1
|
Ari A, Hoops JA, Koyuncu A, Fink JB. Dos and don'ts to optimize transnasal aerosol drug delivery in clinical practice. Expert Opin Drug Deliv 2024:1-12. [PMID: 39104360 DOI: 10.1080/17425247.2024.2388838] [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: 03/05/2024] [Revised: 07/10/2024] [Accepted: 08/01/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Transnasal aerosol drug delivery has become widely accepted for treating acutely ill infants, children, and adults. More recently aerosol administration to wider populations receiving high and low-flow nasal oxygen has become common practice. AREAS COVERED Skepticism of insufficient aerosol delivery to the lungs has been tempered by multiple in vitro explorations of variables to optimize delivery efficiency. Additionally, clinical studies demonstrated comparable clinical responses to orally inhaled aerosols. This paper provides essential clinical guidance on how to improve transnasal aerosol delivery based on device-, settings-, and drug-related optimization to serve as a resource for educational initiatives and quality enhancement endeavors at healthcare institutions. EXPERT OPINION Transnasal aerosol delivery is proliferating worldwide, but indiscriminate use of excessive-high flows, poor selection and placement of aerosol devices and circuits can greatly reduce aerosol delivery and efficacy, potentially compromising treatment to acute and critically ill patients. Attention to these details can improve inhaled dose by an order of magnitude, making the difference between effective treatment and the progression to more invasive ventilatory support, with greater inherent risk and cost. These revelations have prompted specific recommendations for optimal delivery, driving advancements in aerosol generators, formulations, and future device designs to administer aerosols and maximize treatment effectiveness.
Collapse
Affiliation(s)
- Arzu Ari
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Jordan A Hoops
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Ayfer Koyuncu
- Bioengineering Division, College of Engineering, Hacettepe University, Ankara, Turkey
| | - James B Fink
- College of Health Professions, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| |
Collapse
|
2
|
Momin MAM, Farkas D, Hindle M, Hall F, DiBlasi RM, Longest W. Development of a New Dry Powder Aerosol Synthetic Lung Surfactant Product for Neonatal Respiratory Distress Syndrome (RDS) - Part I: In Vitro Testing and Characterization. Pharm Res 2024:10.1007/s11095-024-03740-z. [PMID: 39112775 DOI: 10.1007/s11095-024-03740-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/03/2024] [Indexed: 08/21/2024]
Abstract
PURPOSE Improving the deep lung delivery of aerosol surfactant therapy (AST) with a dry powder formulation may enable significant reductions in dose while providing improved efficacy. The objective of Part I of this two-part study was to present the development of a new dry powder aerosol synthetic lung surfactant (SLS) product and to characterize performance based on aerosol formation and realistic in vitro airway testing leading to aerosol delivery recommendations for subsequent in vivo animal model experiments. METHODS A new micrometer-sized SLS excipient enhanced growth (EEG) dry powder formulation was produced via spray drying and aerosolized using a positive-pressure air-jet dry powder inhaler (DPI) intended for aerosol delivery directly to intubated infants with respiratory distress syndrome (RDS) or infant-size test animals. RESULTS The best-case design (D2) of the air-jet DPI was capable of high emitted dose (> 80% of loaded) and formed a < 2 µm mass median aerodynamic diameter (MMAD) aerosol, but was limited to ≤ 20 mg mass loadings. Testing with a realistic in vitro rabbit model indicated that over half of the loaded dose could penetrate into the lower lung regions. Using the characterization data, a dose delivery protocol was designed in which a 60 mg total loaded dose would be administered and deliver an approximate lung dose of 14.7-17.7 mg phospholipids/kg with a total aerosol delivery period < 5 min. CONCLUSIONS A high-efficiency aerosol SLS product was designed and tested that may enable an order of magnitude reduction in administered phospholipid dose, and provide rapid aerosol administration to infants with RDS.
Collapse
Affiliation(s)
- Mohammad A M Momin
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Dale Farkas
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, Virginia, 23284-3015, USA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Felicia Hall
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Robert M DiBlasi
- Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Worth Longest
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA.
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, Virginia, 23284-3015, USA.
| |
Collapse
|
3
|
DiBlasi RM, Micheletti KJ, Romo T, Malone P, Orth J, Richards E, Kajimoto M, Goldstein JR, Keszler M. Evaluation of lung volumes and gas exchange in surfactant-deficient rabbits between variable and fixed servo pressures during high-frequency jet ventilation. J Perinatol 2024; 44:266-272. [PMID: 38007593 DOI: 10.1038/s41372-023-01832-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/27/2023]
Abstract
OBJECTIVE To investigate a novel servo pressure (SP) setting during high-frequency jet ventilation (HFJV) for a lung protective strategy in a neonatal model of acute respiratory distress. STUDY DESIGN Comparison of efficacy between variable (standard) and fixed SP settings in a randomized animal study using rabbits (n = 10, mean weight = 1.80 kg) with surfactant deficiency by repeated lung lavages. RESULTS Rabbits in the fixed SP group had greater peak inspiratory pressure, SP, minute volume, pH, and PaO2, and lower PaCO2 after lung lavage than the variable SP group. Lung volume monitoring with electrical impedance tomography showed that fixed SP reduced the decline of the global lung tidal variation at 30 min after lung lavage (-17.4% from baseline before lavage) compared to variable SP (-44.9%). CONCLUSION HFJV with fixed SP significantly improved gas exchange and lung volumes compared to variable SP. Applying a fixed SP may have important clinical implications for patients receiving HFJV.
Collapse
Affiliation(s)
- Robert M DiBlasi
- Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, WA, USA.
- Department of Respiratory Care, Seattle Children's Hospital, Seattle, WA, USA.
| | | | - Tina Romo
- Department of Respiratory Care, Seattle Children's Hospital, Seattle, WA, USA
| | - Patrik Malone
- Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, WA, USA
- Department of Respiratory Care, Seattle Children's Hospital, Seattle, WA, USA
| | - Jeff Orth
- Bunnell Inc, Salt Lake City, UT, USA
| | | | - Masaki Kajimoto
- Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Justin R Goldstein
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Martin Keszler
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| |
Collapse
|
4
|
DiBlasi RM, Crandall CN, Engberg RJ, Bijlani K, Ledee D, Kajimoto M, Walther FJ. Evaluation of a Novel Dry Powder Surfactant Aerosol Delivery System for Use in Premature Infants Supported with Bubble CPAP. Pharmaceutics 2023; 15:2368. [PMID: 37896128 PMCID: PMC10609757 DOI: 10.3390/pharmaceutics15102368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 10/29/2023] Open
Abstract
Aerosolized lung surfactant therapy during nasal continuous positive airway pressure (CPAP) support avoids intubation but is highly complex, with reported poor nebulizer efficiency and low pulmonary deposition. The study objective was to evaluate particle size, operational compatibility, and drug delivery efficiency with various nasal CPAP interfaces and gas humidity levels of a synthetic dry powder (DP) surfactant aerosol delivered by a low-flow aerosol chamber (LFAC) inhaler combined with bubble nasal CPAP (bCPAP). A particle impactor characterized DP surfactant aerosol particle size. Lung pressures and volumes were measured in a preterm infant nasal airway and lung model using LFAC flow injection into the bCPAP system with different nasal prongs. The LFAC was combined with bCPAP and a non-heated passover humidifier. DP surfactant mass deposition within the nasal airway and lung was quantified for different interfaces. Finally, surfactant aerosol therapy was investigated using select interfaces and bCPAP gas humidification by active heating. Surfactant aerosol particle size was 3.68 µm. Lung pressures and volumes were within an acceptable range for lung protection with LFAC actuation and bCPAP. Aerosol delivery of DP surfactant resulted in variable nasal airway (0-20%) and lung (0-40%) deposition. DP lung surfactant aerosols agglomerated in the prongs and nasal airways with significant reductions in lung delivery during active humidification of bCPAP gas. Our findings show high-efficiency delivery of small, synthetic DP surfactant particles without increasing the potential risk for lung injury during concurrent aerosol delivery and bCPAP with passive humidification. Specialized prongs adapted to minimize extrapulmonary aerosol losses and nasal deposition showed the greatest lung deposition. The use of heated, humidified bCPAP gases compromised drug delivery and safety. Safety and efficacy of DP aerosol delivery in preterm infants supported with bCPAP requires more research.
Collapse
Affiliation(s)
- Robert M. DiBlasi
- Department of Respiratory Care Therapy, Seattle Children’s Hospital, Seattle, WA 98105, USA
- Center for Respiratory Biology and Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101, USA; (C.N.C.); (R.J.E.); (M.K.)
| | - Coral N. Crandall
- Center for Respiratory Biology and Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101, USA; (C.N.C.); (R.J.E.); (M.K.)
- Quality and Clinical Effectiveness, Seattle Children’s Hospital, Seattle, WA 98105, USA
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Rebecca J. Engberg
- Center for Respiratory Biology and Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101, USA; (C.N.C.); (R.J.E.); (M.K.)
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Kunal Bijlani
- Mechanical Engineering, Zewski Corporation, Magnolia, TX 77354, USA;
| | - Dolena Ledee
- Division of Cardiology, Department of Pediatrics, University of Washington, Seattle, WA 98195, USA;
| | - Masaki Kajimoto
- Center for Respiratory Biology and Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101, USA; (C.N.C.); (R.J.E.); (M.K.)
| | - Frans J. Walther
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA;
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| |
Collapse
|
5
|
Budh HP, Nimbalkar S. Surfactant Replacement Therapy: What’s the New Future? JOURNAL OF NEONATOLOGY 2022; 36:331-347. [DOI: 10.1177/09732179221136963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Surfactant replacement therapy (SRT) can be lifesaving for preterm babies with respiratory distress because of surfactant deficiency. Attempts have been made over the last two decades to make surfactant administration as smooth and as nontraumatic as possible. Lesser invasive techniques, such as less invasive surfactant administration, minimally invasive surfactant therapy, intrapartum pharyngeal surfactant therapy, and the laryngeal mask airway, are preferred over invasive techniques like intubate surfactant extubation to reduce trauma and peridosing adverse effects. However, at present, aerosolized surfactant (AS) via nebulization remains the only truly noninvasive method of SRT. Many animal and human studies have shown promising results with the use of AS with similar clinical effects to an instilled surfactant with greater safety potential. But still AS has not been adapted to routine neonatal care. There is still scope for studies to further strengthen the role of AS. Also, SRT is a constantly changing field with new innovations revolutionizing and replacing old techniques.
Collapse
Affiliation(s)
- Hetal Pramod Budh
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
| | - Somashekhar Nimbalkar
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
| |
Collapse
|
6
|
Walther FJ, Waring AJ. Aerosol Delivery of Lung Surfactant and Nasal CPAP in the Treatment of Neonatal Respiratory Distress Syndrome. Front Pediatr 2022; 10:923010. [PMID: 35783301 PMCID: PMC9240419 DOI: 10.3389/fped.2022.923010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/24/2022] [Indexed: 01/06/2023] Open
Abstract
After shifting away from invasive mechanical ventilation and intratracheal instillation of surfactant toward non-invasive ventilation with nasal CPAP and less invasive surfactant administration in order to prevent bronchopulmonary dysplasia in preterm infants with respiratory distress syndrome, fully non-invasive surfactant nebulization is the next Holy Grail in neonatology. Here we review the characteristics of animal-derived (clinical) and new advanced synthetic lung surfactants and improvements in nebulization technology required to secure optimal lung deposition and effectivity of non-invasive lung surfactant administration. Studies in surfactant-deficient animals and preterm infants have demonstrated the safety and potential of non-invasive surfactant administration, but also provide new directions for the development of synthetic lung surfactant destined for aerosol delivery, implementation of breath-actuated nebulization and optimization of nasal CPAP, nebulizer circuit and nasal interface. Surfactant nebulization may offer a truly non-invasive option for surfactant delivery to preterm infants in the near future.
Collapse
Affiliation(s)
- Frans J. Walther
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Alan J. Waring
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| |
Collapse
|