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Luján M, Cinesi Gómez C, Peñuelas O, Ferrando C, Heili-Frades SB, Carratalá Perales JM, Mas A, Sayas Catalán J, Mediano O, Roca O, García Fernández J, González Varela A, Sempere Montes G, Rialp Cervera G, Hernández G, Millán T, Ferrer Monreal M, Egea Santaolalla C. Multidisciplinary Consensus on the Management of Non-Invasive Respiratory Support in the COVID-19 Patient. Arch Bronconeumol 2024; 60:285-295. [PMID: 38521646 DOI: 10.1016/j.arbres.2024.02.017] [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: 02/19/2024] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/25/2024]
Abstract
Acute respiratory failure due to COVID-19 pneumonia often requires a comprehensive approach that includes non-pharmacological strategies such as non-invasive support (including positive pressure modes, high flow therapy or awake proning) in addition to oxygen therapy, with the primary goal of avoiding endotracheal intubation. Clinical issues such as determining the optimal time to initiate non-invasive support, choosing the most appropriate modality (based not only on the acute clinical picture but also on comorbidities), establishing criteria for recognition of treatment failure and strategies to follow in this setting (including palliative care), or implementing de-escalation procedures when improvement occurs are of paramount importance in the ongoing management of severe COVID-19 cases. Organizational issues, such as the most appropriate setting for management and monitoring of the severe COVID-19 patient or protective measures to prevent virus spread to healthcare workers in the presence of aerosol-generating procedures, should also be considered. While many early clinical guidelines during the pandemic were based on previous experience with acute respiratory distress syndrome, the landscape has evolved since then. Today, we have a wealth of high-quality studies that support evidence-based recommendations to address these complex issues. This document, the result of a collaborative effort between four leading scientific societies (SEDAR, SEMES, SEMICYUC, SEPAR), draws on the experience of 25 experts in the field to synthesize knowledge to address pertinent clinical questions and refine the approach to patient care in the face of the challenges posed by severe COVID-19 infection.
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Affiliation(s)
- Manel Luján
- Servei de Pneumologia, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - César Cinesi Gómez
- Servicio de Urgencias, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Oscar Peñuelas
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Servicio de Medicina Intensiva Hospital Universitario de Getafe, Madrid, Spain
| | - Carlos Ferrando
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Department of Anesthesia and Critical Care, Hospital Clínic, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
| | - Sarah Béatrice Heili-Frades
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Hospital Universitario Fundación Jiménez Díaz Quirón Salud, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), CIBERES, REVA Network, Madrid, Spain
| | | | - Arantxa Mas
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | | | - Olga Mediano
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Sleep Unit, Pneumology Department. Hospital Universitario de Guadalajara, Instituto de Investigación Sanitaria de Castilla la Mancha (IDISCAM), Universidad de Alcalá, Madrid, Spain
| | - Oriol Roca
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Institut de Recerca Parc Taulí-I3PT, Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Javier García Fernández
- Servicio de Anestesiología, UCI Quirúrgica y U. Dolor. H. U. Puerta de Hierro, Madrid, Spain
| | | | | | - Gemma Rialp Cervera
- Servicio de Medicina Intensiva, Hospital Universitari Son Llàtzer, Palma de Mallorca, Spain
| | - Gonzalo Hernández
- Servicio de Medicina Intensiva, Hospital Virgen de la Salud, Toledo, Spain
| | - Teresa Millán
- Servicio de Medicina Intensiva Hospital Universitario Son Espases, Facultad de Medicina de las Islas Baleares, Spain
| | - Miquel Ferrer Monreal
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; UVIIR, Servei de Pneumologia, Institut de Respiratori, Clínic Barcelona, IDIBAPS. Universitat de Barcelona, Barcelona, Spain
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Biney IN, Ari A, Barjaktarevic IZ, Carlin B, Christiani DC, Cochran L, Drummond MB, Johnson K, Kealing D, Kuehl PJ, Li J, Mahler DA, Martinez S, Ohar J, Radonovich LJ, Sood A, Suggett J, Tal-Singer R, Tashkin D, Yates J, Cambridge L, Dailey PA, Mannino DM, Dhand R. Guidance on Mitigating the Risk of Transmitting Respiratory Infections During Nebulization by the COPD Foundation Nebulizer Consortium. Chest 2024; 165:653-668. [PMID: 37977263 DOI: 10.1016/j.chest.2023.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Nebulizers are used commonly for inhaled drug delivery. Because they deliver medication through aerosol generation, clarification is needed on what constitutes safe aerosol delivery in infectious respiratory disease settings. The COVID-19 pandemic highlighted the importance of understanding the safety and potential risks of aerosol-generating procedures. However, evidence supporting the increased risk of disease transmission with nebulized treatments is inconclusive, and inconsistent guidelines and differing opinions have left uncertainty regarding their use. Many clinicians opt for alternative devices, but this practice could impact outcomes negatively, especially for patients who may not derive full treatment benefit from handheld inhalers. Therefore, it is prudent to develop strategies that can be used during nebulized treatment to minimize the emission of fugitive aerosols, these comprising bioaerosols exhaled by infected individuals and medical aerosols generated by the device that also may be contaminated. This is particularly relevant for patient care in the context of a highly transmissible virus. RESEARCH QUESTION How can potential risks of infections during nebulization be mitigated? STUDY DESIGN AND METHODS The COPD Foundation Nebulizer Consortium (CNC) was formed in 2020 to address uncertainties surrounding administration of nebulized medication. The CNC is an international, multidisciplinary collaboration of patient advocates, pulmonary physicians, critical care physicians, respiratory therapists, clinical scientists, and pharmacists from research centers, medical centers, professional societies, industry, and government agencies. The CNC developed this expert guidance to inform the safe use of nebulized therapies for patients and providers and to answer key questions surrounding medication delivery with nebulizers during pandemics or when exposure to common respiratory pathogens is anticipated. RESULTS CNC members reviewed literature and guidelines regarding nebulization and developed two sets of guidance statements: one for the health care setting and one for the home environment. INTERPRETATION Future studies need to explore the risk of disease transmission with fugitive aerosols associated with different nebulizer types in real patient care situations and to evaluate the effectiveness of mitigation strategies.
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Affiliation(s)
- Isaac N Biney
- University Pulmonary and Critical Care, The University of Tennessee Graduate School of Medicine, Knoxville, TN.
| | - Arzu Ari
- Department of Respiratory Care and Texas State Sleep Center, Texas State University, Round Rock, TX
| | - Igor Z Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles Health Sciences, Los Angeles, CA; Division of Liver and Pancreas Transplantation, David Geffen School of Medicine, University of California Los Angeles Health Sciences, Los Angeles, CA
| | - Brian Carlin
- Sleep Medicine and Lung Health Consultants LLC, Pittsburgh, PA
| | - David C Christiani
- Harvard T.H. Chan School of Public Health, Harvard Medical School, Cambridge, MA; Pulmonary and Critical Care Division, Massachusetts General Hospital, Boston, MA
| | | | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Jie Li
- Rush University, Chicago, IL
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH; Valley Regional Hospital, Claremont, NH
| | | | - Jill Ohar
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Lewis J Radonovich
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV
| | - Akshay Sood
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | | | | | - Donald Tashkin
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles Health Sciences, Los Angeles, CA
| | | | - Lisa Cambridge
- Medical Science & Pharmaceutical Alliances, PARI, Inc., Midlothian, VA
| | | | | | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of Tennessee Graduate School of Medicine, Knoxville, TN
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Neary MT, Mulder LM, Kowalski PS, MacLoughlin R, Crean AM, Ryan KB. Nebulised delivery of RNA formulations to the lungs: From aerosol to cytosol. J Control Release 2024; 366:812-833. [PMID: 38101753 DOI: 10.1016/j.jconrel.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
In the past decade RNA-based therapies such as small interfering RNA (siRNA) and messenger RNA (mRNA) have emerged as new and ground-breaking therapeutic agents for the treatment and prevention of many conditions from viral infection to cancer. Most clinically approved RNA therapies are parenterally administered which impacts patient compliance and adds to healthcare costs. Pulmonary administration via inhalation is a non-invasive means to deliver RNA and offers an attractive alternative to injection. Nebulisation is a particularly appealing method due to the capacity to deliver large RNA doses during tidal breathing. In this review, we discuss the unique physiological barriers presented by the lung to efficient nebulised RNA delivery and approaches adopted to circumvent this problem. Additionally, the different types of nebulisers are evaluated from the perspective of their suitability for RNA delivery. Furthermore, we discuss recent preclinical studies involving nebulisation of RNA and analysis in in vitro and in vivo settings. Several studies have also demonstrated the importance of an effective delivery vector in RNA nebulisation therefore we assess the variety of lipid, polymeric and hybrid-based delivery systems utilised to date. We also consider the outlook for nebulised RNA medicinal products and the hurdles which must be overcome for successful clinical translation. In summary, nebulised RNA delivery has demonstrated promising potential for the treatment of several lung-related conditions such as asthma, COPD and cystic fibrosis, to which the mode of delivery is of crucial importance for clinical success.
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Affiliation(s)
- Michael T Neary
- SSPC, The SFI Research Centre for Pharmaceuticals, School of Pharmacy, University College Cork, Ireland; School of Pharmacy, University College Cork, Ireland
| | | | - Piotr S Kowalski
- School of Pharmacy, University College Cork, Ireland; APC Microbiome, University College Cork, Cork, Ireland
| | | | - Abina M Crean
- SSPC, The SFI Research Centre for Pharmaceuticals, School of Pharmacy, University College Cork, Ireland; School of Pharmacy, University College Cork, Ireland
| | - Katie B Ryan
- SSPC, The SFI Research Centre for Pharmaceuticals, School of Pharmacy, University College Cork, Ireland; School of Pharmacy, University College Cork, Ireland.
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Ramachandran S, Prakash P, Mohtar N, Kumar KS, Parumasivam T. Review of inhalable nanoparticles for the pulmonary delivery of anti-tuberculosis drugs. Pharm Dev Technol 2023; 28:978-991. [PMID: 37937865 DOI: 10.1080/10837450.2023.2279691] [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: 12/16/2022] [Accepted: 09/05/2023] [Indexed: 11/09/2023]
Abstract
Tuberculosis is an airborne disease caused by the pathogen, Mycobacterium tuberculosis, which predominantly affects the lungs. World Health Organization (WHO) has reported that about 85% of TB patients are cured with the existing 6-month antibiotic regimen. However, the lengthy oral administration of high-dose anti-TB drugs is associated with significant side effects and leads to drug resistance cases. Alternatively, reformulating existing anti-tubercular drugs into inhalable nanoparticulate systems is a promising strategy to overcome the challenges associated with oral treatment as they could enhance drug retention in the pulmonary region to achieve an optimal drug concentration in the infected lungs. Hence, this review provides an overview of the literature on inhalable nano-formulations for the delivery of anti-TB drugs, including their formulation techniques and preclinical evaluations between the years 2000 and 2020, gathered from electronic journals via online search engines such as Google Scholar and PubMed. Previous in vitro and in vivo studies highlighted that the nano-size, low toxicity, and high efficacy were among the factors influencing the fate of nanoparticulate system upon deposition in the lungs. Although many preclinical studies have shown that inhalable nanoparticles increased therapeutic efficacy and minimised adverse drug reactions when delivered through the pulmonary route, none of them has progressed into clinical trials to date. This could be attributed to the high cost of inhaled regimes due to the expensive production and characterisation of the nanoparticles as well as the need for an inhalation device as compared to the oral treatment. Another barrier could be the lack of medical acceptance due to insufficient number of trained staff to educate the patients on the correct usage of the inhalation device. Hence, these barriers should be addressed satisfactorily to make the inhaled nanoparticles regimen a reality for the treatment of TB.
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Affiliation(s)
- Sowmya Ramachandran
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden, Pulau Pinang, Malaysia
| | - Priyanka Prakash
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden, Pulau Pinang, Malaysia
| | - Noratiqah Mohtar
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden, Pulau Pinang, Malaysia
| | - K Sudesh Kumar
- School of Biological Sciences, Universiti Sains Malaysia, Minden, Pulau Pinang, Malaysia
| | - Thaigarajan Parumasivam
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden, Pulau Pinang, Malaysia
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Thibon C, Vecellio L, Belkhir L, Dubus JC, Robert A, Kabamba B, Reychler G. There Is a Risk of Spread During a Nebulization Session in a Patient with COVID-19. J Aerosol Med Pulm Drug Deliv 2023; 36:268-274. [PMID: 37610849 DOI: 10.1089/jamp.2023.0010] [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: 08/25/2023] Open
Abstract
Introduction: A hypothetical risk of SARS-CoV-2 airborne transmission through nebulization was suggested based on a potential environmental contamination by the fugitive aerosol emitted in the environment during the procedure. The aim of this study was to verify this risk from the fugitive aerosol emitted by COVID-19 patients during one nebulization session. Methods: In this cohort study, COVID-19 patients treated with nebulization were recruited at their admission to the hospital. Patients had to perform a nebulization session while a BioSampler® and a pump were used to vacuum the fugitive aerosol and collect it for SARS-CoV-2 RNA detection. Results: Ten consecutive patients hospitalized with COVID-19 were recruited. The median viral load was 6.5 × 106 copies/mL. Two out of the 10 samples from the fugitive aerosol collected were positive to SARS-CoV-2. Conclusion: The risk of fugitive aerosol contamination with SARS-CoV-2 during nebulization has now been verified.
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Affiliation(s)
- Christophe Thibon
- Secteur de Kinésithérapie et Ergothérapie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
- Service de Pneumologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Laurent Vecellio
- PST A, Université de Tours, Tours, France
- Group Aerosoltherapy GAT of the French Language Respiratory Society-Société de Pneumologie de Langue Française SPLF, Paris, France
| | - Leila Belkhir
- Department of Internal Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jean-Christophe Dubus
- Group Aerosoltherapy GAT of the French Language Respiratory Society-Société de Pneumologie de Langue Française SPLF, Paris, France
- Unité de Pneumologie Pédiatrique, Centre Hospitalo-Universitaire (CHU) Timone-Enfants, Marseille, France
- Aix Marseille Université, IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Annie Robert
- Pole épidémiologie et biostatistique, Institut de recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Benoît Kabamba
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
- Department of Microbiology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Gregory Reychler
- Secteur de Kinésithérapie et Ergothérapie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
- Service de Pneumologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Group Aerosoltherapy GAT of the French Language Respiratory Society-Société de Pneumologie de Langue Française SPLF, Paris, France
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Arnott A, Hart R, McQueen S, Watson M, Sim M. Prospective randomised unblinded comparison of sputum viscosity for three methods of saline nebulisation in mechanically ventilated patients: A pilot study protocol. PLoS One 2023; 18:e0290033. [PMID: 37590203 PMCID: PMC10434882 DOI: 10.1371/journal.pone.0290033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023] Open
Abstract
INTRODUCTION Heat and moisture exchanger (HME) filters are commonly used as passive circuit humidifiers during mechanical ventilation, however, are only ~80% efficient. As a result, patients that undergo mechanical ventilation in critical care with HME filter circuits will be exposed to partial airway humidification. This is associated with detrimental effects including increased secretion load which has been shown to be an independent predictor of failed extubation. Nebulised normal saline is commonly utilised to supplement circuit humidification in ventilated patients with high secretion loads, although there are no randomised control trials evaluating its use. Novel vibrating mesh nebulisers generate a fine aerosol resulting in deeper lung penetration, potentially offering a more effective means of nebulisation in comparison to jet nebulisers. The primary aim of this study is to compare the viscosity of respiratory secretions after treatment with nebulised normal saline administered via vibrating mesh nebuliser or jet nebuliser. METHODS AND ANALYSIS This randomised controlled trial is enrolling 60 mechanically ventilated adult critical care patients breathing on HME filter circuits with high secretion loads. Recruited patients will be randomised to receive nebulised saline via 3 modalities: 1) Continuous vibrating mesh nebuliser; 2) Intermittent vibrating mesh nebuliser or 3) Intermittent jet nebuliser. Over the 72-hr study period, the patients' sputum viscosity (measured using a validated qualitative sputum assessment tool) and physiological parameters will be recorded by an unblinded assessor. A median reduction in secretion viscosity of ≥0.5 on the qualitative sputum assessment score will be deemed as a clinically significant improvement between treatment groups at analysis. DISCUSSION At the conclusion of this trial, we will provisionally determine if nebulised normal saline administered via vibrating mesh nebulisation is superior to traditional jet nebulisation in terms of reduced respiratory secretion viscosity in intubated patients. Results from this pilot study will provide information to power a definitive clinical study. TRIAL REGISTRATION ClinicalTrails.Gov Registry (NCT05635903).
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Affiliation(s)
- Andrew Arnott
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Robert Hart
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Scott McQueen
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Malcolm Watson
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Malcolm Sim
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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O'Toole C, McGrath JA, Joyce M, O'Sullivan A, Thomas C, Murphy S, MacLoughlin R, Byrne MA. Effect of Nebuliser and Patient Interface Type on Fugitive Medical Aerosol Emissions in Adult and Paediatric Patients. Eur J Pharm Sci 2023; 187:106474. [PMID: 37225006 DOI: 10.1016/j.ejps.2023.106474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/19/2023] [Accepted: 05/21/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Open circuit aerosol therapy is associated with the potential for fugitive emissions of medical aerosol. Various nebulisers and interfaces are used in respiratory treatments, including the recent consideration of filtered interfaces. This study aims to quantify fugitive medical aerosols from various nebuliser types, in conjunction with different filtered and non-filtered interfaces. METHODS For both simulated adult and paediatric breathing, four nebuliser types were assessed including; a small volume jet nebuliser (SVN), a breath enhanced jet nebuliser (BEN), a breath actuated jet nebuliser (BAN) and a vibrating mesh nebuliser (VMN). A combination of different interfaces were used including filtered and unfiltered mouthpieces, as well as open, valved and filtered facemasks. Aerosol mass concentrations were measured using an Aerodynamic Particle Sizer at 0.8 m and 2.0 m. Additionally, inhaled dose was assessed. RESULTS Highest mass concentrations recorded were 214 (177, 262) µg m-3 at 0.8 m over 45-minute run. The highest and lowest fugitive emissions were observed for the adult SVN facemask combination, and the adult BAN filtered mouthpiece combination respectively. Fugitive emissions decreased when using breath-actuated (BA) mode compared to continuous (CN) mode on the BAN for the adult and paediatric mouthpiece combination. Lower fugitive emissions were observed when a filtered facemask or mouthpiece was used, compared to unfiltered scenarios. For the simulated adult, highest and lowest inhaled dose were 45.1 (42.6, 45.6)% and 11.0 (10.1,11.9)% for the VMN and SVN respectively. For the simulated paediatric, highest and lowest inhaled dose were 44.0 (42.4, 44.8)% and 6.1 (5.9, 7.0)% for the VMN and BAN CN respectively. Potential inhalation exposure of albuterol was calculated to be up to 0.11 µg and 0.12 µg for a bystander and healthcare worker respectively. CONCLUSION This work demonstrates the need for filtered interfaces in clinical and homecare settings to minimise fugitive emissions and to reduce the risk of secondary exposure to care givers.
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Affiliation(s)
- Ciarraí O'Toole
- Physics, School of Natural Sciences, Ryan Institute's Centre for Climate and Air Pollution Studies, College of Science & Engineering, University of Galway, H91 CF50, Galway, Ireland.
| | - James A McGrath
- Physics, School of Natural Sciences, Ryan Institute's Centre for Climate and Air Pollution Studies, College of Science & Engineering, University of Galway, H91 CF50, Galway, Ireland; Department of Experimental Physics, Maynooth University, Maynooth, Co. Kildare, Ireland.
| | - Mary Joyce
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland.
| | - Andrew O'Sullivan
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland.
| | - Ciara Thomas
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland.
| | - Sarah Murphy
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland.
| | - Ronan MacLoughlin
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland; School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland.
| | - Miriam A Byrne
- Physics, School of Natural Sciences, Ryan Institute's Centre for Climate and Air Pollution Studies, College of Science & Engineering, University of Galway, H91 CF50, Galway, Ireland.
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Frankfort MGH, Lauwers I, Pruijn EMC, Dijkstra SF, Boormans LHG, Schouten NA, van Donkelaar CC, Janssens HM. Minimizing Aerosol Leakage from Facemasks in the COVID-19 Pandemic. J Aerosol Med Pulm Drug Deliv 2023. [PMID: 37172274 DOI: 10.1089/jamp.2022.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
Background: Aerosol therapies with vented facemasks are considered a risk for nosocomial transmission of viruses such as severe acute respiratory syndrome coronavirus 2. The transmission risk can be decreased by minimizing aerosol leakage and filtering the exhaled air. Objective: In this study, we determined which closed facemask designs show the least leakage. Methods: Smoke leakage was quantified during in- and exhalation in a closed system with expiration filter for three infant, six child, and six adult facemasks (three times each mask), using age-appropriate anatomical face models and breathing patterns. To assess leakage, smoke release was recorded and cumulative average pixel intensity (cAPI) was calculated. Results: In the adult group, aircushion edges resulted in less leakage than soft edges (cAPI: 407 ± 250 vs. 774 ± 152) (p = 0.004). The Intersurgical® Economy 5 mask (cAPI: 146 ± 87) also released less smoke than the Intersurgical® Clearlite 5 (cAPI: 748 ± 68) mask with the same size, but different geometry and edge type (p-value <0.05). Moreover, mask size had an effect, as there was a difference between Intersurgical® Economy 4 (cAPI: 708 ± 346) and 5, which have the same geometry but a different size (p-value <0.05). Finally, repositioning masks increased the standard deviations. Mask leakage was not dependent on breathing patterns within the child group. Conclusions: Mask leakage can be minimized by using a closed system with a well-fitting mask that is appropriately positioned. To decrease leakage, and therewith minimize potential viral transmission, selecting a well-fitting mask with an aircushion edge is to be recommended.
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Affiliation(s)
- Mylene G H Frankfort
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Iris Lauwers
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Emerentia M C Pruijn
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Sjoerd F Dijkstra
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Liza H G Boormans
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Nicolaas A Schouten
- TU/e Innovation Space, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Corrinus C van Donkelaar
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Hettie M Janssens
- Department of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Mac Giolla Eain M, Cahill R, MacLoughlin R, Nolan K. Aerosol release, distribution, and prevention during aerosol therapy: a simulated model for infection control. Drug Deliv 2022; 29:10-17. [PMID: 34962221 PMCID: PMC8725970 DOI: 10.1080/10717544.2021.2015482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 10/24/2022] Open
Abstract
Aerosol therapy is used to deliver medical therapeutics directly to the airways to treat respiratory conditions. A potential consequence of this form of treatment is the release of fugitive aerosols, both patient derived and medical, into the environment and the subsequent exposure of caregivers and bystanders to potential viral infections. This study examined the release of these fugitive aerosols during a standard aerosol therapy to a simulated adult patient. An aerosol holding chamber and mouthpiece were connected to a representative head model and breathing simulator. A combination of laser and Schlieren imaging was used to non-invasively visualize the release and dispersion of fugitive aerosol particles. Time-varying aerosol particle number concentrations and size distributions were measured with optical particle sizers at clinically relevant positions to the simulated patient. The influence of breathing pattern, normal and distressed, supplemental air flow, at 0.2 and 6 LPM, and the addition of a bacterial filter to the exhalation port of the mouthpiece were assessed. Images showed large quantities of fugitive aerosols emitted from the unfiltered mouthpiece. The images and particle counter data show that the addition of a bacterial filter limited the release of these fugitive aerosols, with the peak fugitive aerosol concentrations decreasing by 47.3-83.3%, depending on distance from the simulated patient. The addition of a bacterial filter to the mouthpiece significantly reduces the levels of fugitive aerosols emitted during a simulated aerosol therapy, p≤ .05, and would greatly aid in reducing healthcare worker and bystander exposure to potentially harmful fugitive aerosols.
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Affiliation(s)
| | - Ronan Cahill
- School of Medicine, UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Ronan MacLoughlin
- Aerogen Ltd, IDA Business Park, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
| | - Kevin Nolan
- School of Mechanical and Materials Engineering, University College Dublin, Dublin, Ireland
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10
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Abstract
During the early phase of the COVID-19 pandemic, many respiratory therapies were classified as aerosol-generating procedures. This categorization resulted in a broad range of clinical concerns and a shortage of essential medical resources for some patients. In the past 2 years, many studies have assessed the transmission risk posed by various respiratory care procedures. These studies are discussed in this narrative review, with recommendations for mitigating transmission risk based on the current evidence.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois
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11
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Harnois LJ, Alolaiwat AA, Jing G, Fink JB, Dhand R, Li J. Efficacy of Various Mitigation Devices in Reducing Fugitive Emissions from Nebulizers. Respir Care 2022; 67:394-403. [PMID: 34753815 PMCID: PMC9994013 DOI: 10.4187/respcare.09546] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Fugitive aerosol concentrations generated by different nebulizers and interfaces in vivo and mitigation of aerosol dispersion into the environment with various commercially available devices are not known. METHODS Nine healthy volunteers were given 3 mL saline with a small-volume nebulizer (SVN) or vibrating mesh nebulizer (VMN) with a mouthpiece, a mouthpiece with an exhalation filter, an aerosol mask with open ports for SVN and a valved face mask for VMN, and a face mask with a scavenger (Exhalo) in random order. Five of the participants received treatments using a face tent scavenger (Vapotherm) and a mask with exhalation filter with SVN and VMN in a random order. Treatments were performed in an ICU room with 2 particle counters positioned 1 and 3 ft from participants measuring aerosol concentrations at sizes of 0.3-10.0 μm at baseline, before, during, and after each treatment. RESULTS Fugitive aerosol concentrations were higher with SVN than VMN and higher with a face mask than a mouthpiece. Adding an exhalation filter to a mouthpiece reduced aerosol concentrations of 0.3-1.0 μm in size for VMN and 0.3-3.0 μm for SVN (all P < .05). An Exhalo scavenger over the mask reduced 0.5-3.0 μm sized particle concentrations for SVN (all P < .05) but not VMN. Vapotherm scavenger and filter face mask reduced fugitive aerosol concentrations regardless of the nebulizer type. CONCLUSIONS SVN produced higher fugitive aerosol concentrations than VMN, whereas face masks generated higher aerosol concentrations than mouthpieces. Adding an exhalation filter to the mouthpiece or a scavenger to the face mask reduced aerosol concentrations for both SVN and VMN. Vapotherm scavenger and filter face mask reduced fugitive aerosols as effectively as a mouthpiece with an exhalation filter. This study provides guidance for reducing fugitive aerosol emissions from nebulizers in clinical practice.
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Affiliation(s)
- Lauren J Harnois
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois
| | - Amnah A Alolaiwat
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois
| | - Guoqiang Jing
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou Medical University, Binzhou, Shandong, China
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois; and Aerogen Pharma, San Mateo, California
| | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois.
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12
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Fan Y, Liu L, Zhang H, Deng Y, Wang Y, Duan M, Wang H, Wang L, Han L, Liu Y. Exposure of Ophthalmologists to Patients' Exhaled Droplets in Clinical Practice: A Numerical Simulation of SARS-CoV-2 Exposure Risk. Front Public Health 2021; 9:725648. [PMID: 34616707 PMCID: PMC8488202 DOI: 10.3389/fpubh.2021.725648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/24/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Lack of quantification of direct and indirect exposure of ophthalmologists during ophthalmic diagnostic process makes it hard to estimate the infectious risk of aerosol pathogen faced by ophthalmologists at working environment. Methods: Accurate numerical models of thermal manikins and computational fluid dynamics simulations were used to investigate direct (droplet inhalation and mucosal deposition) and indirect exposure (droplets on working equipment) within a half-minute procedure. Three ophthalmic examination or treatment scenarios (direct ophthalmoscopic examination, slit-lamp microscopic examination, and ophthalmic operation) were selected as typical exposure distance, two breathing modes (normal breathing and coughing), three levels of ambient RH (40, 70, and 95%) and three initial droplet sizes (50, 70, and 100 μm) were considered as common working environmental condition. Results: The exposure of an ophthalmologist to a patient's expiratory droplets during a direct ophthalmoscopic examination was found to be 95 times that of a person during normal interpersonal interaction at a distance of 1 m and 12.1, 8.8, and 9.7 times that of an ophthalmologist during a slit-lamp microscopic examination, a surgeon during an ophthalmic operation and an assistant during an ophthalmic operation, respectively. The ophthalmologist's direct exposure to droplets when the patient cough-exhaled was ~7.6 times that when the patient breath-exhaled. Compared with high indoor RH, direct droplet exposure was higher and indirect droplet exposure was lower when the indoor RH was 40%. Conclusion: During the course of performing ophthalmic examinations or treatment, ophthalmologists typically face a high risk of SARS-CoV-2 infection by droplet transmission.
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Affiliation(s)
- Yanchao Fan
- State Key Laboratory of Green Building in Western China, Xi'an University of Architecture and Technology, Xi'an, China
- School of Building Services Science and Engineering, Xi'an University of Architecture and Technology, Xi'an, China
| | - Li Liu
- Department of Building Science, School of Architecture, Tsinghua University, Beijing, China
| | - Hui Zhang
- YuanPu EyePro Biopharm Limited, Chengdu, China
| | - Yingping Deng
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Wang
- State Key Laboratory of Green Building in Western China, Xi'an University of Architecture and Technology, Xi'an, China
- School of Building Services Science and Engineering, Xi'an University of Architecture and Technology, Xi'an, China
| | - Mengjie Duan
- Department of Building Science, School of Architecture, Tsinghua University, Beijing, China
| | - Huan Wang
- Department of Building Science, School of Architecture, Tsinghua University, Beijing, China
| | - Lixiang Wang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China
| | - Leifeng Han
- East China Architectural Design and Research Institute, Shanghai, China
| | - Yalin Liu
- State Key Laboratory of Green Building in Western China, Xi'an University of Architecture and Technology, Xi'an, China
- School of Building Services Science and Engineering, Xi'an University of Architecture and Technology, Xi'an, China
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13
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Brennan LC, O’Sullivan A, MacLoughlin R. Cellular Therapy for the Treatment of Paediatric Respiratory Disease. Int J Mol Sci 2021; 22:ijms22168906. [PMID: 34445609 PMCID: PMC8396271 DOI: 10.3390/ijms22168906] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 12/12/2022] Open
Abstract
Respiratory disease is the leading cause of death in children under the age of 5 years old. Currently available treatments for paediatric respiratory diseases including bronchopulmonary dysplasia, asthma, cystic fibrosis and interstitial lung disease may ameliorate symptoms but do not offer a cure. Cellular therapy may offer a potential cure for these diseases, preventing disease progression into adulthood. Induced pluripotent stem cells, mesenchymal stromal cells and their secretome have shown great potential in preclinical models of lung disease, targeting the major pathological features of the disease. Current research and clinical trials are focused on the adult population. For cellular therapies to progress from preclinical studies to use in the clinic, optimal cell type dosage and delivery methods need to be established and confirmed. Direct delivery of these therapies to the lung as aerosols would allow for lower doses with a higher target efficiency whilst avoiding potential effect of systemic delivery. There is a clear need for research to progress into the clinic for the treatment of paediatric respiratory disease. Whilst research in the adult population forms a basis for the paediatric population, varying disease pathology and anatomical differences in paediatric patients means a paediatric-centric approach must be taken.
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Affiliation(s)
- Laura C. Brennan
- College of Medicine, Nursing & Health Sciences, National University of Ireland, H91 TK33 Galway, Ireland;
| | - Andrew O’Sullivan
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland;
| | - Ronan MacLoughlin
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland;
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- Correspondence:
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Kudrolli A, Chang B, Consalvi J, Deti A, Frechette C, Scoville H, Sheinfeld GR, McGee WT. Mitigating exhalation puffs during oxygen therapy for respiratory disease. PHYSICS OF FLUIDS (WOODBURY, N.Y. : 1994) 2021; 33:081903. [PMID: 34471335 PMCID: PMC8382086 DOI: 10.1063/5.0057227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
We investigate the dispersal of exhalations corresponding to a patient experiencing shortness of breath while being treated for a respiratory disease with oxygen therapy. Respiration through a nasal cannula and a simple O2 mask is studied using a supine manikin equipped with a controllable mechanical lung by measuring aerosol density and flow with direct imaging. Exhalation puffs are observed to travel 0.35 ± 0.02 m upward while wearing a nasal cannula, and 0.29 ± 0.02 m laterally through a simple O2 mask, posing a higher direct exposure risk to caregivers. The aerosol-laden air flows were found to concentrate in narrow conical regions through both devices at several times their concentration level compared with a uniform spreading at the same distance. We test a mitigation strategy by placing a surgical mask loosely over the tested devices. The mask is demonstrated to alleviate exposure by deflecting the exhalations from being launched directly above a supine patient. The surgical mask is found to essentially eliminate the concentrated aerosol regions above the patient over the entire oxygenation rates used in treatment in both devices.
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Affiliation(s)
- Arshad Kudrolli
- Department of Physics, Clark University, Worcester, Massachusetts 01610, USA
| | - Brian Chang
- Department of Physics, Clark University, Worcester, Massachusetts 01610, USA
| | - Jade Consalvi
- Department of Physics, Clark University, Worcester, Massachusetts 01610, USA
| | - Anton Deti
- Department of Physics, Clark University, Worcester, Massachusetts 01610, USA
| | - Christopher Frechette
- University of Massachusetts Medical School-Baystate, Springfield, Massachusetts 01107, USA
| | - Helen Scoville
- University of Massachusetts Medical School-Baystate, Springfield, Massachusetts 01107, USA
| | | | - William T. McGee
- University of Massachusetts Medical School-Baystate, Springfield, Massachusetts 01107, USA
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15
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Electrochemical Discrimination of Salbutamol from Its Excipients in Ventolin TM at Nanoporous Gold Microdisc Arrays. SENSORS 2021; 21:s21123975. [PMID: 34207616 PMCID: PMC8226559 DOI: 10.3390/s21123975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/23/2021] [Accepted: 05/31/2021] [Indexed: 02/02/2023]
Abstract
The emergence of specific drug–device combination products in the inhalable pharmaceutical industry demands more sophistication of device functionality in the form of an embedded sensing platform to increase patient safety and extend patent coverage. Controlling the nebuliser function at a miniaturised, integrated electrochemical sensing platform with rapid response time and supporting novel algorithms could deliver such a technology offering. Development of a nanoporous gold (NPG) electrochemical sensor capable of creating a unique fingerprint signal generated by inhalable pharmaceuticals provided the impetus for our study of the electrooxidation of salbutamol, which is the active bronchodilatory ingredient in VentolinTM formulations. It was demonstrated that, at NPG-modified microdisc electrode arrays, salbutamol is distinguishable from the chloride excipient present at 0.0154 M using linear sweep voltammetry and can be detected amperometrically. In contrast, bare gold microdisc electrode arrays cannot afford such discrimination, as the potential for salbutamol oxidation and chloride adsorption reactions overlap. The discriminative power of NPG originates from the nanoconfinement effect for chloride in the internal pores of NPG, which selectively enhances the electron transfer kinetics of this more sluggish reaction relative to that of the faster, diffusion-controlled salbutamol oxidation. Sensing was performed at a fully integrated three-electrode cell-on-chip using Pt as a quasi-reference electrode.
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16
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Gavriatopoulou M, Ntanasis-Stathopoulos I, Korompoki E, Fotiou D, Migkou M, Tzanninis IG, Psaltopoulou T, Kastritis E, Terpos E, Dimopoulos MA. Emerging treatment strategies for COVID-19 infection. Clin Exp Med 2021; 21:167-179. [PMID: 33128197 PMCID: PMC7598940 DOI: 10.1007/s10238-020-00671-y] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
Abstract
The new type of coronavirus (COVID-19), SARS-CoV-2 originated from Wuhan, China and has led to a worldwide pandemic. COVID-19 is a novel emerging infectious disease caused by SARS-CoV-2 characterized as atypical pneumonia. As of July 1, 2020, more than 10 million people worldwide had been infected with SARS-CoV-2. The typical manifestations of COVID-19 include fever, sore throat, fatigue, cough, and dyspnoea combined with recent exposure. Most of the patients with COVID-19 have mild or moderate disease, however up to 5-10% present with severe and even life-threatening disease course. The mortality rates are approximately 2%. Therefore, there is an urgent need for effective and specific antiviral treatment. Currently, supportive care measures such as ventilation oxygenation and fluid management remain the standard of care. Several clinical trials are currently trying to identify the most potent drug or combination against the disease, and it is strongly recommended to enroll patients into ongoing trials. Antivirals can be proven as safe and effective only in the context of randomized clinical trials. Currently several agents such as chloroquine, hydroxychloroquine, favipiravir, monoclonal antibodies, antisense RNA, corticosteroids, convalescent plasma and vaccines are being evaluated. The large numbers of therapeutic interventions aim to define the most efficacious regimen. The aim of this article is to describe the treatment strategies that have been used for COVID-19 patients and review all the available literature.
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Affiliation(s)
- Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, 11528, Athens, Greece.
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, 11528, Athens, Greece
| | - Eleni Korompoki
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, 11528, Athens, Greece
- Division of Brain Sciences, Imperial College London, London, UK
| | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, 11528, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, 11528, Athens, Greece
| | | | - Theodora Psaltopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, 11528, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, 11528, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, 11528, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 80 Vas. Sofias Avenue, 11528, Athens, Greece
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17
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Goldstein KM, Ghadimi K, Mystakelis H, Kong Y, Meng T, Cantrell S, Von Isenburg M, Gordon A, Ear B, Gierisch JM, Williams JW. Risk of Transmitting Coronavirus Disease 2019 During Nebulizer Treatment: A Systematic Review. J Aerosol Med Pulm Drug Deliv 2021; 34:155-170. [PMID: 33887156 DOI: 10.1089/jamp.2020.1659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: There is an urgent need to understand the risk of viral transmission during nebulizer treatment of patients with coronavirus disease 2019 (COVID-19). Objectives: To assess the risk of transmitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), SARS, Middle East respiratory syndrome (MERS), and influenza with administration of drugs via nebulizer. Methods: We searched multiple electronic databases, including PubMed®, China National Knowledge Infrastructure, Wanfang, preprint databases, and clinicaltrials.gov through December 1, 2020. Any study design in any language describing the risk of viral transmission with nebulizer treatment was eligible. Data were abstracted by one investigator and verified by a second. Results: We identified 22 articles: 1 systematic review, 7 cohort/case-control studies, 7 case series, and 7 simulation-based studies. Eight individual studies involved patients with SARS, five involved MERS, and one involved SARS-CoV-2. The seven cohort/case-control studies (four high risk of bias [ROB], three unclear ROB) found mixed results (median odds ratio 3.91, range 0.08-20.67) based on very weak data among a small number of health care workers (HCWs) with variable use of personal protective equipment (PPE). Case series had multiple potential contributors to transmission. Simulation studies found evidence for droplet dispersion after saline nebulization and measureable influenza viral particles up to 1.7 m from the source after 10 minutes of nebulization with a patient simulator. Study heterogeneity prevented meta-analysis. Conclusions: Case series raise concern of transmission risk, and simulation studies demonstrate droplet dispersion with virus recovery, but specific evidence that exposure to nebulizer treatment increases transmission of coronaviruses similar to COVID-19 is inconclusive. Tradeoffs balancing HCW safety and patient appropriateness can potentially minimize risk, including choice of delivery method for inhaled medications (e.g., nebulizer vs. metered dose inhaler) and PPE (e.g., N95 vs. surgical mask).
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Affiliation(s)
- Karen M Goldstein
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kamrouz Ghadimi
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Yuanyuan Kong
- Clinical Epidemiology and EBM Unit, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Tongtong Meng
- Clinical Epidemiology and EBM Unit, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Durham, North Carolina, USA
| | - Megan Von Isenburg
- Duke University Medical Center Library & Archives, Durham, North Carolina, USA
| | - Adelaide Gordon
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Belinda Ear
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Jennifer M Gierisch
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - John W Williams
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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18
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Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis. Antibiotics (Basel) 2021; 10:antibiotics10050472. [PMID: 33919035 PMCID: PMC8142975 DOI: 10.3390/antibiotics10050472] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 12/18/2022] Open
Abstract
Lung disease is the main cause of morbidity and mortality in cystic fibrosis (CF). CF patients inhale antibiotics regularly as treatment against persistent bacterial infections. The goal of this study was to investigate the effect of clinical intervention on aerosol therapy during the escalation of care using a bench model of adult CF. Droplet size analysis of selected antibiotics was completed in tandem with the delivered aerosol dose (% of total dose) assessments in simulations of various interventions providing oxygen supplementation or ventilatory support. Results highlight the variability of aerosolised dose delivery. In the homecare setting, the vibrating mesh nebuliser (VMN) delivered significantly more than the jet nebuliser (JN) (16.15 ± 0.86% versus 6.51 ± 2.15%). In the hospital setting, using VMN only, significant variability was seen across clinical interventions. In the emergency department, VMN plus mouthpiece (no supplemental oxygen) was seen to deliver (29.02 ± 1.41%) versus low flow nasal therapy (10 L per minute (LPM) oxygen) (1.81 ± 0.47%) and high flow nasal therapy (50 LPM oxygen) (3.36 ± 0.34%). In the ward/intensive care unit, non-invasive ventilation recorded 19.02 ± 0.28%, versus 22.64 ± 1.88% of the dose delivered during invasive mechanical ventilation. These results will have application in the design of intervention-appropriate aerosol therapy strategies and will be of use to researchers developing new therapeutics for application in cystic fibrosis and beyond.
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Singh AK, Verma RK, Mukker JK, Yadav AB, Muttil P, Sharma R, Mohan M, Agrawal AK, Gupta A, Dwivedi AK, Gupta P, Gupta UD, Mani U, Chaudhari BP, Murthy RC, Sharma S, Bhadauria S, Singh S, Rath SK, Misra A. Inhalable particles containing isoniazid and rifabutin as adjunct therapy for safe, efficacious and relapse-free cure of experimental animal tuberculosis in one month. Tuberculosis (Edinb) 2021; 128:102081. [PMID: 33915379 DOI: 10.1016/j.tube.2021.102081] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 03/02/2021] [Accepted: 03/29/2021] [Indexed: 12/18/2022]
Abstract
We investigated the preclinical efficacy and safety/tolerability of biodegradable polymeric particles containing isoniazid (INH) and rifabutin (RFB) dry powder for inhalation (DPI) as an adjunct to oral first-line therapy. Mice and guinea pigs infected with Mycobacterium tuberculosis H37Rv (Mtb) were treated with ∼80 and ∼300 μg of the DPI, respectively, for 3-4 weeks starting 3, 10, and 30 days post-infection. Adjunct combination therapy eliminated culturable Mtb from the lungs and spleens of all but one of 52 animals that received the DPI. Relapse-free cure was not achieved in one mouse that received DPI + oral, human-equivalent doses (HED) of four drugs used in the Directly Observed Treatment, Short Course (DOTS), starting 30 days post-infection. Oral doses (20 mg/Kg/day, each) of INH + RFB reduced Mtb burden from ∼106 to ∼103 colony-forming units. Combining half the oral dose with DPI prevented relapse of infection four weeks after stopping the treatment. The DPI was safe in rodents, guinea pigs, and monkeys at 1, 10, and 100 μg/day doses over 90 days. In conclusion, we show the efficacy and safety/tolerability of the DPI as an adjunct to oral chemotherapy in three different animal models of TB.
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Affiliation(s)
- Amit K Singh
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Rahul K Verma
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | | | - Awadh B Yadav
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Pavan Muttil
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Rolee Sharma
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Mradul Mohan
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Atul K Agrawal
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Anuradha Gupta
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Anil K Dwivedi
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Pushpa Gupta
- National JALMA Institute of Leprosy and Other Mycobacterial Diseases, Agra, 282001, India
| | - Umesh D Gupta
- National JALMA Institute of Leprosy and Other Mycobacterial Diseases, Agra, 282001, India
| | - Uthirappan Mani
- CSIR-Indian Institute of Toxicology Research, Lucknow, 226001, India
| | | | - Ramesh C Murthy
- CSIR-Indian Institute of Toxicology Research, Lucknow, 226001, India
| | - Sharad Sharma
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | | | - Sarika Singh
- CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | | | - Amit Misra
- CSIR-Central Drug Research Institute, Lucknow, 226031, India.
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20
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Lin HL, Fink JB, Ge H. Aerosol delivery via invasive ventilation: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:588. [PMID: 33987286 DOI: 10.21037/atm-20-5665] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In comparison with spontaneously breathing non-intubated subjects, intubated, mechanically ventilated patients encounter various challenges, barriers, and opportunities in receiving medical aerosols. Since the introduction of mechanical ventilation as a part of modern critical care medicine during the middle of the last century, aerosolized drug delivery by jet nebulizers has become a common practice. However, early evidence suggested that aerosol generators differed in their efficacies, and the introduction of newer aerosol technology (metered dose inhalers, ultrasonic nebulizer, vibrating mesh nebulizers, and soft moist inhaler) into the ventilator circuit opened up the possibility of optimizing inhaled aerosol delivery during mechanical ventilation that could meet or exceed the delivery of the same aerosols in spontaneously breathing patients. This narrative review will catalogue the primary variables associated with this process and provide evidence to guide optimal aerosol delivery and dosing during mechanical ventilation. While gaps exist in relation to the appropriate aerosol drug dose, discrepancies in practice, and cost-effectiveness of the administered aerosol drugs, we also present areas for future research and practice. Clinical practice should expand to incorporate these techniques to improve the consistency of drug delivery and provide safer and more effective care for patients.
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Affiliation(s)
- Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan.,Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi.,Department of Respiratory Therapy, Chiayi Chang Gung Memorial Hospital, Chiayi
| | - James B Fink
- Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA.,Aerogen Pharma Corp., San Mateo, California, USA
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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21
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O’Toole C, Joyce M, McGrath JA, O’Sullivan A, Byrne MA, MacLoughlin R. Fugitive aerosols in the intensive care unit: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:592. [PMID: 33987290 PMCID: PMC8105852 DOI: 10.21037/atm-20-2280] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/10/2020] [Indexed: 12/20/2022]
Abstract
The risk of unintended inhalation of fugitive aerosols is becoming a topic of increasing interest in the healthcare arena. These fugitive aerosols may be bioaerosols, generated by the patient themselves through cough or sneeze, or they may be therapeutic medical aerosols, generated by therapeutic medical aerosol generators with the intent of delivery to a specific patient's respiratory tract. This review focus' on therapeutic aerosols in the intensive care unit (ICU) only, those typically generated by nebulisers. In the intensive care environment, patients are generally in receipt of ventilatory support, and the literature suggests that these different support interventions influence fugitive therapeutic medical aerosol emissions in a variety of ways. Predominant ventilatory support interventions include, but are not limited to, invasive mechanical ventilation (MV), non-invasive mechanical ventilation (NIV), high flow nasal therapy (HFNT), and supplemental oxygen delivery in spontaneously breathing patients. Further, factors such as nebuliser type, patient interface, patient breathing pattern, nebuliser position in the patient breathing circuit and medication formulation characteristics also have been shown to exert influence on aerosol concentrations and distance from the source. Here we present the state of the art knowledge in this, as yet, poorly described field of research, and identify the key risks, and subsequently, opportunities to mitigate the risks of unintended exposure of both patients and bystanders during and for periods following the administration of therapeutic aerosols.
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Affiliation(s)
- Ciarraí O’Toole
- School of Physics & Ryan Institute’s Centre for Climate & Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | - Mary Joyce
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
| | - James A. McGrath
- School of Physics & Ryan Institute’s Centre for Climate & Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | | | - Miriam A. Byrne
- School of Physics & Ryan Institute’s Centre for Climate & Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | - Ronan MacLoughlin
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
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22
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Joyce M, McGrath JA, Mac Giolla Eain M, O’Sullivan A, Byrne M, MacLoughlin R. Nebuliser Type Influences Both Patient-Derived Bioaerosol Emissions and Ventilation Parameters during Mechanical Ventilation. Pharmaceutics 2021; 13:199. [PMID: 33540764 PMCID: PMC7912998 DOI: 10.3390/pharmaceutics13020199] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 12/11/2022] Open
Abstract
COVID-19 may lead to serious respiratory complications which may necessitate ventilatory support. There is concern surrounding potential release of patient-derived bioaerosol during nebuliser drug refill, which could impact the health of caregivers. Consequently, mesh nebulisers have been recommended by various clinical practice guidelines. Currently, there is a lack of empirical data describing the potential for release of patient-derived bioaerosol during drug refill. This study examined the release of simulated patient-derived bioaerosol, and the effect on positive end expiratory pressure during nebuliser refill during mechanical ventilation of a simulated patient. During jet nebuliser refill, the positive end expiratory pressure decreased from 4.5 to 0 cm H2O. No loss in pressure was noted during vibrating mesh nebuliser refill. A median particle number concentration of 710 particles cm-3 above ambient was detected when refilling the jet nebuliser in comparison to no increase above ambient detected when using the vibrating mesh nebuliser. The jet nebuliser with the endotracheal tube clamped resulted in 60 particles cm-3 above ambient levels. This study confirms that choice of nebuliser impacts both the potential for patient-derived bioaerosol release and the ability to maintain ventilator circuit pressures and validates the recommended use of mesh nebulisers during mechanical ventilation.
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Affiliation(s)
- Mary Joyce
- Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (M.M.G.E.); (A.O.); (R.M.)
| | - James A. McGrath
- School of Physics & Ryan Institute’s Centre for Climate and Air Pollution Studies, National University of Ireland Galway, H91 CF50 Galway, Ireland; (J.A.M.); (M.B.)
| | - Marc Mac Giolla Eain
- Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (M.M.G.E.); (A.O.); (R.M.)
| | - Andrew O’Sullivan
- Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (M.M.G.E.); (A.O.); (R.M.)
| | - Miriam Byrne
- School of Physics & Ryan Institute’s Centre for Climate and Air Pollution Studies, National University of Ireland Galway, H91 CF50 Galway, Ireland; (J.A.M.); (M.B.)
| | - Ronan MacLoughlin
- Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (M.M.G.E.); (A.O.); (R.M.)
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
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23
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Fennelly M, Keane J, Dolan L, Plant BJ, O'Connor DJ, Sodeau JR, Prentice MB. Containment of procedure-associated aerosols by an extractor tent: effect on nebulized drug particle dispersal. J Hosp Infect 2021; 110:108-113. [PMID: 33484782 PMCID: PMC7817412 DOI: 10.1016/j.jhin.2021.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 02/07/2023]
Abstract
Background Several medical procedures involving the respiratory tract are considered as ‘aerosol-generating procedures’. Aerosols from these procedures may be inhaled by bystanders, and there are consequent concerns regarding the transmission of infection or, specific to nebulized therapy, secondary drug exposure. Aim To assess the efficacy of a proprietary high-efficiency-particulate-air-filtering extractor tent on reducing the aerosol dispersal of nebulized bronchodilator drugs. Methods The study was conducted in an unoccupied outpatient room at St. James's Hospital, Dublin, Ireland. A novel real-time, fluorescent particle counter, the Wideband Integrated Bioaerosol Sensor (WIBS), monitored room air continuously for 3 h. Baseline airborne particle count and count during nebulization of bronchodilator drug solutions were recorded. Findings Nebulization within the tent prevented any increase over background level. Nebulization directly into room air resulted in mean fluorescent particle counts of 4.75 x 105/m3 and 4.21 x 105/m3 for Ventolin and Ipramol, respectively, representing more than 400-fold increases over mean background level. More than 99.3% of drug particles were <2 μm in diameter and therefore small enough to enter the lower respiratory tract. Conclusion The extractor tent was completely effective for the prevention of airborne spread of drug particles of respirable size from nebulized therapy. This suggests that extractor tents of this type would be efficacious for the prevention of airborne infection from aerosol-generating procedures during the COVID-19 pandemic.
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Affiliation(s)
- M Fennelly
- Environmental Research Institute, University College Cork, Cork, Ireland; Department of Pathology, University College Cork, Cork, Ireland.
| | - J Keane
- Respiratory Assessment Unit, St. James's Hospital, Dublin, Ireland
| | - L Dolan
- Respiratory Assessment Unit, St. James's Hospital, Dublin, Ireland
| | - B J Plant
- Adult Cystic Fibrosis Centre, Cork University Hospital, Cork, Ireland
| | - D J O'Connor
- School of Chemical and Pharmaceutical Sciences, Technological University Dublin, Dublin, Ireland
| | - J R Sodeau
- Environmental Research Institute, University College Cork, Cork, Ireland
| | - M B Prentice
- Department of Pathology, University College Cork, Cork, Ireland; APC Microbiome Institute, University College Cork, Cork, Ireland.
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Fink JB, Ehrmann S, Li J, Dailey P, McKiernan P, Darquenne C, Martin AR, Rothen-Rutishauser B, Kuehl PJ, Häussermann S, MacLoughlin R, Smaldone GC, Muellinger B, Corcoran TE, Dhand R. Reducing Aerosol-Related Risk of Transmission in the Era of COVID-19: An Interim Guidance Endorsed by the International Society of Aerosols in Medicine. J Aerosol Med Pulm Drug Deliv 2020; 33:300-304. [PMID: 32783675 PMCID: PMC7757542 DOI: 10.1089/jamp.2020.1615] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/14/2020] [Indexed: 12/12/2022] Open
Abstract
National and international guidelines recommend droplet/airborne transmission and contact precautions for those caring for coronavirus disease 2019 (COVID-19) patients in ambulatory and acute care settings. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, an acute respiratory infectious agent, is primarily transmitted between people through respiratory droplets and contact routes. A recognized key to transmission of COVID-19, and droplet infections generally, is the dispersion of bioaerosols from the patient. Increased risk of transmission has been associated with aerosol generating procedures that include endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, noninvasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation. The knowledge that COVID-19 subjects can be asymptomatic and still shed virus, producing infectious droplets during breathing, suggests that health care workers (HCWs) should assume every patient is potentially infectious during this pandemic. Taking actions to reduce risk of transmission to HCWs is, therefore, a vital consideration for safe delivery of all medical aerosols. Guidelines for use of personal protective equipment (glove, gowns, masks, shield, and/or powered air purifying respiratory) during high-risk procedures are essential and should be considered for use with lower risk procedures such as administration of uncontaminated medical aerosols. Bioaerosols generated by infected patients are a major source of transmission for SARS CoV-2, and other infectious agents. In contrast, therapeutic aerosols do not add to the risk of disease transmission unless contaminated by patients or HCWs.
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Affiliation(s)
- James B. Fink
- Aerogen Pharma Corp., San Mateo, California, USA
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep Research Network, Tours, France
- INSERM, Centre d'étude des Pathologies Respiratoires, U1100, Université de Tours, Tours, France
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Chantal Darquenne
- Department of Medicine, University of California, San Diego, California, USA
| | | | | | | | | | - Ronan MacLoughlin
- Aerogen Limited, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
| | - Gerald C. Smaldone
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, State University of New York at Stony Brook, Stony Brook, New York, USA
| | | | - Timothy E. Corcoran
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rajiv Dhand
- Department of Medicine, Graduate School of Medicine, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
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25
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Yang X, Ou C, Yang H, Liu L, Song T, Kang M, Lin H, Hang J. Transmission of pathogen-laden expiratory droplets in a coach bus. JOURNAL OF HAZARDOUS MATERIALS 2020; 397:122609. [PMID: 32361671 PMCID: PMC7152903 DOI: 10.1016/j.jhazmat.2020.122609] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 05/04/2023]
Abstract
Droplet dispersion carrying viruses/bacteria in enclosed/crowded buses may induce transmissions of respiratory infectious diseases, but the influencing mechanisms have been rarely investigated. By conducting high-resolution CFD simulations, this paper investigates the evaporation and transport of solid-liquid mixed droplets (initial diameter 10 μm and 50 μm, solid to liquid ratio is 1:9) exhaled in a coach bus with 14 thermal manikins. Five air-conditioning supply directions and ambient relative humidity (RH = 35 % and 95 %) are considered. Results show that ventilation effectiveness, RH and initial droplet size significantly influence droplet transmissions in coach bus. 50 μm droplets tend to evaporate completely within 1.8 s and 7 s as RH = 35 % and 95 % respectively, while 0.2 s or less for 10 μm droplets. Thus 10 μm droplets diffuse farther with wider range than 50 μm droplets which tend to deposit more on surfaces. Droplet dispersion pattern differs due to various interactions of gravity, ventilation flows and the upward thermal body plume. The fractions of droplets suspended in air, deposited on wall surfaces are quantified. This study implies high RH, backward supply direction and passengers sitting at nonadjacent seats can effectively reduce infection risk of droplet transmission in buses. Besides taking masks, regular cleaning is also recommended since 85 %-100 % of droplets deposit on object surfaces.
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Affiliation(s)
- Xia Yang
- School of Atmospheric Sciences, Guangdong Province Key Laboratory for Climate Change and Natural Disaster Studies, Sun Yat-sen University, Guangzhou, PR China
| | - Cuiyun Ou
- School of Atmospheric Sciences, Guangdong Province Key Laboratory for Climate Change and Natural Disaster Studies, Sun Yat-sen University, Guangzhou, PR China
| | - Hongyu Yang
- School of Atmospheric Sciences, Guangdong Province Key Laboratory for Climate Change and Natural Disaster Studies, Sun Yat-sen University, Guangzhou, PR China
| | - Li Liu
- Department of Building Science, School of Architecture, Tsinghua University, Beijing, 100084, PR China
| | - Tie Song
- Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, PR China
| | - Min Kang
- Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, PR China
| | - Hualiang Lin
- Department of Epidemiology, School of Public Health, Sun Yat-sen University Guangzhou, PR China
| | - Jian Hang
- School of Atmospheric Sciences, Guangdong Province Key Laboratory for Climate Change and Natural Disaster Studies, Sun Yat-sen University, Guangzhou, PR China; Southern Marine Science and Engineering Guangdong Laboratory (Zhuhai), Zhuhai, PR China.
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26
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Ho JHC, Zhao Y, Liu Z, Zhou X, Chen X, Xianyu Y, Lewis S, Fan L, Tian Y, Chang N, Gong Z, Hu K. Resolution of Coronavirus Disease 2019 Infection and Pulmonary Pathology With Nebulized DAS181: A Pilot Study. Crit Care Explor 2020; 2:e0263. [PMID: 33134951 PMCID: PMC7587449 DOI: 10.1097/cce.0000000000000263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Severe acute respiratory syndrome coronavirus 2 infections commonly lead to respiratory failure and potentially fatal systemic inflammation and organ failure. Nebulized DAS181, a host-directed biologics with sialidase activity, is an investigational drug with antiviral activities on parainfluenza and influenza under phase 3 and phase 2 development. The objective of this study (NCT04324489) is to investigate the safety and effects of nebulized DAS181 on hypoxic coronavirus disease 2019 patients. DESIGN Single-center, prospective, open-label, compassionate use. SETTING Renmin Hospital of Wuhan University, Department of Respiratory and Critical Care Medicine and Department of Infectious Diseases. SUBJECTS Patients 18 to 70 years old who met Chinese criteria for severe coronavirus disease 2019 pneumonia and required supplemental oxygen but not on mechanical ventilator at screening. INTERVENTIONS Nebulized DAS181 (4.5 mg) twice a day for 10 days. MEASUREMENTS AND MAIN RESULTS Three male coronavirus disease 2019 hypoxic patients with bilateral lung involvement completed DAS181 treatment for 10 days. By day 14, all achieved return to room air (primary endpoint) and their nasopharyngeal swabs were negative for severe acute respiratory syndrome coronavirus 2. Clinical severity improved from severe coronavirus disease 2019 at baseline to moderate or mild disease by day 5, consistent with rapid reduction of inflammatory cytokines by days 2-3 and radiologic improvement by days 5-10. No DAS181-related adverse events were reported. CONCLUSIONS Inhalation of DAS181 was well tolerated and potential clinical benefit of DAS181 on hypoxic coronavirus disease 2019 is the reduction of supplemental oxygen need. Efficacy and safety, including pharmacokinetics and viral studies of DAS181 in severe, hypoxic coronavirus disease 2019, should be examined by a double-blind, randomized controlled study.
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Affiliation(s)
| | - Yang Zhao
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Zhenlian Liu
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiaoyang Zhou
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiaobei Chen
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yunyan Xianyu
- Nursing Department, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Stanley Lewis
- Division of Clinical Development, Ansun Biopharma, San Diego, CA
| | - Liya Fan
- Division of Clinical Development, Ansun Biopharma, San Diego, CA
| | - Yuan Tian
- Wuhan University, Wuhan, Hubei, China
| | - Nancy Chang
- Division of Clinical Development, Ansun Biopharma, San Diego, CA
| | - Zuojiong Gong
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Ke Hu
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
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Woods N, MacLoughlin R. Defining a Regulatory Strategy for ATMP/Aerosol Delivery Device Combinations in the Treatment of Respiratory Disease. Pharmaceutics 2020; 12:E922. [PMID: 32993197 PMCID: PMC7601063 DOI: 10.3390/pharmaceutics12100922] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/13/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022] Open
Abstract
Advanced Therapeutic Medicinal Products (ATMP) are a heterogenous group of investigational medicinal products at the forefront of innovative therapies with direct applicability in respiratory diseases. ATMPs include, but are not limited to, stem cells, their secretome, or extracellular vesicles, and each have shown some potential when delivered topically within the lung. This review focuses on that subset of ATMPs. One key mode of delivery that has enabling potential in ATMP validation is aerosol-mediated delivery. The selection of the most appropriate aerosol generator technology is influenced by several key factors, including formulation, patient type, patient intervention, and healthcare economics. The aerosol-mediated delivery of ATMPs has shown promise for the treatment of both chronic and acute respiratory disease in pre-clinical and clinical trials; however, in order for these ATMP device combinations to translate from the bench through to commercialization, they must meet the requirements set out by the various global regulatory bodies. In this review, we detail the potential for ATMP utility in the lungs and propose the nebulization of ATMPs as a viable route of administration in certain circumstances. Further, we provide insight to the current regulatory guidance for nascent ATMP device combination product development within the EU and US.
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Affiliation(s)
- Niamh Woods
- College of Medicine, Nursing & Health Sciences, National University of Ireland, H91 TK33 Galway, Ireland;
| | - Ronan MacLoughlin
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
- Aerogen Ltd., Galway Business Park, H91 HE94 Galway, Ireland
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28
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Yıldız-Peköz A, Ehrhardt C. Advances in Pulmonary Drug Delivery. Pharmaceutics 2020; 12:pharmaceutics12100911. [PMID: 32977672 PMCID: PMC7598662 DOI: 10.3390/pharmaceutics12100911] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/22/2020] [Indexed: 12/27/2022] Open
Abstract
Pulmonary drug delivery represents an attractive, non-invasive administration option. In addition to locally acting drugs, molecules that are intended to produce systemic effects can be delivered via the pulmonary route. Several factors need to be considered in the context of delivering drugs to or via the lungs—in addition to the drug itself, its formulation into an appropriate inhalable dosage form of sufficient stability is critical. It is also essential that this formulation is paired with a suitable inhaler device, which generates an aerosol of a particle/droplet size that ensures deposition in the desired region of the respiratory tract. Lastly, the patient’s (patho-) physiology and inhalation manoeuvre are of importance. This Special Issue brings together recent advances in the areas of inhalation device testing, aerosol formulation development, use of in vitro and in silico models in pulmonary drug deposition and drug disposition studies, and pulmonary delivery of complex drugs, such as vaccines, antibiotics and peptides, to or via the lungs.
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Affiliation(s)
- Ayca Yıldız-Peköz
- Department of Pharmaceutical Technology, Faculty of Pharmacy, İstanbul University, İstanbul 34116, Turkey;
| | - Carsten Ehrhardt
- School of Pharmacy and Pharmaceutical Sciences and Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland
- Correspondence: ; Tel.: +353-1-896-2441
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29
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Kaur R, Weiss TT, Perez A, Fink JB, Chen R, Luo F, Liang Z, Mirza S, Li J. Practical strategies to reduce nosocomial transmission to healthcare professionals providing respiratory care to patients with COVID-19. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:571. [PMID: 32967700 PMCID: PMC7509502 DOI: 10.1186/s13054-020-03231-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023]
Abstract
Coronavirus disease (COVID-19) is an emerging viral infection that is rapidly spreading across the globe. SARS-CoV-2 belongs to the same coronavirus class that caused respiratory illnesses such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). During the SARS and MERS outbreaks, many frontline healthcare workers were infected when performing high-risk aerosol-generating medical procedures as well as when providing basic patient care. Similarly, COVID-19 disease has been reported to infect healthcare workers at a rate of ~ 3% of cases treated in the USA. In this review, we conducted an extensive literature search to develop practical strategies that can be implemented when providing respiratory treatments to COVID-19 patients, with the aim to help prevent nosocomial transmission to the frontline workers.
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Affiliation(s)
- Ramandeep Kaur
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - Tyler T Weiss
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - Andrew Perez
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - Rongchang Chen
- Shenzhen Institute of Respiratory Disease, Shenzhen People's Hospital (First Affiliated Hospital of South University of Science and Technology of China), Shenzhen, China
| | - Fengming Luo
- Department of Respiratory and Critical Care Medicine, West China Medical Center of Sichuan University, Chengdu, China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Medical Center of Sichuan University, Chengdu, China
| | - Sara Mirza
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.
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30
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Nielsen Jeschke K, Bonnesen B, Hansen EF, Jensen JUS, Lapperre TS, Weinreich UM, Hilberg O. Guideline for the management of COVID-19 patients during hospital admission in a non-intensive care setting. Eur Clin Respir J 2020; 7:1761677. [PMID: 33224450 PMCID: PMC7655082 DOI: 10.1080/20018525.2020.1761677] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has presented health-care systems worldwide with novel challenges and experiences and evidence is emerging during the pandemic. Patients requiring hospitalization frequently suffer from respiratory failure of different severities. AIM The aim of this guideline is the treatment of patients with SARS CoV-2 (COVID-19) in hospital; in particular, it addresses the treatment of respiratory failure treated in general Internal Medical- and Pulmonary Medical wards. RESULTS Elderly patients and patients with chronic disease are particularly vulnerable to COVID-19. Target oxygen saturation should be between 92% and 96% in patients without chronic lung diseases. Treatment with >5 L oxygen/min should be in close collaboration with intensive care colleagues and >15 l/min preferably in intensive care units. High-flow nasal canula (HFNC) and long-term Continuous Positive Airway Pressure (CPAP) are recommended for patients not responding to conventional oxygen therapy. Non-invasive ventilation (NIV) is only recommended for selected patients, such as those with a ceiling of treatment or patients presenting with hypercapnic failure. With the use of humidification protective equipment as FFP2-3 masks should be used. Nebulized medication should be avoided, and spacers should be used instead. CONCLUSION Respiratory failure is frequently the cause of hospitalization in patients with COVID-19 and should be monitored closely.
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Affiliation(s)
| | - Barbara Bonnesen
- Department of Internal Medicine, Respiratory Medicine Section, Herlev-Gentofte Hospital, Hellerup, Denmark
| | | | - Jens-Ulrik Stæhr Jensen
- Department of Internal Medicine, Respiratory Medicine Section, Herlev-Gentofte Hospital, Hellerup, Denmark
| | | | - Ulla Møller Weinreich
- Department of Respiratory Diseases, Aalborg University Hospital and the Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Ole Hilberg
- Department of Medicine, Vejle Hospital, Vejle, Denmark
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Ishau S, Reichard JF, Maier A, Niang M, Yermakov M, Grinshpun SA. Estimated dermal exposure to nebulized pharmaceuticals for a simulated home healthcare worker scenario. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2020; 17:193-205. [PMID: 32134702 DOI: 10.1080/15459624.2020.1724297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The duties of home healthcare workers are extensive. One important task that is frequently performed by home healthcare workers is administration of nebulized medications, which may lead to significant dermal exposure. In this simulation study conducted in an aerosol exposure chamber, we administered a surrogate of nebulizer-delivered medications (dispersed sodium chloride, NaCl) to a patient mannequin. We measured the amount of NaCl deposited on the exposed surface of the home healthcare worker mannequin, which represented the exposed skin of a home healthcare worker. Factors such as distance and position of the home healthcare worker, room airflow rate and patient's inspiratory rate were varied to determine their effects on dermal exposure. There was a 2.78% reduction in dermal deposition for every centimeter the home healthcare worker moved away from the patient. Increasing the room's air exchange rate by one air change per hour increased dermal deposition by about 2.93%, possibly due to a decrease in near field particle settling. For every 10-degrees of arc the home healthcare worker is positioned from the left side of the patient toward the right and thus moving into the ventilation airflow direction, dermal deposition increased by about 4.61%. An increase in the patient's inspiratory rate from 15-30 L/min resulted in an average of 14.06% reduction in dermal deposition for the home healthcare worker, reflecting a relative increase in the aerosol fraction inhaled by the patient. The findings of this study elucidate the interactions among factors that contribute to dermal exposure to aerosolized pharmaceuticals administered by home healthcare workers. The results presented in this paper will help develop recommendations on mitigating the health risks related to dermal exposure of home healthcare workers.
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Affiliation(s)
- Simileoluwa Ishau
- Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - John F Reichard
- Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Mamadou Niang
- Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael Yermakov
- Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sergey A Grinshpun
- Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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McGrath JA, O'Toole C, Bennett G, Joyce M, Byrne MA, MacLoughlin R. Investigation of Fugitive Aerosols Released into the Environment during High-Flow Therapy. Pharmaceutics 2019; 11:E254. [PMID: 31159408 PMCID: PMC6630289 DOI: 10.3390/pharmaceutics11060254] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nebulised medical aerosols are designed to deliver drugs to the lungs to aid in the treatment of respiratory diseases. However, an unintended consequence is the potential for fugitive emissions during patient treatment, which may pose a risk factor in both clinical and homecare settings. METHODS The current study examined the potential for fugitive emissions, using albuterol sulphate as a tracer aerosol during high-flow therapy. A nasal cannula was connected to a head model or alternatively, a interface was connected to a tracheostomy tube in combination with a simulated adult and paediatric breathing profile. Two aerodynamic particle sizers (APS) recorded time-series aerosol concentrations and size distributions at two different distances relative to the simulated patient. RESULTS The results showed that the quantity and characteristics of the fugitive emissions were influenced by the interface type, patient type and supplemental gas-flow rate. There was a trend in the adult scenarios; as the flow rate increased, the fugitive emissions and the mass median aerodynamic diameter (MMAD) of the aerosol both decreased. The fugitive emissions were comparable when using the adult breathing profiles for the nasal cannula and tracheostomy interfaces; however, there was a noticeable distinction between the two interfaces when compared for the paediatric breathing profiles. The highest recorded aerosol concentration was 0.370 ± 0.046 mg m-3 from the tracheostomy interface during simulated paediatric breathing with a gas-flow rate of 20 L/min. The averaged MMAD across all combinations ranged from 1.248 to 1.793 µm by the APS at a distance of 0.8 m away from the patient interface. CONCLUSIONS Overall, the results highlight the potential for secondary inhalation of fugitive emissions released during simulated aerosol treatment with concurrent high-flow therapy. The findings will help in developing policy and best practice for risk mitigation from fugitive emissions.
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Affiliation(s)
- James A McGrath
- School of Physics & Centre for Climate and Air Pollution Studies, Ryan Institute, National University of Ireland Galway, H91 CF50 Galway, Ireland.
| | - Ciarraí O'Toole
- School of Physics & Centre for Climate and Air Pollution Studies, Ryan Institute, National University of Ireland Galway, H91 CF50 Galway, Ireland.
| | - Gavin Bennett
- Aerogen, IDA Business Park, Dangan, H91 HE94 Galway, Ireland.
| | - Mary Joyce
- Aerogen, IDA Business Park, Dangan, H91 HE94 Galway, Ireland.
| | - Miriam A Byrne
- School of Physics & Centre for Climate and Air Pollution Studies, Ryan Institute, National University of Ireland Galway, H91 CF50 Galway, Ireland.
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