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Fink JB, Stapleton KW. Nebulizers. J Aerosol Med Pulm Drug Deliv 2024; 37:140-156. [PMID: 38683652 DOI: 10.1089/jamp.2024.29110.jbf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Nebulizers generate aerosols from liquid-based solutions and suspensions. Nebulizers are particularly well suited to delivering larger doses of medication than is practical with inhalers and are used with a broad range of liquid formulations. When the same drug is available in liquid or inhaler form, nebulizers are applicable for use with patients who will not or cannot reliably use a pressurized metered-dosed inhaler (pMDI) or dry powder inhaler (DPI) due to poor lung function, hand-breath coordination, cognitive abilities (e.g., infants, elderly) or device preference. In a nebulizer, liquid medication is placed in a reservoir and fed to an aerosol generator to produce the droplets. A series of tubes and channels direct the aerosol to the patient via an interface such as mouthpiece, mask, tent, nasal prongs or artificial airway. All nebulizers contain these basic parts, although the technology and design used can vary widely and can result in significant difference in ergonomics, directions for use, and performance. While many types of nebulizers have been described, the three categories of modern clinical nebulizers include: (1) pneumatic jet nebulizers (JN); (2) ultrasonic nebulizers (USN); and (3) vibrating mesh nebulizers (VMN). Nebulizers are also described in terms of their reservoir size. Small volume nebulizers (SVNs), most commonly used for medical aerosol therapy, can hold 5 to 20 mL of medication and may be jet, ultrasonic, or mesh nebulizers. Large volume nebulizers, typically jet or ultrasonic nebulizers, hold up to 200 mL and may be used for either bland aerosol therapy or continuous drug administration.
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2
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Ari A, Raghavan N, Diaz M, Rubin BK, Fink JB. Individualized aerosol medicine: Integrating device into the patient. Paediatr Respir Rev 2024; 49:14-23. [PMID: 37739833 DOI: 10.1016/j.prrv.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 09/24/2023]
Abstract
Pulmonary drug delivery is complex due to several challenges including disease-, patient-, and clinicians-related factors. Although many inhaled medications are available in aerosol medicine, delivering aerosolized medications to patients requires effective disease management. There is a large gap in the knowledge of clinicians who select and provide instructions for the correct use of aerosol devices. Since improper device selection, incorrect inhaler technique, and poor patient adherence to prescribed medications may result in inadequate disease control, individualized aerosol medicine is essential for effective disease management and control. The components of individualized aerosol medicine include: (1) Selecting the right device, (2) Selecting the right interface, (3) Educating the patient effectively, and (4) Increasing patient adherence to therapy. This paper reviews each of these components and provides recommendations to integrate the device and interface into the patient for better clinical outcomes.
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Affiliation(s)
- Arzu Ari
- Texas State University, Department of Respiratory Care, USA.
| | | | - Martha Diaz
- Latin American Board of Certification in Respiratory Therapy, Colombia
| | - Bruce K Rubin
- Virginia Commonwealth University School of Medicine, USA.
| | - James B Fink
- Texas State University, Department of Respiratory Care, USA; Aerogen Pharma, USA.
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3
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Koyuncu A, Ari A. Filling the gaps in the evaluation and selection of mobile health technologies in respiratory medicine. Expert Rev Respir Med 2024; 18:159-174. [PMID: 38795074 DOI: 10.1080/17476348.2024.2361048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/24/2024] [Indexed: 05/27/2024]
Abstract
INTRODUCTION Mobile health (mHealth) technology in respiratory medicine is a fast-growing and promising digital technology that is popular among patients and healthcare providers (HCPs). They provide reminders and step-by-step instructions for the correct inhalation technique, monitor patients' adherence to treatment, and facilitate communication between patients and HCPs. AREAS COVERED While numerous mHealth apps have been developed over the years, most applications do not have supporting evidence. Selecting the best mHealth app in respiratory medicine is challenging due to limited studies carrying out mHealth app selection. Although mHealth technologies play an important part in the future of respiratory medicine, there is no single guide on the evaluation and selection of mHealth technologies for patients with pulmonary diseases. This paper aims to provide an overview of mHealth technologies, particularly emphasizing digital inhalers and standalone applications used in asthma. Additionally, it offers insights into the evaluation, selection, and pertinent considerations surrounding mHealth applications in respiratory medicine. EXPERT OPINION Evaluating mHealth apps will take time, resources, and collaboration between stakeholders such as governmental regulatory bodies, subject-matter experts, and industry representatives. Filling the gaps in the evaluation and selection of the mHealth app will improve clinical decision-making, personalized treatments, self-management and disease monitoring in respiratory medicine.
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Affiliation(s)
- Ayfer Koyuncu
- Graduate School of Science and Engineering, Bioengineering Department, Hacettepe University, Ankara, Turkey
| | - Arzu Ari
- College of Health Professions Department of Respiratory Care, Regent's Professor and Associate Dean for Research, Texas State University, Round Rock, TX, USA
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Ari A, Alhamad BR. Evaluating dry powder inhalers: From in vitro studies to mobile health technologies. Respir Med 2023:107281. [PMID: 37244487 DOI: 10.1016/j.rmed.2023.107281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Abstract
Dry powder inhalers (DPIs) are essential in treating patients with pulmonary diseases. Since DPIs were introduced in the 1960s, a remarkable improvement has been made in their technology, dose delivery, efficiency, reproducibility, stability, and performance based on safety and efficacy. While there are many DPIs on the market and several more under development, it is vital to evaluate the performance of DPIs for effective aerosol drug delivery to patients with respiratory disorders. Their performance evaluation includes particle size, metering system, device design, dose preparation, inhalation technique, and patient-device integration. The purpose of this paper is to review current literature evaluating DPIs through in vitro studies, computational fluid models, and in vivo/clinical studies. We will also explain how mobile health applications are used to monitor and evaluate patients' adherence to prescribed medications.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, 200 Bobcat Way, Suite 214, Round Rock, TX, 78665, USA.
| | - Bshayer Ramadan Alhamad
- Respiratory Therapy Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Science, Al Ahsa, Saudi Arabia; King Abdullah International Medical Research Center, Al Ahsa, Saudi Arabia.
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Spence BM, Longest W, Dutta R, Momin MAM, Strickler S, Hindle M. In Vitro Evaluation of Nebulized Pharmaceutical Aerosol Delivery to the Lungs Using a New Heated Dryer System (HDS). AAPS PharmSciTech 2022; 24:10. [PMID: 36451052 PMCID: PMC9994751 DOI: 10.1208/s12249-022-02460-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/04/2022] [Indexed: 12/02/2022] Open
Abstract
The objective of this study was to develop a new heated dryer system (HDS) for high efficiency lung delivery of nebulized aerosol and demonstrate performance with realistic in vitro testing for trans-nasal aerosol administration simultaneously with high-flow nasal cannula (HFNC) therapy and separately for direct oral inhalation (OI) of the aerosol. With the HDS-HFNC and HDS-OI platforms, new active synchronization control routines were developed to sense subject inhalation and coordinate drug aerosol delivery. In vitro experiments were conducted to predict regional drug loss and lung delivery efficiency in systems that included the HDS with various patient interfaces, realistic airway models, and simulated breathing waveforms. For the HDS-HFNC platform and a repeating breathing waveform, total system loss was < 10%, extrathoracic deposition was approximately 6%, and best-case lung delivery efficiency was 75-78% of nebulized dose. Inclusion of randomized breathing with the HFNC system decreased lung delivery efficiency by ~ 10% and had no impact on nasal depositional loss. For the HDS-OI platform and best-case mouthpiece, total system loss was < 8%, extrathoracic deposition was < 1%, and lung delivery efficiency was > 90% of nebulized dose. Normal vs. deep randomized oral inhalation had little impact on performance of the HDS-OI platform and environmental aerosol loss was negligible. In conclusion, both platforms demonstrated the potential for high efficiency lung delivery of the aerosol with the HDS-OI platform having the added advantages of nearly eliminating extrathoracic deposition, being insensitive to breathing waveform, and preventing environmental aerosol loss.
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Affiliation(s)
- Benjamin M Spence
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA.
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA.
| | - Rabijit Dutta
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mohammad A M Momin
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sarah Strickler
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
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Bass K, Momin MAM, Howe C, Aladwani G, Strickler S, Kolanjiyil AV, Hindle M, DiBlasi RM, Longest W. Characterizing the Effects of Nasal Prong Interfaces on Aerosol Deposition in a Preterm Infant Nasal Model. AAPS PharmSciTech 2022; 23:114. [PMID: 35441324 DOI: 10.1208/s12249-022-02259-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/20/2022] [Indexed: 11/30/2022] Open
Abstract
The objective of this study was to characterize the effects of multiple nasal prong interface configurations on nasal depositional loss of pharmaceutical aerosols in a preterm infant nose-throat (NT) airway model. Benchmark in vitro experiments were performed in which a spray-dried powder formulation was delivered to a new preterm NT model with a positive-pressure infant air-jet dry powder inhaler using single- and dual-prong interfaces. These results were used to develop and validate a computational fluid dynamics (CFD) model of aerosol transport and deposition in the NT geometry. The validated CFD model was then used to explore the NT depositional characteristic of multiple prong types and configurations. The CFD model highlighted a turbulent jet effect emanating from the prong(s). Analysis of NT aerosol deposition efficiency curves for a characteristic particle size and delivery flowrate (3 µm and 1.4 L/min (LPM)) revealed little difference in NT aerosol deposition fraction (DF) across the prong insertion depths of 2-5 mm (DF = 16-24%) with the exception of a single prong with 5-mm insertion (DF = 36%). Dual prongs provided a modest reduction in deposition vs. a single aerosol delivery prong at the same flow for insertion depths < 5 mm. The presence of the prongs increased nasal depositional loss by absolute differences in the range of 20-70% compared with existing correlations for ambient aerosols. In conclusion, the use of nasal prongs was shown to have a significant impact on infant NT aerosol depositional loss prompting the need for prong design alterations to improve lung delivery efficiency.
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Thomas B, Pugalenthi A. Currently Available Inhaled Therapies in Asthma and Advances in Drug Delivery and Devices. Indian J Pediatr 2022; 89:387-394. [PMID: 34989948 DOI: 10.1007/s12098-021-03976-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
Medications delivered in the inhaled form remains the cornerstone of medical management of asthma. There have been considerable advances in the development of inhaled medications and devices over the past several decades. Clinicians also have access to regularly updated international guidelines for management of asthma. Despite this, a substantial proportion of children with asthma continue to have persistent poor asthma control and considerable morbidity even in well-resourced settings. The wide selection of medications and devices may complicate clinical decision making. The ideal inhaler would be one that the patient can and will use as advised. One cannot overemphasize the importance of medication adherence and a correct inhaler technique in achieving optimal asthma control. Clinicians who manage children with asthma should have a good understanding of inhaled medications and devices commercially available for the management of asthma and this would help them select the right medication and device for the right patient. This review aims to provide an overview of physiologic basis of inhaler therapy, commonly used inhaled therapies, and the advances in the field of inhaler devices including emerging technologies.
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Affiliation(s)
- Biju Thomas
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore.
- Duke-NUS Medical School, Koo Teck Puat Building, 8 College Road, Singapore.
- Lee Kong Chian School of Medicine, 1 Mandalay Rd, Singapore.
| | - Arun Pugalenthi
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore
- Duke-NUS Medical School, Koo Teck Puat Building, 8 College Road, Singapore
- Lee Kong Chian School of Medicine, 1 Mandalay Rd, Singapore
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8
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Howe C, Momin MAM, Bass K, Aladwani G, Bonasera S, Hindle M, Longest PW. In Vitro Analysis of Nasal Interface Options for High-Efficiency Aerosol Administration to Preterm Infants. J Aerosol Med Pulm Drug Deliv 2022; 35:196-211. [PMID: 35166601 PMCID: PMC9416545 DOI: 10.1089/jamp.2021.0057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: An infant air-jet dry powder inhaler (DPI) platform has recently been developed that in combination with highly dispersible spray-dried powder formulations can achieve high-efficiency aerosolization with low actuation air volumes. The objective of this study was to investigate modifications to the nasal interface section of this platform to improve the aerosol delivery performance through preterm nose-throat (NT) models. Methods: Aerosol delivery performance of multiple nasal interface flow pathways and prong configurations was assessed with two in vitro preterm infant NT models. Two excipient-enhanced growth (EEG) dry powder formulations were explored containing either l-leucine or trileucine as the dispersion enhancer. Performance metrics included aerosol depositional loss in the nasal interface, deposition in the NT models, and tracheal filter deposition, which was used to estimate lung delivery efficiency. Results: The best performing nasal interface replaced the straight flexible prong of the original gradual expansion design with a rigid curved prong (∼20° curvature). The prong modification increased the lung delivery efficiency by 5%-10% (absolute difference) depending on the powder formulation. Adding a metal mesh to the flow pathway, to dissipate the turbulent jet, also improved lung delivery efficiency by ∼5%, while reducing the NT depositional loss by a factor of over twofold compared with the original nasal interface. The platform was also found to perform similarly in two different preterm NT models, with no statistically significant difference between any of the performance metrics. Conclusions: Modifications to the nasal interface of an infant air-jet DPI improved the aerosol delivery through multiple infant NT models, providing up to an additional 10% lung delivery efficiency (absolute difference) with the lead design delivering ∼57% of the loaded dose to the tracheal filter, while performance in two unique preterm airway geometries remained similar.
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Affiliation(s)
- Connor Howe
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mohammad A M Momin
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Karl Bass
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ghali Aladwani
- Department of Mechanical and Nuclear Engineering, 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
| | - Philip Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA.,Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
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9
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Ari A, Blain K, Soubra S, Hanania NA. Treating COPD Patients with Inhaled Medications in the Era of COVID-19 and Beyond: Options and Rationales for Patients at Home. Int J Chron Obstruct Pulmon Dis 2021; 16:2687-2695. [PMID: 34611397 PMCID: PMC8487292 DOI: 10.2147/copd.s332021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/13/2021] [Indexed: 01/29/2023] Open
Abstract
COVID-19 has affected millions of patients, caregivers, and clinicians around the world. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads via droplets and close contact from person to person, and there has been an increased concern regarding aerosol drug delivery due to the potential aerosolizing of viral particles. To date, little focus has been given to aerosol drug delivery to patients with COVID-19 treated at home to minimize their hospital utilization. Since most hospitals were stressed with multiple admissions and experienced restricted healthcare resources in the era of COVID-19 pandemic, treating patients with COPD at home became essential to minimize their hospital utilization. However, guidance on how to deliver aerosolized medications safely and effectively to this patient population treated at home is still lacking. In this paper, we provide some strategies and rationales for device and interface selection, delivery technique, and infection control for patients with COPD who are being treated at home in the era of COVID-19 and beyond.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Karen Blain
- Department of Respiratory Therapy, University of North Carolina Wilmington, Wilmington, NC, USA
| | - Said Soubra
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Nicola A Hanania
- Airways Clinical Research Center, Baylor College of Medicine, Houston, TX, USA
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Artzy-Schnirman A, Arber Raviv S, Doppelt Flikshtain O, Shklover J, Korin N, Gross A, Mizrahi B, Schroeder A, Sznitman J. Advanced human-relevant in vitro pulmonary platforms for respiratory therapeutics. Adv Drug Deliv Rev 2021; 176:113901. [PMID: 34331989 PMCID: PMC7611797 DOI: 10.1016/j.addr.2021.113901] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 07/20/2021] [Accepted: 07/24/2021] [Indexed: 02/08/2023]
Abstract
Over the past years, advanced in vitro pulmonary platforms have witnessed exciting developments that are pushing beyond traditional preclinical cell culture methods. Here, we discuss ongoing efforts in bridging the gap between in vivo and in vitro interfaces and identify some of the bioengineering challenges that lie ahead in delivering new generations of human-relevant in vitro pulmonary platforms. Notably, in vitro strategies using foremost lung-on-chips and biocompatible "soft" membranes have focused on platforms that emphasize phenotypical endpoints recapitulating key physiological and cellular functions. We review some of the most recent in vitro studies underlining seminal therapeutic screens and translational applications and open our discussion to promising avenues of pulmonary therapeutic exploration focusing on liposomes. Undeniably, there still remains a recognized trade-off between the physiological and biological complexity of these in vitro lung models and their ability to deliver assays with throughput capabilities. The upcoming years are thus anticipated to see further developments in broadening the applicability of such in vitro systems and accelerating therapeutic exploration for drug discovery and translational medicine in treating respiratory disorders.
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Affiliation(s)
- Arbel Artzy-Schnirman
- Department of Biomedical, Technion - Israel Institute of Technology, 32000 Haifa, Israel
| | - Sivan Arber Raviv
- Department of Chemical, Technion - Israel Institute of Technology, 32000 Haifa, Israel
| | | | - Jeny Shklover
- Department of Chemical, Technion - Israel Institute of Technology, 32000 Haifa, Israel
| | - Netanel Korin
- Department of Biomedical, Technion - Israel Institute of Technology, 32000 Haifa, Israel
| | - Adi Gross
- Department of Biotechnology and Food Engineering, Technion - Israel Institute of Technology, 32000 Haifa, Israel
| | - Boaz Mizrahi
- Department of Biotechnology and Food Engineering, Technion - Israel Institute of Technology, 32000 Haifa, Israel
| | - Avi Schroeder
- Department of Chemical, Technion - Israel Institute of Technology, 32000 Haifa, Israel
| | - Josué Sznitman
- Department of Biomedical, Technion - Israel Institute of Technology, 32000 Haifa, Israel.
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11
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Ari A, Fink JB. Quantifying Delivered Dose with Jet and Mesh Nebulizers during Spontaneous Breathing, Noninvasive Ventilation, and Mechanical Ventilation in a Simulated Pediatric Lung Model with Exhaled Humidity. Pharmaceutics 2021; 13:pharmaceutics13081179. [PMID: 34452139 PMCID: PMC8400423 DOI: 10.3390/pharmaceutics13081179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 11/21/2022] Open
Abstract
Acutely ill children may transition between spontaneous breathing (SB), noninvasive ventilation (NIV), and mechanical ventilation (MV), and commonly receive the same drug dosage with each type of ventilatory support and interface. This study aims to determine the aerosol deposition with jet (JN) and mesh nebulizers (MN) during SB, NIV, and MV using a pediatric lung model. Drug delivery with JN (Mistymax10) and MN (Aerogen Solo) was compared during SB, NIV, and MV using three different lung models set to simulate the same breathing parameters (Vt 250 mL, RR 20 bpm, I:E ratio 1:3). A heated humidifier was placed between the filter and test lung to simulate exhaled humidity (35 ± 2 °C, 100% RH) with all lung models. Albuterol sulfate (2.5 mg/3 mL) was delivered, and the drug deposited on an absolute filter was eluted and analyzed with spectrophotometry. Aerosol delivery with JN was not significantly different during MV, NIV, and SB (p = 0.075), while inhaled dose obtained with MN during MV was greater than NIV and SB (p = 0.001). The delivery efficiency of MN was up to 3-fold more than JN during MV (p = 0.008), NIV (p = 0.005), and SB (p = 0.009). Delivered dose with JN was similar during MV, NIV, and SB, although the delivery efficiency of MN differs with different modes of ventilation.
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Affiliation(s)
- Arzu Ari
- Correspondence: ; Tel.: +1-512-716-2691
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12
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Ke WR, Chang RYK, Kwok PCL, Tang P, Chen L, Chen D, Chan HK. Administration of dry powders during respiratory supports. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:596. [PMID: 33987294 DOI: 10.21037/atm-20-3946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Inhaled drugs are routinely used for the treatment of respiratory-supported patients. To date, pressurized metered dose inhalers and nebulizers are the two platforms routinely employed in the clinical setting. The scarce utilization of the dry powder inhaler (DPI) platform is partly due to the lack of in vivo data that proves optimal delivery and drug efficacy are achievable. Additionally, fitting a DPI in-line to the respiratory circuit is not as straightforward as with the other aerosol delivery platforms. Importantly, there is a common misconception that the warm and humidified inspiratory air in respiratory supports, even for a short exposure, will deteriorate powder formulation compromising its delivery and efficacy. However, some recent studies have dispelled this myth, showing successful delivery of dry powders through the humidified circuit of respiratory supports. Compared with other aerosol delivery devices, the use of DPIs during respiratory supports possesses unique advantages such as rapid delivery and high dose. In this review, we presented in vitro studies showing various setups employing commercial DPIs and effects of ventilator parameters on the aerosol delivery. Inclusion of novel DPIs was also made to illustrate characteristics of an ideal inhaler that would give high lung dose with low powder deposition loss in tracheal tubes and respiratory circuits. Clinical trials are urgently needed to confirm the benefits of administration of dry powders in ventilated patients, thus enabling translation of powder delivery into practice.
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Affiliation(s)
- Wei-Ren Ke
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rachel Yoon Kyung Chang
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Philip Chi Lip Kwok
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Patricia Tang
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lan Chen
- Hangzhou Chance Pharmaceuticals, Hangzhou, China
| | - Donghao Chen
- Hangzhou Chance Pharmaceuticals, Hangzhou, China
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Alharbi AS, Yousef AA, Alharbi SA, Al-Shamrani A, Alqwaiee MM, Almeziny M, Said YS, Alshehri SA, Alotaibi FN, Mosalli R, Alawam KA, Alsaadi MM. Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus. Ann Thorac Med 2021; 16:188-218. [PMID: 34012486 PMCID: PMC8109687 DOI: 10.4103/atm.atm_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022] Open
Abstract
The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.
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Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahd Hospital of the University, Khobar, Saudi Arabia
| | - Saleh A. Alharbi
- Department of Pediatrics, Umm Al-Qura University, Mecca, Saudi Arabia
- Department of Pediatrics, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mansour M. Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mohammed Almeziny
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Yazan S. Said
- Department of Pediatrics, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Saleh Ali Alshehri
- Department of Emergency, Pediatric Emergency Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Faisal N. Alotaibi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura University, Makkah, Saudi Arabia
- Department of Pediatrics, International Medical Center, Jeddah, Saudi Arabia
| | - Khaled Ali Alawam
- Department of Respiratory Therapy Sciences, Inaya Medical College, Riyadh, Saudi Arabia
| | - Muslim M. Alsaadi
- Department of Pediatrics, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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14
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Ari A. A path to successful patient outcomes through aerosol drug delivery to children: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:593. [PMID: 33987291 PMCID: PMC8105845 DOI: 10.21037/atm-20-1682] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/03/2020] [Indexed: 11/06/2022]
Abstract
Although using aerosolized medications is a mainstay of treatment in children with asthma and other respiratory diseases, there are many issues in terms of device and interface selection, delivery technique and dosing, as well as patient and parental education that have not changed for half a century. Also, due to many aerosol devices and interfaces available on the market and the broad range of patient characteristics and requirements, providing effective aerosol therapy to children becomes a challenge. While aerosol delivery devices are equally effective, if they are age-appropriate and used correctly, the majority of aerosol devices require multiple steps to be used efficiently. Unfortunately, many children with pulmonary diseases have problems with the correct delivery technique and do not gain therapeutic benefits from therapy that result in poor disease management and increased healthcare costs. Therefore, the purpose of this paper is to review the current knowledge on aerosol delivery devices used in children and guide clinicians on the optimum device- and interface-selection, delivery technique, and dosing in this patient population. Strategies on how to deliver aerosolized medications in crying and distressed children and how to educate parents on aerosol therapy and promote patient adherence to prescribed medications are also provided. Future directions of aerosol therapy in children should focus on these issues and implement policies and clinical practices that highlight the potential solutions to these problems.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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15
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Durak H, Uysal G. The Effect of Cartoon Watching and Distraction Card on Physiologic Parameters and Fear Levels During Inhalation Therapy in Children: A Randomized Controlled Study. J Trop Pediatr 2021; 67:6178989. [PMID: 33742204 DOI: 10.1093/tropej/fmab018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The study was conducted as a randomized controlled study to investigate the effect of cartoon watching and distraction cards on physiologic parameters and fear levels in children with acute bronchitis in the emergency department. METHODS Ninety-nine children with acute bronchitis aged 3-6 years were randomized in the emergency department. The study was conducted with three groups: cartoon group, distraction card group, and the control group. Data were collected using a follow-up form and the Children's Fear Scale. RESULTS The difference between the mean pulse rates of the groups evaluated by an observer nurse was found to be statistically significant. The pulse rates of the cartoon and distraction card groups were lower than in the control group during inhalation therapy (p < 0.05). The difference between the mean fear scores in the cartoon and control groups as evaluated by the observer nurse and the accompanying parent was found to be statistically significant during after inhalation therapy (p < 0.01). CONCLUSION It was observed that watching cartoons during inhalation therapy was more effective in reducing the level of fear in children that distraction card.
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Affiliation(s)
- Hülya Durak
- Child Emergency Service, Kocaeli University Research and Practice Hospital, Izmit, Turkey
| | - Gülzade Uysal
- Faculty of Health Sciences, Istanbul Okan University, Istanbul, Turkey
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16
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Casula L, Sinico C, Valenti D, Pini E, Pireddu R, Schlich M, Lai F, Maria Fadda A. Delivery of beclomethasone dipropionate nanosuspensions with an electronic cigarette. Int J Pharm 2021; 596:120293. [PMID: 33497704 DOI: 10.1016/j.ijpharm.2021.120293] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/16/2021] [Accepted: 01/17/2021] [Indexed: 01/14/2023]
Abstract
The aim of this work was to ascertain the ability of electronic nicotine delivery systems (ENDS) to deliver drug nanocrystals through the produced aerosol. A nanocrystal nanosuspension of beclomethasone dipropionate, a synthetic chlorinated corticosteroid diester commonly used by inhalation in the treatment of asthma and chronic obstructive pulmonary disease, was prepared with a wet media milling technique using Poloxamer 188 as stabilizer. The obtained nanosuspension was thoroughly characterized by different techniques: transmission electron microscopy, photon correlation spectroscopy, X-ray powder diffractometry and Fourier transform infrared spectroscopy. The nanosuspension was then loaded in the cartomizer of the electronic cigarette and the produced aerosol was collected and analysed, confirming the presence of drug nanocrystals. The results of this study suggested the possible alternative use of ENDS as medical device for the delivery of poorly soluble drugs.
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Affiliation(s)
- Luca Casula
- Dipartimento di Scienze della Vita e dell'Ambiente, Sezione di Scienze del Farmaco, CNBS, Università degli Studi di Cagliari, Cagliari 09124, Italy
| | - Chiara Sinico
- Dipartimento di Scienze della Vita e dell'Ambiente, Sezione di Scienze del Farmaco, CNBS, Università degli Studi di Cagliari, Cagliari 09124, Italy
| | - Donatella Valenti
- Dipartimento di Scienze della Vita e dell'Ambiente, Sezione di Scienze del Farmaco, CNBS, Università degli Studi di Cagliari, Cagliari 09124, Italy
| | - Elena Pini
- DISFARM, Sezione di Chimica Generale e Organica "A. Marchesini", Università degli Studi di Milano, Via Venezian 21, Milano 20133, Italy
| | - Rosa Pireddu
- Dipartimento di Scienze della Vita e dell'Ambiente, Sezione di Scienze del Farmaco, CNBS, Università degli Studi di Cagliari, Cagliari 09124, Italy
| | - Michele Schlich
- Dipartimento di Scienze della Vita e dell'Ambiente, Sezione di Scienze del Farmaco, CNBS, Università degli Studi di Cagliari, Cagliari 09124, Italy; Laboratory of Nanotechnology for Precision Medicine, Istituto Italiano di Tecnologia, Genova 16163, Italy
| | - Francesco Lai
- Dipartimento di Scienze della Vita e dell'Ambiente, Sezione di Scienze del Farmaco, CNBS, Università degli Studi di Cagliari, Cagliari 09124, Italy.
| | - Anna Maria Fadda
- Dipartimento di Scienze della Vita e dell'Ambiente, Sezione di Scienze del Farmaco, CNBS, Università degli Studi di Cagliari, Cagliari 09124, Italy
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17
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Harb HS, Saeed H, Madney YM, Abdelrahman MA, Osama H, Esquinas AM, Abdelrahim ME. Update efficacy of aerosol therapy with noninvasive ventilator approach (non-invasive ventilation and nasal high flow). J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2020.101922] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Choosing the right inhaler for the right patient: Considerations for effective management of patients with chronic obstructive pulmonary disease or asthma. J Am Assoc Nurse Pract 2020; 32:89-99. [PMID: 31895754 DOI: 10.1097/jxx.0000000000000366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Effective management of chronic respiratory disorders such as chronic obstructive pulmonary disease and asthma necessitates that patients inhale their medication. However, lack of detailed guidelines on the technological and mechanical functions of inhalers limits the ability of health care providers (HCPs) to personalize inhaler choice for patients. Numerous types of inhalers are currently available which offer their own distinct advantages and disadvantages. Independent of the drug class, the choice of inhaler may be influenced by many factors (e.g., inhaler attributes and the efficiency with which it delivers the medication, patient characteristics and preferences, dosing regimen, clinical setting, and support available for both patients and HCPs). This article attempts to summarize the inhalation technology and factors influencing inhaler choice and use and to provide an approach for matching the right inhaler to the right patient. CONCLUSIONS Identifying factors related to inhaler choice is critical to ensuring adherence to treatment and patients' ability to use their inhaler correctly. IMPLICATIONS FOR PRACTICE This review will help HCPs engage their patients in decision-making for inhaler choice and facilitate selection of the correct inhaler for each patient (i.e., one that they will use).
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Ari A. PROMOTING SAFE AND EFFECTIVE USE OF AEROSOL DEVICES IN COVID-19:RISKS AND SUGGESTIONS FOR VIRAL TRANSMISSION. Expert Opin Drug Deliv 2020; 17:1509-1513. [PMID: 32799579 DOI: 10.1080/17425247.2020.1811225] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Arzu Ari
- College of Health Professions, Department of Respiratory Care Texas State University , Round Rock, TX, USA
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20
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Chang KH, Moon SH, Yoo SK, Park BJ, Nam KC. Aerosol Delivery of Dornase Alfa Generated by Jet and Mesh Nebulizers. Pharmaceutics 2020; 12:pharmaceutics12080721. [PMID: 32751886 PMCID: PMC7463544 DOI: 10.3390/pharmaceutics12080721] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 11/23/2022] Open
Abstract
Recent reports on mesh nebulizers suggest the possibility of stable nebulization of various therapeutic protein drugs. In this study, the in vitro performance and drug stability of jet and mesh nebulizers were examined for dornase alfa and compared with respect to their lung delivery efficiency in BALB/c mice. We compared four nebulizers: two jet nebulizers (PARI BOY SX with red and blue nozzles), a static mesh nebulizer (NE-U150), and a vibrating mesh nebulizer (NE-SM1). The enzymatic activity of dornase alfa was assessed using a kinetic fluorometric DNase activity assay. Both jet nebulizers had large residual volumes between 24% and 27%, while the volume of the NE-SM1 nebulizer was less than 2%. Evaluation of dornase alfa aerosols produced by the four nebulizers showed no overall loss of enzymatic activity or protein content and no increase in aggregation or degradation. The amount of dornase alfa delivered to the lungs was highest for the PARI BOY SX-red jet nebulizer. This result confirmed that aerosol droplet size is an important factor in determining the efficiency of dornase alfa delivery to the lungs. Further clinical studies and analysis are required before any conclusions can be drawn regarding the clinical safety and efficacy of these nebulizers.
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Affiliation(s)
- Kyung Hwa Chang
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea; (K.H.C.); (S.-H.M.)
| | - Sang-Hyub Moon
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea; (K.H.C.); (S.-H.M.)
| | - Sun Kook Yoo
- Department of Medical Engineering, Yonsei University College of Medicine, Seoul 03722, Korea;
| | - Bong Joo Park
- Department of Electrical & Biological Physics, Kwangwoon University, Seoul 01897, Korea
- Institute of Biomaterials, Kwangwoon University, Seoul 01897, Korea
- Correspondence: (B.J.P.); (K.C.N.); Tel.: +82-2-940-8629 (B.J.P.); +82-31-961-5802 (K.C.N.)
| | - Ki Chang Nam
- Department of Medical Engineering, Dongguk University College of Medicine, Goyang-si, Gyeonggi-do 10326, Korea; (K.H.C.); (S.-H.M.)
- Correspondence: (B.J.P.); (K.C.N.); Tel.: +82-2-940-8629 (B.J.P.); +82-31-961-5802 (K.C.N.)
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21
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Chiner Vives E, Fernández Fabrellas E, Agüero Balbín R, Martínez García MÁ. Aerosolterapia. OPEN RESPIRATORY ARCHIVES 2020. [DOI: 10.1016/j.opresp.2020.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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22
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Madney YM, Laz NI, Elberry AA, Rabea H, Abdelrahim ME. The influence of changing interfaces on aerosol delivery within high flow oxygen setting in adults: An in-vitro study. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2019.101365] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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23
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Ari A, Fink JB. Recent advances in aerosol devices for the delivery of inhaled medications. Expert Opin Drug Deliv 2020; 17:133-144. [PMID: 31959028 DOI: 10.1080/17425247.2020.1712356] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Aerosolized medications are commonly prescribed for the treatment of patients with pulmonary diseases, and there has been an increased interest in the development of aerosol delivery devices over the years. Technical innovations have advanced device design, novel features such as breath actuation, dose tracking, portability, and feedback mechanism during treatment that improved the performance of aerosol devices, and effectiveness of inhalation therapy.Areas covered: The purpose of this paper is to review recent advances in aerosol devices for delivery of inhaled medications.Expert opinion: Drug formulations and device designs are rapidly evolving to make more consistent dosing across a broad range of inspiratory efforts, to maximize dose and target specific areas of the diseased lung.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, College of Health Professions, Round Rock, TX, USA
| | - James B Fink
- Department of Respiratory Care, Texas State University, College of Health Professions, Round Rock, TX, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
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24
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Alalwan MA, Fink JB, Ari A. In vitro evaluation of aerosol drug delivery with and without high flow nasal cannula in children. Pediatr Pulmonol 2019; 54:1968-1973. [PMID: 31468741 DOI: 10.1002/ppul.24501] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 08/14/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To quantify aerosol delivery with or without a high flow nasal cannula (HFNC) in place using pressurized metered-dose inhaler (pMDI) and jet nebulizer (JN) with facemask in a simulated spontaneously breathing pediatric lung model. METHODS An upper airway model of a 9-month-old infant (Sophia Anatomical Infant Nose-Throat) with an absolute filter distal to the trachea was connected to a breathing simulator to simulate pediatric parameters (tidal volume = 100 mL, respiratory rate = 30 breaths/min, and I:E ratio = 1:1.4). Oxygen at 3 L/min was administered through an infant HFNC (Fisher & Paykel Healthcare Ltd, Auckland, New Zealand) attached to the nares of the model. Albuterol sulfate (2.5 mg/3 mL) was delivered with JN attached to an aerosol facemask and powered by air at 8 L/min. Ventolin Hydrofluoroalkane (HFA) (360 μg) was administered using pMDI connected to a valved holding chamber (VHC) with a facemask. Aerosol was administered to the model with and without HFNC in the nares (n = 3). Drug was eluted from the filter and quantified using spectrophotometry. Independent t tests were performed for data analysis (P < .05). RESULTS Aerosol deposition was greater without HFNC (6.05% ± 1.53% and 39.54% ± 8.98% for JN and pMDI/VHC, respectively) than with HFNC using JN (2.91% ± 0.23%; P = .024) and pMDI/VHC (6.04% ± 0.28%; P = .003). Delivery efficiency of pMDI/VHC was greater than JN with or without nasal cannula in place (P = .0001 and .003, respectively). CONCLUSION Aerosol administered via facemask over HFNC was less efficient than removing HFNC during administration. When delivering medical aerosol by facemask, the benefit of increased aerosol delivery must be weighed against the changes in oxygen delivery and risk of lung derecruitment when nasal prongs are removed.
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Affiliation(s)
- Mahmood A Alalwan
- Department of Respiratory Therapy, Inaya Medical College, Riyadh, Saudi Arabia
| | - James B Fink
- Department of Respiratory Care, Texas State University, Round Rock, Texas
| | - Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, Texas
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25
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Soyer Ö, Kahveci M, Büyüktiryaki B, Arık Yılmaz E, Karaatmaca B, Esenboğa S, Gür Çetinkaya P, Şahiner ÜM, Şekerel BE. Mesh nebulizer is as effective as jet nebulizer in clinical practice of acute asthma in children. Turk J Med Sci 2019; 49:1008-1013. [PMID: 31269786 PMCID: PMC7018340 DOI: 10.3906/sag-1812-133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background/aim The aim of this study was to compare the effect of salbutamol delivered to children by jet nebulizer (JN) and mesh nebulizer (MN). Materials and methods Children admitted with acute asthma were treated with 3 doses of nebulized salbutamol, 1 given by MN. The patients’ vital signs, lung function measurements, modified pulmonary index score (MPIS), and whole body plethysmography (WBP) measurements were evaluated before and 20 min after each dose of salbutamol. Results Thirty-onechildren [9.5 (6.4–17.2) years, 67.7% male, 32.3% female] with mild (67.7%) and moderate (32.3%) asthma attacks were included in the study. The improvements with MN were comparable with JN in terms of changes in pretreatment and posttreatment forced expiratory volume in the first second (FEV1) (2.57 ± 4.57, 3.65 ± 5.44; P = 0.44), forced vital capacity (FVC) (2.52 ± 5.29, 4.17 ± 7.54; P = 0.28), heart rate (7.33 ± 10.21, 4.14 ± 9.32; P = 0.24), peripheral capillary oxygen saturation (SpO2) (0.38 ± 0.23, 0.43 ± 0.15; P = 0.83), and modified pulmonary index score (MPIS) (−6.30 ± 22.70, −8.77 ± 25.46; P = 0.70). The pre- and posttreatment values of total lung capacity (TLC), residual volume (RV), specific conductance (sGaw), and RV/TLC were similar for the JN and MN groups. Adverse effects were not different: however, complaints of palpitation were significantly higher in the posttreatment MN group than the pretreatment MN group (32.3% vs 9.7%, respectively, P = 0.016). Conclusions These findings support the previous evidence found in studies of adults that MN is as effective as and as safe as JN in the treatment of acute asthma in children.
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Affiliation(s)
- Özge Soyer
- Department of Pediatric Allergy, Medical Faculty, Hacettepe University, Ankara, Turkey
| | - Melike Kahveci
- Department of Pediatric Allergy, Medical Faculty, Hacettepe University, Ankara, Turkey
| | - Betül Büyüktiryaki
- Department of Pediatric Allergy, Medical Faculty, Hacettepe University, Ankara, Turkey
| | - Ebru Arık Yılmaz
- Department of Pediatric Allergy, Medical Faculty, Hacettepe University, Ankara, Turkey
| | - Betül Karaatmaca
- Department of Pediatric Allergy, Medical Faculty, Hacettepe University, Ankara, Turkey
| | - Saliha Esenboğa
- Department of Pediatric Allergy, Medical Faculty, Hacettepe University, Ankara, Turkey
| | - Pınar Gür Çetinkaya
- Department of Pediatric Allergy, Medical Faculty, Hacettepe University, Ankara, Turkey
| | - Ümit Murat Şahiner
- Department of Pediatric Allergy, Medical Faculty, Hacettepe University, Ankara, Turkey
| | - Bülent Enis Şekerel
- Department of Pediatric Allergy, Medical Faculty, Hacettepe University, Ankara, Turkey
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26
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Abstract
Appropriate selection and correct use of inhalation devices is an integral component in the management of asthma and chronic obstructive pulmonary disease (COPD). It is well known that there are many challenges with the use of inhalers, and no one device suits all patients. Challenges can range from difficulties related to lung disease severity and pulmonary function to physical considerations, including manual dexterity and comorbidities such as arthritis. In terms of device selection and adherence, patient engagement and satisfaction are also important factors to consider. Furthermore, problems with inhaler use can be most evident in children and older patients. Here, we discuss aspects for consideration with commonly used devices, including nebulizers, pressurized metered-dose inhalers, dry powder inhalers, and the soft mist inhaler. As each inhaler offers varying technical properties, a tailored and personalized approach to the selection of the most appropriate device for the patient is highly recommended in order to increase the likelihood of achieving improved disease outcomes and enhance persistence with device adherence. Importantly, education and support is crucial, not only to enable patients to recognize the need for optimal disease management, but also to help them develop good inhaler technique. In addition, health care professionals should also aim to increase their knowledge of the devices they prescribe, and develop systems to ensure that they offer comprehensive support to patients in clinical practice. Considering these aspects, this review discusses potential strategies to help address the challenges of inhaler use in asthma and COPD.
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Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, Airways Disease Section, London, UK,
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27
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Abstract
Asthma is the most common chronic airway disease in children, with more than half the reported cases of persistent asthma starting in children below the age of 3 years. Asthma diagnosis in preschool children has proven to be challenging due to the heterogeneity of the disease, the continuing development of the immune system in such a young population, and lack of diagnostic options such as lung function measurement. Early diagnosis and treatment of asthmatic symptoms will improve patients' quality of life and help reduce disease morbidity. However, validated treatment options are scarce due to paucity of data and lack of conclusive studies in such a young patient population. Adjusting study design and endpoints to capture more reliable data with minimal risk of harm to patients is necessary. This thematic series review outlines the current position on preschool asthma, consolidates the current understanding of risk factors and diagnostic hurdles, and emphasizes the importance of early detection and management to help improve patients' quality of life, both present and future. Particular focus was given to anticholinergics and their emerging role in the treatment and control of asthma in pediatric patients.
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Affiliation(s)
- Christian Vogelberg
- Department of Pediatric Pulmonology and Allergy, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany,
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28
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Chandel A, Goyal AK, Ghosh G, Rath G. Recent advances in aerosolised drug delivery. Biomed Pharmacother 2019; 112:108601. [PMID: 30780107 DOI: 10.1016/j.biopha.2019.108601] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 01/10/2019] [Accepted: 01/18/2019] [Indexed: 10/27/2022] Open
Abstract
Pulmonary route is extensively studied for the diagnosis and treatment of pulmonary and extra pulmonary disease conditions such as asthma, tuberculosis, emphysema, and bronchitis. Formulation design, inhalation device and particle size play key role in determining the aerosol performance. The lack of desired clinical outcome along with the problem regarding efficacy or any adverse drug effect may arise due to improper training and education in use of the device to control the actuation and aerosol inhalation. This review summarizes the difference in the mechanistic features of current marketed aerosol delivery devices with respect to mechanism of aerosol generation with possible advancements in the aerosol design. The delivery options in the pulmonary route and its merits together with the limitations are also discussed. An update is provided regarding the current research and clinical outcome of the use of inhalational technology.
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Affiliation(s)
- Akshay Chandel
- Department of pharmaceutics, I.S.F. College of Pharmacy, Moga, Punjab, India
| | - Amit K Goyal
- National Institute of Animal Biotechnology, Hyderabad, India
| | - Goutam Ghosh
- Siksha 'O' Anusandhan (Deemed to be University), Kalinga Nagar, Bhubaneswar, Odisha, India
| | - Goutam Rath
- Department of pharmaceutics, I.S.F. College of Pharmacy, Moga, Punjab, India.
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29
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Kerwin EM, Donohue JF, Ferguson GT, Ganapathy V, Ozol-Godfrey A, Rajagopalan K. Satisfaction with the Use of eFlow Closed-System Nebulizer in Patients with Moderate-to-Very Severe Chronic Obstructive Pulmonary Disease: Findings from a Long-Term Safety Study. J Aerosol Med Pulm Drug Deliv 2019; 32:24-33. [DOI: 10.1089/jamp.2018.1477] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Edward M. Kerwin
- Clinical Research Institute of Southern Oregon, PC, Medford, Oregon
| | - James F. Donohue
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Gary T. Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, Michigan
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30
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Rangaraj N, Pailla SR, Sampathi S. Insight into pulmonary drug delivery: Mechanism of drug deposition to device characterization and regulatory requirements. Pulm Pharmacol Ther 2018; 54:1-21. [PMID: 30447295 DOI: 10.1016/j.pupt.2018.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/09/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Nagarjun Rangaraj
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER-HYD), Balanagar, Telangana, 500037, India
| | - Sravanthi Reddy Pailla
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER-HYD), Balanagar, Telangana, 500037, India
| | - Sunitha Sampathi
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER-HYD), Balanagar, Telangana, 500037, India.
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31
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Dosing challenges in respiratory therapies. Int J Pharm 2018; 548:659-671. [PMID: 30033395 DOI: 10.1016/j.ijpharm.2018.07.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/20/2018] [Accepted: 07/01/2018] [Indexed: 01/16/2023]
Abstract
The pulmonary route of administration has been commonly used for local lung conditions such as asthma and chronic obstructive pulmonary disease (COPD). Recently, with the advent of new technologies available for both formulation and device design, molecules usually delivered at high doses, such as antibiotics and insulin to treat cystic fibrosis (CF) and diabetes, respectively, can now be delivered by inhalation as a dry powder. These molecules are generally delivered in milligrams instead of traditional microgram quantities. High dose delivery is most commonly achieved via dry powder inhalers (DPIs), breath activated devices designed with a formulated powder containing micronized drug with aerodynamic diameters between 1 and 5 µm. The powder formulation may also contain other excipients and/or carrier particles to improve the flowability and aerosol dispersion of the powder. A drawback with high doses is that the formulation contains a great number of fine particles, leading to a greater degree of cohesive forces, producing strongly bound agglomerates. With greater cohesive forces holding fine particles together, higher dispersion forces are needed for efficient de-agglomeration and aerosolisation. This requirement of greater dispersion forces has led to different dry powder formulations and vastly different inhaler designs. The purpose of this review is to evaluate the different formulation types, various DPI devices currently available, and how these affect the aerosolisation process and delivery of high dosed inhalable dry powder formulations to the lungs.
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32
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Wachtel H, Nagel M, Engel M, El Azzi G, Sharma A, Suggett J. In vitro and clinical characterization of the valved holding chamber AeroChamber Plus ® Flow-Vu ® for administrating tiotropium Respimat ® in 1-5-year-old children with persistent asthmatic symptoms. Respir Med 2018; 137:181-190. [PMID: 29605203 DOI: 10.1016/j.rmed.2018.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND When characterizing inhalation products, a comprehensive assessment including in vitro, pharmacokinetic (PK), and clinical data is required. We conducted a characterization of tiotropium Respimat® when administered with AeroChamber Plus® Flow-Vu® anti-static valved holding chamber (test VHC) with face mask in 1-5-year-olds with persistent asthmatic symptoms. METHODS In vitro tiotropium dose and particle size distribution delivered into a cascade impactor were evaluated under fixed paediatric and adult flow rates between actuation and samplings. The tiotropium mass likely to reach children's lungs was assessed by tidal breathing simulations and an ADAM-III Child Model. PK exposure to tiotropium in preschool children with persistent asthmatic symptoms (using test VHC) was compared with pooled data from nine Phase 2/3 trials in older children, adolescents, and adults with symptomatic persistent asthma not using test VHC. RESULTS At fixed inspiratory flow rates, emitted mass and fine particle dose decreased under lower flow conditions; dose reduction was observed when Respimat® was administered by test VHC at paediatric flow rates. In <5-year-old children, such a dose reduction is appropriate. In terms of dose per kg/body weight, in vitro-delivered dosing in children was comparable with adults. Transmission and aerosol holding properties of Respimat® when administered with test VHC were fully sufficient for aerosol delivery to patients. At zero delay, particles <5 μm (most relevant fraction) exhibited a transfer efficacy of ≥60%. The half-time was>10 s, allowing multiple breaths. Standardized tidal inhalation resulted in an emitted mass from the test VHC of approximately one-third of labelled dose, independent of coordination and face mask use, indicating predictable tiotropium administration by test VHC with Respimat®. Tiotropium exposure in 1-5-year-old patients using the test VHC, when adjusted by height or body surface, was comparable with that in older age groups without VHCs; no overexposure was observed. Adverse events were less frequent with tiotropium (2.5 μg, n = 20 [55.6%]; 5 μg, n = 18 [58.1%]) than placebo (n = 25 [73.5%]). CONCLUSIONS Our findings provide good initial evidence to suggest that tiotropium Respimat® may be administered with AeroChamber Plus® Flow-Vu® VHC in 1-5-year-old patients with persistent asthmatic symptoms. To confirm the clinical efficacy and safety in these patients, additional trials are required. CLINICAL TRIALS REGISTRY NUMBER The trial was registered under NCT01634113 at http://www.clinicaltrials.gov.
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Affiliation(s)
- Herbert Wachtel
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany.
| | - Mark Nagel
- Trudell Medical International, London, Ontario, Canada.
| | - Michael Engel
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany.
| | - Georges El Azzi
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany.
| | - Ashish Sharma
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany.
| | - Jason Suggett
- Trudell Medical International, London, Ontario, Canada.
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Deng Q, Ou C, Chen J, Xiang Y. Particle deposition in tracheobronchial airways of an infant, child and adult. THE SCIENCE OF THE TOTAL ENVIRONMENT 2018; 612:339-346. [PMID: 28854390 DOI: 10.1016/j.scitotenv.2017.08.240] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/22/2017] [Accepted: 08/22/2017] [Indexed: 05/04/2023]
Abstract
BACKGROUND Particle deposition in human airways is important for assessing both health effects of inhaled particles and therapeutic efficacy of inhaled drug aerosols, but is not well understood for infants and children. OBJECTIVE We investigate particle deposition in infants and children by using computational fluid dynamics (CFD), and compare this with particle deposition in adults. METHODS We chose three population age groups: 7-month infant, 4-year old child, and 20-year old adult. Both airway structures and breathing conditions are considered to vary as a human grows from infancy to adulthood. We investigated deposition of micron-size particles (1-10μm) in both the upper (G3-G6) and lower (G9-G12) tracheobronchial (TB) airways under sedentary conditions. RESULTS We found that particle deposition in both upper and lower airways is the highest in an infant, next in a child, and lowest in an adult. As age increases, particle deposition decreases in the upper airways but increases in the lower. For infants, inertial impaction is the dominant deposition mechanism, thus particles are deposited more in the upper airways than in the lower. However, particles are deposited more in the lower airways than in the upper in adults, as gravitational sedimentation is the dominant deposition mechanism. CONCLUSION Given the differences in the airway structure and particle deposition mechanisms, particle deposition in infants and children differs from that in adults, not only in the efficiency of deposition but also in the site. Our findings provide evidence that "children are not small adults".
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Affiliation(s)
- Qihong Deng
- School of Energy Science and Engineering, Central South University, Changsha, China; XiangYa School of Public Health, Central South University, Changsha, China.
| | - Cuiyun Ou
- School of Energy Science and Engineering, Central South University, Changsha, China
| | - Jiao Chen
- School of Energy Science and Engineering, Central South University, Changsha, China
| | - Yuguang Xiang
- School of Energy Science and Engineering, Central South University, Changsha, China
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Shinta Devi NLP, Nurhaeni N, Hayati H. Effect of Audiovisual Distraction on Distress and Oxygenation Status in Children Receiving Aerosol Therapy. Compr Child Adolesc Nurs 2017; 40:14-21. [DOI: 10.1080/24694193.2017.1386966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Nani Nurhaeni
- Faculty of Nursing Universitas Indonesia, Jalan Bahder Djohan Campus, Depok, Indonesia
| | - Happy Hayati
- Faculty of Nursing Universitas Indonesia, Jalan Bahder Djohan Campus, Depok, Indonesia
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Al-Subu AM, Hagen S, Eldridge M, Boriosi J. Aerosol therapy through high flow nasal cannula in pediatric patients. Expert Rev Respir Med 2017; 11:945-953. [PMID: 28994337 DOI: 10.1080/17476348.2017.1391095] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION High flow nasal cannula (HFNC) is increasingly used in pediatric patients suffering from respiratory failure. In some disease processes, patients may also benefit from aerosol therapy. Therefore, the use of HFNC to deliver aerosolized medications is a convenient and attractive option. Areas covered: This review aims to appraise available evidence concerning the efficiency of aerosol nebulized therapy delivery using HFNC in pediatric patients. Expert commentary: Delivery of aerosol particles is a very complex process and depends on the use of oxygen vs. heliox, nebulizer type and position within the HFNC circuit, patient's breathing effort and pattern, and more importantly cannula size and flow rates. Current in vitro evidence suggests the amount of aerosol delivery is likely to be very low at high flows. Clinical studies are limited in pediatric patients and given the limited clinical data, it is not possible to make recommendations for or against aerosol delivery through HFNC for pediatric patients.
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Affiliation(s)
- Awni M Al-Subu
- a Division of Pediatric Critical Care Medicine , University of Wisconsin-Madison , Madison , WI , USA
| | - Scott Hagen
- a Division of Pediatric Critical Care Medicine , University of Wisconsin-Madison , Madison , WI , USA
| | - Marlowe Eldridge
- a Division of Pediatric Critical Care Medicine , University of Wisconsin-Madison , Madison , WI , USA
| | - Juan Boriosi
- a Division of Pediatric Critical Care Medicine , University of Wisconsin-Madison , Madison , WI , USA
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Wachtel H, Kattenbeck S, Dunne S, Disse B. The Respimat® Development Story: Patient-Centered Innovation. Pulm Ther 2017. [DOI: 10.1007/s41030-017-0040-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Dhanani J, Fraser JF, Chan HK, Rello J, Cohen J, Roberts JA. Fundamentals of aerosol therapy in critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:269. [PMID: 27716346 PMCID: PMC5054555 DOI: 10.1186/s13054-016-1448-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Drug dosing in critically ill patients is challenging due to the altered drug pharmacokinetics–pharmacodynamics associated with systemic therapies. For many drug therapies, there is potential to use the respiratory system as an alternative route for drug delivery. Aerosol drug delivery can provide many advantages over conventional therapy. Given that respiratory diseases are the commonest causes of critical illness, use of aerosol therapy to provide high local drug concentrations with minimal systemic side effects makes this route an attractive option. To date, limited evidence has restricted its wider application. The efficacy of aerosol drug therapy depends on drug-related factors (particle size, molecular weight), device factors, patient-related factors (airway anatomy, inhalation patterns) and mechanical ventilation-related factors (humidification, airway). This review identifies the relevant factors which require attention for optimization of aerosol drug delivery that can achieve better drug concentrations at the target sites and potentially improve clinical outcomes.
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Affiliation(s)
- Jayesh Dhanani
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, 4029, QLD, Australia.
| | - John F Fraser
- Department of Intensive Care Medicine, The Prince Charles Hospital, Brisbane, Australia.,Critical Care Research Group, The University of Queensland, Brisbane, Australia
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Jordi Rello
- Critical Care Department, Hospital Vall d'Hebron, Barcelona, Spain.,CIBERES, Vall d'Hebron Institut of Research, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Jeremy Cohen
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, 4029, QLD, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, 4029, QLD, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Herston, Brisbane, Australia.,School of Pharmacy, The University of Queensland, Brisbane, Australia
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Dekhuijzen PNR, Lavorini F, Usmani OS. Patients' perspectives and preferences in the choice of inhalers: the case for Respimat(®) or HandiHaler(®). Patient Prefer Adherence 2016; 10:1561-72. [PMID: 27574405 PMCID: PMC4993394 DOI: 10.2147/ppa.s82857] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Poor inhaler technique hampers the efficacy of drug therapy in asthma and chronic obstructive pulmonary disease. Not only does this affect individual patient care, but it also impacts on the wider health care economics associated with these conditions. Treatment guidelines recommend a systematic approach to drug class selection; however, standardization of inhaler selection is currently difficult owing to the complexity of the interaction between the inhaler device and the patient. Specifically, individual patient preference can influence how successful a treatment is overall. This article reviews inhaler devices from the patient perspective, with a particular focus on the dry powder inhaler HandiHaler(®) and Respimat(®) Soft Mist™ Inhaler. It discusses factors that influence device preference and treatment compliance and reviews tools that can aid health care professionals to better match inhaler devices to individual patients' needs.
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Affiliation(s)
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
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Ari A. Drug delivery interfaces: A way to optimize inhalation therapy in spontaneously breathing children. World J Clin Pediatr 2016; 5:281-287. [PMID: 27610343 PMCID: PMC4978620 DOI: 10.5409/wjcp.v5.i3.281] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/03/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
There are several different types of drug delivery interfaces available on the market. Using the right interface for aerosol drug delivery to children is essential for effective inhalation therapy. However, clinicians usually focus on selecting the right drug-device combination and often overlook the importance of interface selection that lead to suboptimal drug delivery and therapeutic response in neonates and pediatrics. Therefore, it is necessary to critically assess each interface and understand its advantage and disadvantages in aerosol drug delivery to this patient population. The purpose of this paper is to provide a critical assessment of drug delivery interfaces used for the treatment of children with pulmonary diseases by emphasizing advantages and problems associated with their use during inhalation therapy.
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Ari A, Fink JB. Differential Medical Aerosol Device and Interface Selection in Patients during Spontaneous, Conventional Mechanical and Noninvasive Ventilation. J Aerosol Med Pulm Drug Deliv 2016; 29:95-106. [DOI: 10.1089/jamp.2015.1266] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Arzu Ari
- Division of Respiratory Therapy, Georgia State University, Atlanta, Georgia
| | - James B. Fink
- Division of Respiratory Therapy, Georgia State University, Atlanta, Georgia
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Sunbul FS, Fink JB, Harwood R, Sheard MM, Zimmerman RD, Ari A. Comparison of HFNC, bubble CPAP and SiPAP on aerosol delivery in neonates: An in-vitro study. Pediatr Pulmonol 2015; 50:1099-106. [PMID: 25491434 DOI: 10.1002/ppul.23123] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 09/13/2014] [Accepted: 09/27/2014] [Indexed: 11/05/2022]
Abstract
UNLABELLED Aerosol drug delivery via high flow nasal cannula (HFNC), bubble continuous positive airway pressure (CPAP), and synchronized inspiratory positive airway pressure (SiPAP) has not been quantified in spontaneously breathing premature infants. OBJECTIVES The purpose of this study was to compare aerosol delivery via HFNC, bubble CPAP, and SiPAP in a model of a simulated spontaneously breathing preterm infant. WORKING HYPOTHESIS The types of CPAP systems and nebulizer positions used during aerosol therapy will impact aerosol deposition in simulated spontaneously breathing infants. STUDY DESIGN Quantitative, comparative, in-vitro study. METHODOLOGY A breath simulator was set to preterm infant settings (VT : 9 ml, RR: 50 bpm and Ti: 0.5 sec) and connected to the trachea of an anatomical upper airway model of a preterm infant via collecting filter distal to the trachea. The HFNC (Optiflow; Fisher & Paykel), Bubble CPAP (Fisher & Paykel), and SiPAP (Carefusion) were attached to the nares of the model via each device's proprietary nasal cannula and set to deliver a baseline of 5 cm H2 O pressure. Albuterol sulfate (2.5 mg/0.5 ml) was aerosolized with a mesh nebulizer (Aeroneb Solo) positioned(1) proximal to the patient and(2) prior to the humidifier (n = 5). The drug was eluted from the filter with 0.1 N HCl and analyzed via spectrophotometry (276 nm). Data were analyzed using descriptive statistics, t-tests, and one-way analysis of variance (ANOVA), with P < 0.05 significant. RESULTS At position 1, the trend of lower deposition (mean ± SD%) across devices was not significant (0.90 ± 0.26, 0.70 ± 0.16 and 0.59 ± 0.19, respectively; P = 0.098); however, in position 2, drug delivery with SiPAP (0.79 ± 0.11) was lower compared to both HFNC (1.30 ± 0.17; P = 0.003) and bubble CPAP (1.24 ± 0.24; p = 0.008). Placement of the nebulizer prior to the humidifier increased deposition with all devices (P < 0.05). CONCLUSIONS Aerosol can be delivered via all three devices used in this study. Device selection and nebulizer position impacted aerosol delivery in this simulated model of a spontaneously breathing preterm infant.
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Affiliation(s)
- Fatemah S Sunbul
- Georgia State University, Division of Respiratory Therapy, Atlanta, Georgia
| | - James B Fink
- Georgia State University, Division of Respiratory Therapy, Atlanta, Georgia
| | - Robert Harwood
- Georgia State University, Division of Respiratory Therapy, Atlanta, Georgia
| | - Meryl M Sheard
- Georgia State University, Division of Respiratory Therapy, Atlanta, Georgia
| | - Ralph D Zimmerman
- Georgia State University, Division of Respiratory Therapy, Atlanta, Georgia
| | - Arzu Ari
- Georgia State University, Division of Respiratory Therapy, Atlanta, Georgia
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Prime D, de Backer W, Hamilton M, Cahn A, Preece A, Kelleher D, Baines A, Moore A, Brealey N, Moynihan J. Effect of Disease Severity in Asthma and Chronic Obstructive Pulmonary Disease on Inhaler-Specific Inhalation Profiles Through the ELLIPTA® Dry Powder Inhaler. J Aerosol Med Pulm Drug Deliv 2015; 28:486-97. [PMID: 26372467 PMCID: PMC4685483 DOI: 10.1089/jamp.2015.1224] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Two studies were undertaken to characterize the maximal effort inhalation profiles of healthy subjects and patients with asthma or chronic obstructive pulmonary disease (COPD) through a moderate-resistance dry powder inhaler (DPI). Correlations between inhaler-specific inhalation characteristics and inhaler-independent lung function parameters were investigated. METHODS Healthy subjects (n = 15), patients with mild, moderate, or severe asthma (n = 45), and patients with mild, moderate, severe, or very-severe COPD (n = 60) were included in the studies. Inhalation pressure drop versus time profiles were recorded using an instrumented ELLIPTA® DPI or bespoke resistor component with equivalent resistivity. Inhaler-independent lung function assessments included pharyngometry, spirometry, plethysmography, and diffusion. RESULTS For the inhaler-specific inhalation profiles, the mean maximal effort peak inspiratory flow rates (PIFRs) varied across the subgroups from 65.8-110.6 L/min (range: 41.6-142.9). Peak pressure drop, PIFR, inhaled volume, and average inhalation flow rate (primary endpoints) did not differ markedly between healthy subjects and patients with asthma or mild COPD. Moderate, severe, and very-severe COPD patients demonstrated lower mean peak pressure drops, PIFRs and inhaled volumes, which tended to decrease with increasing COPD severity. Severe and very-severe COPD patients demonstrated shorter mean inhalation times compared with all other participants. Inhaler-independent lung function parameters were consistent with disease severity, and statistically significant (p < 0.05) strong correlations (R > 0.7) with components of the inhaler-specific inhalation profiles were observed in the COPD cohort; correlations in the asthma cohort tended to be weaker. CONCLUSIONS All participants achieved a maximal effort PIFR ≥ 41.6 L/min through the moderate resistance of the ELLIPTA inhaler. Patients with asthma achieved similar inhalation profiles to healthy subjects, but increasing COPD severity tended to reduce a patient's inhalation capability. Correlation analyses suggest that some lung function parameters may be a useful indicator of ability to inhale efficiently through a moderate-resistance DPI, such as the ELLIPTA inhaler.
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Affiliation(s)
- David Prime
- 1 GSK Research and Development Ltd., Ware, Hertfordshire, United Kingdom
| | - Wilfried de Backer
- 2 Department of Pulmonary Medicine, University Hospital and University of Antwerp , Belgium
| | - Melanie Hamilton
- 1 GSK Research and Development Ltd., Ware, Hertfordshire, United Kingdom
| | - Anthony Cahn
- 3 Medicines Discovery and Development, GSK , Stevenage, Hertfordshire, United Kingdom
| | - Andrew Preece
- 4 Respiratory Therapy Area Unit, GSK , Stockley Park West, Middlesex, United Kingdom
| | | | - Amanda Baines
- 3 Medicines Discovery and Development, GSK , Stevenage, Hertfordshire, United Kingdom
| | - Alison Moore
- 4 Respiratory Therapy Area Unit, GSK , Stockley Park West, Middlesex, United Kingdom
| | - Noushin Brealey
- 4 Respiratory Therapy Area Unit, GSK , Stockley Park West, Middlesex, United Kingdom
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A Handling Study to Assess the Use of the Respimat® Soft Mist™ Inhaler in Children Aged 4–12 Years. Pulm Ther 2015. [DOI: 10.1007/s41030-015-0002-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Devices for oral and respiratory paediatric medicines: What do healthcare professionals think? Int J Pharm 2015; 492:304-15. [DOI: 10.1016/j.ijpharm.2015.05.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 05/07/2015] [Accepted: 05/14/2015] [Indexed: 11/16/2022]
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Kamin W, Frank M, Kattenbeck S, Moroni-Zentgraf P, Wachtel H, Zielen S. A Handling Study to Assess Use of the Respimat(®) Soft Mist™ Inhaler in Children Under 5 Years Old. J Aerosol Med Pulm Drug Deliv 2015; 28:372-81. [PMID: 25844687 PMCID: PMC4601632 DOI: 10.1089/jamp.2014.1159] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Respimat® Soft Mist™ Inhaler (SMI) is a hand-held device that generates an aerosol with a high, fine-particle fraction, enabling efficient lung deposition. The study objective was to assess inhalation success among children using Respimat SMI, and the requirement for assistance by the parent/caregiver and/or a valved holding chamber (VHC). Methods: This open-label study enrolled patients aged <5 years with respiratory disease and history of coughing and/or recurrent wheezing. Patients inhaled from the Respimat SMI (air only; no aerosol) using a stepwise configuration: “1” (dose released by child); “2” (dose released by parent/caregiver), and “3” (Respimat SMI with VHC, facemask, and parent/caregiver help). Co-primary endpoints included the ability to perform successful inhalation as assessed by the investigators using a standardized handling questionnaire and evaluation of the reasons for success. Inhalation profile in the successful handling configuration was verified with a pneumotachograph. Patient satisfaction and preferences were investigated in a questionnaire. Results: Of the children aged 4 to <5 years (n=27) and 3 to <4 years (n=30), 55.6% and 30.0%, respectively, achieved success without a VHC or help; with assistance, another 29.6% and 10.0%, respectively, achieved success, and the remaining children were successful with VHC. All children aged 2 to <3 years (n=20) achieved success with the Respimat SMI and VHC. Of those aged <2 years (n=22), 95.5% had successful handling of the Respimat SMI with VHC and parent/caregiver help. Inhalation flow profiles generally confirmed the outcome of the handling assessment by the investigators. Most parent/caregiver and/or child respondents were satisfied with operation, instructions for use, handling, and ease of holding the Respimat SMI with or without a VHC. Conclusions: The Respimat SMI is suitable for children aged <5 years; however, children aged <5 years are advised to add a VHC to complement its use.
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Affiliation(s)
- Wolfgang Kamin
- 1 Children's Hospital , Evangelisches Krankenhaus Hamm, Hamm, Germany
| | | | | | | | | | - Stefan Zielen
- 3 Children's Hospital, Allergology, Pneumology and Cystic Fibrosis, Goethe-University , Frankfurt am Main, Germany
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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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Abstract
Using aerosolized medications for the treatment of children has gained importance over the years. However, aerosol drug delivery to infants and pediatrics is not an easy task as it has been influenced by many challenges. Most aerosol devices have been designed for use in adults not for children. Therefore, they require some critical assessment in device selection and often a level of adaptation for use with smaller children. It is well documented that each aerosol device and interface that have been used for the treatment of children has its own advantages and challenges in drug delivery. This paper provides a comprehensive review of dosing, drug-device combination, aerosol devices and interfaces used for drug delivery to children with pulmonary diseases. Solutions to the challenges with the aim of optimizing aerosol therapy in this patient population are also discussed.
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Affiliation(s)
- Arzu Ari
- Georgia State University, Division of Respiratory Therapy, Atlanta, GA 30302-4019, USA
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Fink JB. Delivery of Inhaled Drugs for Infants and Small Children: A Commentary on Present and Future Needs. Clin Ther 2012; 34:S36-45. [DOI: 10.1016/j.clinthera.2012.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 10/08/2012] [Accepted: 10/11/2012] [Indexed: 10/27/2022]
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