1
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Seidl LL, Moog R, Graeser KA. Antisense oligonucleotides and their technical suitability to nebulization. Int J Pharm 2024; 661:124390. [PMID: 38936443 DOI: 10.1016/j.ijpharm.2024.124390] [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: 01/17/2024] [Revised: 06/17/2024] [Accepted: 06/24/2024] [Indexed: 06/29/2024]
Abstract
In vivo studies investigating the inhalative efficacy of biotherapeutics, such as nucleic acids, usually do not perform an aerosolization step, rather the solution is directly administered into the lungs e.g. intratracheally. In addition, there is currently very little information on the behavior of nucleic acid solutions when subjected to the physical stress of the nebulization process. In this study, the aim was to assess the technical suitability of Locked Nucleic Acids (LNAs), as a model antisense oligonucleotide, towards nebulization using two commercially available nebulizers. A jet nebulizer (Pari LC Plus) and a vibrating mesh nebulizer (Aerogen Solo) were employed and solutions of five different LNAs investigated in terms of their physical and chemical stability to nebulization and the quality of the generated aerosols. The aerosol properties of the Aerogen Solo were mainly influenced by the viscosity of the solutions with the output rate and the droplet size decreasing with increasing viscosity. The Pari LC Plus was less susceptible to viscosity and overall the droplet size was smaller. The LNAs tolerated both nebulization processes and the integrity of the molecules was shown. Chemical stability of the molecules from the Aerogen Solo was confirmed, whereas aerosol generation with the Pari LC Plus jet nebulizer led to a slight increase of phosphodiester groups in a fully phosphorothiolated backbone of the LNAs. Overall, it could be shown that nebulization of different LNAs is possible and inhalation can therefore be considered a potential route of administration.
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Affiliation(s)
- Leonardo L Seidl
- Roche Pharma Research and Early Development, Therapeutic Modalities, pCMC, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Grenzacherstrasse 124, 4070 Basel, Switzerland; Technical University of Munich, TUM School of Natural Sciences, Boltzmannstr. 10, 85748 Garching, Germany
| | - Regina Moog
- Roche Pharma Research and Early Development, Therapeutic Modalities, pCMC, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Grenzacherstrasse 124, 4070 Basel, Switzerland
| | - Kirsten A Graeser
- Roche Pharma Research and Early Development, Therapeutic Modalities, pCMC, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Grenzacherstrasse 124, 4070 Basel, Switzerland.
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2
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Turuvekere Vittala Murthy N, Vlasova K, Renner J, Jozic A, Sahay G. A new era of targeting cystic fibrosis with non-viral delivery of genomic medicines. Adv Drug Deliv Rev 2024; 209:115305. [PMID: 38626860 DOI: 10.1016/j.addr.2024.115305] [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: 01/06/2024] [Revised: 03/27/2024] [Accepted: 04/09/2024] [Indexed: 04/21/2024]
Abstract
Cystic fibrosis (CF) is a complex genetic respiratory disorder that necessitates innovative gene delivery strategies to address the mutations in the gene. This review delves into the promises and challenges of non-viral gene delivery for CF therapy and explores strategies to overcome these hurdles. Several emerging technologies and nucleic acid cargos for CF gene therapy are discussed. Novel formulation approaches including lipid and polymeric nanoparticles promise enhanced delivery through the CF mucus barrier, augmenting the potential of non-viral strategies. Additionally, safety considerations and regulatory perspectives play a crucial role in navigating the path toward clinical translation of gene therapy.
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Affiliation(s)
| | - Kseniia Vlasova
- Department of Pharmaceutical Sciences, College of Pharmacy at Oregon State University, Corvallis, OR 97331, USA
| | - Jonas Renner
- Department of Pharmaceutical Sciences, College of Pharmacy at Oregon State University, Corvallis, OR 97331, USA
| | - Antony Jozic
- Department of Pharmaceutical Sciences, College of Pharmacy at Oregon State University, Corvallis, OR 97331, USA
| | - Gaurav Sahay
- Department of Pharmaceutical Sciences, College of Pharmacy at Oregon State University, Corvallis, OR 97331, USA; Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR 97201, USA; Department of Biomedical Engineering, Robertson Life Sciences Building, Oregon Health & Science University, Portland, OR 97201, USA.
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3
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Zhang D, Zhao H, Li P, Wu X, Liang Y. Research Progress on Liposome Pulmonary Delivery of Mycobacterium tuberculosis Nucleic Acid Vaccine and Its Mechanism of Action. J Aerosol Med Pulm Drug Deliv 2024. [PMID: 38669118 DOI: 10.1089/jamp.2023.0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Traditional vaccines have played an important role in the prevention and treatment of infectious diseases, but they still have problems such as low immunogenicity, poor stability, and difficulty in inducing lasting immune responses. In recent years, the nucleic acid vaccine has emerged as a relatively cheap and safe new vaccine. Compared with traditional vaccines, nucleic acid vaccine has some unique advantages, such as easy production and storage, scalability, and consistency between batches. However, the direct administration of naked nucleic acid vaccine is not ideal, and safer and more effective vaccine delivery systems are needed. With the rapid development of nanocarrier technology, the combination of gene therapy and nanodelivery systems has broadened the therapeutic application of molecular biology and the medical application of biological nanomaterials. Nanoparticles can be used as potential drug-delivery vehicles for the treatment of hereditary and infectious diseases. In addition, due to the advantages of lung immunity, such as rapid onset of action, good efficacy, and reduced adverse reactions, pulmonary delivery of nucleic acid vaccine has become a hot spot in the field of research. In recent years, lipid nanocarriers have become safe, efficient, and ideal materials for vaccine delivery due to their unique physical and chemical properties, which can effectively reduce the toxic side effects of drugs and achieve the effect of slow release and controlled release, and there have been a large number of studies using lipid nanocarriers to efficiently deliver target components into the body. Based on the delivery of tuberculosis (TB) nucleic acid vaccine by lipid carrier, this article systematically reviews the advantages and mechanism of liposomes as a nucleic acid vaccine delivery carrier, so as to lay a solid foundation for the faster and more effective development of new anti-TB vaccine delivery systems in the future.
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Affiliation(s)
- Danyang Zhang
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, China
- Postgraduate Department of Heibei North University, Zhangjiakou, China
| | - Haimei Zhao
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, China
- Postgraduate Department of Heibei North University, Zhangjiakou, China
| | - Ping Li
- Postgraduate Department of Heibei North University, Zhangjiakou, China
| | - Xueqiong Wu
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Yan Liang
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Senior Department of Tuberculosis, The Eighth Medical Center of PLA General Hospital, Beijing, China
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4
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Le NHA, Brenker J, Shenoda A, Sheikh Z, Gum J, Ong HX, Traini D, Alan T. Oscillating high aspect ratio micro-channels can effectively atomize liquids into uniform aerosol droplets and dial their size on-demand. LAB ON A CHIP 2024; 24:1676-1684. [PMID: 38305095 DOI: 10.1039/d3lc00816a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Ultrasonic atomization of liquids into micrometer-diameter droplets is crucial across multiple fields, ranging from drug delivery, to spectrometry and printing. Controlling the size and uniformity of the generated droplets on-demand is crucial in all these applications. However, existing systems lack the required precision to tune the droplet properties, and the underlying droplet formation mechanism under high-frequency ultrasonic actuation remains poorly understood due to experimental constraints. Here, we present an atomization platform, which overcomes these current limitations. Our device utilizes oscillating high aspect ratio micro-channels to extract liquids from various inlets (ranging from sessile droplets to large beakers), bound them in a precisely defined narrow region, and, controllably atomize them on-demand. The droplet size can be precisely dialled from 3.6 μm to 6.8 μm by simply tuning the actuation parameters. Since the approach does not need nozzles, meshes or impacting jets, stresses exerted on the liquid samples are reduced, hence it is gentler on delicate samples. The precision offered by the technique allows us for the first time to experimentally visualise the oscillating fluid interface at the onset of atomization at MHz frequencies, and demonstrate its applications for targeted respiratory drug delivery.
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Affiliation(s)
- Nguyen Hoai An Le
- Dynamic Micro Devices Laboratory, Mechanical and Aerospace Engineering, Monash University, Melbourne, 3800, VIC, Australia.
| | - Jason Brenker
- Dynamic Micro Devices Laboratory, Mechanical and Aerospace Engineering, Monash University, Melbourne, 3800, VIC, Australia.
| | - Abanoub Shenoda
- Dynamic Micro Devices Laboratory, Mechanical and Aerospace Engineering, Monash University, Melbourne, 3800, VIC, Australia.
| | - Zara Sheikh
- Respiratory Technology, Woolcock Institute of Medical Research, Sydney, Australia
| | - Jackson Gum
- Dynamic Micro Devices Laboratory, Mechanical and Aerospace Engineering, Monash University, Melbourne, 3800, VIC, Australia.
| | - Hui Xin Ong
- Respiratory Technology, Woolcock Institute of Medical Research, Sydney, Australia
- Macquarie Medical School, Department of Biological Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Australia
| | - Daniela Traini
- Respiratory Technology, Woolcock Institute of Medical Research, Sydney, Australia
- Macquarie Medical School, Department of Biological Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Australia
| | - Tuncay Alan
- Dynamic Micro Devices Laboratory, Mechanical and Aerospace Engineering, Monash University, Melbourne, 3800, VIC, Australia.
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5
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Xia W, Kolli AR, Kuczaj AK, Szostak J, Lam S, Toh WW, Purwanti A, Tan WT, Ng R, Phillips B, Peitsch MC, Hoeng J. Aerosol delivery and spatiotemporal tissue distribution of hydroxychloroquine in rat lung. Eur J Pharm Sci 2024; 194:106693. [PMID: 38184016 DOI: 10.1016/j.ejps.2024.106693] [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: 11/14/2023] [Revised: 12/29/2023] [Accepted: 01/01/2024] [Indexed: 01/08/2024]
Abstract
Inhalation enables the delivery of drugs directly to the lung, increasing the retention for prolonged exposure and maximizing the therapeutic index. However, the differential regional lung exposure kinetics and systemic pharmacokinetics are not fully known, and their estimation is critical for pulmonary drug delivery. The study evaluates the pharmacokinetics of hydroxychloroquine in different regions of the respiratory tract for multiple routes of administration. We also evaluated the influence of different inhaled formulations on systemic and lung pharmacokinetics by identifying suitable nebulizers followed by early characterization of emitted aerosol physicochemical properties. The salt- and freebase-based formulations required different nebulizers and generated aerosol with different physicochemical properties. An administration of hydroxychloroquine by different routes resulted in varied systemic and lung pharmacokinetics, with oral administration resulting in low tissue concentrations in all regions of the respiratory tract. A nose-only inhalation exposure resulted in higher and sustained lung concentrations of hydroxychloroquine with a lung parenchyma-to-blood ratio of 386 after 1440 min post-exposure. The concentrations of hydroxychloroquine in different regions of the respiratory tract (i.e., nasal epithelium, larynx, trachea, bronchi, and lung parenchyma) varied over time, indicating different retention kinetics. The spatiotemporal distribution of hydroxychloroquine in the lung is different due to the heterogeneity of cell types, varying blood perfusion rate, clearance mechanisms, and deposition of inhaled aerosol along the respiratory tract. In addition to highlighting the varied lung physiology, these results demonstrate the ability of the lung to retain increased levels of inhaled lysosomotropic drugs. Such findings are critical for the development of future inhalation-based therapeutics, aiming to optimize target site exposure, enable precision medicine, and ultimately enhance clinical outcomes.
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Affiliation(s)
- Wenhao Xia
- PMI R&D, Philip Morris International Research Laboratories Pte. Ltd., Science Park II, Singapore
| | - Aditya R Kolli
- PMI R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, Neuchâtel CH-2000, Switzerland.
| | - Arkadiusz K Kuczaj
- PMI R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, Neuchâtel CH-2000, Switzerland
| | - Justyna Szostak
- PMI R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, Neuchâtel CH-2000, Switzerland
| | - Sharon Lam
- PMI R&D, Philip Morris International Research Laboratories Pte. Ltd., Science Park II, Singapore
| | - Wei Wen Toh
- PMI R&D, Philip Morris International Research Laboratories Pte. Ltd., Science Park II, Singapore
| | - Asef Purwanti
- PMI R&D, Philip Morris International Research Laboratories Pte. Ltd., Science Park II, Singapore
| | - Wei Teck Tan
- PMI R&D, Philip Morris International Research Laboratories Pte. Ltd., Science Park II, Singapore
| | - Raymond Ng
- PMI R&D, Philip Morris International Research Laboratories Pte. Ltd., Science Park II, Singapore
| | - Blaine Phillips
- PMI R&D, Philip Morris International Research Laboratories Pte. Ltd., Science Park II, Singapore
| | - Manuel C Peitsch
- PMI R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, Neuchâtel CH-2000, Switzerland
| | - Julia Hoeng
- PMI R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, Neuchâtel CH-2000, Switzerland
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6
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Yousry C, Goyal M, Gupta V. Excipients for Novel Inhaled Dosage Forms: An Overview. AAPS PharmSciTech 2024; 25:36. [PMID: 38356031 DOI: 10.1208/s12249-024-02741-w] [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: 07/22/2023] [Accepted: 01/05/2024] [Indexed: 02/16/2024] Open
Abstract
Pulmonary drug delivery is a form of local targeting to the lungs in patients with respiratory disorders like cystic fibrosis, pulmonary arterial hypertension (PAH), asthma, chronic pulmonary infections, and lung cancer. In addition, noninvasive pulmonary delivery also presents an attractive alternative to systemically administered therapeutics, not only for localized respiratory disorders but also for systemic absorption. Pulmonary delivery offers the advantages of a relatively low dose, low incidence of systemic side effects, and rapid onset of action for some drugs compared to other systemic administration routes. While promising, inhaled delivery of therapeutics is often complex owing to factors encompassing mechanical barriers, chemical barriers, selection of inhalation device, and limited choice of dosage form excipients. There are very few excipients that are approved by the FDA for use in developing inhaled drug products. Depending upon the dosage form, and inhalation devices such as pMDIs, DPIs, and nebulizers, different excipients can be used to provide physical and chemical stability and to deliver the dose efficiently to the lungs. This review article focuses on discussing a variety of excipients that have been used in novel inhaled dosage forms as well as inhalation devices.
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Affiliation(s)
- Carol Yousry
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, 8000 Utopia Parkway, Queens, New York, 11439, USA
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Kasr El-Aini, Cairo, 11562, Egypt
- Department of Pharmaceutics and Industrial Pharmacy, School of Pharmacy, Newgiza University, Giza, Egypt
| | - Mimansa Goyal
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, 8000 Utopia Parkway, Queens, New York, 11439, USA
| | - Vivek Gupta
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, 8000 Utopia Parkway, Queens, New York, 11439, USA.
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7
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Neary MT, Mulder LM, Kowalski PS, MacLoughlin R, Crean AM, Ryan KB. Nebulised delivery of RNA formulations to the lungs: From aerosol to cytosol. J Control Release 2024; 366:812-833. [PMID: 38101753 DOI: 10.1016/j.jconrel.2023.12.012] [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: 06/16/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
In the past decade RNA-based therapies such as small interfering RNA (siRNA) and messenger RNA (mRNA) have emerged as new and ground-breaking therapeutic agents for the treatment and prevention of many conditions from viral infection to cancer. Most clinically approved RNA therapies are parenterally administered which impacts patient compliance and adds to healthcare costs. Pulmonary administration via inhalation is a non-invasive means to deliver RNA and offers an attractive alternative to injection. Nebulisation is a particularly appealing method due to the capacity to deliver large RNA doses during tidal breathing. In this review, we discuss the unique physiological barriers presented by the lung to efficient nebulised RNA delivery and approaches adopted to circumvent this problem. Additionally, the different types of nebulisers are evaluated from the perspective of their suitability for RNA delivery. Furthermore, we discuss recent preclinical studies involving nebulisation of RNA and analysis in in vitro and in vivo settings. Several studies have also demonstrated the importance of an effective delivery vector in RNA nebulisation therefore we assess the variety of lipid, polymeric and hybrid-based delivery systems utilised to date. We also consider the outlook for nebulised RNA medicinal products and the hurdles which must be overcome for successful clinical translation. In summary, nebulised RNA delivery has demonstrated promising potential for the treatment of several lung-related conditions such as asthma, COPD and cystic fibrosis, to which the mode of delivery is of crucial importance for clinical success.
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Affiliation(s)
- Michael T Neary
- SSPC, The SFI Research Centre for Pharmaceuticals, School of Pharmacy, University College Cork, Ireland; School of Pharmacy, University College Cork, Ireland
| | | | - Piotr S Kowalski
- School of Pharmacy, University College Cork, Ireland; APC Microbiome, University College Cork, Cork, Ireland
| | | | - Abina M Crean
- SSPC, The SFI Research Centre for Pharmaceuticals, School of Pharmacy, University College Cork, Ireland; School of Pharmacy, University College Cork, Ireland
| | - Katie B Ryan
- SSPC, The SFI Research Centre for Pharmaceuticals, School of Pharmacy, University College Cork, Ireland; School of Pharmacy, University College Cork, Ireland.
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8
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Zhang Y, Li Q, Sun C, Gu Y, Qi Z, Li J. The effect of nebulized heparin on clinical outcomes in mechanically ventilated patients: a meta-analysis and review of the literature. J Int Med Res 2023; 51:3000605231201340. [PMID: 37815327 PMCID: PMC10566280 DOI: 10.1177/03000605231201340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/29/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE To determine the relationship between use of nebulized heparin and clinical outcomes in mechanically ventilated patients. METHODS The Medline, Embase, Web of Science, Cochrane Library, and PubMed databases were searched for relevant randomized controlled trials (RCTs), published between database inception and May 2022. Primary outcomes were intensive care unit (ICU) length of stay and in-hospital mortality; secondary outcomes included duration of mechanical ventilation, ventilator-free days (VFDs) in 28 days, and length of hospitalization. The study protocol was registered on PROSPERO (registration No: CRD42022345533). RESULTS A total of eight RCTs (651 patients) were included. Nebulized heparin was associated with reduced ICU length of stay (six studies; mean difference [MD] -1.10, 95% confidence interval [CI] -1.87, -0.33, I2 = 76%), reduced duration of mechanical ventilation (two studies; MD -2.63, 95% CI -3.68, -1.58, I2 = 92%) and increased VFDs in 28 days (two studies; MD 4.22, 95% CI 1.10, 7.35, I2 = 18%), without increased incidence of adverse events, such as bleeding; but was not associated with a reduction in length of hospitalization (three studies; MD -1.00, 95% CI -2.90, -0.90, I2 = 0%) or in-hospital mortality (five studies; odds ratio 1.10, 95% CI 0.69, 1.77, I2 = 0%). CONCLUSION Nebulized heparin reduces ICU length of stay and duration of mechanical ventilation in mechanically ventilated patients, but has no effect on length of hospitalization or mortality.
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Affiliation(s)
- Yi Zhang
- Department of Respiratory and Critical Care Medicine, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Qiankun Li
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Changan Sun
- Intensive Care Unit, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Yue Gu
- Department of Respiratory and Critical Care Medicine, Yantai Affiliated Hospital of Binzhou Medical University, Binzhou Medical University, Shandong, China
| | - Zhijiang Qi
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China; National Centre for Respiratory Medicine, Beijing, China
| | - Jun Li
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
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9
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Sudduth ER, Trautmann-Rodriguez M, Gill N, Bomb K, Fromen CA. Aerosol pulmonary immune engineering. Adv Drug Deliv Rev 2023; 199:114831. [PMID: 37100206 PMCID: PMC10527166 DOI: 10.1016/j.addr.2023.114831] [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: 02/01/2023] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
Aerosolization of immunotherapies poses incredible potential for manipulating the local mucosal-specific microenvironment, engaging specialized pulmonary cellular defenders, and accessing mucosal associated lymphoid tissue to redirect systemic adaptive and memory responses. In this review, we breakdown key inhalable immunoengineering strategies for chronic, genetic, and infection-based inflammatory pulmonary disorders, encompassing the historic use of immunomodulatory agents, the transition to biological inspired or derived treatments, and novel approaches of complexing these materials into drug delivery vehicles for enhanced release outcomes. Alongside a brief description of key immune targets, fundamentals of aerosol drug delivery, and preclinical pulmonary models for immune response, we survey recent advances of inhaled immunotherapy platforms, ranging from small molecules and biologics to particulates and cell therapies, as well as prophylactic vaccines. In each section, we address the formulation design constraints for aerosol delivery as well as advantages for each platform in driving desirable immune modifications. Finally, prospects of clinical translation and outlook for inhaled immune engineering are discussed.
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Affiliation(s)
- Emma R Sudduth
- Department of Chemical and Biomolecular Engineering, University of Delaware, Newark, DE 19716, USA
| | | | - Nicole Gill
- Department of Chemical and Biomolecular Engineering, University of Delaware, Newark, DE 19716, USA
| | - Kartik Bomb
- Department of Chemical and Biomolecular Engineering, University of Delaware, Newark, DE 19716, USA
| | - Catherine A Fromen
- Department of Chemical and Biomolecular Engineering, University of Delaware, Newark, DE 19716, USA.
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10
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Hsu YC, Li HH, Chiu LC, Chiang WC, Fang TP, Lin HL. Predicting Inhaled Drug Dose Generated by Mesh Nebulizers. J Aerosol Med Pulm Drug Deliv 2023; 36:162-170. [PMID: 37219568 DOI: 10.1089/jamp.2022.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
Background: The lung dose of nebulized drugs for spontaneous breathing is influenced by breathing patterns and nebulizer performance. This study aimed to develop a system for measuring breath patterns and a formula for estimating inhaled drugs, and then to validate the hypothesized prediction formula. Methods: An in vitro model was first used to determine correlations among the delivered dose, breath patterns, and doses deposited on the accessories and reservoirs testing with a breathing simulator to generate 12 adult breathing patterns (n = 5). A pressure sensor was developed to measure breathing parameters and used along with a prediction formula that accounted for the initial charge dose, respiratory pattern, and dose on the accessory and reservoir of a nebulizer. Three brands of nebulizers were tested by placing salbutamol (5.0 mg/2.5 mL) in the drug holding chamber. Ten healthy individuals participated in the ex vivo study to validate the prediction formula. The agreement between the predicted and inhaled doses was analyzed using the Bland-Altman plot. Results: The in vitro model showed that the inspiratory time to total respiratory cycle time (Ti/Ttotal; %) was significantly directly correlated with the delivered dose among the respiratory factors, followed by inspiratory flow, respiratory rate, and tidal volume. The ex vivo model showed that Ti/Ttotal was significantly directly correlated with the delivered dose among the respiratory factors, in addition to the nebulization time and accessory dose. The Bland-Altman plots for the ex vivo model showed similar results between the two methods. Large differences in inhaled dose measured at the mouth were observed among the subjects, ranging from 12.68% to 21.68%; however, the difference between the predicted dose and inhaled dose was lower, at 3.98%-5.02%. Conclusions: The inhaled drug dose could be predicted with the hypothesized estimation formula, which was validated by the agreement between the inhaled and predicted doses of breathing patterns of healthy individuals.
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Affiliation(s)
| | - Hsin-Hsien Li
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Li-Chung Chiu
- Department of Pulmonary and Critical Care, Chang Gung Memorial Hospital-Linkou Branch, Taoyuan, Taiwan
| | | | - Tien-Pei Fang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Respiratory Care, Chang Gung University of Technology and Science, Chiayi, Taiwan
| | - Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Respiratory Care, Chang Gung University of Technology and Science, Chiayi, Taiwan
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11
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Stella GM, Lettieri S, Piloni D, Ferrarotti I, Perrotta F, Corsico AG, Bortolotto C. Smart Sensors and Microtechnologies in the Precision Medicine Approach against Lung Cancer. Pharmaceuticals (Basel) 2023; 16:1042. [PMID: 37513953 PMCID: PMC10385174 DOI: 10.3390/ph16071042] [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: 06/08/2023] [Revised: 06/23/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND AND RATIONALE The therapeutic interventions against lung cancer are currently based on a fully personalized approach to the disease with considerable improvement of patients' outcome. Alongside continuous scientific progresses and research investments, massive technologic efforts, innovative challenges, and consolidated achievements together with research investments are at the bases of the engineering and manufacturing revolution that allows a significant gain in clinical setting. AIM AND METHODS The scope of this review is thus to focus, rather than on the biologic traits, on the analysis of the precision sensors and novel generation materials, as semiconductors, which are below the clinical development of personalized diagnosis and treatment. In this perspective, a careful revision and analysis of the state of the art of the literature and experimental knowledge is presented. RESULTS Novel materials are being used in the development of personalized diagnosis and treatment for lung cancer. Among them, semiconductors are used to analyze volatile cancer compounds and allow early disease diagnosis. Moreover, they can be used to generate MEMS which have found an application in advanced imaging techniques as well as in drug delivery devices. CONCLUSIONS Overall, these issues represent critical issues only partially known and generally underestimated by the clinical community. These novel micro-technology-based biosensing devices, based on the use of molecules at atomic concentrations, are crucial for clinical innovation since they have allowed the recent significant advances in cancer biology deciphering as well as in disease detection and therapy. There is an urgent need to create a stronger dialogue between technologists, basic researchers, and clinicians to address all scientific and manufacturing efforts towards a real improvement in patients' outcome. Here, great attention is focused on their application against lung cancer, from their exploitations in translational research to their application in diagnosis and treatment development, to ensure early diagnosis and better clinical outcomes.
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Affiliation(s)
- Giulia Maria Stella
- Department of Internal Medicine and Medical Therapeutics, University of Pavia Medical School, 27100 Pavia, Italy
- Cardiothoracic and Vascular Department, Unit of Respiratory Diseases, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Sara Lettieri
- Department of Internal Medicine and Medical Therapeutics, University of Pavia Medical School, 27100 Pavia, Italy
- Cardiothoracic and Vascular Department, Unit of Respiratory Diseases, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Davide Piloni
- Department of Internal Medicine and Medical Therapeutics, University of Pavia Medical School, 27100 Pavia, Italy
- Cardiothoracic and Vascular Department, Unit of Respiratory Diseases, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Ilaria Ferrarotti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia Medical School, 27100 Pavia, Italy
- Cardiothoracic and Vascular Department, Unit of Respiratory Diseases, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Fabio Perrotta
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", 80131 Napoli, Italy
- U.O.C. Clinica Pneumologica "L. Vanvitelli", A.O. dei Colli, Ospedale Monaldi, 80131 Napoli, Italy
| | - Angelo Guido Corsico
- Department of Internal Medicine and Medical Therapeutics, University of Pavia Medical School, 27100 Pavia, Italy
- Cardiothoracic and Vascular Department, Unit of Respiratory Diseases, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Chandra Bortolotto
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia Medical School, 27100 Pavia, Italy
- Department of Diagnostic Services and Imaging, Unit of Radiology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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12
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Julia Altube M, Perez N, Lilia Romero E, José Morilla M, Higa L, Paula Perez A. Inhaled lipid nanocarriers for pulmonary delivery of glucocorticoids: previous strategies, recent advances and key factors description. Int J Pharm 2023:123146. [PMID: 37330156 DOI: 10.1016/j.ijpharm.2023.123146] [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: 02/15/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Abstract
In view of the strong anti-inflammatory activity of glucocorticoids (GC) they are used in the treatment of almost all inflammatory lung diseases. In particular, inhaled GC (IGC) allow high drug concentrations to be deposited in the lung and may reduce the incidence of adverse effects associated with systemic administration. However, rapid absorption through the highly absorbent surface of the lung epithelium may limit the success of localized therapy. Therefore, inhalation of GC incorporated into nanocarriers is a possible approach to overcome this drawback. In particular, lipid nanocarriers, which showed high pulmonary biocompatibility and are well known in the pharmaceutical industry, have the best prospects for pulmonary delivery of GC by inhalation. This review provides an overview of the pre-clinical applications of inhaled GC-lipid nanocarriers based on several key factors that will determine the efficiency of local pulmonary GC delivery: 1) stability to nebulization, 2) deposition profile in the lungs, 3) mucociliary clearance, 4) selective accumulation in target cells, 5) residence time in the lung and systemic absorption and 6) biocompatibility. Finally, novel preclinical pulmonary models for inflammatory lung diseases are also discussed.
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Affiliation(s)
- María Julia Altube
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - Noelia Perez
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - Eder Lilia Romero
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - María José Morilla
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - Leticia Higa
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - Ana Paula Perez
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina.
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13
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Chang KH, Park BJ, Nam KC. Aerosolization Performance of Immunoglobulin G by Jet and Mesh Nebulizers. AAPS PharmSciTech 2023; 24:125. [PMID: 37225929 DOI: 10.1208/s12249-023-02579-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/01/2023] [Indexed: 05/26/2023] Open
Abstract
Recently, many preclinical and clinical studies have been conducted on the delivery of therapeutic antibodies to the lungs using nebulizers, but standard treatment guidelines have not yet been established. Our objective was to compare nebulization performance according to the low temperature and concentration of immunoglobulin G (IgG) solutions in different types of nebulizers, and to evaluate the stability of IgG aerosols and the amount delivered to the lungs. The output rate of the mesh nebulizers decreased according to the low temperature and high concentration of IgG solution, whereas the jet nebulizer was unaffected by the temperature and concentration of IgG. An impedance change of the piezoelectric vibrating element in the mesh nebulizers was observed because of the lower temperature and higher viscosity of IgG solution. This affected the resonance frequency of the piezoelectric element and lowered the output rate of the mesh nebulizers. Aggregation assays using a fluorescent probe revealed aggregates in IgG aerosols from all nebulizers. The delivered dose of IgG to the lungs in mice was highest at 95 ng/mL in the jet nebulizer with the smallest droplet size. Evaluation of the performance of IgG solution delivered to the lungs by three types of nebulizers could provide valuable parameter information for determination on dose of therapeutic antibody by nebulizers.
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Affiliation(s)
- Kyung Hwa Chang
- Department of Medical Engineering, Dongguk University College of Medicine, 32 Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10326, South Korea
| | - Bong Joo Park
- Department of Electrical & Biological Physics and Institute of Biomaterials, Kwangwoon University, Seoul, 01897, South Korea
| | - Ki Chang Nam
- Department of Medical Engineering, Dongguk University College of Medicine, 32 Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10326, South Korea.
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14
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Wang Z, Zhang Z, Wang Q, Zeng L, Jin J. A nasal spray vaccination device based on Laval nozzle and its experimental test. Sci Rep 2023; 13:6267. [PMID: 37069262 PMCID: PMC10109226 DOI: 10.1038/s41598-023-33452-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/13/2023] [Indexed: 04/19/2023] Open
Abstract
In order to realize the application of the nasal spray vaccination in the prevention and protection of respiratory infectious diseases, a nasal spray vaccination device is designed in this paper. The device uses a Laval nozzle structure to generate a high-speed airflow that impinges on the vaccine reagent and forms nebulized particles. Through optimizing of the Laval nozzle structure and testing experiments on spray particle size, spray velocity, spray angle and spray rate, a set of parameters which is applicable to actual nasal spray vaccination is obtained. The experimental results show that when the air source pressure is 2 bar, the spray angle is about 15°, the diameter of the spray particles Dv50 is about 17 μm, the volume fraction of particles with diameter smaller than 10um is about 24%, the spray rate is close to 300 μl/s. The vaccine activity tests demonstrate that under these conditions, not only the biological activity of vaccines is guaranteed, but also the delivery efficiency is well assured.
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Affiliation(s)
- Zhong Wang
- Guangzhou Laboratory, Guangzhou, 510005, China
| | - Zhengyuan Zhang
- Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, 510530, China
| | - Qian Wang
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510182, China
| | | | - Jian Jin
- Guangzhou Laboratory, Guangzhou, 510005, China.
- School of Mechanical Engineering, Hefei University of Technology, Hefei, 230009, China.
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15
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Creane S, Joyce M, MacLoughlin R, Weldon S, Dalton JP, Taggart CC. In vitro evaluation of the potential use of snake-derived peptides in the treatment of respiratory infections using inhalation therapy: A proof of concept study. Eur J Pharm Sci 2023; 183:106398. [PMID: 36740103 DOI: 10.1016/j.ejps.2023.106398] [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: 09/13/2022] [Revised: 01/16/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
Inhalation therapy using nebulisers is an attractive non-invasive route for drug delivery, particularly for the treatment of lung infections with anti-inflammatory and anti-microbial compounds. This study evaluated the suitability of three snake-derived peptides (termed Sn1b, SnE1 and SnE1-F), which we have recently shown have potent anti-inflammatory and bacteriostatic activities, for nebulisation using a vibrating mesh nebuliser (VMN). The effect of nebulisation on peptide concentration, stability and function were assessed, prior to progression to aerodynamic particle size distribution, and in vitro drug delivery in simulated adult spontaneous breathing and mechanical ventilated patient models. When nebulised, all three peptides exhibited similar functions to their non-nebulised counterparts and were found to be respirable during simulated mechanical ventilation. Based on the assessment of the droplet distributions of nebulised peptides using a Next Generation Impactor (NGI) demonstrated that if administered in vivo each peptide would likely be delivered to the lower airways. These data suggest that nebulisation using a VMN is a viable means of anti-microbial / anti-inflammatory peptide delivery targeting microbial respiratory infections, and possibly even systemic infections.
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Affiliation(s)
- Shannice Creane
- Airway Innate Immunity Research (AiiR) Group, Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Mary Joyce
- Research & Development, Science & Emerging Technologies, Aerogen Limited, Galway Business Park, Galway H91 HE94, Ireland
| | - Ronan MacLoughlin
- Research & Development, Science & Emerging Technologies, Aerogen Limited, Galway Business Park, Galway H91 HE94, Ireland; School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, D02 YN77, Ireland; School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin D02 PN40, Ireland
| | - Sinéad Weldon
- Airway Innate Immunity Research (AiiR) Group, Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - John P Dalton
- Zoology Department, School of Natural Sciences, Centre for One Health, Ryan Institute, National University of Ireland Galway, Galway, Ireland.; School of Biological Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Clifford C Taggart
- Airway Innate Immunity Research (AiiR) Group, Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK..
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16
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N V, Lokavarapu BR. Enhanced Optimal Parameter-Based Nebulizer Design for Flow Analysis of Fluticasone Propionate. AAPS PharmSciTech 2023; 24:85. [PMID: 36949186 DOI: 10.1208/s12249-023-02548-1] [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: 12/14/2022] [Accepted: 02/28/2023] [Indexed: 03/24/2023] Open
Abstract
A jet nebulizer sprays a fine mist or aerosol directly into the lungs to reduce inflammation, expand airways, and make breathing easier for respiratory patients. Asthma, COPD, emphysema, and cystic fibrosis are treated with jet nebulizers. They are chosen over other nebulizers for their shorter treatment time and wider medication compatibility. For mechanically ventilated patients, jet nebulizers humidify oxygen to provide bronchodilators, antibiotics, and other respiratory medications. Additionally, they treat pneumonia, bronchitis, and other lung infections. Aerosol therapy requires medical jet nebulizers. However, experiment setup is time-consuming and challenging to enhance smaller droplet output. The study is aimed at enhancing the nebulizer and process parameters using numerical simulation and comparing the results to experimental data from the Malvern Spraytec™ laser diffraction system. This numerical model improves nebulization knowledge and predicts process parameters that affect output. Ansys Fluent was used to analyze a Creo-designed jet nebulizer solid model. The Spraytec™ experimental method was utilized to characterize fluticasone propionate's aerosol output and build the best nebulizer. Laser diffraction and computational fluid dynamics (CFD) analysis measured the nebulizer aerosol output. Comparing particle size data between 2 and 5 μm. The results are similar, with a difference of 4.20%. Taguchi optimization found the optimal process parameter, and a conformation test enhanced the process parameter. The nebulizer generates 8.57% more fluticasone propionate at optimal particle size. The optimized nebulizer generates aerosols reliably and speeds up patient recovery.
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Affiliation(s)
- Vinoth N
- School of Mechanical Engineering, Vellore Institute of Technology, Chennai, Vandalur-Kelambakkam Road, Chennai, 600127, Tamil Nadu, India
| | - Bhaskara Rao Lokavarapu
- School of Mechanical Engineering, Vellore Institute of Technology, Chennai, Vandalur-Kelambakkam Road, Chennai, 600127, Tamil Nadu, India.
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17
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O'Neil JA, Villasmil-Urdaneta LA. A path forward in the development of new aerosol drug delivery devices for pediatrics. Respir Med 2023; 211:107210. [PMID: 36907367 DOI: 10.1016/j.rmed.2023.107210] [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: 01/06/2023] [Revised: 02/24/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023]
Abstract
Inhaled medications are widely accepted as being the optimal route for treating pediatric respiratory diseases, a leading cause of hospitalization and death. Despite jet nebulizers being the preferred inhalation device for neonates and infants, current devices face performance issues with most of the drug never reaching the target lung location. Previous work has aimed to improve pulmonary drug deposition, yet nebulizer efficiency remains low. The development of an inhalant therapy that is efficacious and safe for pediatrics depends on a well-designed delivery system and formulation. To accomplish this, the field needs to rethink the current practice of basing pediatric treatments on adult studies. The rapidly evolving pediatric patient (i.e. neonates to eighteen) needs to be considered because they are different from adults with respect to airway anatomy, breathing patterns, and adherence. Previous research approaches to improve deposition efficiency have been limited due to the complexity of combining physics, which drives aerosol transport and deposition, and biology, especially within the area of pediatrics. To address these critical knowledge gaps, we need a better understanding of how patient age and disease state affect deposition of aerosolized drugs. The complexity of the multiscale respiratory system makes scientific investigation very challenging. The authors have simplified the complex problem into five components with these three areas as ones to address first: how the aerosol is (i) generated in a medical device, (ii) delivered to the patient, and (iii) deposited inside the lung. In this review, we discuss the technological advances and innovations made from experiments, simulations, and predictive models in each of these areas. In addition, we discuss the impact on patient treatment efficacy and recommend a clinical direction, with a focus on pediatrics. In each area, a series of research questions are posed and steps for future research to improve efficacy in aerosol drug delivery are outlined.
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Affiliation(s)
- Jennifer A O'Neil
- College of Engineering Technology, Department of Manufacturing and Mechanical Engineering Technology, Rochester Institute of Technology, 78 Lomb Memorial Drive, Golisano Hall 1361, Rochester, NY, USA.
| | - Larry A Villasmil-Urdaneta
- College of Engineering Technology, Department of Manufacturing and Mechanical Engineering Technology, Rochester Institute of Technology, Rochester, NY, USA
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18
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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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19
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Al-Jipouri A, Almurisi SH, Al-Japairai K, Bakar LM, Doolaanea AA. Liposomes or Extracellular Vesicles: A Comprehensive Comparison of Both Lipid Bilayer Vesicles for Pulmonary Drug Delivery. Polymers (Basel) 2023; 15:polym15020318. [PMID: 36679199 PMCID: PMC9866119 DOI: 10.3390/polym15020318] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 12/31/2022] [Accepted: 01/01/2023] [Indexed: 01/11/2023] Open
Abstract
The rapid and non-invasive pulmonary drug delivery (PDD) has attracted great attention compared to the other routes. However, nanoparticle platforms, like liposomes (LPs) and extracellular vesicles (EVs), require extensive reformulation to suit the requirements of PDD. LPs are artificial vesicles composed of lipid bilayers capable of encapsulating hydrophilic and hydrophobic substances, whereas EVs are natural vesicles secreted by cells. Additionally, novel LPs-EVs hybrid vesicles may confer the best of both. The preparation methods of EVs are distinguished from LPs since they rely mainly on extraction and purification, whereas the LPs are synthesized from their basic ingredients. Similarly, drug loading methods into/onto EVs are distinguished whereby they are cell- or non-cell-based, whereas LPs are loaded via passive or active approaches. This review discusses the progress in LPs and EVs as well as hybrid vesicles with a special focus on PDD. It also provides a perspective comparison between LPs and EVs from various aspects (composition, preparation/extraction, drug loading, and large-scale manufacturing) as well as the future prospects for inhaled therapeutics. In addition, it discusses the challenges that may be encountered in scaling up the production and presents our view regarding the clinical translation of the laboratory findings into commercial products.
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Affiliation(s)
- Ali Al-Jipouri
- Institute for Transfusion Medicine, University Hospital Essen, University of Duisburg-Essen, D-45147 Essen, Germany
- Correspondence: (A.A.-J.); (A.A.D.)
| | - Samah Hamed Almurisi
- Department of Pharmaceutical Technology, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan 25200, Malaysia
| | - Khater Al-Japairai
- Department of Pharmaceutical Engineering, Faculty of Chemical and Process Engineering Technology, Universiti Malaysia Pahang, Gambang 26300, Malaysia
| | - Latifah Munirah Bakar
- Faculty of Applied Sciences, Universiti Teknologi MARA (UiTM) Selangor, Shah Alam 40450, Malaysia
| | - Abd Almonem Doolaanea
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University College MAIWP International (UCMI), Kuala Lumpur 68100, Malaysia
- Correspondence: (A.A.-J.); (A.A.D.)
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20
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Elbardisy B, Boraie N, Galal S. Tadalafil Nanoemulsion Mists for Treatment of Pediatric Pulmonary Hypertension via Nebulization. Pharmaceutics 2022; 14:pharmaceutics14122717. [PMID: 36559211 PMCID: PMC9784672 DOI: 10.3390/pharmaceutics14122717] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/20/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Oral tadalafil (TD) proved promising in treating pediatric pulmonary arterial hypertension (PAH). However, to ensure higher efficacy and reduce the systemic side effects, targeted delivery to the lungs through nebulization was proposed as an alternative approach. This poorly soluble drug was previously dissolved in nanoemulsions (NEs). However, the formulations could not resist aqueous dilution, which precluded its dilution with saline for nebulization. Thus, the current study aimed to modify the previous systems into dilutable TD-NEs and assess their suitability for a pulmonary application. In this regard, screening of various excipients was conducted to optimize the former systems; different formulations were selected and characterized in terms of physicochemical properties, nebulization performance, stability following sterilization, and biocompatibility. Results showed that the optimal system comprised of Capmul-MCM-EP:Labrafac-lipophile (1:1) (w/w) as oil, Labrasol:Poloxamer-407 (2:1) (w/w) as surfactant mixture (Smix) and water. The optimum formulation P2TD resisted aqueous dilution, exhibited reasonable drug loading (2.45 mg/mL) and globule size (25.04 nm), acceptable pH and viscosity for pulmonary administration, and could be aerosolized using a jet nebulizer. Moreover, P2TD demonstrated stability following sterilization and a favorable safety profile confirmed by both in-vitro and in-vivo toxicity studies. These favorable findings make P2TD promising for the treatment of pediatric PAH.
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Affiliation(s)
- Bassant Elbardisy
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University, Alexandria 21521, Egypt
- Institute for Technical Chemistry, Braunschweig University of Technology, Hagenring 30, 38106 Braunschweig, Germany
- Correspondence: or
| | - Nabila Boraie
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University, Alexandria 21521, Egypt
| | - Sally Galal
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University, Alexandria 21521, Egypt
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21
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Kang JH, Yang MS, Kwon TK, Kim DW, Park CW. Inhaled deep eutectic solvent based-nanoemulsion of pirfenidone in idiopathic pulmonary fibrosis. J Control Release 2022; 352:570-585. [PMID: 36341935 DOI: 10.1016/j.jconrel.2022.10.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
Pirfenidone (PRF), the first FDA-approved drug to treat idiopathic pulmonary fibrosis (IPF) and formulated as an oral dosage form, has many side effects. To enhance the therapeutic effect, we discovered a high-load nanoemulsion using a novel deep eutectic solvent (DES) and developed an inhalation drug with improved bioavailability. The DES of PRF and N-acetylcysteine were discovered, and their physicochemical properties were evaluated in this study. The mechanism of DES formation was confirmed by FT-IR and 1H NMR and suggested to involve hydrogen bonding. The DES nanoemulsion in which the nano-sized droplets were dispersed is optimized by mixing the DES and distilled water in a ratio. The in vivo pharmacokinetic study showed that the pulmonary route of administration is superior to that of the oral route, and the DES nanoemulsion is superior to that of the PRF solution in achieving better bioavailability and lung distribution. The therapeutic effect of PRF for IPF could be confirmed through in vivo pharmacodynamics studies, including lung function assessment, enzyme-linked immunosorbent assay, histology, and micro-computed tomography using the bleomycin-induced IPF rat model. In addition, the pulmonary route administration of PRF is advantageous in reducing the toxicity risk.
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Affiliation(s)
- Ji-Hyun Kang
- College of Pharmacy, Chungbuk National University, Cheongju, Republic of Korea
| | - Min-Seok Yang
- College of Pharmacy, Chungbuk National University, Cheongju, Republic of Korea
| | - Taek Kwan Kwon
- College of Pharmacy, Chungbuk National University, Cheongju, Republic of Korea
| | - Dong-Wook Kim
- College of Pharmacy, Wonkwang University, Iksan, Republic of Korea
| | - Chun-Woong Park
- College of Pharmacy, Chungbuk National University, Cheongju, Republic of Korea.
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22
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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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23
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Yadav D, Wairagu PM, Kwak M, Jin JO, Jin JO. Nanoparticle-Based Inhalation Therapy for Pulmonary Diseases. Curr Drug Metab 2022; 23:882-896. [PMID: 35927812 DOI: 10.2174/1389200223666220803103039] [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: 02/01/2022] [Revised: 04/04/2022] [Accepted: 04/29/2022] [Indexed: 01/05/2023]
Abstract
The lung is exposed to various pollutants and is the primary site for the onset of various diseases, including infections, allergies, and cancers. One possible treatment approach for such pulmonary diseases involves direct administration of therapeutics to the lung so as to maintain the topical concentration of the drug. Particles with nanoscale diameters tend to reach the pulmonary region. Nanoparticles (NPs) have garnered significant interest for applications in biomedical and pharmaceutical industries because of their unique physicochemical properties and biological activities. In this article, we describe the biological and pharmacological activities of NPs as well as summarize their potential in the formulation of drugs employed to treat pulmonary diseases. Recent advances in the use of NPs in inhalation chemotherapy for the treatment of lung diseases have also been highlighted.
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Affiliation(s)
- Dhananjay Yadav
- Department of Life Science, Yeungnam University, Gyeongsan 38541, South Korea
| | - Peninah M Wairagu
- Department of Biochemistry and Biotechnology, The Technical University of Kenya, Nairobi, Kenya
| | - Minseok Kwak
- Department of Chemistry, Pukyong National University, Busan 48513, Korea
| | - Jun-O Jin
- Department of Microbiology, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jun-O Jin
- Department of Biotechnology, ITM University, Gwalior, Madhya Pradesh, 474011, India.,Research Institute of Cell Culture, Yeungnam University, Gyeongsan 38541, Korea
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Li Y, Cai S, Shen H, Chen Y, Ge Z, Yang W. Recent advances in acoustic microfluidics and its exemplary applications. BIOMICROFLUIDICS 2022; 16:031502. [PMID: 35712527 PMCID: PMC9197543 DOI: 10.1063/5.0089051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/24/2022] [Indexed: 05/14/2023]
Abstract
Acoustic-based microfluidics has been widely used in recent years for fundamental research due to its simple device design, biocompatibility, and contactless operation. In this article, the basic theory, typical devices, and technical applications of acoustic microfluidics technology are summarized. First, the theory of acoustic microfluidics is introduced from the classification of acoustic waves, acoustic radiation force, and streaming flow. Then, various applications of acoustic microfluidics including sorting, mixing, atomization, trapping, patterning, and acoustothermal heating are reviewed. Finally, the development trends of acoustic microfluidics in the future were summarized and looked forward to.
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Affiliation(s)
- Yue Li
- School of Electromechanical and Automotive Engineering, Yantai University, Yantai 264005, China
| | - Shuxiang Cai
- School of Electromechanical and Automotive Engineering, Yantai University, Yantai 264005, China
| | - Honglin Shen
- School of Electromechanical and Automotive Engineering, Yantai University, Yantai 264005, China
| | - Yibao Chen
- School of Electromechanical and Automotive Engineering, Yantai University, Yantai 264005, China
| | - Zhixing Ge
- State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of Sciences, Shenyang 110016, China
| | - Wenguang Yang
- School of Electromechanical and Automotive Engineering, Yantai University, Yantai 264005, China
- Author to whom correspondence should be addressed:
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25
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Naidu H, Kahraman O, Feng H. Novel applications of ultrasonic atomization in the manufacturing of fine chemicals, pharmaceuticals, and medical devices. ULTRASONICS SONOCHEMISTRY 2022; 86:105984. [PMID: 35395443 PMCID: PMC8991379 DOI: 10.1016/j.ultsonch.2022.105984] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/03/2022] [Accepted: 03/15/2022] [Indexed: 06/14/2023]
Abstract
Liquid atomization as a fluid disintegration method has been used in many industrial applications such as spray drying, coating, incineration, preparation of emulsions, medical devices, etc. The usage of ultrasonic energy for atomizing liquid is gaining interest as a green and energy-efficient alternative to traditional mechanical atomizers. In the past two decades, efforts have been made to explore new applications of ultrasonic misting for downstream separation of chemicals, e.g., bioethanol, from their aqueous solutions. Downstream separation of a chemical from its aqueous solutions is known to be an energy-intensive process. Conventional distillation is featured by low energy efficiency and inability to separate azeotropic mixtures, and thus novel alternatives, such as ultrasonic separation have been explored to advance the separation technology. Ultrasonic misting has been reported to generate mist and vapor mixture in a gaseous phase that is enriched in solute (e.g., ethanol), under non-thermal, non-equilibrium, and phase change free conditions. This review article takes an in-depth look into the recent advancements in ultrasound-mediated separation of organic molecules, especially bioethanol, from their aqueous solutions. An effort was made to analyze and compare the experimental setups used, mist collection methods, droplet size distribution, and separation mechanism. In addition, the applications of ultrasonic atomization in the production of pharmaceuticals and medical devices are discussed.
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Affiliation(s)
- Haripriya Naidu
- Department of Food Science and Human Nutrition, University of Illinois Urbana Champaign, 1304 West Pennsylvania Avenue, Urbana, IL 61801, USA.
| | - Ozan Kahraman
- Applied Food Sciences, 2500 Crosspark Road, Coralville, IA 52241, USA.
| | - Hao Feng
- Department of Food Science and Human Nutrition, University of Illinois Urbana Champaign, 1304 West Pennsylvania Avenue, Urbana, IL 61801, USA; Department of Agricultural and Biological Engineering, University of Illinois Urbana Champaign, 1304 West Pennsylvania Avenue, Urbana, IL 61801, USA.
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26
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Otto M, Kropp Y, Viergutz T, Thiel M, Tsagogiorgas C. [Nebulization of emergency medications in the south German rescue service]. Anaesthesist 2022; 71:110-116. [PMID: 34156480 PMCID: PMC8218572 DOI: 10.1007/s00101-021-00992-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/18/2021] [Accepted: 04/23/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND In German emergency rescue services, inhalation treatment is routinely carried out by qualified health personnel. Standard operating procedures (SOP) for nebulization are neither uniform throughout Germany nor available in all federal states. Standardized recommendations with respect to which nebulizer type should be used are missing. The aerosol output as well as the drug deposition rates of jet and mesh nebulizers, however, differ considerably. Mesh devices can achieve a threefold higher lung deposition. Their use in emergency departments has also been shown to be associated with a better patient outcome when compared to jet nebulizers. OBJECTIVE This survey was designed to evaluate the type of nebulizer used in the south German rescue services. Special attention was paid to the influence of existing SOP on the decision to perform nebulization during emergency treatment. MATERIAL AND METHODS A total of 4800 emergency paramedics working in Baden-Württemberg, Bavaria and Rhineland-Palatinate received a questionnaire with a total of 17 questions on the implementation of drug nebulization in the daily practice. RESULTS Despite the existence of more efficient nebulizer types, the jet nebulizer was by far the most frequently used nebulizer in the south German rescue services. The deposition rates of both the jet and mesh nebulizers were considerably overestimated by most respondents; however, 77.5% of all respondents could not give any information about the deposition rates of the mesh nebulizer. Only two thirds of all respondents carried out nebulization treatment on the basis of SOP. The implementation of SOP, however, was pivotal to the application of nebulization during emergencies. If SOP were in place,76.9% of the responders used aerosol treatment compared to 23.1% when there were none. The perceived safety when using nebulization during emergencies was also significantly higher (p = 0.013) when SOP were implemented. CONCLUSION The exclusive use of mesh nebulizers could standardize the treatment of emergency patients in the south German rescue services. The use of mesh devices might possibly improve patient outcomes, even if clinical studies are still lacking. Nebulizer treatment differs between the federal states. A comprehensive implementation of SOP for nebulization treatment might support this process and could increase the application frequency and the perceived safety of nebulization during emergencies. A better training of paramedic personnel could improve the knowledge of aerosols as a treatment option for emergency patients and help to classify the advantages and disadvantages of the different aerosol generators available.
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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
| | - T Viergutz
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, 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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Anderson S, Atkins P, Bäckman P, Cipolla D, Clark A, Daviskas E, Disse B, Entcheva-Dimitrov P, Fuller R, Gonda I, Lundbäck H, Olsson B, Weers J. Inhaled Medicines: Past, Present, and Future. Pharmacol Rev 2022; 74:48-118. [PMID: 34987088 DOI: 10.1124/pharmrev.120.000108] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/06/2021] [Indexed: 12/21/2022] Open
Abstract
The purpose of this review is to summarize essential pharmacological, pharmaceutical, and clinical aspects in the field of orally inhaled therapies that may help scientists seeking to develop new products. After general comments on the rationale for inhaled therapies for respiratory disease, the focus is on products approved approximately over the last half a century. The organization of these sections reflects the key pharmacological categories. Products for asthma and chronic obstructive pulmonary disease include β -2 receptor agonists, muscarinic acetylcholine receptor antagonists, glucocorticosteroids, and cromones as well as their combinations. The antiviral and antibacterial inhaled products to treat respiratory tract infections are then presented. Two "mucoactive" products-dornase α and mannitol, which are both approved for patients with cystic fibrosis-are reviewed. These are followed by sections on inhaled prostacyclins for pulmonary arterial hypertension and the challenging field of aerosol surfactant inhalation delivery, especially for prematurely born infants on ventilation support. The approved products for systemic delivery via the lungs for diseases of the central nervous system and insulin for diabetes are also discussed. New technologies for drug delivery by inhalation are analyzed, with the emphasis on those that would likely yield significant improvements over the technologies in current use or would expand the range of drugs and diseases treatable by this route of administration. SIGNIFICANCE STATEMENT: This review of the key aspects of approved orally inhaled drug products for a variety of respiratory diseases and for systemic administration should be helpful in making judicious decisions about the development of new or improved inhaled drugs. These aspects include the choices of the active ingredients, formulations, delivery systems suitable for the target patient populations, and, to some extent, meaningful safety and efficacy endpoints in clinical trials.
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Affiliation(s)
- Sandra Anderson
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Paul Atkins
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Per Bäckman
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - David Cipolla
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Andrew Clark
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Evangelia Daviskas
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Bernd Disse
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Plamena Entcheva-Dimitrov
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Rick Fuller
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Igor Gonda
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Hans Lundbäck
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Bo Olsson
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Jeffry Weers
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
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Seif SM, Ma E, Rabea H, Saeed H, Abdelrahim MEA. Aerosol delivery of inhalation devices with different add-on connections to invasively ventilated COPD subjects: An in-vivo study. Eur J Pharm Sci 2021; 167:105988. [PMID: 34492291 DOI: 10.1016/j.ejps.2021.105988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/06/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022]
Abstract
Aerosol delivery to mechanically ventilated patients requires add-on connections to place the inhalation device within the ventilation circuit. The study aimed to evaluate the performance of Combihaler in dual limb invasive mechanical ventilation (IMV). A ventilator with a humidified dual limb circuit was adjusted to volume-controlled mode to imitate the adult breathing parameters. 24 (12 females) intubated chronic obstructive pulmonary disease (COPD) subjects had undergone the study. All patients were prescribed inhaled salbutamol dose delivered by either a metered-dose inhaler (pMDI) or vibrating mesh nebulizer (VMN). Each subject received salbutamol in four different inhalation device/connection conditions; pMDI+VMN+Combihaler, VMN+Combihaler, VMN+T-piece, and pMDI+T-piece. They were individually placed in the inspiratory limb at Y-piece. 5mg salbutamol was delivered by VMN with and without 2 pMDI puffs of salbutamol (100 µg), and 500µg was delivered by pMDI+T-piece. After aerosol delivery, two urine samples were collected from the patient; 30 min post-inhalation (USAL0.5) and cumulatively 24 h post-inhalation (USAL24) as indexes of lung deposition and systemic absorption, respectively. For the ex-vivo study, a collecting filter was placed before an endotracheal tube (ETT) to collect the delivered inhalable dose. In-vitro aerodynamic characteristics were also investigated. pMDI+VMN+Combihaler delivered more salbutamol to the lung and the ex-vivo filter than VMN+T-piece (p˂0.05, p≤0.01, respectively). VMN delivered a higher salbutamol amount to the lung, systemically, and the ex-vivo filter than pMDI+T-piece (p˂0.001). pMDI+VMN+Combihaler and VMN+Combihaler delivered aerosols with a less mass median aerodynamic diameter (MMAD) and higher fine particle fraction (FPF) compared to VMN+T-piece (p≤0.01 for MMAD, p˂0.01 for FPF) and pMDI+T-piece (p˂0.01 for both MMAD and FPF). Results of the study showed that pMDI+VMN+ Combihaler delivered more salbutamol than VMN+T-piece in IMV and demonstrate that 5 puffs (500-µg) of salbutamol with pMDI+T-piece has a lower aerosol delivering power at the level of USAL0.5, USAL24, and the ex-vivo inhalable dose than 5 mg nebulized salbutamol by VMNs in IMV.
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Affiliation(s)
- Salah M Seif
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Elnady Ma
- Chest Diseases Department, Kasr Al Einy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hoda Rabea
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Haitham Saeed
- 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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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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30
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Effect of functional principle, delivery technique, and connection used on aerosol delivery from different nebulizers: An in-vitro study. Pulm Pharmacol Ther 2021; 70:102054. [PMID: 34280581 DOI: 10.1016/j.pupt.2021.102054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/15/2021] [Accepted: 07/11/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Nebulizers can be divided according to their functional principle into jet, ultrasonic and vibrating mesh nebulizers with intermittent or continuous aerosol delivery and may be used with many different adapters and connections and all can influence their efficiency. The aim of the present work was to evaluate the effect functional principle, delivery technique, and connection used on aerosol delivered from four different nebulizers. METHODS Four nebulizers were used in the study; three of them were jet nebulizers (JNs; AeroEclipse, NebuTech, En ful Kit) and one of them was Aerogen Solo vibrating mesh nebulizers (VMN). AeroEclipse and NebuTech are intermittent output nebulizers, while the rest are continuous output nebulizers. Aerogen Solo was used with either a standard T-piece or Aerogen Ultra holding chamber, and En ful Kit was used with a standard T-piece or Circulaire II holding chamber. 2 ml of salbutamol was nebulized to determine the total emitted dose (TED) and aerodynamic droplet characteristics of the emitted aerosol from the 6 different sets (4 nebulizers with T-piece and 2 holding chambers). RESULTS The mean ± SD TED from VMN was significantly higher than all the JNs (p < 0.05). Aerogen Ultra with VMN did not show a significant effect on TED compare to T-piece, but it significantly increased (p < 0.05) fine particle dose (FPD; 3091.5 ± 189.4 μg) and fine particle fraction (FPF; 72.7 ± 3.6%). However, the Circulaire II with En ful Kit had significantly higher TED, FPD, and FPF compared to T-piece (p < 0.05). Intermittent JNs (AeroEclipse and NebuTech) had significantly higher TED (p < 0.05) compared to the continuous JNs (En ful Kit) with no significant effect on the other parameters studied. AeroEclipse had the highest MMAD and Aerogen Solo Ultra has the lowest in MMAD. CONCLUSIONS The functional principle, delivery technique, and connection used had a significant effect on aerosol delivered from nebulizers. VMNs are significantly better than JNs. Intermittent delivery has significantly better TED than continuous delivery. Holding chamber with both VMNs and JNs improved aerosol delivery compared to standard T-piece.
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Dau VT, Bui TT, Tran CD, Nguyen TV, Nguyen TK, Dinh T, Phan HP, Wibowo D, Rehm BHA, Ta HT, Nguyen NT, Dao DV. In-air particle generation by on-chip electrohydrodynamics. LAB ON A CHIP 2021; 21:1779-1787. [PMID: 33730135 DOI: 10.1039/d0lc01247e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Electrohydrodynamic atomization has been emerging as a powerful approach for respiratory treatment, including the generation and delivery of micro/nanoparticles as carriers for drugs and antigens. In this work, we present a new conceptual design in which two nozzles facilitate dual electrospray coexisting with ionic wind at chamfered tips by a direct current power source. Experimental results by a prototype have demonstrated the capability of simultaneously generating-and-delivering a stream of charged reduced particles. The concept can be beneficial to pulmonary nano-medicine delivery since the mist of nanoparticles is migrated without any restriction of either the collector or the assistance of external flow, but is pretty simple in designing and manufacturing devices.
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Affiliation(s)
- Van T Dau
- School of Engineering and Built Environment, Griffith University, Australia. and Centre of Catalysis and Clean Energy, Griffith University, Australia
| | - Tung T Bui
- University of Engineering and Technology, Vietnam National University, Hanoi, Vietnam
| | - Canh-Dung Tran
- School of Mechanical and Electrical Engineering, University of Southern Queensland, Australia
| | - Thanh Viet Nguyen
- Queensland Micro and Nanotechnology Centre, Griffith University, Australia
| | - Tuan-Khoa Nguyen
- Queensland Micro and Nanotechnology Centre, Griffith University, Australia
| | - Toan Dinh
- School of Mechanical and Electrical Engineering, University of Southern Queensland, Australia
| | - Hoang-Phuong Phan
- Queensland Micro and Nanotechnology Centre, Griffith University, Australia
| | - David Wibowo
- Centre for Cell Factories and Biopolymers, Griffith Institute for Drug Discovery, Griffith University, Australia
| | - Bernd H A Rehm
- Centre for Cell Factories and Biopolymers, Griffith Institute for Drug Discovery, Griffith University, Australia
| | - Hang Thu Ta
- Queensland Micro and Nanotechnology Centre, Griffith University, Australia and School of Environment and Science, Griffith University, Australia
| | - Nam-Trung Nguyen
- Queensland Micro and Nanotechnology Centre, Griffith University, Australia
| | - Dzung V Dao
- School of Engineering and Built Environment, Griffith University, Australia. and Queensland Micro and Nanotechnology Centre, Griffith University, Australia
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Lin HL, Fink JB, Ge H. Aerosol delivery via invasive ventilation: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:588. [PMID: 33987286 DOI: 10.21037/atm-20-5665] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In comparison with spontaneously breathing non-intubated subjects, intubated, mechanically ventilated patients encounter various challenges, barriers, and opportunities in receiving medical aerosols. Since the introduction of mechanical ventilation as a part of modern critical care medicine during the middle of the last century, aerosolized drug delivery by jet nebulizers has become a common practice. However, early evidence suggested that aerosol generators differed in their efficacies, and the introduction of newer aerosol technology (metered dose inhalers, ultrasonic nebulizer, vibrating mesh nebulizers, and soft moist inhaler) into the ventilator circuit opened up the possibility of optimizing inhaled aerosol delivery during mechanical ventilation that could meet or exceed the delivery of the same aerosols in spontaneously breathing patients. This narrative review will catalogue the primary variables associated with this process and provide evidence to guide optimal aerosol delivery and dosing during mechanical ventilation. While gaps exist in relation to the appropriate aerosol drug dose, discrepancies in practice, and cost-effectiveness of the administered aerosol drugs, we also present areas for future research and practice. Clinical practice should expand to incorporate these techniques to improve the consistency of drug delivery and provide safer and more effective care for patients.
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Affiliation(s)
- Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan.,Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi.,Department of Respiratory Therapy, Chiayi Chang Gung Memorial Hospital, Chiayi
| | - James B Fink
- Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA.,Aerogen Pharma Corp., San Mateo, California, USA
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Mayor A, Thibert B, Huille S, Respaud R, Audat H, Heuzé-Vourc'h N. Inhaled antibodies: formulations require specific development to overcome instability due to nebulization. Drug Deliv Transl Res 2021; 11:1625-1633. [PMID: 33768475 PMCID: PMC7993445 DOI: 10.1007/s13346-021-00967-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 12/13/2022]
Abstract
Abstract Respiratory infections are life-threatening and therapeutic antibodies (Ab) have a tremendous opportunity to benefit to patients with pneumonia due to multidrug resistance bacteria or emergent virus, before a vaccine is manufactured. In respiratory infections, inhalation of anti-infectious Ab may be more relevant than intravenous (IV) injection-the standard route-to target the site of infection and improve Ab therapeutic index. One major challenge associated to Ab inhalation is to prevent protein instability during the aerosolization process. Ab drug development for IV injection aims to design a high-quality product, stable to different environment stress. In this study, we evaluated the suitability of Ab formulations developed for IV injection to be extended for inhalation delivery. We studied the aerosol characteristics and the aggregation profile of three Ab formulations developed for IV injection after nebulization, with two mesh nebulizers. Although the formulations for IV injection were compatible with mesh nebulization and deposition into the respiratory tract, the Ab were more unstable during nebulization than exposition to a vigorous shaking. Overall, our findings indicate that Ab formulations developed for IV delivery may not easily be repurposed for inhalation delivery and point to the requirement of a specific formulation development for inhaled Ab. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s13346-021-00967-w.
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Affiliation(s)
- Alexie Mayor
- INSERM, Centre D'Etude Des Pathologies Respiratoires, Universite François Rabelais de Tours, 10 Boulevard Tonnellé, U1100F-37032, Tours, France
- University of Tours, Tours, France
- Sanofi, Formulation and Process Development, Impasse Des Ateliers, 94400, Vitry-sur-Seine, France
| | - Béatrice Thibert
- Sanofi, Formulation and Process Development, Impasse Des Ateliers, 94400, Vitry-sur-Seine, France
| | - Sylvain Huille
- Sanofi, Formulation and Process Development, Impasse Des Ateliers, 94400, Vitry-sur-Seine, France
| | | | - Héloïse Audat
- Sanofi, Formulation and Process Development, Impasse Des Ateliers, 94400, Vitry-sur-Seine, France
| | - Nathalie Heuzé-Vourc'h
- INSERM, Centre D'Etude Des Pathologies Respiratoires, Universite François Rabelais de Tours, 10 Boulevard Tonnellé, U1100F-37032, Tours, France.
- University of Tours, Tours, France.
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Klenk FK, DeSimoi V, Wolf G, Schulz BS. Evaluation of different cleaning methods for feline inhalation chambers after bacterial contamination. J Feline Med Surg 2021; 23:181-184. [PMID: 32228277 PMCID: PMC10741356 DOI: 10.1177/1098612x20913352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Inhalation chambers are commonly used for the delivery of aerosol drugs to cats with respiratory disease. The aim of the study was to identify successful cleaning methods for inhalation devices after standardised bacterial contamination. METHODS Spacer devices of two different manufacturers were used: RC Chamber (Cegla Medizintechnik) and Aerokat (Trudell Medical International). The bacterial contamination was performed using Pseudomonas aeruginosa. Previously marked areas of the chamber were contaminated with 50 μl of bacterial solution, containing between 2.2 ×105 and 2.1 ×108 colony-forming units/ml each. After cleaning the devices as recommended by each manufacturer (RC Chamber: special microwave cleaning bag [n = 5] or boiling water with liquid dish detergent for 15 mins [n = 5]; Aerokat: rinsing in a solution of lukewarm water and liquid dish detergent for 15 mins), chambers were air-dried for 24 h and samples for bacterial culture were taken from three defined areas. Sample material was applied on Müller-Hinton agar plates and subsequently incubated for 24 h at 37°C. RESULTS Bacterial contamination was not detected in any of the examined inhalation devices using the recommended cleaning methods. CONCLUSIONS AND RELEVANCE If inhalation chambers are cleaned following the manufacturers' recommendations, successful bacterial decontamination can be expected.
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Affiliation(s)
- Friederike K Klenk
- Clinic of Small Animal Medicine, LMU
University of Munich, Munich, Germany
| | - Vanessa DeSimoi
- Clinic of Small Animal Medicine, LMU
University of Munich, Munich, Germany
| | - Georg Wolf
- Institute for Infectious Diseases and
Zoonoses, LMU University of Munich, Munich, Germany
| | - Bianka S Schulz
- Clinic of Small Animal Medicine, LMU
University of Munich, Munich, Germany
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Wang Y, Zhang L, Wu GR, Zhou Q, Yue H, Rao LZ, Yuan T, Mo B, Wang FX, Chen LM, Sun F, Song J, Xiong F, Zhang S, Yu Q, Yang P, Xu Y, Zhao J, Zhang H, Xiong W, Wang CY. MBD2 serves as a viable target against pulmonary fibrosis by inhibiting macrophage M2 program. SCIENCE ADVANCES 2021; 7:sciadv.abb6075. [PMID: 33277324 PMCID: PMC7775789 DOI: 10.1126/sciadv.abb6075] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 10/29/2020] [Indexed: 05/22/2023]
Abstract
Despite past extensive studies, the mechanisms underlying pulmonary fibrosis (PF) still remain poorly understood. Here, we demonstrated that lungs originating from different types of patients with PF, including coronavirus disease 2019, systemic sclerosis-associated interstitial lung disease, and idiopathic PF, and from mice following bleomycin (BLM)-induced PF are characterized by the altered methyl-CpG-binding domain 2 (MBD2) expression in macrophages. Depletion of Mbd2 in macrophages protected mice against BLM-induced PF. Mbd2 deficiency significantly attenuated transforming growth factor-β1 (TGF-β1) production and reduced M2 macrophage accumulation in the lung following BLM induction. Mechanistically, Mbd2 selectively bound to the Ship promoter in macrophages, by which it repressed Ship expression and enhanced PI3K/Akt signaling to promote the macrophage M2 program. Therefore, intratracheal administration of liposomes loaded with Mbd2 siRNA protected mice from BLM-induced lung injuries and fibrosis. Together, our data support the possibility that MBD2 could be a viable target against PF in clinical settings.
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Affiliation(s)
- Yi Wang
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Lei Zhang
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Guo-Rao Wu
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Qing Zhou
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Huihui Yue
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Li-Zong Rao
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Guilin Medical University, 212 Renmin Road, Guilin 541000, China
| | - Ting Yuan
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Guilin Medical University, 212 Renmin Road, Guilin 541000, China
| | - Biwen Mo
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Guilin Medical University, 212 Renmin Road, Guilin 541000, China
| | - Fa-Xi Wang
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Long-Min Chen
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Fei Sun
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Jia Song
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Fei Xiong
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Shu Zhang
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Qilin Yu
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Ping Yang
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Yongjian Xu
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Jianping Zhao
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China
| | - Huilan Zhang
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China.
| | - Weining Xiong
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China.
- Department of Respiratory Medicine, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Lu, Shanghai 200011, China
| | - Cong-Yi Wang
- The Center for Biomedical Research, NHC Key Laboratory of Respiratory Diseases, Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, 1095 Jiefang Ave., Wuhan 430030, China.
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Matthews AA, Ee PLR, Ge R. Developing inhaled protein therapeutics for lung diseases. MOLECULAR BIOMEDICINE 2020; 1:11. [PMID: 34765995 PMCID: PMC7595758 DOI: 10.1186/s43556-020-00014-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/15/2020] [Indexed: 12/28/2022] Open
Abstract
Biologic therapeutics such as protein/polypeptide drugs are conventionally administered systemically via intravenous injection for the treatment of diseases including lung diseases, although this approach leads to low target site accumulation and the potential risk for systemic side effects. In comparison, topical delivery of protein drugs to the lung via inhalation is deemed to be a more effective approach for lung diseases, as proteins would directly reach the target in the lung while exhibiting poor diffusion into the systemic circulation, leading to higher lung drug retention and efficacy while minimising toxicity to other organs. This review examines the important considerations and challenges in designing an inhaled protein therapeutics for local lung delivery: the choice of inhalation device, structural changes affecting drug deposition in diseased lungs, clearance mechanisms affecting an inhaled protein drug’s lung accumulation, protein stability, and immunogenicity. Possible approaches to overcoming these issues will also be discussed.
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Lin HL, Chen CS, Fink JB, Lee GH, Huang CW, Chen JC, Chiang ZY. In Vitro Evaluation of a Vibrating-Mesh Nebulizer Repeatedly Use over 28 Days. Pharmaceutics 2020; 12:pharmaceutics12100971. [PMID: 33076232 PMCID: PMC7602390 DOI: 10.3390/pharmaceutics12100971] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 12/20/2022] Open
Abstract
This in vitro study evaluates the performance of a disposable vibrating-mesh nebulizer when used for 28 days. A lung model was used to simulate the breathing pattern of an adult with chronic obstructive pulmonary disease. The vibrating-mesh nebulizer was used for three treatments/day over 28 days without cleaning after each test. Results showed that the inhaled drug dose was similar during four weeks of use (p = 0.157), with 16.73 ± 4.46% at baseline and 15.29 ± 2.45%, 16.21 ± 2.21%, 17.56 ± 1.98%, and 17.13 ± 1.81%, after the first, second, third, and fourth weeks, respectively. The particle size distribution, residual drug volume, and nebulization time remained similar across four weeks of use (p = 0.110, p = 0.763, and p = 0.573, respectively). Mesh was inspected using optical microscopy and showed that approximately 50% of mesh pores were obscured after 84 runs, and light penetration through the aperture plate was significantly reduced after the 21st use (p < 0.001) with no correlation to nebulizer performance. We conclude that the vibrating-mesh nebulizer delivered doses of salbutamol solution effectively over four weeks without cleaning after each use even though the patency and clarity of the aperture plate were reduced by the first week of use.
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Affiliation(s)
- Hui-Ling Lin
- Department of Respiratory Therapy, Collage of Medicine, Chang Gung University, Taoyuan 33301, Taiwan; (G.-H.L.); (C.-W.H.); (J.-C.C.); (Z.Y.C.)
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chiayi 61301, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 61301, Taiwan
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu City 30013, Taiwan;
- Correspondence:
| | - Chi-Shuo Chen
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu City 30013, Taiwan;
| | - James B. Fink
- Aerogen Pharma Corp., San Mateo, CA 94043, USA;
- Department of Respiratory Care, University of Texas, Round Rock, TX 78665, USA
| | - Guo-Hao Lee
- Department of Respiratory Therapy, Collage of Medicine, Chang Gung University, Taoyuan 33301, Taiwan; (G.-H.L.); (C.-W.H.); (J.-C.C.); (Z.Y.C.)
| | - Chun-Wei Huang
- Department of Respiratory Therapy, Collage of Medicine, Chang Gung University, Taoyuan 33301, Taiwan; (G.-H.L.); (C.-W.H.); (J.-C.C.); (Z.Y.C.)
| | - Jui-Chi Chen
- Department of Respiratory Therapy, Collage of Medicine, Chang Gung University, Taoyuan 33301, Taiwan; (G.-H.L.); (C.-W.H.); (J.-C.C.); (Z.Y.C.)
| | - Zi Yi Chiang
- Department of Respiratory Therapy, Collage of Medicine, Chang Gung University, Taoyuan 33301, Taiwan; (G.-H.L.); (C.-W.H.); (J.-C.C.); (Z.Y.C.)
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Douafer H, Andrieu V, Wafo E, Brunel JM. Characterization of a new aerosol antibiotic/adjuvant combination for the treatment of P. aeruginosa lung infections. Int J Pharm 2020; 586:119548. [DOI: 10.1016/j.ijpharm.2020.119548] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 12/27/2022]
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Douafer H, Andrieu V, Brunel JM. Scope and limitations on aerosol drug delivery for the treatment of infectious respiratory diseases. J Control Release 2020; 325:276-292. [PMID: 32652109 DOI: 10.1016/j.jconrel.2020.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 01/24/2023]
Abstract
The rise of antimicrobial resistance has created an urgent need for the development of new methods for antibiotics delivery to patients with pulmonary infections in order to mainly increase the effectiveness of the drugs administration, to minimize the risk of emergence of resistant strains, and to prevent patients reinfection. Since bacterial resistance is often related to antibiotic concentration, their pulmonary administration could eradicate strains resistant to the same drug at the concentration achieved through the systemic circulation. Pulmonary administration offers several advantages; it directly targets the site of the infection which allows the inhaled dose of the drug to be reduced compared to that administered orally or parenterally while keeping the same local effect. The review article is made with an objective to compile information about various existing modern technologies developed to provide greater patient compliance and reduce the undesirable side effect of the drugs. In conclusion, aerosol antibiotic delivery appears as one of the best technologies for the treatment of pulmonary infectious diseases and able to limit the systemic adverse effects related to the high drug dose and to make life easier for the patients.
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Affiliation(s)
- Hana Douafer
- Aix Marseille Univ, INSERM, SSA, MCT, 13385 Marseille, France
| | - Véronique Andrieu
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, 13385 Marseille, France
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McCarthy SD, González HE, Higgins BD. Future Trends in Nebulized Therapies for Pulmonary Disease. J Pers Med 2020; 10:E37. [PMID: 32397615 PMCID: PMC7354528 DOI: 10.3390/jpm10020037] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/15/2022] Open
Abstract
Aerosol therapy is a key modality for drug delivery to the lungs of respiratory disease patients. Aerosol therapy improves therapeutic effects by directly targeting diseased lung regions for rapid onset of action, requiring smaller doses than oral or intravenous delivery and minimizing systemic side effects. In order to optimize treatment of critically ill patients, the efficacy of aerosol therapy depends on lung morphology, breathing patterns, aerosol droplet characteristics, disease, mechanical ventilation, pharmacokinetics, and the pharmacodynamics of cell-drug interactions. While aerosol characteristics are influenced by drug formulations and device mechanisms, most other factors are reliant on individual patient variables. This has led to increased efforts towards more personalized therapeutic approaches to optimize pulmonary drug delivery and improve selection of effective drug types for individual patients. Vibrating mesh nebulizers (VMN) are the dominant device in clinical trials involving mechanical ventilation and emerging drugs. In this review, we consider the use of VMN during mechanical ventilation in intensive care units. We aim to link VMN fundamentals to applications in mechanically ventilated patients and look to the future use of VMN in emerging personalized therapeutic drugs.
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Affiliation(s)
- Sean D. McCarthy
- Anaesthesia, School of Medicine, National University of Ireland Galway, H91 TK33 Galway, Ireland; (S.D.M.); (H.E.G.)
- Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, H91 TK33 Galway, Ireland
| | - Héctor E. González
- Anaesthesia, School of Medicine, National University of Ireland Galway, H91 TK33 Galway, Ireland; (S.D.M.); (H.E.G.)
- Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, H91 TK33 Galway, Ireland
| | - Brendan D. Higgins
- Physiology, School of Medicine, National University of Ireland Galway, H91 TK33 Galway, Ireland
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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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42
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Sécher T, Mayor A, Heuzé-Vourc'h N. Inhalation of Immuno-Therapeutics/-Prophylactics to Fight Respiratory Tract Infections: An Appropriate Drug at the Right Place! Front Immunol 2019; 10:2760. [PMID: 31849954 PMCID: PMC6896187 DOI: 10.3389/fimmu.2019.02760] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/12/2019] [Indexed: 01/18/2023] Open
Affiliation(s)
- Thomas Sécher
- INSERM U1100, Centre d'Etude des Pathologies Respiratoires, Tours, France.,Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
| | - Alexie Mayor
- INSERM U1100, Centre d'Etude des Pathologies Respiratoires, Tours, France.,Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
| | - Nathalie Heuzé-Vourc'h
- INSERM U1100, Centre d'Etude des Pathologies Respiratoires, Tours, France.,Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
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43
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Anderson CF, Chakroun RW, Su H, Mitrut RE, Cui H. Interface-Enrichment-Induced Instability and Drug-Loading-Enhanced Stability in Inhalable Delivery of Supramolecular Filaments. ACS NANO 2019; 13:12957-12968. [PMID: 31651153 PMCID: PMC7043235 DOI: 10.1021/acsnano.9b05556] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Filamentous microorganisms traveling in aerosol particles display enhanced deposition and retention in the lungs. Inspired by this shape-related biological effect, we report here on the use of supramolecular filaments as potential inhalable drug carriers within aerosols via jet nebulization. We found that the peptide design and supramolecular stability play a crucial role in the interfacial stability and aerosolization properties of the supramolecular filaments. Monomeric units with a positively charged C-terminus produced filaments with reduced aerosol stability, promoting morphological changes after nebulization. Conversely, having a neutral or negatively charged terminus yielded filaments with enhanced stability, where supramolecular integrity is maintained with only reduced length. Our results suggest that molecular enrichment at the air-liquid interface during nebulization is the primary factor to deplete the monomeric peptide amphiphiles in solution, accounting for the observed morphological disruption/transitions. Importantly, encapsulation of drugs and dyes within filaments notably stabilize their supramolecular structure during nebulization, and the loaded filaments exhibit a linear release profile from a nebulizer device. We envision the use of this supramolecular carrier system as an effective platform for the inhalation-based treatment of many lung diseases.
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Affiliation(s)
- Caleb F. Anderson
- Department of Chemical and Biomolecular Engineering and Institute for NanoBioTechnology, Johns Hopkins University, 3400 North Charles Street, Baltimore, Maryland 21218, United States
| | - Rami W. Chakroun
- Department of Chemical and Biomolecular Engineering and Institute for NanoBioTechnology, Johns Hopkins University, 3400 North Charles Street, Baltimore, Maryland 21218, United States
| | - Hao Su
- Department of Chemical and Biomolecular Engineering and Institute for NanoBioTechnology, Johns Hopkins University, 3400 North Charles Street, Baltimore, Maryland 21218, United States
| | - Roxana E. Mitrut
- Department of Chemical and Biomolecular Engineering and Institute for NanoBioTechnology, Johns Hopkins University, 3400 North Charles Street, Baltimore, Maryland 21218, United States
| | - Honggang Cui
- Department of Chemical and Biomolecular Engineering and Institute for NanoBioTechnology, Johns Hopkins University, 3400 North Charles Street, Baltimore, Maryland 21218, United States
- Department of Oncology and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
- Center for Nanomedicine, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, 400 North Broadway, Baltimore, Maryland 21231, United States
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44
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Beck-Broichsitter M. Stability of Polymer Coatings on Nebulizer Membranes During Aerosol Generation. J Pharm Sci 2019; 108:3750-3754. [PMID: 31473213 DOI: 10.1016/j.xphs.2019.08.020] [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: 05/05/2019] [Revised: 08/12/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
Abstract
The dimensions of orifices found in aperture plates used for nebulization can be modified by thin polymer coatings with the aim to control the size distribution of the generated aerosol droplets. However, the stability of such polymer coatings on the surface of nebulizer membranes during aerosol generation has not been elucidated. Nebulizer membranes made of stainless steel were covered with a thin film of poly(chloro-p-xylylene) (~1 μm) in the presence or absence of a silane-based adhesion promoter. Thereby, the orifice cross-sections of the nebulizer membrane were reduced by ~50%, accompanied by a remarkable decline in droplet size. Upon continuous nebulization of aqueous test liquids, the droplet size generated by the nonconditioned (no silane), poly(chloro-p-xylylene)-coated membranes reverted to that of the uncoated nebulizer membrane within ~5 min. By contrast, no such rapid return of droplet size to "baseline" values was noticed for the silane-conditioned, poly(chloro-p-xylylene)-coated counterparts. Scanning electron microscopy exhibited significant polymer detachment from the orifices of the nonconditioned (no silane) membranes and thus confirmed the findings from laser diffraction. Overall, silane-based adhesion promoters can increase the persistence of poly(chloro-p-xylylene) coatings on nebulizer membranes during aerosol generation.
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Affiliation(s)
- Moritz Beck-Broichsitter
- Medical Clinic II, Department of Internal Medicine, Justus-Liebig-Universität, Klinikstr. 33, D-35392 Giessen, Germany.
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45
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Making Concentrated Antibody Formulations Accessible for Vibrating-Mesh Nebulization. J Pharm Sci 2019; 108:2588-2592. [DOI: 10.1016/j.xphs.2019.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/17/2019] [Accepted: 03/08/2019] [Indexed: 01/03/2023]
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46
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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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47
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Dhooria S, Chaudhary S, Ram B, Sehgal IS, Muthu V, Prasad KT, Aggarwal AN, Agarwal R. A Randomized Trial of Nebulized Lignocaine, Lignocaine Spray, or Their Combination for Topical Anesthesia During Diagnostic Flexible Bronchoscopy. Chest 2019; 157:198-204. [PMID: 31299247 DOI: 10.1016/j.chest.2019.06.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/20/2019] [Accepted: 06/27/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The optimal mode of delivering topical anesthesia during flexible bronchoscopy remains unknown. This article compares the efficacy and safety of nebulized lignocaine, lignocaine oropharyngeal spray, or their combination. METHODS Consecutive subjects were randomized 1:1:1 to receive nebulized lignocaine (2.5 mL of 4% solution, group A), oropharyngeal spray (10 actuations of 10% lignocaine, group B), or nebulization (2.5 mL, 4% lignocaine) and two actuations of 10% lignocaine spray (group C). The primary outcome was the subject-rated severity of cough according to a visual analog scale. The secondary outcomes included bronchoscopist-rated severity of cough and overall procedural satisfaction on a visual analog scale, total lignocaine dose, subject's willingness to undergo a repeat procedure, adverse reactions to lignocaine, and others. RESULTS A total of 1,050 subjects (median age, 51 years; 64.8% men) were included. The median (interquartile range) score for subject-rated cough severity was significantly lower in group B compared to group C or group A (4 [1-10] vs 11 [4-24] vs 13 [5-30], respectively; P < .001). The bronchoscopist-rated severity of cough was also the least (P < .001), and the overall satisfaction was highest in group B (P < .001). The cumulative lignocaine dose administered was the least in group B (P < .001). A significantly higher proportion of subjects (P < .001) were willing to undergo a repeat bronchoscopy in group B (73.7%) than in groups A (49.1%) and C (59.4%). No lignocaine-related adverse events were observed. CONCLUSIONS Ten actuations of 10% lignocaine oropharyngeal spray were superior to nebulized lignocaine or their combination for topical anesthesia during diagnostic flexible bronchoscopy. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03109392; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivani Chaudhary
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Babu Ram
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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48
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Zhang Y, Cheng BCY, Li C, Tao Y, Yu C, Liu X, Gao X, Luo G. Characterization and comparison of Re-Du-Ning aerosol particles generated by different jet nebulizers. RSC Adv 2019; 9:30292-30301. [PMID: 35530199 PMCID: PMC9072082 DOI: 10.1039/c9ra06177k] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 09/18/2019] [Indexed: 01/04/2023] Open
Abstract
Inhalation therapy is the first-line therapy for the treatment of respiratory diseases. Re-Du-Ning inhalation solution (RIS) is an aerosol derivative from the Re-Du-Ning injection and has been clinically used to treat respiratory diseases like pneumonia for more than twenty years in China. However, the aerosolization and inhalation performances of RIS using different nebulizers have not been characterized, which may affect the therapeutic effects of RIS on respiratory diseases. We investigated the inhalation performances of RIS using five different nebulizers utilizing Spraytec, breath simulator of BRS 2000 and NGI techniques. We tested 5 different types of jet nebulizer, using RIS and an adult breathing pattern, to determine the difference in aerosol delivery over time. The particle size distribution of RIS was monitored by a Spraytec laser particle sizer. Fine particle fraction (FPF) and mass median aerodynamic diameter (MMAD) for RIS were measured using NGI. Aerosol deposited on the filter was analysed using HPLC. Nebulization time was much longer for the Pari Boy SX (red) nebulizer than for the other nebulizers, with the minimum delivery rate (DR) and the maximum total delivered dose (TDD) and total exhalation dose (TED). Nebulization time for Pari Boy SX (blue) was the lowest, with the highest DR and the lowest TDD and TED. Furthermore, the aerodynamic particle size of RIS was much larger for the Pari blue and Pari LC Plus than other nebulizers. Pari red produced the smallest aerodynamic particle size of RIS in these five nebulizers. In addition, a good linear relationship was found between MMAD and D50 in these five nebulizers. The results demonstrated that Pari Boy SX (red) delivered most slowly and produced the smallest aerodynamic particle size of the RIS aerosols, which may be applied to manage lower respiratory diseases. Moreover, Pari LC Plus and Pari Boy SX (blue) emitted quickly and generated larger aerodynamic particle size of RIS aerosols, which could be used to treat upper respiratory diseases. A good linear relationship between MMAD and D50 showed Spraytec could be a reliable technique for the development, evaluation and quality control of aerosol particles of inhalation solution preparations. Delivery dose uniformity determination by BRS 2000 breath simulator and realtime particle size distribution monitoring by Spraytec.![]()
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Affiliation(s)
- Yi Zhang
- School of Chinese Materia Medica
- Beijing University of Chinese Medicine
- Beijing 100102
- China
| | - Brian Chi-Yan Cheng
- College of Professional and Continuing Education
- Hong Kong Polytechnic University
- China
- Quality Healthcare Medical Services
- China
| | - Cui Li
- China Institute of Chinese Materia Medica
- China Academy of Chinese Medical Science
- Beijing 100700
- China
| | - Yonghua Tao
- Increase Pharm (Tianjin) Institute Co., Ltd
- Tianjin 300382
- China
| | - Chanjuan Yu
- School of Chinese Materia Medica
- Beijing University of Chinese Medicine
- Beijing 100102
- China
- Interdisciplinary Research Center on Multi-omics of TCM
| | - Xinyue Liu
- School of Chinese Materia Medica
- Beijing University of Chinese Medicine
- Beijing 100102
- China
- Interdisciplinary Research Center on Multi-omics of TCM
| | - Xiaoyan Gao
- School of Chinese Materia Medica
- Beijing University of Chinese Medicine
- Beijing 100102
- China
- Interdisciplinary Research Center on Multi-omics of TCM
| | - Gan Luo
- School of Chinese Materia Medica
- Beijing University of Chinese Medicine
- Beijing 100102
- China
- Interdisciplinary Research Center on Multi-omics of TCM
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49
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Surasarang SH, Sahakijpijarn S, Florova G, Komissarov AA, Nelson CL, Perenlei E, Fukuda S, Wolfson MR, Shaffer TH, Idell S, Williams RO. Nebulization of Single-Chain Tissue-Type and Single-Chain Urokinase Plasminogen Activator for Treatment of Inhalational Smoke-Induced Acute Lung Injury. J Drug Deliv Sci Technol 2018; 48:19-27. [PMID: 30123328 DOI: 10.1016/j.jddst.2018.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Single-chain tissue-type plasminogen activator (sctPA) and single-chain urokinase plasminogen activator (scuPA) have attracted interest as enzymes for the treatment of inhalational smoke-induced acute lung injury (ISALI). In this study, the pulmonary delivery of commercial human sctPA and lyophilized scuPA and their reconstituted solution forms were demonstrated using vibrating mesh nebulizers (Aeroneb® Pro (active) and EZ Breathe® (passive)). Both the Aeroneb® Pro and EZ Breathe® vibrating mesh nebulizers produced atomized droplets of protein solution of similar size of less than about 5 μm, which is appropriate for pulmonary delivery. Enzymatic activities of scuPA and of sctPA were determined after nebulization and both remained stable (88.0% and 93.9%). Additionally, the enzymatic activities of sctPA and tcuPA were not significantly affected by excipients, lyophilization or reconstitution conditions. The results of these studies support further development of inhaled formulations of fibrinolysins for delivery to the lungs following smoke-induced acute pulmonary injury.
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Affiliation(s)
- Soraya Hengsawas Surasarang
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Sawittree Sahakijpijarn
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Galina Florova
- The University of Texas Health Science Center at Tyler, School of Medical Biological Sciences, Tyler, TX, USA
| | - Andrey A Komissarov
- The University of Texas Health Science Center at Tyler, School of Medical Biological Sciences, Tyler, TX, USA
| | - Christina L Nelson
- The University of Texas Medical Branch, Translational Intensive Care Unit, Galveston, TX, USA
| | - Enkhbaatar Perenlei
- The University of Texas Medical Branch, Translational Intensive Care Unit, Galveston, TX, USA
| | - Satoshi Fukuda
- The University of Texas Medical Branch, Translational Intensive Care Unit, Galveston, TX, USA
| | - Marla R Wolfson
- Lewis Katz School of Medicine at Temple University, Departments of Physiology, Thoracic Medicine and Surgery, Pediatrics, Philadelphia, PA, USA
| | - Thomas H Shaffer
- Lewis Katz School of Medicine at Temple University, Departments of Physiology, Thoracic Medicine and Surgery, Pediatrics, Philadelphia, PA, USA.,Jefferson Medical College/Thomas Jefferson University, Department of Pediatrics, Philadelphia, PA, USA
| | - Steven Idell
- The University of Texas Health Science Center at Tyler, School of Medical Biological Sciences, Tyler, TX, USA
| | - Robert O Williams
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
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50
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Bodier-Montagutelli E, Mayor A, Vecellio L, Respaud R, Heuzé-Vourc’h N. Designing inhaled protein therapeutics for topical lung delivery: what are the next steps? Expert Opin Drug Deliv 2018; 15:729-736. [DOI: 10.1080/17425247.2018.1503251] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Elsa Bodier-Montagutelli
- Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
- Centre d'Etude des Pathologies Respiratoires, U1100, INSERM, Centre d’Etude des Pathologies Respiratoires, Tours, France
- CHRU de Tours, Service de Pharmacie, Tours, France
| | - Alexie Mayor
- Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
- Centre d'Etude des Pathologies Respiratoires, U1100, INSERM, Centre d’Etude des Pathologies Respiratoires, Tours, France
- Formulation Development Unit – Biotherapeutics, Sanofi Aventis Recherche Développement, Vitry-sur-Seine, France
| | - Laurent Vecellio
- Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
- Centre d'Etude des Pathologies Respiratoires, U1100, INSERM, Centre d’Etude des Pathologies Respiratoires, Tours, France
| | - Renaud Respaud
- Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
- Centre d'Etude des Pathologies Respiratoires, U1100, INSERM, Centre d’Etude des Pathologies Respiratoires, Tours, France
- CHRU de Tours, Service de Pharmacie, Tours, France
| | - Nathalie Heuzé-Vourc’h
- Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
- Centre d'Etude des Pathologies Respiratoires, U1100, INSERM, Centre d’Etude des Pathologies Respiratoires, Tours, France
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