, only LFNC, HFNC, and FM were tested in the infant study. The mesh nebulizer was tested at 2, 4, and 6 L/min with LFNC, 4 and 6 L/min with HFNC, and 6 L/min with FM and MP. The jet nebulizer was operated at 6 and 8 L/min with FM and 6 L/min with LFNC, HFNC, and MP (n = 5). The drug was eluted from the filter and analyzed by spectrophotometry. Factorial analysis of variance and post hoc comparisons were used for data analysis. P < .05 was considered statistically significant. RESULTS Delivery efficiency of mesh nebulizers is two to fourfold more than jet nebulizers used with HFNC, FM, and MP. No statistical difference was found between jet and mesh nebulizers used with LFNC in infants (P = .643) and pediatrics (P = .255). Aerosol delivery with MP was the best compared to other interfaces used in pediatrics (P < .05). As the second-best interface in aerosol drug delivery, the delivery efficiency of FM was greater than HFNC (P = .0001) and LFNC (P = .0001). Increasing flow rate with LFNC and HFNC decreased aerosol delivery with the mesh nebulizer in both infants and pediatrics. CONCLUSION The type of nebulizer, delivery interface, and flow rate used in the treatment of children affect aerosol drug delivery.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, College of Health Professions, Texas State University, Round Rock, Texas
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Adorni G, Seifert G, Buttini F, Colombo G, Stecanella LA, Krämer I, Rossi A. Aerosolization Performance of Jet Nebulizers and Biopharmaceutical Aspects. Pharmaceutics 2019; 11:pharmaceutics11080406. [PMID: 31405254 PMCID: PMC6723557 DOI: 10.3390/pharmaceutics11080406] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 01/01/2023] Open
Abstract
In this work, 13 jet nebulizers, some of which in different configurations, were investigated in order to identify the biopharmaceutical constraints related to the quality attributes of the medicinal products, which affect their safety, efficiency, compliance, and effectiveness. The aerosolization parameters, including the aerosol output, aerosol output rate, mass median aerodynamic diameter, and fine particle fraction, were determined according to the European Standard EN 13544-1, using sodium fluoride as a reference formulation. A comparison between the aerosol output nebulization time and the fine particle fraction displayed a correlation between the aerosol quality and the nebulization rate. Indeed, the quality of the nebulization significantly increased when the rate of aerosol emission was reduced. Moreover, the performance of the nebulizers was analyzed in terms of respirable delivered dose and respirable dose delivery rate, which characterize nebulization as the rate and amount of respirable product that could be deposited into the lungs. Depending on which of these two latter parameters was used, the nebulizers showed different performances. The differences, in terms of the rate and amount of delivered aerosol, could provide relevant information for the appropriate choice of nebulizer as a function of drug product, therapy, and patient characteristics.
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Affiliation(s)
- Greta Adorni
- Food and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Gerrit Seifert
- Apotheke, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Francesca Buttini
- Food and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
- Interdepartmental Center for Innovation in Health Products, BIOPHARMANET TEC, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Gaia Colombo
- Department of Life Sciences and Biotechnology, University of Ferrara, Via Fossato di Mortara 17/19, 44121 Ferrara, Italy
| | - Luciano A Stecanella
- Food and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Irene Krämer
- Apotheke, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Alessandra Rossi
- Food and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy.
- Interdepartmental Center for Innovation in Health Products, BIOPHARMANET TEC, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy.
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Longest W, Spence B, Hindle M. Devices for Improved Delivery of Nebulized Pharmaceutical Aerosols to the Lungs. J Aerosol Med Pulm Drug Deliv 2019; 32:317-339. [PMID: 31287369 DOI: 10.1089/jamp.2018.1508] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Nebulizers have a number of advantages for the delivery of inhaled pharmaceutical aerosols, including the use of aqueous formulations and the ability to deliver process-sensitive proteins, peptides, and biological medications. A frequent disadvantage of nebulized aerosols is poor lung delivery efficiency, which wastes valuable medications, increases delivery times, and may increase side effects of the medication. A focus of previous development efforts and previous nebulizer reviews, has been an improvement of the underlying nebulization technology controlling the breakup of a liquid into droplets. However, for a given nebulization technology, a wide range of secondary devices and strategies can be implemented to significantly improve lung delivery efficiency of the aerosol. This review focuses on secondary devices and technologies that can be implemented to improve the lung delivery efficiency of nebulized aerosols and potentially target the region of drug delivery within the lungs. These secondary devices may (1) modify the aerosol size distribution, (2) synchronize aerosol delivery with inhalation, (3) reduce system depositional losses at connection points, (4) improve the patient interface, or (5) guide patient inhalation. The development of these devices and technologies is also discussed, which often includes the use of computational fluid dynamic simulations, three-dimensional printing and rapid prototype device and airway model construction, realistic in vitro experiments, and in vivo analysis. Of the devices reviewed, the implementation of streamlined components may be the most direct and lowest cost approach to enhance aerosol delivery efficiency within nonambulatory nebulizer systems. For applications involving high-dose medications or precise dose administration, the inclusion of active devices to control aerosol size, guide inhalation, and synchronize delivery with inhalation hold considerable promise.
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Affiliation(s)
- Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia.,Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia
| | - Benjamin Spence
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia
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Chang KH, Moon SH, Oh JY, Yoon YS, Gu N, Lim CY, Park BJ, Nam KC. Comparison of Salbutamol Delivery Efficiency for Jet versus Mesh Nebulizer Using Mice. Pharmaceutics 2019; 11:pharmaceutics11040192. [PMID: 31010218 PMCID: PMC6523426 DOI: 10.3390/pharmaceutics11040192] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/11/2019] [Accepted: 04/17/2019] [Indexed: 11/16/2022] Open
Abstract
Recent reports using a breathing simulator system have suggested that mesh nebulizers provide more effective medication delivery than jet nebulizers. In this study, the performances of jet and mesh nebulizers were evaluated by comparing their aerosol drug delivery efficiencies in mice. We compared four home nebulizers: two jet nebulizers (PARI BOY SX with red and blue nozzles), a static mesh nebulizer (NE-U22), and a vibrating mesh nebulizer (NE-SM1). After mice were exposed to salbutamol aerosol, the levels of salbutamol in serum and lung were estimated by ELISA. The residual volume of salbutamol was the largest at 34.6% in PARI BOY SX, while the values for NE-U22 and NE-SM1 mesh nebulizers were each less than 1%. The salbutamol delivery efficiencies of NE-U22 and NE-SM1 were higher than that of PARI BOY SX, as the total delivered amounts of lung and serum were 39.9% and 141.7% as compared to PARI BOY SX, respectively. The delivery efficiency of the mesh nebulizer was better than that of the jet nebulizer. Although the jet nebulizer can generate smaller aerosol particles than the mesh nebulizer used in this study, the output rate of the jet nebulizer is low, resulting in lower salbutamol delivery efficiency. Therefore, clinical validation of the drug delivery efficiency according to nebulizer type is necessary to avoid overdose and reduced drug wastage.
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Affiliation(s)
- Kyung Hwa Chang
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Sang-Hyub Moon
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Jin Young Oh
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Young-Soon Yoon
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Namyi Gu
- Department of Clinical Pharmacology and Therapeutics, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Chi-Yeon Lim
- Department of Biostatistics, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea.
| | - Bong Joo Park
- Department of Electrical Biological Physics and Institute of Biomaterials, Kwangwoon University, Seoul 01897, Korea.
| | - Ki Chang Nam
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea.
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Bennett G, Joyce M, Fernández EF, MacLoughlin R. Comparison of aerosol delivery across combinations of drug delivery interfaces with and without concurrent high-flow nasal therapy. Intensive Care Med Exp 2019; 7:20. [PMID: 30945044 PMCID: PMC6447636 DOI: 10.1186/s40635-019-0245-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current clinical practice during high-flow nasal therapy (HFNT) involves utilization of a nasal cannula to provide humidification, with a facemask placed over the cannula to deliver aerosol. Few studies have compared aerosol delivery across various delivery interfaces during HFNT. The objective of this study was to address this gap in the literature and evaluate aerosol delivery using two nebulizer types across different drug delivery interfaces, nasal cannula, facemask, and mouthpiece, during simulated adult HFNT. METHODS A facemask or mouthpiece and/or a nasal cannula were positioned on an anatomically correct adult head model. The head model was connected to a breathing simulator via a collection filter. Both healthy breathing pattern and distressed breathing patterns were utilized. Aerosol dose was determined by quantifying the mass of drug captured on a filter positioned distal to the trachea. RESULTS During simulated healthy breathing, a significantly greater aerosol dose was observed when the vibrating mesh nebulizer (VMN) was integrated with HFNT alone, supplying aerosol and humidified air simultaneously (2.88 ± 0.15%), as opposed to using with a facemask (0.33 ± 0.07%, 1.62 ± 0.46%, and 1.07 ± 0.25% at 0 L/min (LPM), 2LPM, and 6LPM, respectively) or mouthpiece (0.56 ± 0.13%, 2.16 ± 0.06%, and 1.82 ± 0.41% at 0LPM, 2LPM, and 6LPM). In addition, aerosol delivery was also significantly greater when the VMN was integrated into simulated HFNT (2.88 ± 0.15%), in comparison with using the jet nebulizer (JN) with a facemask (0.82 ± 0.16%) or a mouthpiece (0.86 ± 0.11%). During simulated distressed breathing, a significantly greater aerosol dose was observed when the VMN was integrated with HFNT, supplying aerosol and humidified air simultaneously (6.81 ± 0.45%), compared with using a facemask (0.86 ± 0.04%, 2.96 ± 0.26%, and 4.23 ± 0.93% at 0LPM, 2LPM, and 6LPM) or mouthpiece (0.73 ± 0.37%, 0.97 ± 0.20%, and 3.11 ± 0.53% at 0LPM, 2LPM, and 6LPM, respectively). Aerosol delivery was also greater when the VMN was integrated into HFNT (6.81 ± 0.45%), in comparison with using the JN with a facemask (5.72 ± 0.71%) or a mouthpiece (0.69 ± 0.53%). Furthermore, across all drug delivery interfaces, and in line with previous reports, aerosol delivery was greater during simulated distressed breathing, in comparison with simulated healthy adult breathing. CONCLUSIONS This article will be of considerable benefit in enhancing the understanding of aerosol delivery during HFNT, an increasingly adopted therapeutic intervention by healthcare professionals.
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Affiliation(s)
- Gavin Bennett
- Aerogen Limited, IDA Business Park, Dangan, Galway, Ireland
| | - Mary Joyce
- Aerogen Limited, IDA Business Park, Dangan, Galway, Ireland
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Abstract
Asthma is the most common chronic airway disease in children, with more than half the reported cases of persistent asthma starting in children below the age of 3 years. Asthma diagnosis in preschool children has proven to be challenging due to the heterogeneity of the disease, the continuing development of the immune system in such a young population, and lack of diagnostic options such as lung function measurement. Early diagnosis and treatment of asthmatic symptoms will improve patients' quality of life and help reduce disease morbidity. However, validated treatment options are scarce due to paucity of data and lack of conclusive studies in such a young patient population. Adjusting study design and endpoints to capture more reliable data with minimal risk of harm to patients is necessary. This thematic series review outlines the current position on preschool asthma, consolidates the current understanding of risk factors and diagnostic hurdles, and emphasizes the importance of early detection and management to help improve patients' quality of life, both present and future. Particular focus was given to anticholinergics and their emerging role in the treatment and control of asthma in pediatric patients.
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Affiliation(s)
- Christian Vogelberg
- Department of Pediatric Pulmonology and Allergy, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany,
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Bechtel K, Bhatnagar A, Auerbach M. Simulation-based research to improve infant health outcomes: Using the infant simulator to prevent infant shaking. Infant Behav Dev 2018; 56:101263. [PMID: 29903429 DOI: 10.1016/j.infbeh.2018.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 10/14/2022]
Abstract
Simulation is a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions. We will first provide an introduction to simulation in healthcare and describe the two types of simulation-based research (SBR) in the pediatric population. We will then provide an overview of the use of SBR to improve health outcomes for infants in health care settings and to improve parent-child interactions using the infant simulator. Finally, we will discuss previous and future research using simulation to reduce morbidity and mortality from abusive head trauma, the most common cause of traumatic death in infancy.
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Affiliation(s)
- Kirsten Bechtel
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511, United States.
| | - Ambika Bhatnagar
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511, United States
| | - Marc Auerbach
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511, United States
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Comparison of the Clinical Efficacy of Salbutamol with Jet and Mesh Nebulizers in Asthmatic Children. Pulm Med 2018; 2018:1648652. [PMID: 29732223 PMCID: PMC5872591 DOI: 10.1155/2018/1648652] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 12/02/2017] [Accepted: 12/26/2017] [Indexed: 11/17/2022] Open
Abstract
Background Ultrasonic, jet, and mesh nebulizers have all been used in the treatment for asthma. Mesh nebulizers reportedly offer the best inhalation efficiency. Methods This study aimed to clarify the utility of the mesh nebulizer, compared to jet nebulizers, in the treatment of pediatric asthma patients. Participants included 88 children <6 years old who were receiving treatment for asthma at Murayama Pediatric Clinic. Heart rate, peripheral oxygen saturation in arterial blood, and Mitsui symptom scores were compared before and after treatment with a mesh nebulizer (n = 43) or jet nebulizer (n = 45) using a salbutamol inhalation solution (0.2 ml for children ≧ 2 years old, n = 51; 0.1 ml for children < 2 years old, n = 37). Results Other than required inhalation time, clinical findings did not differ between mesh and jet groups. In both groups, heart rate increased significantly in patients treated with 0.2 ml (1000 microg) of salbutamol. Conclusions and Clinical Relevance The required inhalation time of the mesh nebulizer was superior to the jet nebulizer. Children ≧ 2 years with mild asthma attacks experienced a significantly increased heart rate in both groups. The dose of salbutamol (0.2 ml for ≧2 years) used for asthma attacks should be reconsidered in mild asthma.
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Morikawa Y, Miura M, Furuhata MY, Morino S, Omori T, Otsuka M, Chiga M, Obonai T, Hataya H, Kaneko T, Ishikura K, Honda M, Hasegawa Y. Nebulized hypertonic saline in infants hospitalized with moderately severe bronchiolitis due to RSV infection: A multicenter randomized controlled trial. Pediatr Pulmonol 2018; 53:358-365. [PMID: 29327810 DOI: 10.1002/ppul.23945] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 12/13/2017] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The efficacy of nebulized hypertonic saline (HS) therapy for shortening hospital length of stay (LOS) or improving bronchiolitic symptoms remains controversial. Most studies enrolled small numbers of subjects and did not consider the role of respiratory syncytial virus (RSV), the most common cause of acute bronchiolitis. Our aim was to evaluate the efficacy and safety of nebulized HS therapy for acute bronchiolitis due to RSV in moderately ill hospitalized infants. MATERIALS AND METHODS This was an open-label, multicenter, randomized controlled trial comparing a nebulized HS treatment group with a normal saline (NS) group. The subjects, 128 infants with bronchiolitis due to RSV, were admitted to five hospitals in Tokyo, Japan. Three-percent HS or NS was administered via bronchodilator four times daily post-admission. The primary outcome was LOS, defined as the time until the patients fulfilled the discharge criteria, namely, absence of fever, no need for supplemental oxygen, and adequate feeding. Survival analysis was conducted in accordance with the intention-to-treat principle. RESULTS The baseline characteristics were similar between the two groups. There was no significant overall difference in LOS between the groups (4.81 ± 2.14 days in HS vs 4.61 ± 2.18 days in NS; P = 0.60). Survival analysis by log-rank test also showed no significance (P = 0.62). Multivariate adjustment did not significantly alter the results. The treatment was well-tolerated, with no adverse effects attributable to the use of HS. CONCLUSIONS Nebulized HS therapy did not significantly reduce LOS among infants with bronchiolitis due to RSV.
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Affiliation(s)
- Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masaru Miura
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Pediatric Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | | | - Saeko Morino
- Department of Infectious Diseases, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tae Omori
- Department of Pediatrics, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masahiro Otsuka
- Department of Pediatrics, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Michiko Chiga
- Department of Pediatrics, Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan
| | - Toshimasa Obonai
- Department of Pediatrics, Tokyo Metropolitan Health and Medical Treatment Corporation, Tama-Hokubu Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tetsuji Kaneko
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kenji Ishikura
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yukihiro Hasegawa
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Ehrmann S. Vibrating Mesh Nebulisers – Can Greater Drug Delivery to the Airways and Lungs Improve Respiratory Outcomes? ACTA ACUST UNITED AC 2018. [DOI: 10.17925/erpd.2018.4.1.33] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Aerosols are an increasingly important mode of delivery of drugs, particularly bronchodilators, for the treatment of respiratory diseases, notably asthma and chronic obstructive pulmonary disease. The most common type of nebuliser is the jet nebuliser (JN); they have been in use for more than a century but these devices can be cumbersome to use and may sometimes deliver insufficient amounts of drug. A more recent development in aerosol therapy is the vibrating mesh nebuliser (VMN) which is very user friendly and is more efficient than the JNs due to an extremely low residual volume. Scintigraphy images from studies of volunteer subjects using radio-labelled aerosol treatment show that VMN-generated aerosols deliver more drug to patients in a shorter period of time than JN-generated aerosols. Various bench, animal model and small clinical studies have shown that VMNs are more efficient than JNs in drug delivery, potentially improving clinical outcomes. These studies have included various breathing circuits used in mechanical ventilation (MV), non-invasive ventilation, high-flow nasal cannula systems and devices for spontaneously breathing patients. The efficiency of drug delivery was affected by factors including the position of the nebuliser in the circuit and humidity. Some studies have shown potential substantial savings by hospitals in the cost of MV treatments after switching from metered dose inhalers to VMNs. VMNs have also been shown to be effective for the administration of inhaled antibiotics, corticosteroids and other drugs. Larger studies of the effects of VMNs on patient outcomes are needed but they are likely to be an increasingly important means of administering therapies to a burgeoning population with respiratory disease.
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Dong J, Shang Y, Inthavong K, Chan HK, Tu J. Numerical Comparison of Nasal Aerosol Administration Systems for Efficient Nose-to-Brain Drug Delivery. Pharm Res 2017; 35:5. [PMID: 29288465 DOI: 10.1007/s11095-017-2280-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/12/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE Nose-to-brain drug administration along the olfactory and trigeminal nerve pathways offers an alternative route for the treatment of central nervous system (CNS) disorders. The characterization of particle deposition remains difficult to achieve in experiments. Alternative numerical approach is applied to identify suitable aerosol particle size with maximized inhaled doses. METHODS This study numerically compared the drug delivery efficiency in a realistic human nasal cavity between two aerosol drug administration systems targeting the olfactory region: the aerosol mask system and the breath-powered bi-directional system. Steady inhalation and exhalation flow rates were applied to both delivery systems. The discrete phase particle tracking method was employed to capture the aerosol drug transport and deposition behaviours in the nasal cavity. Both overall and regional deposition characteristics were analysed in detail. RESULTS The results demonstrated the breath-powered drug delivery approach can produce superior olfactory deposition with peaking olfactory deposition fractions for diffusive 1 nm particles and inertial 10 μm. While for particles in the range of 10 nm to 2 μm, no significant olfactory deposition can be found, indicating the therapeutic agents should avoid this size range when targeting the olfactory deposition. CONCLUSIONS The breath-powered bi-directional aerosol delivery approach shows better drug delivery performance globally and locally, and improved drug administration doses can be achieved in targeted olfactory region.
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Affiliation(s)
- Jingliang Dong
- School of Engineering, RMIT University, PO Box 71, Bundoora, VIC, 3083, Australia
| | - Yidan Shang
- School of Engineering, RMIT University, PO Box 71, Bundoora, VIC, 3083, Australia
| | - Kiao Inthavong
- School of Engineering, RMIT University, PO Box 71, Bundoora, VIC, 3083, Australia
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Jiyuan Tu
- School of Engineering, RMIT University, PO Box 71, Bundoora, VIC, 3083, Australia. .,Key Laboratory of Ministry of Education for Advanced Reactor Engineering and Safety, Institute of Nuclear and New Energy Technology, Tsinghua University, PO Box 1021, Beijing, 100086, China.
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44
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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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45
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Al-Subu AM, Hagen S, Eldridge M, Boriosi J. Aerosol therapy through high flow nasal cannula in pediatric patients. Expert Rev Respir Med 2017; 11:945-953. [PMID: 28994337 DOI: 10.1080/17476348.2017.1391095] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION High flow nasal cannula (HFNC) is increasingly used in pediatric patients suffering from respiratory failure. In some disease processes, patients may also benefit from aerosol therapy. Therefore, the use of HFNC to deliver aerosolized medications is a convenient and attractive option. Areas covered: This review aims to appraise available evidence concerning the efficiency of aerosol nebulized therapy delivery using HFNC in pediatric patients. Expert commentary: Delivery of aerosol particles is a very complex process and depends on the use of oxygen vs. heliox, nebulizer type and position within the HFNC circuit, patient's breathing effort and pattern, and more importantly cannula size and flow rates. Current in vitro evidence suggests the amount of aerosol delivery is likely to be very low at high flows. Clinical studies are limited in pediatric patients and given the limited clinical data, it is not possible to make recommendations for or against aerosol delivery through HFNC for pediatric patients.
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Affiliation(s)
- Awni M Al-Subu
- a Division of Pediatric Critical Care Medicine , University of Wisconsin-Madison , Madison , WI , USA
| | - Scott Hagen
- a Division of Pediatric Critical Care Medicine , University of Wisconsin-Madison , Madison , WI , USA
| | - Marlowe Eldridge
- a Division of Pediatric Critical Care Medicine , University of Wisconsin-Madison , Madison , WI , USA
| | - Juan Boriosi
- a Division of Pediatric Critical Care Medicine , University of Wisconsin-Madison , Madison , WI , USA
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46
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Trend S, von Ungern-Sternberg BS, Devadason SG, Schultz A, Everard ML. Current options in aerosolised drug therapy for children receiving respiratory support. Anaesthesia 2017; 72:1388-1397. [PMID: 28872662 DOI: 10.1111/anae.14011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2017] [Indexed: 11/30/2022]
Abstract
Inhalation of aerosolised medications are the mainstay of treatment for a number of chronic lung diseases and have several advantages over systemically-administered medications. These include more rapid onset of action for drugs such as β-adrenergic agonists when compared with oral medication, high luminal doses for inhaled antibiotics when used to treat endobronchial infection, and an improved therapeutic index compared with systemic delivery for these and other classes of drugs such as corticosteroids. The use of aerosolised drugs to treat patients whose tracheas are intubated is less well established, in part because systemic delivery via the intravenous route can be a simpler alternative for many drugs. Consequently, research in this area is largely limited to a number of in vitro studies and very few clinical trials. Unfortunately, a lack of focus in this area has resulted in a number of practices which at best are ineffective, and at worst dangerous for the patient. Although there have been some attempts to re-invigorate research in order to improve delivery systems, current devices are, to a great extent, based on long-standing technology developed more than 50 years ago. In this review, we explore current knowledge and provide guidance as to when and how the inhaled route may be of value when treating patients whose tracheas are intubated, and we set out the challenges facing those attempting to advance the topic. We conclude by reviewing current areas of interest that may lead to more effective and widespread use of aerosols in the treatment of intubated patients.
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Affiliation(s)
- S Trend
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.,Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - B S von Ungern-Sternberg
- School of Medicine and Pharmacology, Perth, Australia.,Department of Anaesthesia and Pain Management, Perth, Australia
| | - S G Devadason
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - A Schultz
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.,Telethon Kids Institute, University of Western Australia, Perth, Australia.,Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Australia
| | - M L Everard
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.,Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Australia
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Harb HS, Elberry AA, Rabea H, Fathy M, Abdelrahim ME. Is Combihaler usable for aerosol delivery in single limb non-invasive mechanical ventilation? J Drug Deliv Sci Technol 2017. [DOI: 10.1016/j.jddst.2017.05.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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48
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Dugernier J, Hesse M, Jumetz T, Bialais E, Roeseler J, Depoortere V, Michotte JB, Wittebole X, Ehrmann S, Laterre PF, Jamar F, Reychler G. Aerosol Delivery with Two Nebulizers Through High-Flow Nasal Cannula: A Randomized Cross-Over Single-Photon Emission Computed Tomography-Computed Tomography Study. J Aerosol Med Pulm Drug Deliv 2017; 30:349-358. [PMID: 28463044 DOI: 10.1089/jamp.2017.1366] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND High-flow nasal cannula use is developing in ICUs. The aim of this study was to compare aerosol efficiency by using two nebulizers through a high-flow nasal cannula: the most commonly used jet nebulizer (JN) and a more efficient vibrating-mesh nebulizer (VN). METHODS Aerosol delivery of diethylenetriaminepentaacetic acid labeled with technetium-99m (4 mCi/4 mL) to the lungs by using a VN (Aerogen Solo®; Aerogen Ltd., Galway, Ireland) and a constant-output JN (Opti-Mist Plus Nebulizer®; ConvaTec, Bridgewater, NJ) through a high-flow nasal cannula (Optiflow®; Fisher & Paykel, New Zealand) was compared in six healthy subjects. Flow rate was set at 30 L/min through the heated humidified circuit. Pulmonary and extrapulmonary deposition was measured by single-photon emission computed tomography combined with a low-dose computed tomographic scan and by planar scintigraphy. RESULTS Lung deposition was only 3.6 (2.1-4.4) and 1 (0.7-2)% of the nominal dose with the VN and the JN, respectively (p < 0.05). The JN showed higher retained doses than the VN. However, both nebulizers were associated with substantial deposition in the single limb circuit, the humidification chamber, and the nasal cannula [58.2 (51.6-61.6)% of the nominal dose with the VN versus 19.2 (15.8-22.9)% of the nominal dose with the JN, p < 0.05] and in the upper respiratory tract [17.6 (13.4-27.9)% of the nominal dose with the VN and 8.6 (6.0-11.0)% of the nominal dose with the JN, p < 0.05], especially in the nasal cavity. CONCLUSIONS In the specific conditions of the study, pulmonary drug delivery through the high-flow nasal cannula is about 1%-4% of the initial amount of drugs placed in the nebulizer, despite the higher efficiency of the VN as compared with the JN.
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Affiliation(s)
- Jonathan Dugernier
- 1 Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL and Dermatologie, Cliniques Universitaires Saint-Luc , Brussels, Belgium .,2 Soins Intensifs, Cliniques Universitaires Saint-Luc , Brussels, Belgium .,3 Médecine Physique, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Michel Hesse
- 4 Médecine Nucléaire, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | | | - Emilie Bialais
- 1 Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL and Dermatologie, Cliniques Universitaires Saint-Luc , Brussels, Belgium .,2 Soins Intensifs, Cliniques Universitaires Saint-Luc , Brussels, Belgium .,3 Médecine Physique, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Jean Roeseler
- 2 Soins Intensifs, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Virginie Depoortere
- 4 Médecine Nucléaire, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Jean-Bernard Michotte
- 5 Haute Ecole de Santé Vaud, Filière Physiothérapie, University of Applied Sciences and Arts Western Switzerland , Lausanne, Switzerland
| | - Xavier Wittebole
- 2 Soins Intensifs, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Stephan Ehrmann
- 6 Université François Rabelais , Tours, France .,7 INSERM, Centre d'étude des Pathologies Respiratoires , Tours, France .,8 CHRU de Tours, Réanimation Polyvalente , Tours, France
| | | | - François Jamar
- 4 Médecine Nucléaire, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Gregory Reychler
- 1 Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL and Dermatologie, Cliniques Universitaires Saint-Luc , Brussels, Belgium .,3 Médecine Physique, Cliniques Universitaires Saint-Luc , Brussels, Belgium .,9 Pneumologie, Cliniques Universitaires Saint-Luc , Brussels, Belgium
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49
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Ari A, Fink JB. Inhalation therapy in patients with tracheostomy: a guide to clinicians. Expert Rev Respir Med 2017; 11:201-208. [PMID: 28228052 DOI: 10.1080/17476348.2017.1289843] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Inhalation therapy has become a popular procedure for the treatment of patients with tracheostomy. However, clinicians are faced with many challenges during inhalation therapy because of the many factors affecting aerosol therapy to this patient population, and the lack of literature providing guidance in this area of research. Areas covered: The purpose of this paper is to describe the factors affecting aerosol drug delivery to patients with tracheostomy and to explain how to optimize inhalation therapy through device selection, interface selection and delivery technique in this patient population. Expert commentary: Many factors affect inhalation therapy in this patient population and without understanding the impact of these factors on aerosol drug delivery, clinicians will not be able to provide the treatment properly and patients may not benefit from prescribed medications. In the next 5 years, aerosol medicine will continue to experience tremendous growth with new devices and drug/device combinations. However, these advances will have minimal impact on inhalation therapy in patients with tracheostomy unless we provide guidance and training to clinicians on optimizing aerosol drug delivery to this patient population.
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Affiliation(s)
- Arzu Ari
- a Department of Respiratory Therapy , Georgia State University , Atlanta , GA , USA
| | - James B Fink
- a Department of Respiratory Therapy , Georgia State University , Atlanta , GA , USA
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50
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Sutherasan Y, Ball L, Raimondo P, Caratto V, Sanguineti E, Costantino F, Ferretti M, Kacmarek RM, Pelosi P. Effects of ventilator settings, nebulizer and exhalation port position on albuterol delivery during non-invasive ventilation: an in-vitro study. BMC Pulm Med 2017; 17:9. [PMID: 28068958 PMCID: PMC5223303 DOI: 10.1186/s12890-016-0347-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/12/2016] [Indexed: 11/14/2022] Open
Abstract
Background Few studies have investigated the factors affecting aerosol delivery during non-invasive ventilation (NIV). Our aim was to investigate, using a bench-top model, the effect of different ventilator settings and positions of the exhalation port and nebulizer on the amount of albuterol delivered to a lung simulator. Methods A lung model simulating spontaneous breathing was connected to a single-limb NIV ventilator, set in bi-level positive airway pressure (BIPAP) with inspiratory/expiratory pressures of 10/5, 15/10, 15/5, and 20/10 cmH2O, or continuous positive airway pressure (CPAP) of 5 and 10 cmH2O. Three delivery circuits were tested: a vented mask with the nebulizer directly connected to the mask, and an unvented mask with a leak port placed before and after the nebulizer. Albuterol was collected on a filter placed after the mask and then the delivered amount was measured with infrared spectrophotometry. Results Albuterol delivery during NIV varied between 6.7 ± 0.4% to 37.0 ± 4.3% of the nominal dose. The amount delivered in CPAP and BIPAP modes was similar (22.1 ± 10.1 vs. 24.0 ± 10.0%, p = 0.070). CPAP level did not affect delivery (p = 0.056); in BIPAP with 15/5 cmH2O pressure the delivery was higher compared to 10/5 cmH2O (p = 0.033) and 20/10 cmH2O (p = 0.014). Leak port position had a major effect on delivery in both CPAP and BIPAP, the best performances were obtained with the unvented mask, and the nebulizer placed between the leak port and the mask (p < 0.001). Conclusions In this model, albuterol delivery was marginally affected by ventilatory settings in NIV, while position of the leak port had a major effect. Nebulizers should be placed between an unvented mask and the leak port in order to maximize aerosol delivery.
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Affiliation(s)
- Yuda Sutherasan
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Division of pulmonary and critical care medicine, Faculty of medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Lorenzo Ball
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
| | - Pasquale Raimondo
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Dipartimento di Anestesia, Rianimazione e Terapia Intensiva, Università degli Studi di Foggia, Foggia, Italy
| | - Valentina Caratto
- Department of Chemistry and Industrial Chemistry, University of Genoa, Genoa, Italy.,SPIN-CNR, Genoa, Italy
| | - Elisa Sanguineti
- Department of Chemistry and Industrial Chemistry, University of Genoa, Genoa, Italy.,SPIN-CNR, Genoa, Italy
| | - Federico Costantino
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Maurizio Ferretti
- Department of Chemistry and Industrial Chemistry, University of Genoa, Genoa, Italy.,SPIN-CNR, Genoa, Italy
| | - Robert M Kacmarek
- Department of Anesthesiology, Harvard Medical school, Department of Anesthesiology, Critical Care and Pain Medicine, and the Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paolo Pelosi
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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