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Darquenne C, Corcoran TE, Lavorini F, Sorano A, Usmani OS. The effects of airway disease on the deposition of inhaled drugs. Expert Opin Drug Deliv 2024; 21:1175-1190. [PMID: 39136493 PMCID: PMC11412782 DOI: 10.1080/17425247.2024.2392790] [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: 02/14/2024] [Revised: 05/06/2024] [Accepted: 08/12/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION The deposition of inhaled medications is the first step in the pulmonary pharmacokinetic process to produce a therapeutic response. Not only lung dose but more importantly the distribution of deposited drug in the different regions of the lung determines local bioavailability, efficacy, and clinical safety. Assessing aerosol deposition patterns has been the focus of intense research that combines the fields of physics, radiology, physiology, and biology. AREAS COVERED The review covers the physics of aerosol transport in the lung, experimental, and in-silico modeling approaches to determine lung dose and aerosol deposition patterns, the effect of asthma, chronic obstructive pulmonary disease, and cystic fibrosis on aerosol deposition, and the clinical translation potential of determining aerosol deposition dose. EXPERT OPINION Recent advances in in-silico modeling and lung imaging have enabled the development of realistic subject-specific aerosol deposition models, albeit mainly in health. Accurate modeling of lung disease still requires additional refinements in existing imaging and modeling approaches to better characterize disease heterogeneity in peripheral airways. Nevertheless, recent patient-centric innovation in inhaler device engineering and the incorporation of digital technology have led to more consistent lung deposition and improved targeting of the distal airways, which better serve the clinical needs of patients.
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Affiliation(s)
- Chantal Darquenne
- Department of Medicine, University of California, San Diego, CA, USA
| | | | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandra Sorano
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London, London, UK
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Kisielinski K, Hockertz S, Hirsch O, Korupp S, Klosterhalfen B, Schnepf A, Dyker G. Wearing face masks as a potential source for inhalation and oral uptake of inanimate toxins - A scoping review. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2024; 275:115858. [PMID: 38537476 DOI: 10.1016/j.ecoenv.2023.115858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 04/12/2024]
Abstract
BACKGROUND From 2020 to 2023 many people around the world were forced to wear masks for large proportions of the day based on mandates and laws. We aimed to study the potential of face masks for the content and release of inanimate toxins. METHODS A scoping review of 1003 studies was performed (database search in PubMed/MEDLINE, qualitative and quantitative evaluation). RESULTS 24 studies were included (experimental time 17 min to 15 days) evaluating content and/or release in 631 masks (273 surgical, 228 textile and 130 N95 masks). Most studies (63%) showed alarming results with high micro- and nanoplastics (MPs and NPs) release and exceedances could also be evidenced for volatile organic compounds (VOCs), xylene, acrolein, per-/polyfluoroalkyl substances (PFAS), phthalates (including di(2-ethylhexyl)-phthalate, DEHP) and for Pb, Cd, Co, Cu, Sb and TiO2. DISCUSSION Of course, masks filter larger dirt and plastic particles and fibers from the air we breathe and have specific indications, but according to our data they also carry risks. Depending on the application, a risk-benefit analysis is necessary. CONCLUSION Undoubtedly, mask mandates during the SARS-CoV-2 pandemic have been generating an additional source of potentially harmful exposition to toxins with health threatening and carcinogenic properties at population level with almost zero distance to the airways.
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Affiliation(s)
- Kai Kisielinski
- Social Medicine, Emergency Medicine and Clinical Medicine (Surgery), Private Practice, 40212 Düsseldorf, Germany.
| | - Stefan Hockertz
- Toxicology, Pharmacology, Immunology, tpi consult AG, Haldenstr. 1, CH 6340 Baar, Switzerland
| | - Oliver Hirsch
- Department of Psychology, FOM University of Applied Sciences, 57078 Siegen, Germany
| | - Stephan Korupp
- Surgeon, Emergency Medicine, Private Practice, 52070 Aachen, Germany
| | - Bernd Klosterhalfen
- Institute of Pathology, Dueren Hospital, Roonstrasse 30, 52351 Dueren, Germany
| | - Andreas Schnepf
- Institute of Inorganic Chemistry, University of Tübingen, Auf der Morgenstelle 18, 72076 Tübingen, Germany
| | - Gerald Dyker
- Faculty of Chemistry and Biochemistry, Ruhr University Bochum, Universitätsstraße 150, 44801 Bochum, Germany
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Yu P, Xue C, Rosenthal J, Jiang JJ. Effects of vocal fold lesions on particle deposition in a mouth-throat model: A numerical study. Auris Nasus Larynx 2024; 51:120-124. [PMID: 37164816 DOI: 10.1016/j.anl.2023.04.012] [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: 11/10/2022] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Dysphonia is very common worldwide and aerosol drug inhalation is an important treatment for patients with dysphonia. This study aimed to explore the effects of vocal fold (VF) lesions on the particle deposition pattern using computational modeling. METHODS A realistic mouth-throat (MT) model of a healthy adult was constructed based on computed tomography images. Small and large vocal fold lesions were incorporated in the original model. A steady inhalation flowrate of 15 and 30 liter per minute (LPM) was used as the velocity inlet and monodisperse particles with diameters of 5 to 10 µm were simulated. RESULTS Particles of larger size are more likely to be deposited in MT models, most of them distributed in oral cavity, oropharynx and supraglottis. The ideal sizes at 30 LPM ranged over 7-10 µm for healthy VFs and 6-8 µm for VF lesions. The best sizes at 15 LPM ranged over 6-8 µm for healthy VFs and 8-9 µm for VF lesions. CONCLUSION Based on this study, VF lesions influence the deposition pattern in the glottis obviously. The ideal sizes differ at the flow rates of 15 and 30 LPM.
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Affiliation(s)
- Pengcheng Yu
- 1st Department of Otolaryngology, Eye Ear Nose & Throat Hospital, Fudan University, 200031 Shanghai, China
| | - Chao Xue
- 1st Department of Otolaryngology, Eye Ear Nose & Throat Hospital, Fudan University, 200031 Shanghai, China
| | - Jonah Rosenthal
- 2nd University of Wisconsin-Madison School of Medicine and Public Health, Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, 53792 Madison, WI, USA
| | - Jack J Jiang
- 1st Department of Otolaryngology, Eye Ear Nose & Throat Hospital, Fudan University, 200031 Shanghai, China; 2nd University of Wisconsin-Madison School of Medicine and Public Health, Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, 53792 Madison, WI, USA.
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Yu P, Xue C, Boeckenstedt B, Olsen H, Jiang JJ. Effects of vocal fold adduction on the particle deposition in the glottis: A numerical analysis and in vitro assessment. Comput Biol Med 2023; 166:107537. [PMID: 37820560 DOI: 10.1016/j.compbiomed.2023.107537] [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: 11/29/2022] [Revised: 09/15/2023] [Accepted: 09/27/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The efficacy of inhalation therapy depends on the drug deposition in the human respiratory tract. This study investigates the effects of vocal fold adduction on the particle deposition in the glottis. METHODS A realistic mouth-throat (MT) geometry was built based on CT images of a healthy adult (MT-A). Mild (MT-B) and great (MT-C) vocal fold (VF) adduction were incorporated in the original model. Monodisperse particles range in size from 3 to 12 μm were simulated at inspiration flow rates of 15, 30 and 45 L per minute (LPM). The regional deposition of drug aerosols was performed in 3D-printed models and quantified using high-performance liquid chromatography. RESULTS Both the numerical analysis and in vitro experiments show that most particles are deposited in the mouth, pharynx and supraglottis, while few are deposited in the glottis and subglottis. For most cases in MT-A, the particle quantity in glottis is lower than 0.02 N/mm2 at 15 and 30 LPM while they increase dramatically at 45 LPM. It peaked at 0.347 N/mm2 for 5-μm particles at 45 LPM in MT-B and 2.324 N/mm2 for 6-μm particles at 30 LPM in MT-C. The lowest drug mass faction in the glottis in vitro were found at 15 LPM for MT-A and MT-C, and at 30 LPM for MT-B, whereas it peaked at 45 LPM for all MT models, 0.71% in MT-A, 1.16% in MT-B, and 2.53% in MT-C, respectively. CONCLUSION Based on the results of this study, larger particles are more likely to be deposited in the oral cavity, oropharynx, and supraglottis than in the glottis. However, particle deposition in the glottis generally increases with VF adduction and greater inspiratory flow rates.
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Affiliation(s)
- Pengcheng Yu
- Department of Otolaryngology, EENT Hospital, Fudan University, Shanghai, 200031, China
| | - Chao Xue
- Department of Otolaryngology, EENT Hospital, Fudan University, Shanghai, 200031, China
| | - Bella Boeckenstedt
- University of Wisconsin-Madison School of Medicine and Public Health, Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Madison, WI, 53792, USA
| | - Halli Olsen
- University of Wisconsin-Madison School of Medicine and Public Health, Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Madison, WI, 53792, USA
| | - Jack J Jiang
- University of Wisconsin-Madison School of Medicine and Public Health, Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Madison, WI, 53792, USA.
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Farkas D, Thomas ML, Hassan A, Bonasera S, Hindle M, Longest W. Near Elimination of In Vitro Predicted Extrathoracic Aerosol Deposition in Children Using a Spray-Dried Antibiotic Formulation and Pediatric Air-Jet DPI. Pharm Res 2023; 40:1193-1207. [PMID: 35761163 PMCID: PMC10616820 DOI: 10.1007/s11095-022-03316-9] [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: 03/18/2022] [Accepted: 06/10/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE This study evaluated the in vitro aerosol performance of a dry powder antibiotic product that combined a highly dispersible tobramycin powder with a previously optimized pediatric air-jet dry powder inhaler (DPI) across a subject age range of 2-10 years. METHODS An excipient enhanced growth (EEG) formulation of the antibiotic tobramycin (Tobi) was prepared using a small particle spray drying technique that included mannitol as the hygroscopic excipient and trileucine as the dispersion enhancer. The Tobi-EEG formulation was aerosolized using a positive-pressure pediatric air-jet DPI that included a 3D rod array. Realistic in vitro experiments were conducted in representative airway models consistent with children in the age ranges of 2-3, 5-6 and 9-10 years using oral or nose-to-lung administration, non-humidified or humidified airway conditions, and constant or age-specific air volumes. RESULTS Across all conditions tested, mouth-throat depositional loss was < 1% and nose-throat depositional loss was < 3% of loaded dose. Lung delivery efficiency was in the range of 77.3-85.1% of loaded dose with minor variations based on subject age (~ 8% absolute difference), oral or nasal administration (< 2%), and delivered air volume (< 2%). Humidified airway conditions had an insignificant impact on extrathoracic depositional loss and significantly increased aerosol size at the exit of a representative lung chamber. CONCLUSIONS In conclusion, the inhaled antibiotic product nearly eliminated extrathoracic depositional loss, demonstrated high efficiency nose-to-lung antibiotic aerosol delivery in pediatric airway models for the first time, and provided ~ 80% lung delivery efficiency with little variability across subject age and administered air volume.
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Affiliation(s)
- Dale Farkas
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, Virginia, 23284-3015 , USA
| | - Morgan L Thomas
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, Virginia, 23284-3015 , USA
| | - Amr Hassan
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Serena Bonasera
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, Virginia, 23284-3015 , USA.
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA.
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Dhanani J, Taniguchi LU, Ranzani OT. Optimising aerosolized therapies in critically ill patients. Intensive Care Med 2022; 48:1418-1421. [PMID: 35804200 DOI: 10.1007/s00134-022-06800-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Jayesh Dhanani
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Leandro U Taniguchi
- Emergency Medicine Discipline, Clinical Hospital, University of São Paulo, São Paulo, Brazil.,Syrian-Lebanese Institute of Teaching and Research, São Paulo, Brazil
| | - Otavio T Ranzani
- Barcelona Institute for Global Health, ISGlobal, Universitat Pompeu Fabra (UPF), CIBER Epidemiología Y Salud Pública (CIBERESP), Barcelona, Spain.,Pulmonary Division, Heart Institute, Faculty of Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Madueño L, Kecorius S, Löndahl J, Schnelle-Kreis J, Wiedensohler A, Pöhlker M. A novel in-situ method to determine the respiratory tract deposition of carbonaceous particles reveals dangers of public commuting in highly polluted megacity. Part Fibre Toxicol 2022; 19:61. [PMID: 36109745 PMCID: PMC9476571 DOI: 10.1186/s12989-022-00501-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/30/2022] [Indexed: 12/04/2022] Open
Abstract
Background Exposure to air pollutants is one of the major environmental health risks faced by populations globally. Information about inhaled particle deposition dose is crucial in establishing the dose–response function for assessing health-related effects due to exposure to air pollution. Objective This study aims to quantify the respiratory tract deposition (RTD) of equivalent black carbon (BC) particles in healthy young adults during a real-world commuting scenario, analyze factors affecting RTD of BC, and provide key parameters for the assessment of RTD. Methods A novel in situ method was applied to experimentally determine the RTD of BC particles among subjects in the highly polluted megacity of Metro Manila, Philippines. Exposure measurements were made for 40 volunteers during public transport and walking. Results The observed BC exposure concentration was up to 17-times higher than in developed regions. The deposition dose rate (DDR) of BC was up to 3 times higher during commute inside a public transport compared to walking (11.6 versus 4.4 μg hr−1, respectively). This is twice higher than reported in similar studies. The average BC mass deposition fraction (DF) was found to be 43 ± 16%, which can in large be described by individual factors and does not depend on gender. Conclusions Commuting by open-sided public transport, commonly used in developing regions, poses a significant health risk due to acquiring extremely high doses of carcinogenic traffic-related pollutants. There is an urgent need to drastically update air pollution mitigation strategies for reduction of dangerously high emissions of BC in urban setting in developing regions. The presented mobile measurement set-up to determine respiratory tract deposition dose is a practical and cost-effective tool that can be used to investigate respiratory deposition in challenging environments. Supplementary Information The online version contains supplementary material available at 10.1186/s12989-022-00501-x.
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Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, Khilnani GC, Chaudhary D, Singla R, Koul PA, Mahashur AA, Ghoshal AG, Behera D, Christopher DJ, Talwar D, Ganguly D, Paramesh H, Gupta KB, Kumar T M, Motiani PD, Shankar PS, Chawla R, Guleria R, Jindal SK, Luhadia SK, Arora VK, Vijayan VK, Faye A, Jindal A, Murar AK, Jaiswal A, M A, Janmeja AK, Prajapat B, Ravindran C, Bhattacharyya D, D'Souza G, Sehgal IS, Samaria JK, Sarma J, Singh L, Sen MK, Bainara MK, Gupta M, Awad NT, Mishra N, Shah NN, Jain N, Mohapatra PR, Mrigpuri P, Tiwari P, Narasimhan R, Kumar RV, Prasad R, Swarnakar R, Chawla RK, Kumar R, Chakrabarti S, Katiyar S, Mittal S, Spalgais S, Saha S, Kant S, Singh VK, Hadda V, Kumar V, Singh V, Chopra V, B V. Indian Guidelines on Nebulization Therapy. Indian J Tuberc 2022; 69 Suppl 1:S1-S191. [PMID: 36372542 DOI: 10.1016/j.ijtb.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/16/2023]
Abstract
Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.
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Affiliation(s)
- S K Katiyar
- Department of Tuberculosis & Respiratory Diseases, G.S.V.M. Medical College & C.S.J.M. University, Kanpur, Uttar Pradesh, India.
| | - S N Gaur
- Vallabhbhai Patel Chest Institute, University of Delhi, Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater NOIDA, Uttar Pradesh, India
| | - R N Solanki
- Department of Tuberculosis & Chest Diseases, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Raj Kumar
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, National Centre of Allergy, Asthma & Immunology; University of Delhi, Delhi, India
| | - G C Khilnani
- PSRI Institute of Pulmonary, Critical Care, & Sleep Medicine, PSRI Hospital, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhary
- Department of Pulmonary & Critical Care Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rupak Singla
- Department of Tuberculosis & Respiratory Diseases, National Institute of Tuberculosis & Respiratory Diseases (formerly L.R.S. Institute), Delhi, India
| | - Parvaiz A Koul
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Ashok A Mahashur
- Department of Respiratory Medicine, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
| | - A G Ghoshal
- National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
| | - D Behera
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepak Talwar
- Metro Centre for Respiratory Diseases, Noida, Uttar Pradesh, India
| | | | - H Paramesh
- Paediatric Pulmonologist & Environmentalist, Lakeside Hospital & Education Trust, Bengaluru, Karnataka, India
| | - K B Gupta
- Department of Tuberculosis & Respiratory Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India
| | - Mohan Kumar T
- Department of Pulmonary, Critical Care & Sleep Medicine, One Care Medical Centre, Coimbatore, Tamil Nadu, India
| | - P D Motiani
- Department of Pulmonary Diseases, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - P S Shankar
- SCEO, KBN Hospital, Kalaburagi, Karnataka, India
| | - Rajesh Chawla
- Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Department of Pulmonary Medicine & Sleep Disorders, AIIMS, New Delhi, India
| | - S K Jindal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Luhadia
- Department of Tuberculosis and Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - V K Arora
- Indian Journal of Tuberculosis, Santosh University, NCR Delhi, National Institute of TB & Respiratory Diseases Delhi, India; JIPMER, Puducherry, India
| | - V K Vijayan
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, University of Delhi, Delhi, India
| | - Abhishek Faye
- Centre for Lung and Sleep Disorders, Nagpur, Maharashtra, India
| | | | - Amit K Murar
- Respiratory Medicine, Cronus Multi-Specialty Hospital, New Delhi, India
| | - Anand Jaiswal
- Respiratory & Sleep Medicine, Medanta Medicity, Gurugram, Haryana, India
| | - Arunachalam M
- All India Institute of Medical Sciences, New Delhi, India
| | - A K Janmeja
- Department of Respiratory Medicine, Government Medical College, Chandigarh, India
| | - Brijesh Prajapat
- Pulmonary and Critical Care Medicine, Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
| | - C Ravindran
- Department of TB & Chest, Government Medical College, Kozhikode, Kerala, India
| | - Debajyoti Bhattacharyya
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, Army Hospital (Research & Referral), New Delhi, India
| | | | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Centre for Research and Treatment of Allergy, Asthma & Bronchitis, Department of Chest Diseases, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Jogesh Sarma
- Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Lalit Singh
- Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - M K Sen
- Department of Respiratory Medicine, ESIC Medical College, NIT Faridabad, Haryana, India; Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mahendra K Bainara
- Department of Pulmonary Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nilkanth T Awad
- Department of Pulmonary Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, M.K.C.G. Medical College, Berhampur, Orissa, India
| | - Naveed N Shah
- Department of Pulmonary Medicine, Chest Diseases Hospital, Government Medical College, Srinagar, Jammu & Kashmir, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care & Sleep Medicine, PSRI, New Delhi, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Parul Mrigpuri
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pawan Tiwari
- School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - R Narasimhan
- Department of EBUS and Bronchial Thermoplasty Services at Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Vijai Kumar
- Department of Pulmonary Medicine, MediCiti Medical College, Hyderabad, Telangana, India
| | - Rajendra Prasad
- Vallabhbhai Patel Chest Institute, University of Delhi and U.P. Rural Institute of Medical Sciences & Research, Safai, Uttar Pradesh, India
| | - Rajesh Swarnakar
- Department of Respiratory, Critical Care, Sleep Medicine and Interventional Pulmonology, Getwell Hospital & Research Institute, Nagpur, Maharashtra, India
| | - Rakesh K Chawla
- Department of, Respiratory Medicine, Critical Care, Sleep & Interventional Pulmonology, Saroj Super Speciality Hospital, Jaipur Golden Hospital, Rajiv Gandhi Cancer Hospital, Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - S Chakrabarti
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sonam Spalgais
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | | | - Surya Kant
- Department of Respiratory (Pulmonary) Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - V K Singh
- Centre for Visceral Mechanisms, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Virendra Singh
- Mahavir Jaipuria Rajasthan Hospital, Jaipur, Rajasthan, India
| | - Vishal Chopra
- Department of Chest & Tuberculosis, Government Medical College, Patiala, Punjab, India
| | - Visweswaran B
- Interventional Pulmonology, Yashoda Hospitals, Hyderabad, Telangana, India
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9
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Bass K, Farkas D, Hassan A, Bonasera S, Hindle M, Longest PW. High-Efficiency Dry Powder Aerosol Delivery to Children: Review and Application of New Technologies. JOURNAL OF AEROSOL SCIENCE 2021; 153:105692. [PMID: 33716317 PMCID: PMC7945982 DOI: 10.1016/j.jaerosci.2020.105692] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
While dry powder aerosol formulations offer a number of advantages, their use in children is often limited due to poor lung delivery efficiency and difficulties with consistent dry powder inhaler (DPI) usage. Both of these challenges can be attributed to the typical use of adult devices in pediatric subjects and a lack of pediatric-specific DPI development. In contrast, a number of technologies have recently been developed or progressed that can substantially improve the efficiency and reproducibility of DPI use in children including: (i) nose-to-lung administration with small particles, (ii) active positive-pressure devices, (iii) structures to reduce turbulence and jet momentum, and (iv) highly dispersible excipient enhanced growth particle formulations. In this study, these technologies and their recent development are first reviewed in depth. A case study is then considered in which these technologies are simultaneously applied in order to enable the nose-to-lung administration of dry powder aerosol to children with cystic fibrosis (CF). Using a combination of computational fluid dynamics (CFD) analysis and realistic in vitro experiments, device performance, aerosol size increases and lung delivery efficiency are considered for pediatric-CF subjects in the age ranges of 2-3, 5-6 and 9-10 years old. Results indicate that a new 3D rod array structure significantly improves performance of a nasal cannula reducing interface loss by a factor of 1.5-fold and produces a device emitted mass median aerodynamic diameter (MMAD) of 1.67 μm. For all ages considered, approximately 70% of the loaded dose reaches the lower lung beyond the lobar bronchi. Moreover, significant and rapid size increase of the aerosol is observed beyond the larynx and illustrates the potential for targeting lower airway deposition. In conclusion, concurrent CFD and realistic in vitro analysis indicates that a combination of multiple new technologies can be implemented to overcome obstacles that currently limit the use of DPIs in children as young as two years of age.
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Affiliation(s)
- Karl Bass
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA
| | - Dale Farkas
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA
| | - Amr Hassan
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA
| | - Serena Bonasera
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA
| | - P. Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA
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10
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Lizal F, Elcner J, Jedelsky J, Maly M, Jicha M, Farkas Á, Belka M, Rehak Z, Adam J, Brinek A, Laznovsky J, Zikmund T, Kaiser J. The effect of oral and nasal breathing on the deposition of inhaled particles in upper and tracheobronchial airways. JOURNAL OF AEROSOL SCIENCE 2020; 150:105649. [PMID: 32904428 PMCID: PMC7455204 DOI: 10.1016/j.jaerosci.2020.105649] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 08/05/2020] [Accepted: 08/13/2020] [Indexed: 05/21/2023]
Abstract
The inhalation route has a substantial influence on the fate of inhaled particles. An outbreak of infectious diseases such as COVID-19, influenza or tuberculosis depends on the site of deposition of the inhaled pathogens. But the knowledge of respiratory deposition is important also for occupational safety or targeted delivery of inhaled pharmaceuticals. Simulations utilizing computational fluid dynamics are becoming available to a wide spectrum of users and they can undoubtedly bring detailed predictions of regional deposition of particles. However, if those simulations are to be trusted, they must be validated by experimental data. This article presents simulations and experiments performed on a geometry of airways which is available to other users and thus those results can be used for intercomparison between different research groups. In particular, three hypotheses were tested. First: Oral breathing and combined breathing are equivalent in terms of particle deposition in TB airways, as the pressure resistance of the nasal cavity is so high that the inhaled aerosol flows mostly through the oral cavity in both cases. Second: The influence of the inhalation route (nasal, oral or combined) on the regional distribution of the deposited particles downstream of the trachea is negligible. Third: Simulations can accurately and credibly predict deposition hotspots. The maximum spatial resolution of predicted deposition achievable by current methods was searched for. The simulations were performed using large-eddy simulation, the flow measurements were done by laser Doppler anemometry and the deposition has been measured by positron emission tomography in a realistic replica of human airways. Limitations and sources of uncertainties of the experimental methods were identified. The results confirmed that the high-pressure resistance of the nasal cavity leads to practically identical velocity profiles, even above the glottis for the mouth, and combined mouth and nose breathing. The distribution of deposited particles downstream of the trachea was not influenced by the inhalation route. The carina of the first bifurcation was not among the main deposition hotspots regardless of the inhalation route or flow rate. On the other hand, the deposition hotspots were identified by both CFD and experiments in the second bifurcation in both lungs, and to a lesser extent also in both the third bifurcations in the left lung.
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Affiliation(s)
- Frantisek Lizal
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Jakub Elcner
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Jan Jedelsky
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Milan Maly
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Miroslav Jicha
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Árpád Farkas
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
- Centre for Energy Research, Konkoly-Thege Miklós u. 29-33, 1121, Budapest, Hungary
| | - Miloslav Belka
- Brno University of Technology, Faculty of Mechanical Engineering, Energy Institute, Technicka 2896/2, Brno, 616 69, Czech Republic
| | - Zdenek Rehak
- Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 602 00, Czech Republic
| | - Jan Adam
- Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 602 00, Czech Republic
- ÚJV Řež, a.s., Hlavni 130, Husinec-Rez, Rez 250 68, Czech Republic
| | - Adam Brinek
- CEITEC - Central European Institute of Technology, Brno University of Technology, Purkynova 123, Brno, 612 00, Czech Republic
| | - Jakub Laznovsky
- CEITEC - Central European Institute of Technology, Brno University of Technology, Purkynova 123, Brno, 612 00, Czech Republic
| | - Tomas Zikmund
- CEITEC - Central European Institute of Technology, Brno University of Technology, Purkynova 123, Brno, 612 00, Czech Republic
| | - Jozef Kaiser
- CEITEC - Central European Institute of Technology, Brno University of Technology, Purkynova 123, Brno, 612 00, Czech Republic
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11
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Dugernier J, Reychler G, Vecellio L, Ehrmann S. Nasal High-Flow Nebulization for Lung Drug Delivery: Theoretical, Experimental, and Clinical Application. J Aerosol Med Pulm Drug Deliv 2019; 32:341-351. [DOI: 10.1089/jamp.2019.1524] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Jonathan Dugernier
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Soins Intensifs, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Médecine Physique, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Grégory Reychler
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Service de pneumologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Laurent Vecellio
- Centre d'études des pathologies respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Stephan Ehrmann
- Centre d'études des pathologies respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
- Médecine intensive réanimation, Centre d'investigation clinique CIC INSERM 1415, CHRU de Tours, Tours, France
- CRICS-TriggerSep Research Network
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12
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Ari A. Effect of nebulizer type, delivery interface, and flow rate on aerosol drug delivery to spontaneously breathing pediatric and infant lung models. Pediatr Pulmonol 2019; 54:1735-1741. [PMID: 31313534 DOI: 10.1002/ppul.24449] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/08/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Different types of nebulizers, interfaces, and flow rates are used to deliver aerosolized medications to children. The purpose of this study was to determine the effect of nebulizer type, delivery interface, and flow rate on aerosol drug delivery to spontaneously breathing pediatric and infant lung models. METHODOLOGY A teaching mannequin was attached to a sinusoidal pump via a collecting filter at the bronchi to simulate a spontaneously breathing child (Vt: 250 mL, RR: 20 bpm and Ti: 1 second) and infant (Vt = 100 mL, RR = 30 bpm, Ti: 0.7 seconds). Albuterol sulfate was nebulized with jet (Misty Max 10; Cardinal Health) and mesh (Aerogen Solo; Aerogen) nebulizers using a low-flow nasal cannula (LFNC; Hudson), a high-flow nasal cannula (HFNC; Fisher & Paykel), face mask (FM; Hudson), and mouthpiece (MP; Cardinal Health). While all interfaces were used in the pediatric study, only LFNC, HFNC, and FM were tested in the infant study. The mesh nebulizer was tested at 2, 4, and 6 L/min with LFNC, 4 and 6 L/min with HFNC, and 6 L/min with FM and MP. The jet nebulizer was operated at 6 and 8 L/min with FM and 6 L/min with LFNC, HFNC, and MP (n = 5). The drug was eluted from the filter and analyzed by spectrophotometry. Factorial analysis of variance and post hoc comparisons were used for data analysis. P < .05 was considered statistically significant. RESULTS Delivery efficiency of mesh nebulizers is two to fourfold more than jet nebulizers used with HFNC, FM, and MP. No statistical difference was found between jet and mesh nebulizers used with LFNC in infants (P = .643) and pediatrics (P = .255). Aerosol delivery with MP was the best compared to other interfaces used in pediatrics (P < .05). As the second-best interface in aerosol drug delivery, the delivery efficiency of FM was greater than HFNC (P = .0001) and LFNC (P = .0001). Increasing flow rate with LFNC and HFNC decreased aerosol delivery with the mesh nebulizer in both infants and pediatrics. CONCLUSION The type of nebulizer, delivery interface, and flow rate used in the treatment of children affect aerosol drug delivery.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, College of Health Professions, Texas State University, Round Rock, Texas
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13
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Farkas D, Hindle M, Bonasera S, Bass K, Longest W. Development of an Inline Dry Powder Inhaler for Oral or Trans-Nasal Aerosol Administration to Children. J Aerosol Med Pulm Drug Deliv 2019; 33:83-98. [PMID: 31464559 DOI: 10.1089/jamp.2019.1540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Dry powder inhalers (DPIs) offer a number of advantages, such as rapid delivery of high-dose inhaled medications; however, DPI use in children is often avoided due to low lung delivery efficiency and difficulty in operating the device. The objective of this study was to develop a high-efficiency inline DPI for administering aerosol therapy to children with the option of using either an oral or trans-nasal approach. Methods: An inline DPI was developed that consisted of hollow inlet and outlet capillaries, a powder chamber, and a nasal or oral interface. A ventilation bag or compressed air was used to actuate the device and simultaneously provide a full deep inspiration consistent with a 5-year-old child. The powder chamber was partially filled with a model spray-dried excipient enhanced growth powder formulation with a mass of 10 mg. Device aerosolization was characterized with cascade impaction, and aerosol transmissions through oral and nasal in vitro models were assessed. Results: Best device performance was achieved when all actuation air passed through the powder chamber (no bypass flow) resulting in an aerosol mean mass median aerodynamic diameter (MMAD) <1.75 μm and a fine particle fraction (<5 μm) ≥90% based on emitted dose. Actuation with the ventilation bag enabled lung delivery efficiency through the nasal and oral interfaces to a tracheal filter of 60% or greater, based on loaded dose. In both oral and nose-to-lung (N2L) administrations, extrathoracic depositional losses were <10%. Conclusion: In conclusion, this study has proposed and initially developed an efficient inline DPI for delivering spray-dried formulations to children using positive pressure operation. Actuation of the device with positive pressure enabled effective N2L aerosol administration with a DPI, which may be beneficial for subjects who are too young to use a mouthpiece or to simultaneously treat the nasal and lung airways of older children.
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Affiliation(s)
- Dale Farkas
- Department of Mechanical and Nuclear Engineering and Virginia Commonwealth University, Richmond, Virginia
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia
| | - Serena Bonasera
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia
| | - Karl Bass
- Department of Mechanical and Nuclear Engineering and Virginia Commonwealth University, Richmond, Virginia
| | - Worth Longest
- Department of Mechanical and Nuclear Engineering and Virginia Commonwealth University, Richmond, Virginia.,Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia
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14
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Waskiw-Ford M, Wu A, Mainra A, Marchand N, Alhuzaim A, Bourbeau J, Smith BM, Jensen D. Effect of Inhaled Nebulized Furosemide (40 and 120 mg) on Breathlessness during Exercise in the Presence of External Thoracic Restriction in Healthy Men. Front Physiol 2018; 9:86. [PMID: 29483879 PMCID: PMC5816054 DOI: 10.3389/fphys.2018.00086] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/25/2018] [Indexed: 01/04/2023] Open
Abstract
Inhalation of nebulized furosemide has been shown to alleviate breathlessness provoked experimentally in health and disease; however, it remains unclear whether the efficacy of nebulized furosemide on breathlessness is dose-dependent. We tested the hypothesis that inhaled nebulized furosemide would be associated with a dose-dependent relief of breathlessness during exercise testing in the setting of abnormal restrictive constraints on tidal volume (VT) expansion. In a randomized, double-blind, crossover study, 24 healthy men aged 25.3 ± 1.2 years (mean ± SE) completed a symptom-limited constant-load cycle endurance exercise test in the setting of external thoracic restriction via chest wall strapping to reduce vital capacity by ~20% following single-dose inhalation nebulized furosemide (40 and 120 mg) and 0.9% saline. Compared with 0.9% saline, neither 40 nor 120 mg of inhaled nebulized furosemide had an effect on ratings of perceived breathlessness during exercise or an effect on cardiometabolic, ventilatory, breathing pattern, or dynamic operating lung volume responses during exercise. Urine production rate, the percentage of participants reporting an "urge to urinate" and the intensity of perceived "urge to urinate" were all significantly greater after inhaling the 120 mg furosemide solution compared with both 0.9% saline and 40 mg furosemide solutions. We concluded that, under the experimental conditions of this study, inhalation of nebulized furosemide at doses of 40 and 120 mg did not alleviate breathlessness during exercise in healthy men.
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Affiliation(s)
- Marcus Waskiw-Ford
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, McGill University, Montréal, QC, Canada
| | - Anne Wu
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, McGill University, Montréal, QC, Canada
| | - Amar Mainra
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, McGill University, Montréal, QC, Canada
| | - Noah Marchand
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, McGill University, Montréal, QC, Canada
| | - Abdullatif Alhuzaim
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, McGill University, Montréal, QC, Canada
| | - Jean Bourbeau
- Department of Medicine, Respiratory Division, McGill University, Montréal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Montréal Chest Institute, McGill University Health Centre, Montréal, QC, Canada.,Meakins-Christie Laboratories, Research Institute of the McGill University Health Centre, Montréal, QC, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montréal, QC, Canada.,Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Center, Montréal, QC, Canada.,Research Centre for Physical Activity and Health, McGill University, Montréal, QC, Canada
| | - Benjamin M Smith
- Department of Medicine, Respiratory Division, McGill University, Montréal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Montréal Chest Institute, McGill University Health Centre, Montréal, QC, Canada.,Meakins-Christie Laboratories, Research Institute of the McGill University Health Centre, Montréal, QC, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montréal, QC, Canada.,Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Center, Montréal, QC, Canada.,Research Centre for Physical Activity and Health, McGill University, Montréal, QC, Canada
| | - Dennis Jensen
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, McGill University, Montréal, QC, Canada.,Department of Medicine, Respiratory Division, McGill University, Montréal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit, Montréal Chest Institute, McGill University Health Centre, Montréal, QC, Canada.,Meakins-Christie Laboratories, Research Institute of the McGill University Health Centre, Montréal, QC, Canada.,Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Center, Montréal, QC, Canada.,Research Centre for Physical Activity and Health, McGill University, Montréal, QC, Canada
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15
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Bräunlich J, Wirtz H. Oral Versus Nasal High-Flow Bronchodilator Inhalation in Chronic Obstructive Pulmonary Disease. J Aerosol Med Pulm Drug Deliv 2017; 31:248-254. [PMID: 29261402 DOI: 10.1089/jamp.2017.1432] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nasal high flow (NHF) alters breathing patterns, stabilizes fraction of inspired oxygen (FiO2) during respiratory distress, helps to keep up hemostasis in the airways, and washes out the upper airways. Particularly the support of inspiratory flow and decrease in functional dead space are interesting mechanisms of action with regard to aerosol delivery. Several laboratory investigations have studied aerosol delivery via the nasal route by using NHF, whereas clinical benefits are poorly evaluated. METHODS Thirty patients with stable chronic obstructive pulmonary disease Gold D were recruited. In a randomized order, they inhaled a salbutamol 2.5 mg/ipratropium bromide 500 μg solution oral or NHF adapted on the second study day. A jet nebulizer was used as aerosol delivery device. The chosen flow rate was 35 L/min. RESULTS Four patients refused to repeat the procedure, for example, for inconvenience or fear of delayed discharge, and were not included in the intention-to-treat analysis. All remaining patients tolerated both inhalation systems well. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), airway resistance (Rtot), and residual volume (RV) were significantly altered after bronchodilator inhalation with each of the both devices. The two different ways of combined bronchodilator inhalation resulted in very comparable changes in FVC, FEV1, relative 1 second-capacity (FEV1%FVC), Rtot, total lung capacity (TLC), RV, and residual volume expressed as percent of TLC (RV%TLC). However, in between devices, no difference was observed on comparing the postinhalational measurements of FVC, FEV1, Rtot, and RV. CONCLUSIONS We conclude from this proof-of-principle kind of study that inhalation of combined bronchodilators adapted to an NHF device is similarly effective to inhalation with a standard oral aerosol nebulizer. (Clinical Trails NCT02885103).
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Affiliation(s)
- Jens Bräunlich
- Department of Respiratory Medicine, University of Leipzig , Leipzig, Germany
| | - Hubert Wirtz
- Department of Respiratory Medicine, University of Leipzig , Leipzig, Germany
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16
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Réminiac F, Vecellio L, Loughlin RM, Le Pennec D, Cabrera M, Vourc'h NH, Fink JB, Ehrmann S. Nasal high flow nebulization in infants and toddlers: An in vitro and in vivo scintigraphic study. Pediatr Pulmonol 2017; 52:337-344. [PMID: 27392199 DOI: 10.1002/ppul.23509] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/20/2016] [Accepted: 06/08/2016] [Indexed: 12/15/2022]
Abstract
Aerosol therapy in infants and toddlers is challenging. Nebulization within a nasal high flow (NHF) circuit is attractive. The aim of this study was to quantify aerosol lung deposition when combined with NHF as compared with standard practice. Lung doses were measured scintigraphically after nebulization with jet and mesh nebulizer placed within a NHF circuit in a spontaneously breathing non-human primate model (macaque) and in the anatomical bench SAINT model, respectively representing a full-term newborn and a 9-month-old toddler. In the SAINT model, lung depositions observed with the mesh nebulizer placed in the NHF circuit set at 2 and 4 L/min were 3.3% and 4.2% of the nebulizer charge, respectively, and similar to the 1.70% observed with the control standard facemask jet nebulization (6 L/min flow). In the macaque model, the depositions observed with the mesh nebulizer in the NHF circuit set at 2 and 4 L/min were 0.49% and 0.85%, respectively, also similar to the control measurement (0.71%). Mesh nebulization within a NHF circuit set at 8 L/min and jet nebulization either within a NHF circuit or placed on top of the cannula (NHF set at 2 L/min; total flow of 8 L/min), resulted in a significantly lower lung depositions. Mesh nebulization within a NHF circuit delivering up to 4 L/min gas is likely to be at least as effective than jet nebulization with a facemask in infants and toddlers. Aerosol facemask placement on top of cannulas or jet nebulization within the NHF circuit may be less effective. Pediatr Pulmonol. 2017;52:337-344. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- François Réminiac
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France.,CHRU de Tours, Anesthésie-réanimation, Tours, France.,CHRU de Tours, Réanimation polyvalente, Tours, France
| | - Laurent Vecellio
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France.,Faculté de médecine, Aerodrug, DTF Medical, Tours, France
| | | | - Deborah Le Pennec
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France
| | - Maria Cabrera
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France
| | - Nathalie Heuzé Vourc'h
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France
| | | | - Stephan Ehrmann
- Université François Rabelais, Tours, France.,INSERM, Centre d'Étude des Pathologies Respiratoires, Tours, France.,CHRU de Tours, Réanimation polyvalente, Tours, France
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17
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Réminiac F, Bodet-Contentin L, Vecellio L, Dequin PF, Ehrmann S. Aérosolthérapie au cours de l’assistance respiratoire non invasive. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1158-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Lee YH, Kwon GY, Park DY, Bang JY, Jang DM, Lee SH, Lee EK, Choi BM, Noh GJ. Efficiency of a New Mesh-Type Nebulizer (NE-SM1 NEPLUS) for Intrapulmonary Delivery of Ipratropium Bromide in Surgical Patients. Basic Clin Pharmacol Toxicol 2015; 118:313-9. [DOI: 10.1111/bcpt.12499] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 09/29/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Yong-Hun Lee
- Department of Anaesthesiology and Pain Medicine; Asan Medical Centre; University of Ulsan College of Medicine; Seoul Korea
| | - Gu-Youn Kwon
- Ulsan Graduate School of Medicine and Science; Seoul Korea
| | - Do-Yang Park
- Department of Clinical Pharmacology and Therapeutics; Asan Medical Centre; University of Ulsan College of Medicine; Seoul Korea
| | - Ji-Yeon Bang
- Department of Anaesthesiology and Pain Medicine; Asan Medical Centre; University of Ulsan College of Medicine; Seoul Korea
| | - Dong-Min Jang
- Department of Anaesthesiology and Pain Medicine; Asan Medical Centre; University of Ulsan College of Medicine; Seoul Korea
| | - Soo-Han Lee
- Department of Veterinary Internal Medicine; College of Veterinary Medicine; Konkuk University; Seoul Korea
| | - Eun-Kyung Lee
- Department of Statistics; Ewha Womans University; Seoul Korea
| | - Byung-Moon Choi
- Department of Anaesthesiology and Pain Medicine; Asan Medical Centre; University of Ulsan College of Medicine; Seoul Korea
| | - Gyu-Jeong Noh
- Department of Anaesthesiology and Pain Medicine; Asan Medical Centre; University of Ulsan College of Medicine; Seoul Korea
- Department of Clinical Pharmacology and Therapeutics; Asan Medical Centre; University of Ulsan College of Medicine; Seoul Korea
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19
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Maccari JG, Teixeira C, Gazzana MB, Savi A, Dexheimer-Neto FL, Knorst MM. Inhalation therapy in mechanical ventilation. J Bras Pneumol 2015; 41:467-72. [PMID: 26578139 PMCID: PMC4635094 DOI: 10.1590/s1806-37132015000000035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 06/29/2015] [Indexed: 12/04/2022] Open
Abstract
Patients with obstructive lung disease often require ventilatory support via invasive or noninvasive mechanical ventilation, depending on the severity of the exacerbation. The use of inhaled bronchodilators can significantly reduce airway resistance, contributing to the improvement of respiratory mechanics and patient-ventilator synchrony. Although various studies have been published on this topic, little is known about the effectiveness of the bronchodilators routinely prescribed for patients on mechanical ventilation or about the deposition of those drugs throughout the lungs. The inhaled bronchodilators most commonly used in ICUs are beta adrenergic agonists and anticholinergics. Various factors might influence the effect of bronchodilators, including ventilation mode, position of the spacer in the circuit, tube size, formulation, drug dose, severity of the disease, and patient-ventilator synchrony. Knowledge of the pharmacological properties of bronchodilators and the appropriate techniques for their administration is fundamental to optimizing the treatment of these patients.
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Affiliation(s)
| | - Cassiano Teixeira
- Unidade de Terapia Intensiva Adulto, Hospital Moinhos de Vento, Porto Alegre (RS) Brasil
| | | | - Augusto Savi
- Unidade de Terapia Intensiva Adulto, Hospital Moinhos de Vento, Porto Alegre (RS) Brasil
| | | | - Marli Maria Knorst
- Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil
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Réminiac F, Vecellio L, Heuzé-Vourc'h N, Petitcollin A, Respaud R, Cabrera M, Pennec DL, Diot P, Ehrmann S. Aerosol Therapy in Adults Receiving High Flow Nasal Cannula Oxygen Therapy. J Aerosol Med Pulm Drug Deliv 2015. [PMID: 26196740 DOI: 10.1089/jamp.2015.1219] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND High flow nasal cannula oxygen therapy (HFT) is increasingly used in intensive and emergency care departments. Patients suffering from respiratory failure, who are likely to benefit from HFT, may require aerosolized bronchodilators; therefore, combining nebulization with HFT may be relevant. This study aimed to identify the optimal settings for the implementation of nebulization within an adult HFT circuit. METHODS We assessed the mass and the particle size distribution of the aerosol emitted from the nasal cannula (inhalable mass) using mesh- and jet-nebulizers placed at various positions in the HFT circuit. Thereafter, the most relevant combination was used to evaluate the mass of salbutamol delivered downstream of an anatomical model reproducing aerosol deposition and leakage at the nasal and pharyngeal levels (respirable mass). The influence of HFT flow rate (30, 45, and 60 L/min), of breathing pattern (quiet and respiratory distress pattern) as well as of opened and closed mouth breathing was assessed. RESULTS The most efficient position was that of a nebulizer placed upstream from the humidification chamber (inhalable mass ranging from 26% to 32% of the nebulizer charge). Using a mesh nebulizer, we observed a respirable mass ranging from 2% to 10% of the nebulizer charge. Higher HFT flow rates and open mouth breathing were associated with a lower efficiency. Simulating respiratory distress (i.e., increasing the simulated patient inspiratory flow) did not hamper drug delivery as compared to a quiet breathing pattern. CONCLUSIONS Placing nebulizers within a HFT circuit upstream from the humidification chamber may enable to deliver clinically relevant masses of aerosol at the cannula outlet, but more importantly downstream of the nose and pharynx, even in case of high patients' inspiratory flow. This method of aerosol therapy is expected to produce a bronchodilatatory effect to be evaluated in the clinical settings.
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Affiliation(s)
- François Réminiac
- 1 Université François Rabelais , Tours, France .,2 INSERM , Centre d'Étude des Pathologies Respiratoires, Tours, France .,3 Pôle d'anesthésie-réanimation, CHRU de Tours , Tours, France .,4 Réanimation polyvalente, CHRU de Tours , Tours, France
| | - Laurent Vecellio
- 1 Université François Rabelais , Tours, France .,2 INSERM , Centre d'Étude des Pathologies Respiratoires, Tours, France .,5 Aerodrug, DTF Medical , Faculté de médecine, Tours, France
| | - Nathalie Heuzé-Vourc'h
- 1 Université François Rabelais , Tours, France .,2 INSERM , Centre d'Étude des Pathologies Respiratoires, Tours, France
| | | | | | - Maria Cabrera
- 1 Université François Rabelais , Tours, France .,2 INSERM , Centre d'Étude des Pathologies Respiratoires, Tours, France
| | - Deborah Le Pennec
- 1 Université François Rabelais , Tours, France .,2 INSERM , Centre d'Étude des Pathologies Respiratoires, Tours, France
| | - Patrice Diot
- 1 Université François Rabelais , Tours, France .,2 INSERM , Centre d'Étude des Pathologies Respiratoires, Tours, France .,8 Pneumologie, CHRU de Tours , Tours, France
| | - Stephan Ehrmann
- 1 Université François Rabelais , Tours, France .,2 INSERM , Centre d'Étude des Pathologies Respiratoires, Tours, France .,4 Réanimation polyvalente, CHRU de Tours , Tours, France
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Wang H, Sebrié C, Ruaud J, Guillot G, Bouazizi K, Willoquet G, Maître X, Darrasse L, de Rochefort L. Aerosol deposition in the lungs of spontaneously breathing rats using Gd‐DOTA‐based contrast agents and ultra‐short echo time MRI at 1.5 Tesla. Magn Reson Med 2015; 75:594-605. [DOI: 10.1002/mrm.25617] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 11/22/2014] [Accepted: 12/16/2014] [Indexed: 01/05/2023]
Affiliation(s)
- Hongchen Wang
- Imagerie par Résonance Magnétique Médicale et Multi‐Modalités (UMR8081)IR4M, Univ. Paris‐Sud, CNRSOrsay France
| | - Catherine Sebrié
- Imagerie par Résonance Magnétique Médicale et Multi‐Modalités (UMR8081)IR4M, Univ. Paris‐Sud, CNRSOrsay France
| | - Jean‐Pierre Ruaud
- Imagerie par Résonance Magnétique Médicale et Multi‐Modalités (UMR8081)IR4M, Univ. Paris‐Sud, CNRSOrsay France
| | - Geneviève Guillot
- Imagerie par Résonance Magnétique Médicale et Multi‐Modalités (UMR8081)IR4M, Univ. Paris‐Sud, CNRSOrsay France
| | - Khaoula Bouazizi
- Imagerie par Résonance Magnétique Médicale et Multi‐Modalités (UMR8081)IR4M, Univ. Paris‐Sud, CNRSOrsay France
| | - Georges Willoquet
- Imagerie par Résonance Magnétique Médicale et Multi‐Modalités (UMR8081)IR4M, Univ. Paris‐Sud, CNRSOrsay France
| | - Xavier Maître
- Imagerie par Résonance Magnétique Médicale et Multi‐Modalités (UMR8081)IR4M, Univ. Paris‐Sud, CNRSOrsay France
| | - Luc Darrasse
- Imagerie par Résonance Magnétique Médicale et Multi‐Modalités (UMR8081)IR4M, Univ. Paris‐Sud, CNRSOrsay France
| | - Ludovic de Rochefort
- Imagerie par Résonance Magnétique Médicale et Multi‐Modalités (UMR8081)IR4M, Univ. Paris‐Sud, CNRSOrsay France
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Dash S, Xiao C, Morgantini C, Koulajian K, Lewis GF. Intranasal insulin suppresses endogenous glucose production in humans compared with placebo in the presence of similar venous insulin concentrations. Diabetes 2015; 64:766-74. [PMID: 25288674 DOI: 10.2337/db14-0685] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Intranasal insulin (INI) has been shown to modulate food intake and food-related activity in the central nervous system in humans. Because INI increases insulin concentration in the cerebrospinal fluid, these effects have been postulated to be mediated via insulin action in the brain, although peripheral effects of insulin cannot be excluded. INI has been shown to lower plasma glucose in some studies, but whether it regulates endogenous glucose production (EGP) is not known. To assess the role of INI in the regulation of EGP, eight healthy men were studied in a single-blind, crossover study with two randomized visits (one with 40 IU INI and the other with intranasal placebo [INP] administration) 4 weeks apart. EGP was assessed under conditions of an arterial pancreatic clamp, with a primed, constant infusion of deuterated glucose and infusion of 20% dextrose as required to maintain euglycemia. Between 180 and 360 min after administration, INI significantly suppressed EGP by 35.6% compared with INP, despite similar venous insulin concentrations. In conclusion, INI lowers EGP in humans compared with INP, despite similar venous insulin concentrations. INI may therefore be of value in treating excess liver glucose production in diabetes.
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Affiliation(s)
- Satya Dash
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada, and Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Changting Xiao
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada, and Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Cecilia Morgantini
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada, and Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Khajag Koulajian
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada, and Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gary F Lewis
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada, and Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Amirav I, Borojeni AAT, Halamish A, Newhouse MT, Golshahi L. Nasal versus oral aerosol delivery to the "lungs" in infants and toddlers. Pediatr Pulmonol 2015; 50:276-283. [PMID: 24482309 DOI: 10.1002/ppul.22999] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 01/05/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The oral route has been considered superior to the nasal route for aerosol delivery to the lower respiratory tract (LRT) in adults and children. However, there are no data comparing aerosol delivery via the oral and nasal routes in infants. The aim of this study was to compare nasal and oral delivery of aerosol in anatomically correct replicas of infants' faces containing both nasal and oral upper airways. METHODS Three CT-derived upper respiratory tract ("URT") replicas representing infants/toddlers aged 5, 14 and 20 months were studied and aerosol delivery to the "lower respiratory tract" (LRT) by either the oral or nasal route for each of the replicas was measured at the "tracheal" opening. A radio-labeled (99mDTPA) normal saline solution aerosol was generated by a soft-mist inhaler (SMIRespimat® Boehringer Ingelheim, Germany) and aerosol was delivered via a valved holding chamber (Respichamber® TMI, London, Canada) and an air-tight mask (Unomedical, Inc., McAllen, TX). A breath simulator was connected to the replicas and an absolute filter at the "tracheal" opening captured the aerosol representing "LRT" dose. Age-appropriate mask dimensions and breathing patterns were employed for each of the airway replicas. Two different tidal volumes (Vt ) were used for comparing the nasal versus oral routes. RESULTS Nasal delivery to the LRT exceeded that of oral delivery in the 5- and 14-month models and was equivalent in the 20-month model. Differences between nasal and oral delivery diminished with "age"/size. Similar findings were observed with lower and higher tidal volumes (Vt ). CONCLUSION Nasal breathing for aerosol delivery to the "LRT" is similar to, or more efficient than, mouth breathing in infant/toddler models, contrary to what is observed in older children and adults. Pediatr Pulmonol. 2015; 50:276-283. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Israel Amirav
- Pediatric Department, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada.,University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Michael T Newhouse
- Firestone Institute for Respiratory Health, St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
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Ari A, de Andrade AD, Sheard M, AlHamad B, Fink JB. Performance Comparisons of Jet and Mesh Nebulizers Using Different Interfaces in Simulated Spontaneously Breathing Adults and Children. J Aerosol Med Pulm Drug Deliv 2014; 28:281-9. [PMID: 25493535 DOI: 10.1089/jamp.2014.1149] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Different types of nebulizers and interfaces are used for the treatment of adults and children with pulmonary diseases. The purpose of this study was to determine the efficiency of a mesh nebulizer (MN) with a proprietary adapter and a jet nebulizer (JN) under different configurations in adult and pediatric models of spontaneous breathing. We hypothesize that delivery efficiency of JN and MN will differ depending on the interface used during aerosol therapy in simulated spontaneously breathing adult and pediatric models. While we expect that aerosol delivery with JN will be less efficient than MN, we also hypothesize that lung deposition obtained with the adult lung model will be more than that with the pediatric lung model in all conditions tested in this study. METHODS A lung model using a teaching manikin connected to a sinusoidal pump via a collecting filter at the level of the bronchi simulating a spontaneously breathing adult (Vt 500 mL, RR 15 bpm, I:E ratio 1:2) or pediatric patient (Vt 150 mL, RR 25 bpm, I:E ratio 1:2). Albuterol sulfate (2.5 mg/3 mL) was aerosolized with JN (Mistymax 10, Airlife) or MN (Aerogen Solo(®), Aerogen) with the Adapter (Aerogen Solo(®) Adapter, Aerogen Ltd, Galway, Ireland) using mouthpiece, aerosol mask, and valved-mask in adults and the dragon mask, aerosol mask, and valved-mask in pediatrics (n=3). The Adapter, specifically designed for MN, was attached to all the interfaces used in this study with supplemental oxygen of 2 lpm, and in addition, the MP was tested with no additional flow in the adult model. The JN was driven with 10 lpm based on the manufacturer's label. Drug was eluted from the filter and analyzed via spectrophotometry. Descriptive statistics, dependent t-test and one-way analysis of variance were used for data analysis. Significant level was set at 0.05. RESULTS In adults, delivery efficiency of JN with the valved mask was significantly greater than that with the aerosol mask (p=0.01). Aerosol delivery of JN with the mouthpiece was not statistically significant from the valved mask (p=0.123) and the aerosol mask (p=0.193). Drug delivery with MN with mouthpiece (15.42±1.4%) and valved-mask (15.15±1.1%) was greater than the open aerosol mask (7.54±0.39%; p=0.0001) in the adult lung model. With no flow mouthpiece delivery increased>2 fold (34.9±3.1%; p=.0001) compared to use of 2 lpm of flow. Using the JN with the pediatric model deposition with valved-mask (5.3±0.8%), dragon mask (4.7±0.9%), and aerosol mask (4.1±0.3%) were similar (p>0.05); while drug delivery with MN via valved-mask (11.1±0.7%) was greater than the dragon mask (6.44±0.3%; p=0.002) and aerosol mask (4.6±0.4%; p=0.002), and the dragon mask was more efficient than the open aerosol mask (p=0.009) CONCLUSION: The type of nebulizer and interface used for aerosol therapy affects delivery efficiency in these simulated spontaneously breathing adult and pediatric models. Drug delivery was greatest with the valved-mouthpiece and mask with JN and MN, while the standard aerosol mask was least efficient in these simulated spontaneously breathing adult and pediatric lung models. Delivery efficiency of JN was less than MN in all conditions tested in this study except in the aerosol mask. Lung deposition obtained with the adult lung model was more than that with the pediatric lung model.
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Affiliation(s)
- Arzu Ari
- 1 Department of Respiratory Therapy, Georgia State University , Atlanta, Georgia
| | | | - Meryl Sheard
- 1 Department of Respiratory Therapy, Georgia State University , Atlanta, Georgia
| | - Bshayer AlHamad
- 1 Department of Respiratory Therapy, Georgia State University , Atlanta, Georgia
| | - James B Fink
- 1 Department of Respiratory Therapy, Georgia State University , Atlanta, Georgia
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25
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Goralski JL, Davis SD. Breathing easier: addressing the challenges of aerosolizing medications to infants and preschoolers. Respir Med 2014; 108:1069-74. [PMID: 25012949 DOI: 10.1016/j.rmed.2014.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/03/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
An increasing number of patients are dependent on aerosolized therapy to manage pulmonary diseases, including asthma, cystic fibrosis, and pulmonary arterial hypertension. An aerosol therapy is only useful if it can be appropriately and consistently delivered in the desired dose to the lower respiratory tract. Many factors affect this deposition in young children, including anatomical and physiologic differences between adults and children, patient-mask interface issues, the challenge of administering medication to uncooperative children, and behavioral adherence. Moreover, the techniques used to assess aerosol delivery to pediatric patients need to be carefully evaluated as new therapies and drug-device combinations are tested. In this review, we will address some of the challenges of delivering aerosolized medications to pediatric patients.
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Affiliation(s)
- Jennifer L Goralski
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Division of Pediatric Pulmonology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Stephanie D Davis
- James Whitcomb Riley Hospital for Children, Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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26
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Dhand R. Aerosol therapy in patients receiving noninvasive positive pressure ventilation. J Aerosol Med Pulm Drug Deliv 2011; 25:63-78. [PMID: 22191396 DOI: 10.1089/jamp.2011.0929] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In selected patients, noninvasive positive pressure ventilation (NIPPV) with a facemask is now commonly employed as the first choice for providing mechanical ventilation in the intensive care unit (ICU). Aerosol therapy for treatment of acute or acute-on-chronic respiratory failure in this setting may be delivered by pressurized metered-dose inhaler (pMDI) with a chamber spacer and facemask or nebulizer and facemask. This article reviews the host of factors influencing aerosol delivery with these devices during NIPPV. These factors include (1) the type of ventilator, (2) mode of ventilation, (3) circuit conditions, (4) type of interface, (5) type of aerosol generator, (6) drug-related factors, (7) breathing parameters, and (8) patient-related factors. Despite the impediments to efficient aerosol delivery because of continuous gas flow, high inspiratory flow rates, air leaks, circuit humidity, and patient-ventilator asynchrony, significant therapeutic effects are achieved after inhaled bronchodilator administration to patients with asthma and chronic obstructive pulmonary disease. Similarly to invasive mechanical ventilation, careful attention to the technique of drug administration is required to optimize therapeutic effects of inhaled therapies during NIPPV. Assessment of the patient's ability to tolerate a facemask, the level of respiratory distress, hemodynamic status, and synchronization of aerosol generation with inspiratory airflow are important factors contributing to the success of aerosol delivery during NIPPV. Further research into novel delivery methods, such as the use of NIPPV with nasal cannulae, could enhance the efficiency, ease of use, and reproducibility of inhalation therapy during noninvasive ventilation.
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Affiliation(s)
- Rajiv Dhand
- Division of Pulmonary, Critical Care, and Environmental Medicine, Department of Internal Medicine, University of Missouri, Columbia, Missouri 65212, USA.
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Yeo LY, Friend JR, McIntosh MP, Meeusen ENT, Morton DAV. Ultrasonic nebulization platforms for pulmonary drug delivery. Expert Opin Drug Deliv 2010; 7:663-79. [PMID: 20459360 DOI: 10.1517/17425247.2010.485608] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Since the 1950s, ultrasonic nebulizers have played an important role in pulmonary drug delivery. As the process in which aerosol droplets are generated is independent and does not require breath-actuation, ultrasonic nebulizers, in principle, offer the potential for instantaneously fine-tuning the dose administered to the specific requirements of a patient, taking into account the patient's breathing pattern, physiological profile and disease state. Nevertheless, owing to the difficulties and limitations associated with conventional designs and technologies, ultrasonic nebulizers have never been widely adopted, and have in recent years been in a state of decline. AREAS COVERED IN THIS REVIEW An overview is provided on the advances in new miniature ultrasonic nebulization platforms in which large increases in lung dose efficiency have been reported. WHAT THE READER WILL GAIN In addition to a discussion of the underlying mechanisms governing ultrasonic nebulization, in which there appears to be widely differing views, the advantages and shortcomings of conventional ultrasonic nebulization technology are reviewed and advanced state-of-the-art technologies that have been developed recently are discussed. TAKE HOME MESSAGE Recent advances in ultrasonic nebulization technology demonstrate significant potential for the development of smart, portable inhalation therapy platforms for the future. Nevertheless, there remain considerable challenges that need to be addressed before such personalized delivery systems can be realized. These have to be addressed across the spectrum from fundamental physics through to in vivo device testing and dealing with the relevant regulatory framework.
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Affiliation(s)
- Leslie Y Yeo
- Monash University, Department of Mechanical and Aerospace Engineering, Micro/Nanophysics Research Laboratory, Clayton, VIC 3800, Australia.
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Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med 2008; 40:247-55. [PMID: 19081697 DOI: 10.1016/j.jemermed.2008.06.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 05/30/2008] [Accepted: 06/22/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite demonstration of equivalent efficacy of beta agonist delivery using a metered dose inhaler (MDI) with spacer vs. nebulizer in asthma patients, use of a nebulizer remains standard practice. OBJECTIVES We hypothesize that beta agonist delivery with a MDI/disposable spacer combination is an effective and low-cost alternative to nebulizer delivery for acute asthma in an inner-city population. METHODS This study was a prospective, randomized, double-blinded, placebo-controlled trial with 60 acute asthma adult patients in two inner-city emergency departments. Subjects (n = 60) received albuterol with either a MDI/spacer combination or nebulizer. The spacer group (n = 29) received albuterol by MDI/spacer followed by placebo nebulization. The nebulizer group (n = 29) received placebo by MDI/spacer followed by albuterol nebulization. Peak flows, symptom scores, and need for rescue bronchodilatator were monitored. Median values were compared with the Kolmogorov-Smirnov test. RESULTS Patients in the two randomized groups had similar baseline characteristics. The severity of asthma exacerbation, median peak flows, and symptom scores were not significantly different between the two groups. The median (interquartile range) improvement in peak flow was 120 (75-180) L/min vs. 120 (80-155) L/min in the spacer and nebulizer groups, respectively (p = 0.56). The median improvement in the symptom score was 7 (5-9) vs. 7 (4-9) in the spacer and nebulizer groups, respectively (p = 0.78). The median cost of treatment per patient was $10.11 ($10.03-$10.28) vs. $18.26 ($9.88-$22.45) in the spacer and nebulizer groups, respectively (p < 0.001). CONCLUSION There is no evidence of superiority of nebulizer to MDI/spacer beta agonist delivery for emergency management of acute asthma in the inner-city adult population. MDI/spacer may be a more economical alternative to nebulizer delivery.
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Chopra P, Kanoje V, Semwal A, Ray A. Therapeutic potential of inhaled p38 mitogen-activated protein kinase inhibitors for inflammatory pulmonary diseases. Expert Opin Investig Drugs 2008; 17:1411-25. [PMID: 18808304 DOI: 10.1517/13543784.17.10.1411] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Over the past two decades, p38 MAPK (mitogen-activated protein kinase) has been the subject of intense multidisciplinary research. p38 MAPK inhibitors have been shown to be efficacious in several disease models, including rheumatoid arthritis, psoriasis, Crohn's disease, and stroke. Recent studies support a role for p38 MAPK in the development, maintenance, and/or exacerbation of a number of pulmonary diseases, such as asthma, cystic fibrosis, idiopathic pulmonary fibrosis, and chronic obstructive pulmonary disease (COPD). OBJECTIVE Many previous attempts to develop p38 MAPK inhibitors have failed as a result of unacceptable safety profiles. These toxicities have been varied and are believed to derive from different off-target effects. METHOD The above concerns can be overcome by delivering the compound locally to minimize whole-body burden, resulting in low exposure to the gastrointestinal, liver, and CNS. This review discusses the role of p38 MAPK in various inflammatory diseases, followed by the toxicity concerns associated with p38 MAPK inhibition. It also highlights the possible beneficial effect of delivering drugs via the inhalation route. CONCLUSION We present proof-of-principle confirming the therapeutic potential of inhaled p38 inhibitors for asthma and other inflammatory pulmonary diseases.
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Affiliation(s)
- Puneet Chopra
- Ranbaxy Research Laboratories, Department of Pharmacology, New Drug Discovery Research, Plot No-20, Sector-18, Gurgaon-122001-Haryana, India.
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Hess DR. The mask for noninvasive ventilation: principles of design and effects on aerosol delivery. ACTA ACUST UNITED AC 2007; 20 Suppl 1:S85-98; discussion S98-9. [PMID: 17411410 DOI: 10.1089/jam.2007.0574] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
There has been much clinical and academic interest in the use of noninvasive positive-pressure ventilation (NPPV) in patients with acute and chronic respiratory failure. The use of NPPV in appropriately selected patients improves survival and decreases the need for endotracheal intubation. The most commonly used interfaces for NPPV are nasal masks or oronasal masks, but nasal pillows, mouthpieces, total face masks, and helmets can also be used. Critical care ventilators, portable volume ventilators, and ventilators designed specifically for NPPV can be used. There are three options for aerosol delivery during NPPV. The patient can be removed from NPPV and the aerosol administered by nebulizer or MDI in the standard manner, the aerosol can be delivered by nebulizer placed in-line between the circuit and the mask, or a spacer chamber can be placed between the circuit and the mask. There is presently no commercially available system designed specifically for aerosol delivery during NPPV with a bilevel (BiPAP) ventilator. However, in vitro and in vivo studies have demonstrated that a significant amount of bronchodilator can be administered by in-line nebulizer or MDI during NPPV. The evidence base for aerosol delivery during NPPV is not nearly as mature as the evidence for aerosol delivery during invasive mechanical ventilation. With NPVV, issues related to the optimal interface, ventilator settings, and aerosol generator (nebulizer versus MDI) are largely unexplored.
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Affiliation(s)
- Dean R Hess
- Department of Anesthesia, Harvard Medical School, Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Finlay WH, Martin AR. Modeling of aerosol deposition with interface devices. ACTA ACUST UNITED AC 2007; 20 Suppl 1:S19-26; discussion S27-8. [PMID: 17411402 DOI: 10.1089/jam.2007.0554] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Various approaches can be used to mathematically model the performance of different masks, mouthpieces, and aerosol delivery devices. The sophistication of such models can vary widely, from the use of simple algebraic empirical correlations to advanced computational fluid dynamics simulations. Bench-top testing is also often used to model aspects of devices, since it is difficult to capture certain aspects of device behavior with mathematical models. These various approaches to modeling differ in their limitations. Empirical correlations exist for predicting the effects of varying mouthpiece diameter and mouth-throat dimensions on extrathoracic losses, but are restricted to stable, nonballistic aerosols in certain flow rate ranges. Computational fluid dynamics (CFD) simulations that solve the Reynolds-averaged Navier-Stokes (RANS) equations typically require near-wall turbulence corrections in order to adequately model mouth-throat deposition, while Large Eddy Simulation (LES) removes this deficiency. Bench-top models that use replicas of the extrathoracic airways vary in their accuracy and generality in replicating the filtering properties of these airways. Choosing and using these various modeling approaches for evaluating patient-device interfaces requires knowledge of their merits and pitfalls, a brief discussion of which is given here.
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Affiliation(s)
- W H Finlay
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
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Shirk MB, Donahue KR, Shirvani J. Unlabeled uses of nebulized medications. Am J Health Syst Pharm 2007; 63:1704-16. [PMID: 16960254 DOI: 10.2146/ajhp060015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The uses, dosing recommendations, benefits, and disadvantages of unlabeled drugs administered by nebulization are reviewed. SUMMARY Nebulization is gaining popularity as a treatment alternative, and many drugs are used unlabeled in a nebulized form, including the opioids, lidocaine, magnesium sulfate, amphotericin B, and colistin. The opioids are frequently used to treat dyspnea in end-stage diseases. Common dosages include 1-2 mg every two hours as needed for hydromorphone and 25-50 microg every two hours for fentanyl citrate. Lidocaine can be used to relieve bronchoconstriction and cough symptoms as well as acting as a local anesthetic. It is typically given in a dose between 20 and 160 mg. Nebulized magnesium sulfate can be used in managing acute asthma and is given in dosages between 125 and 250 mg every 20 minutes, with no more than four consecutive doses. Nebulized amphotericin B can be used to prevent infections in immunocompromised patients. A typical amphotericin B regimen is 25 mg every 24 hours. Nebulized colistin is being studied in the prevention and treatment of gram-negative infections and in patients awaiting lung transplants. Colistin is often given as 75 mg every 12 hours to combat infections. CONCLUSION Unlabeled nebulization of opioids, lidocaine, magnesium, amphotericin B, and colistin is an alternative method of treatment for patients with pulmonary problems or infections or for those undergoing bronchoscopy. More research is needed to develop guidelines for their use since nebulization may provide benefits to many patients who otherwise cannot be treated or would be at risk of systemic adverse effects of the drugs.
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Affiliation(s)
- Mary Beth Shirk
- Department of Pharmacy, The Ohio State University Medical Center (OSUMC), Columbus, OH 43210-1228, USA.
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Berger WE. Paediatric pulmonary drug delivery: considerations in asthma treatment. Expert Opin Drug Deliv 2006; 2:965-80. [PMID: 16296802 DOI: 10.1517/17425247.2.6.965] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aerosol therapy, the preferred route of administration for glucocorticosteroids and short-acting beta(2)-adrenergic agonists in the treatment of paediatric asthma, may be given via nebulisers, metered-dose inhalers and dry powder inhalers. For glucocorticosteroids, therapy with aerosolised medication results in higher concentrations of drug at the target organ with minimal systemic side effects compared with oral treatments. The dose of drug that reaches the airways in children with asthma is dependent on both the delivery device and patient-related factors. Factors that affect aerosol drug delivery are reviewed briefly. Advantages and disadvantages of each device and device-specific factors that influence patient preferences are examined. Although age-based device recommendations have been made, the optimal choice for drug delivery is the one that the patient or caregiver prefers to use, can use correctly and is most likely to use consistently.
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Affiliation(s)
- William E Berger
- Allergy and Asthma Associates of Southern California, Mission Viejo, CA 92691-6410, USA.
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Brown VA, Wilkins PA. Advanced Techniques in the Diagnosis and Management of Infectious Pulmonary Diseases in Horses. Vet Clin North Am Equine Pract 2006; 22:633-51, xi. [PMID: 16882489 DOI: 10.1016/j.cveq.2006.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Techniques for novel approaches to the diagnosis and management of equine pulmonary disease continue to be developed and used in clinical practice. Diagnostic techniques involving immunoassays and nucleic acid-based tests not only decrease the time in which results become available but increase the sensitivity and specificity of test results. These assays do not substitute for careful clinical evaluation but can shorten the time to a confirmed accurate diagnosis, and thus allow for early initiation of therapeutic strategies and prevention protocols. With further understanding of the molecular biology and immunology of equine pulmonary disease, diagnostic and management techniques should become further refined.
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Affiliation(s)
- Valerie A Brown
- New Bolton Center, University of Pennsylvania School of Veterinary Medicine, 382 West Street Road, Kennett Square, PA 19348, USA.
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Abstract
Inhalational drug delivery is the primary mode of asthma therapy in children and is the main focus of this article. Pressurized metered dose inhalers (pMDIs) are now the method of choice in infants and children under 5 years old, when used in combination with an appropriate valved holding chamber or spacer. Spacers are particularly important for steroid inhalation to maximize lung deposition and minimize unwanted oropharyngeal deposition. Optimal inhalation technique with a pMDI-spacer in infants is to inhale the drug by breathing tidally through the spacer. Drug delivery to the lungs using pMDIs can vary greatly, depending on the formulation used and the age of the child. Dry powder inhalers (DPIs) are driven by the peak inspiratory flow of the patient and are usually not appropriate for children under 5 or 6 years of age. Nebulizers continue to play a role in the treatment of acute asthma where high doses of bronchodilator are required, though multiple doses via pMDI spacer may suffice. Important drug delivery issues specific to children include compliance, use of mask versus mouthpiece, lower tidal volumes and inspiratory flows, determination of appropriate dosages, and minimization of adverse local and systemic effects.
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Affiliation(s)
- Sunalene G Devadason
- School of Paediatrics and Child Health, University of Western Australia, Princess Margaret Hospital for Children, Perth, Australia.
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Schüepp KG, Jauernig J, Janssens HM, Tiddens HAWM, Straub DA, Stangl R, Keller M, Wildhaber JH. In VitroDetermination of the Optimal Particle Size for Nebulized Aerosol Delivery to Infants. ACTA ACUST UNITED AC 2005; 18:225-35. [PMID: 15966777 DOI: 10.1089/jam.2005.18.225] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We investigated the in vitro influence of breathing patterns on lung dose (LD) and particle size distribution in an infant upper airway cast model in order to determine the optimal particle size for nebulized aerosol delivery to infants. Budesol (nebulizer solution of budesonide) delivery from a perforated vibrating membrane nebulizer (eFlow Baby functional prototype) through an upper airway cast of a nine month old infant (SAINT-model) was measured at a fixed respiratory rate (RR) of 30 breaths per minute (bpm) and a tidal volume (Vt) of 50, 100, and 200 mL, respectively, and at a fixed Vt of 100 mL and a RR of 30, 60, and 78 bpm, respectively. LD expressed as a percentage of the nominal dose (ND; range, 5.8-30.3%) decreased with increasing Vt (p < 0.001) and with increasing RR (p < 0.001). Median mass aerodynamic diameter (MMAD) after passage (range, 2.4-3.4 microm) through the upper airway cast showed a negative correlation with increasing Vt (p < 0.001) and with increasing RR (p = 0.015). Particles available as LD for all simulated breathing pattern showed a particle size distribution with a MMAD of 2.4 microm and a geometric standard deviation (GSD) of 1.56. From our in vitro study, we conclude that the optimal particle size for nebulized aerosols for inhalation therapy for infants should have a MMAD of <2.4 microm.
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Affiliation(s)
- Karen G Schüepp
- Swiss Paediatric Respiratory Research Group, Division of Respiratory Medicine, University Children's Hospital, Zürich, Switzerland.
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Everard ML. Inhaler devices in infants and children: challenges and solutions. ACTA ACUST UNITED AC 2004; 17:186-95. [PMID: 15294070 DOI: 10.1089/0894268041457129] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Mark L Everard
- Department of Respiratory Medicine, Sheffield Children's Hospital, Sheffield, United Kingdom.
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38
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Schüepp KG, Straub D, Möller A, Wildhaber JH. Deposition of aerosols in infants and children. ACTA ACUST UNITED AC 2004; 17:153-6. [PMID: 15294065 DOI: 10.1089/0894268041457228] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
There is still a lack of knowledge in the field of aerosol therapy in children, particularly in young children. The amount of drug delivered from a commercially available inhalation device that reaches the lungs of children is generally low. The choice of an optimal combination of delivery device and drug formulation based on individual patient related factors is crucial. Aerosols with a small MMAD and a narrow GSD are required for a sufficient inhalation therapy in early childhood. The development of combinations of delivery devices and drug formulations fulfilling the requirements for an efficient inhalation therapy in young children is likely to increase the therapeutical options in this age group.
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Affiliation(s)
- Karen G Schüepp
- Swiss Paediatric Respiratory Research Group, Department of Respiratory Medicine, University Children's Hospital, Zurich, Switzerland
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Berger WE, Shapiro GG. The use of inhaled corticosteroids for persistent asthma in infants and young children. Ann Allergy Asthma Immunol 2004; 92:387-399; quiz 399-402, 463. [PMID: 15104189 DOI: 10.1016/s1081-1206(10)61773-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To review pediatric trials of inhaled corticosteroid (ICS) therapy and summarize data on the pediatric use of devices to facilitate delivery of ICSs. DATA SOURCES Relevant articles regarding ICS treatment of persistent asthma in children younger than 5 years were identified from MEDLINE and reference lists of review articles. STUDY SELECTION Key articles were selected by the authors. RESULTS Clinical trials from the United States and Europe consistently demonstrated that ICS therapy is the most favorable treatment option with regard to safety and efficacy for infants and young children with persistent asthma. This contention is supported by numerous trials of budesonide inhalation suspension in children ranging from 6 months through 8 years of age and data from older children treated with fluticasone propionate. CONCLUSIONS As the only corticosteroid available in the United States as a nebulized formulation and the only ICS product extensively studied in young children and infants, budesonideinhalation suspension is an appropriate first-line therapy for treatment of persistent asthma in this population.
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Affiliation(s)
- William E Berger
- Allergy and Asthma Associates of Southern California, Mission Viejo, California 92691, USA.
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Abstract
Inhalation is the preferred route for asthma therapy, since it offers a rapid onset of drug action, requires smaller doses, and reduces systemic effects compared with other routes of administration. Unfortunately, inhalation devices are frequently used in an empirical manner rather than on evidence-based awareness.A wide variety of nebulizers are available. Conventional jet nebulizers are highly inefficient, as much of the aerosol is wasted during exhalation. However, incorporating an extra open vent into the system has considerably increased the amount of drug that patients receive. Breath-assisted open vent nebulizers limit the loss of aerosol during exhalation, but are dependent on the patient's inspiratory flow. Ultrasonic nebulizers produce a high mass output and have a short nebulization time, but are inefficient for delivering suspensions or viscous solutions. Adaptive aerosol delivery devices release a precise dose that is tailored to the individual patient's breathing pattern. Nebulizers have several drawbacks, and their use should be limited to patients who cannot correctly manage other devices.Pressurized metered-dose inhalers (pMDI) are practical, cheap and multidose. However, there are several problems with their use. Breath-actuated MDI are easy to use and can be activated by very low flow. However, young children may not be able to use them efficiently. Dry powder inhalers (DPI) are portable and easy to use. They are indicated either for rescue bronchodilator therapy or for regular treatment with inhaled corticosteroids and long-acting bronchodilators. The use of spacers reduces oropharyngeal deposition and improves drug delivery to the lung. Spacers do not require patient coordination, but some general rules must be followed for their optimal use.Thus, the choice of a delivery device mainly depends on the age of the patient, the drug to be administered and the condition to be treated. Proper education is also essential when prescribing an inhalation device.
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41
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Reychler G, Keyeux A, Cremers C, Veriter C, Rodenstein DO, Liistro G. Comparison of Lung Deposition in Two Types of Nebulization. Chest 2004; 125:502-8. [PMID: 14769731 DOI: 10.1378/chest.125.2.502] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND So-called intrapulmonary percussive ventilation (IPV), frequently coupled with a nebulizer, is increasingly used as a physiotherapy technique; however, its physiologic and clinical values have not been rigorously assessed. STUDY OBJECTIVE To compare in vitro and in vivo characteristics of the nebulizer of the IPV device (Percussionaire; Percussionaire Corporation; Sandpoint, ID) with those of standard jet nebulization (SST) [SideStream; Medic-Aid; West Sussex, UK]. DESIGN Aerodynamic particle size was studied by an cascade impactor. The deposition of (99m)Tc-diethylenetriaminepenta-acetic acid was measured in 10 healthy subjects by tomoscintigraphy during spontaneous breathing with both nebulizers. MEASUREMENTS AND RESULTS The mass median aerodynamic diameter (0.2 micro m vs 1.89 micro m for IPV and SST, respectively) and the fine-particle fraction (16.2% vs 67.5%, respectively) were significantly smaller with IPV. In vivo, respiratory frequency (RF) was lower with the IPV device (10.1 +/- 3.4 breaths/min vs 14.6 +/- 3.4 breaths/min, p = 0.002). Whole-body deposition was significantly higher with IPV (15.63% vs 9.31%), but it was due to a higher extrapulmonary deposition. Although intrapulmonary deposition (IPD) was not different with both devices (4.20% for SST vs 2.49% for IPV), it was much more variable with IPV, compared to SST. The penetration index into the lung was higher with IPV than SST when normalized for RF (0.045 +/- 0.018 breaths/min vs 0.026 +/- 0.013 breaths/min, p = 0.007). CONCLUSION The two techniques showed comparable lung deposition despite a large difference in particle size. However, IPV IPD was too variable and thus too unpredictable to recommend its use for drug delivery to the lung.
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Affiliation(s)
- Gregory Reychler
- Department of Physical Medicine and Rehabilitation, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
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Abstract
Delivering aerosolised drugs to infants poses a number of challenges. It is clear that drug delivery is possible via the inhaled route but to date it has been difficult to demonstrate clearly therapeutic benefit from the use of any conventional therapy in the vast majority of infants. This is probably related to the nature of pulmonary disease in this age group. While most aerosol scientists focus on factors such as aerosol size and airways geometry drug delivery, as in all age groups, is most dependent upon patient behaviour. A small amount of drug reaches the lungs of distressed infants. Consideration of patient device interactions is vital if successful drug delivery is to be achieved and this includes consideration of mask design. Doses reaching the lungs are generally very low when considered in terms of the nominal dose but when considered in terms of dose delivered per kilogram body weight drug delivery to the lungs is generally similar to or greater than in adults. Upper airways deposition is relatively greater than in older subjects, in large part because of nasal breathing, and this will affect the 'therapeutic index' of some drugs.
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Affiliation(s)
- Mark L Everard
- Department of Respiratory Medicine, Sheffield Children's Hospital, Western Bank, Sheffield S10 2TH, UK.
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44
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Devadason SG, Le Souef PN. Age-associated factors influencing the efficacy of various forms of aerosol therapy. JOURNAL OF AEROSOL MEDICINE : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR AEROSOLS IN MEDICINE 2002; 15:343-5. [PMID: 12396423 DOI: 10.1089/089426802760292690] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- S G Devadason
- Department of Paediatrics, University of Western Australia, Perth, Western Australia.
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45
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Rodrigo GJ, Rodrigo C. [Controversies in the use of beta-agonists in the treatment of acute asthma]. Arch Bronconeumol 2002; 38:322-8. [PMID: 12199932 DOI: 10.1016/s0300-2896(02)75226-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- G J Rodrigo
- Departamento de Emergencia, Hospital Central de las FF.AA., Montevideo, Uruguay
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O'Callaghan C, White J, Jackson J, Barry P, Kantar A. The output of flunisolide from different nebulisers. J Pharm Pharmacol 2002; 54:565-9. [PMID: 11999135 DOI: 10.1211/0022357021778682] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The objective of this study was to determine the output, in-vitro, solution of a concentrated solution of flunisolide from two different nebulisers under simulated breathing conditions. The BimboNeb and Nebula nebulisers were used to nebulise 2.6 mL of flunisolide solution (600 microg). Particle size was determined by inertial impaction and the total output of drug from the nebulisers under simulated breathing conditions was measured using a sinus flow pump. Two different breathing patterns were used, simulating nebuliser use by a child and an adult. The mass median aerodynamic diameter of flunisolide particles from the BimboNeb and Nebula were both 3.9 microm. With the simulated paediatric breathing pattern, both nebulisers delivered similar amounts of flunisolide (56.4 microg (s.d. 1.4 microg) and 56.1 microg (5 microg) over 5 min from the BimboNeb and Nebula, respectively). With the adult breathing pattern, flunisolide delivery from the BimboNeb was increased to 88.9 microg (3.3 microg), but delivery from the Nebula was only slightly increased to 64.6 microg (1.4 microg). With both nebulisers, little drug was released after 5 min of nebulisation. Both nebulisers delivered 9-15% of the nominal dose of flunisolide to the breathing simulator, a similar percentage to previous studies with budesonide and more than previous studies with beclometasone. Drug delivery from the BimboNeb, but not the Nebula, was affected by the simulated breathing pattern. This study suggests that drug delivery from nebulisers is dependent upon the interaction between the nebuliser, the drug and the patient.
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Affiliation(s)
- Chris O'Callaghan
- Department of Child Health, University of Leicester, Leicester Royal Infirmary, UK.
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47
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Leversha AM, Campanella SG, Aickin RP, Asher MI. Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma. J Pediatr 2000; 136:497-502. [PMID: 10753248 DOI: 10.1016/s0022-3476(00)90013-1] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare the costs and effectiveness of albuterol by metered dose inhaler (MDI) and spacer versus nebulizer in young children with moderate and severe acute asthma. DESIGN Randomized, double-blind, placebo-controlled trial in an emergency department at a children's hospital. The participants were children 1 to 4 years of age with moderate to severe acute asthma. Patients assigned to the spacer group received albuterol (600 microg) by MDI by spacer (AeroChamber) followed by placebo by nebulizer (n = 30). The nebulizer group received placebo MDI by spacer followed by 2.5 mg albuterol by nebulizer (n = 30). Treatments were repeated at 20-minute intervals until the patient was judged to need no further doses of bronchodilator, or a total of 6 treatments. RESULTS Clinical score, heart rate, respiratory rate, auscultatory findings, and oxygen saturation were recorded at baseline, after each treatment, and 60 minutes after the last treatment. Baseline characteristics and asthma severity were similar for the treatment groups. The spacer was as effective as the nebulizer for clinical score, respiratory rate, and oxygen saturation but produced a greater reduction in wheezing (P =.03). Heart rate increased to a greater degree in the nebulizer group (11.0/min vs 0.17/min for spacer, P <.01). Fewer children in the spacer group required admission (33% vs 60% in the nebulizer group, P =.04, adjusted for sex). No differences were seen in rates of tremor or hyperactivity. The mean cost of each emergency department presentation was NZ$825 for the spacer group and NZ$1282 for the nebulizer group (P =.03); 86% of children and 85% of parents preferred the spacer. CONCLUSION The MDI and spacer combination was a cost-effective alternative to a nebulizer in the delivery of albuterol to young children with moderate and severe acute asthma.
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Affiliation(s)
- A M Leversha
- Department of Paediatrics, University of Auckland, and Emergency Department, Starship Children's Hospital, Auckland, New Zealand
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48
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Agertoft L, Pedersen S, Nikander K. Drug delivery from the Turbuhaler and Nebuhaler pressurized metered dose inhaler to various age groups of children with asthma. JOURNAL OF AEROSOL MEDICINE : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR AEROSOLS IN MEDICINE 2000; 12:161-9. [PMID: 10623332 DOI: 10.1089/jam.1999.12.161] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A total of 198 children aged 3 to 15 years inhaled a single dose of 200 micrograms budesonide from a Nebuhaler pressurized metered dose inhaler (pMDI) and a Turbuhaler dry powder inhaler in a randomized crossover study. The budesonide dose delivered to a patient was assessed by measuring the amount of drug deposited on a filter inserted between the inhaler outlet and the patient's mouth. The dose of budesonide deposited on the filter and the estimated dose of particles with a mass median aerodynamic diameter (MMAD) of 5 microns or less after inhalation from the Turbuhaler were both approximately twice the values inhaled from the pMDI Nebuhaler in children less than 5 years of age (P < 0.01). The variation in the dose delivered to the patient was similar for the two inhalers in children over 5 years old. In 3- to 4-year-old children, dose delivery to the patient was higher and/or more consistent from the pMDI Nebuhaler than from the Turbuhaler. Filter dose after Turbuhaler treatment varied significantly from peak inspiratory flow rate through the Turbuhaler (PIFTbh) (P < 0.01). The percentage of children producing a PIFTbh greater than 50 L/min decreased with age (89%, 45%, and 14% in 5-, 4-, and 3-year-old children, respectively). It is concluded that drug delivery to a child with asthma varies with age and inhalation device. Further studies are needed to assess the clinical importance of this finding.
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Affiliation(s)
- L Agertoft
- Department of Pediatrics, Kolding Hospital, Denmark.
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Wilson D, Burniston M, Moya E, Parkin A, Smye S, Robinson P, Littlewood J. Improvement of nebulised antibiotic delivery in cystic fibrosis. Arch Dis Child 1999; 80:348-52. [PMID: 10086942 PMCID: PMC1717907 DOI: 10.1136/adc.80.4.348] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To investigate deposition patterns and to assess the delivery rate of two nebuliser systems in children with cystic fibrosis (CF). METHODS Thirty three children with CF on regular treatment with nebulised antibiotics had radioisotope scans performed using technetium-99m labelled aerosol antibiotic generated by a Ventstream nebuliser (median mass diameter (MMD), 3.3 microm; delivery rate, 0. 075 ml/min) under conditions similar to their routine home practice. The inhomogeneity of the images was scored on a 1-10 rating scale (a low score indicating even distribution of the antibiotic), and stomach deposition was measured as a percentage of overall deposition. Twenty patients had a repeat scan using an Optimist nebuliser (MMD, 1.8 microm; delivery rate, 0.02 ml/min). RESULTS The mean inhomogeneity scores were 5.4 in the Ventstream group and 3. 5 in the Optimist group. Mean stomach deposition was 17.3% in the 33 patients using the Ventstream nebuliser. There was an inverse relation between height and stomach deposition (r = 0.69). In the 20 patients who had both nebulisers, the mean percentages of stomach deposition for the Ventstream and Optimist nebulisers were 11.8% and 1.6%, respectively. The Ventstream nebuliser delivered antibiotic at an average 2.8 times faster rate than the Optimist nebuliser. IMPLICATIONS A smaller particle size results in a more homogenous distribution of the antibiotic in the lungs with decreased stomach deposition. This should not be seen as a recommendation to use the Optimist nebuliser because more antibiotic was delivered to most parts of the lung with the Ventstream because of its increased delivery rate.
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Affiliation(s)
- D Wilson
- Department of Medical Physics, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK.
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50
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Agertoft L, Andersen A, Weibull E, Pedersen S. Systemic availability and pharmacokinetics of nebulised budesonide in preschool children. Arch Dis Child 1999; 80:241-7. [PMID: 10325704 PMCID: PMC1717853 DOI: 10.1136/adc.80.3.241] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To evaluate the systemic availability and basic pharmacokinetic parameters of budesonide after nebulisation and intravenous administration in preschool children with chronic asthma. METHODS Plasma concentrations of budesonide were measured for three hours after an intravenous infusion of 125 micrograms budesonide. The children then inhaled a nominal dose of 1 mg budesonide through the mouthpiece of a Pari LC Jet Plus nebuliser connected to a Pari Master compressor, and the plasma concentrations of budesonide were measured for another six hours. The amount of budesonide inhaled by the patient ("dose to subject") was determined by subtracting from the amount of budesonide put into the nebuliser, the amount remaining in the nebuliser after nebulisation, the amount emitted to the ambient air (filter), and the amount found in the mouth rinsing water. RESULTS Ten patients aged 3 to 6 years completed both the intravenous and the inhaled treatment. The mean dose to subject was 23% of the nominal dose. The systemic availability of budesonide was estimated to be 6.1% of the nominal dose (95% confidence intervals (CI), 4.6% to 8.1%) or 26.3% of the dose to subject (95% CI, 20.3% to 34.1%). Budesonide clearance was 0.54 l/min (95% CI, 0.46 to 0.62), steady state volume of distribution 55 litres (95% CI, 45 to 68), and the terminal half life was 2.3 hours (95% CI, 2.0 to 2.6). CONCLUSIONS Approximately 6% of the nominal dose (26% of the dose to subject) reached the systemic circulation of young children after inhalation of nebulised budesonide. This is about half the systemic availability found in healthy adults using the same nebuliser.
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Affiliation(s)
- L Agertoft
- Department of Paediatrics, Kolding Hospital, Denmark
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