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Corcoran T. Carrier Gases and Their Effects on Aerosol Drug Delivery. J Aerosol Med Pulm Drug Deliv 2021; 34:71-78. [PMID: 33691471 DOI: 10.1089/jamp.2021.29035.tc] [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: 11/12/2022] Open
Abstract
Carrier gases provide the medium for delivery of inhaled aerosol therapies. The physical properties of these gases substantially affect both fluid and aerosol mechanics in the lung. Gas density affects both the pressure/flow relationship in the airways and the extent of turbulence within the flow. These physical properties also affect the operation of some components of respiratory and aerosol drug delivery equipment. The lower resistance associated with breathing low density gases has prompted many studies of therapeutic applications. This includes the respiration of helium-oxygen gas mixtures to improve oxygenation and carbon dioxide removal, and the use of these gases to improve the delivery of inhaled medications. Results of these studies have been mixed but meta-analyses indicate a benefit of helium-oxygen respiration for croup and bronchiolitis and for bronchodilator delivery in obstructive disease. Some of the variability demonstrated in these studies is likely associated with specific technical aspects of how the gases are delivered. The utility of alternate carrier gases for aerosol delivery would be facilitated by simultaneous assessment of both aerosol deposition and clinical effect during studies. Previous successful applications may offer a basis for improved delivery system designs that fully realize the effects that might be available with these gases.
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Affiliation(s)
- Tim Corcoran
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania USA
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2
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Häussermann S, Sommerer K, Scheuch G. Regional Lung Deposition: In Vivo Data. J Aerosol Med Pulm Drug Deliv 2020; 33:291-299. [PMID: 33021414 DOI: 10.1089/jamp.2020.29032.sh] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The method section of this chapter on in vivo regional lung deposition highlights a nonradioactive method to measure regional deposition, which uses a photometer to quantify inhaled and exhaled particles and in that way is able to estimate the lung region from which the particles are exhaled and to what amount. The radioactive methods cover the measurement of clearance of the deposited particles as well as different imaging techniques to determine regional deposition. The result section reviews in vivo trials in human subjects. It also addresses different parameters that influence the regional deposition in the lungs: particle size, inhalation maneuver, carrier gas, disease, and inhalation device. All of these factors can affect regional deposition significantly. By choosing specific values of these parameters, it should be feasible to target different regions of the lungs for the therapy of different diseases.
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Karim HMR, Esquinas AM, Ziatabar S, Insalaco G, Skoczyński S, Šarc I, Ferini-Strambi L, Özyiğit LP, Hernández-Gilsoul T, Singha SK, Ciobanu L, Gutiérrez JLS, Szkulmowski Z, Piervincenzi E, Aguiar M, El-Khatib MF, Corcione N, Kaya AG, Çiledağ A, Kaya A, Valli G, Pierucci P, Resta O, Steiropoulos P, De Marco F, Caldeira V, Mina BA. Continuous Positive Airway Pressure (CPAP) in Non-Apneic Asthma: A Clinical Review of Current Evidence. Turk Thorac J 2020; 21:274-279. [PMID: 32687789 DOI: 10.5152/turkthoracj.2019.19049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/10/2019] [Indexed: 11/22/2022]
Abstract
The use of continuous positive airway pressure (CPAP) in asthma has been a point of debate over the past several years. Various studies, including those on animals and humans have attempted to understand the role and pathophysiology of CPAP in patients with either well controlled or poorly controlled asthma. The aim of this manuscript is to review the currently available literature on the physiologic and clinical effects of CPAP in animal models of asthma and on humans with stable asthma.
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Affiliation(s)
| | - Antonio M Esquinas
- Department of Intensive Care Unit, Hospital General University Morales Meseguer, Murcia, Spain
| | - Sally Ziatabar
- Department of Internal Medicine, Northwell Health - Lenox Hill Hospital, New York, USA
| | - Giuseppe Insalaco
- Institute of Biomedicine and Molecular Immunology, Italian National Research Council, Palermo, Italy
| | - Szymon Skoczyński
- Department of Pulmonology, Medical University of Silesia, Katowice, Poland
| | - Irena Šarc
- Department for Noninvasive Ventilation, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | | | - Leyla Pur Özyiğit
- Department of Respiratory Medicine, Allergy and Immunology, Koç University Hospital, İstanbul, Turkey
| | | | - Subrata Kumar Singha
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, India
| | - Laura Ciobanu
- Department of Internal Medicine and Pulmonology, Clinical Hospital of Rehabilitation Lasi, Lasi, Romania
| | - José Luis Sandoval Gutiérrez
- Department of Pulmonary and Critical Care, Instituto Nacional de Enfermedades Respiratorias, México City, Mexico
| | - Zbigniew Szkulmowski
- Department of Anesthesia and Intensive Care Unit, University Hospital No 1 In Bydgoszcz Collegium Medicum in Bydgoszcz University Nicolaus Copernicus in Torun, Bydgoszcz, Poland
| | - Edoardo Piervincenzi
- Department of Anesthesia and Intensive Carei, Sapienza University of Rome, Rome, Italy
| | - Margarida Aguiar
- Department of Pulmonology, Hospital Beatriz Angelo, Lisbon, Portugal
| | - Mohamad F El-Khatib
- Department of Anesthesiology, American University of Beirut, Beirut, Lebanon
| | - Nadia Corcione
- Department of Anesthesia, Critical Care and Emergency Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Aslıhan Gürün Kaya
- Department of Chest Diseases, Ankara University School of Medicine, Ankara, Turkey
| | - Aydın Çiledağ
- Department of Chest Diseases, Ankara University School of Medicine, Ankara, Turkey
| | - Akın Kaya
- Department of Chest Diseases, Ankara University School of Medicine, Ankara, Turkey
| | - Gabriele Valli
- Department of Emergency Medicine, Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy
| | - Paola Pierucci
- Department of Cardiothoracic, Respiratory and Sleep Medicine, Policlinico University Hospital, Bari, Italy
| | - Onofrio Resta
- Department of Cardiothoracic, Respiratory and Sleep Medicine, Policlinico University Hospital, Bari, Italy
| | | | | | - Vania Caldeira
- Department of Pulmonology, Hospital de Santa Marta-Centro Hospital, Lisboa, Portugal
| | - Bushra A Mina
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Northwell Health - Lenox Hill Hospital, New York, USA
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Li J, Harnois LJ, Markos B, Roberts KM, Homoud SA, Liu J, Mirza S, Vines D. Epoprostenol Delivered via High Flow Nasal Cannula for ICU Subjects with Severe Hypoxemia Comorbid with Pulmonary Hypertension or Right Heart Dysfunction. Pharmaceutics 2019; 11:pharmaceutics11060281. [PMID: 31207936 PMCID: PMC6631264 DOI: 10.3390/pharmaceutics11060281] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 12/20/2022] Open
Abstract
Inhaled epoprostenol (iEPO) has been utilized to improve oxygenation in mechanically ventilated subjects with severe hypoxemia, but the evidence for iEPO via high-flow nasal cannula (HFNC) is rare. Following approval by the institutional review board, this retrospective cohort study evaluated subjects who received iEPO via HFNC for more than 30 min to treat severe hypoxemia comorbid with pulmonary hypertension or right heart dysfunction between July 2015 and April 2018. A total of 11 subjects were enrolled in the study of whom 4 were male (36.4%), age 57.5 ± 22.1 years, and APACHE II score at ICU admission was 18.5 ± 5.7. Ten subjects had more than three chronic heart or lung comorbidities; seven of them used home oxygen. After inhaling epoprostenol, subjects' SpO2/FIO2 ratio improved from 107.5 ± 26.3 to 125.5 ± 31.6 (p = 0.026) within 30-60 min. Five subjects (45.5%) had SpO2/FIO2 improvement >20%, which was considered as a positive response. Heart rate, blood pressure, and respiratory rate were not significantly different. Seven subjects did not require intubation, and seven subjects were discharged home. This retrospective study demonstrated the feasibility of iEPO via HFNC in improving oxygenation. Careful titration of flow while evaluating subjects' response may help identify responders and avoid delaying other interventions. This study supports the need for a larger prospective randomized control trial to further evaluate the efficacy of iEPO via HFNC in improving outcomes.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Lauren J Harnois
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Bethelhem Markos
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Keith M Roberts
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Salma Al Homoud
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Jing Liu
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Sara Mirza
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - David Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
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Galindo-Filho VC, Alcoforado L, Rattes C, Paiva DN, Brandão SCS, Fink JB, Dornelas de Andrade A. A mesh nebulizer is more effective than jet nebulizer to nebulize bronchodilators during non-invasive ventilation of subjects with COPD: A randomized controlled trial with radiolabeled aerosols. Respir Med 2019; 153:60-67. [PMID: 31170543 DOI: 10.1016/j.rmed.2019.05.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 05/06/2019] [Accepted: 05/27/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Beneficial effects from non-invasive ventilation (NIV) in acute COPD are well-established, but the impact of nebulization during NIV has not been well described. AIM To compare pulmonary deposition and distribution across regions of interest with administration of radiolabeled aerosols generated by vibrating mesh nebulizers (VMN) and jet nebulizer (JN) during NIV. METHODS A crossover single dose study involving 9 stable subjects with moderate to severe COPD randomly allocated to receive aerosol administration by the VMN Aerogen and the MistyNeb jet nebulizer operating with oxygen at 8 lpm during NIV. Radiolabeled bronchodilators (fill volume of 3 mL: 0.5 mL salbutamol 2.5 mg + 0.125 mL ipratropium 0.25 mg and physiologic saline up to 3 mL) were delivered until sputtering during NIV (pressures of 12 cmH2O and 5 cmH2O - inspiratory and expiratory, respectively) using an oro-nasal facemask. Radioactivity counts were performed using a gamma camera and regions of interest (ROIs) were delimited. Aerosol mass balance based on counts from the lungs, upper airways, stomach, nebulizer, circuit, inspiratory and expiratory filters, and mask were determined and expressed as a percentage of the total. RESULTS Both inhaled and lung doses were greater with VMN (22.78 ± 3.38% and 12.05 ± 2.96%, respectively) than JN (12.51 ± 6.31% and 3.14 ± 1.71%; p = 0.008). Residual drug volume was lower in VMN than in JN (3.08 ± 1.3% versus 46.44 ± 5.83%, p = 0.001). Peripheral deposition of radioaerosol was significantly lower with JN than VMN. CONCLUSIONS VMN deposited > 3 fold more radioaerosol into the lungs of moderate to severe COPD patients than JN during NIV.
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Affiliation(s)
| | - Luciana Alcoforado
- Department of Physicaltherapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.
| | - Catarina Rattes
- Department of Physicaltherapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.
| | - Dulciane Nunes Paiva
- Department of Physicaltherapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.
| | | | - James B Fink
- Division of Respiratory Care, Rush Medical School, Chicago, IL, USA.
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Kaminsky DA, Chapman DG, Holbrook JT, Henderson RJ, Sugar EA, Mastronarde J, Teague WG, Busk M, Sumino K, Dixon AE, Wise RA, Irvin CG. Older age and obesity are associated with increased airway closure in response to methacholine in patients with asthma. Respirology 2019; 24:638-645. [PMID: 30838750 DOI: 10.1111/resp.13496] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 11/29/2018] [Accepted: 01/02/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVE The reduction of forced expiratory volume in 1 s (FEV1 ) in response to methacholine challenge in asthma may reflect two components: airway narrowing, assessed by the change in FEV1 /forced vital capacity (FVC), and airway closure, assessed by the change in FVC. The purpose of this study was to determine the degree and determinants of airway closure in response to methacholine in a large group of asthmatic patients participating in studies conducted by the American Lung Association-Airways Clinical Research Centers (ALA-ACRC). METHODS We used the methacholine challenge data from participants in five studies of the ALA-ACRC to determine the closing index, defined as the contribution of airway closure to the decrease in FEV1 , and calculated as %ΔFVC/%ΔFEV1 . RESULTS There were a total of 936 participants with asthma, among whom the median closing index was 0.67 relative to that of a published healthy population of 0.54. A higher closing index was associated with increased age (10-year increments) (0.04, 95% CI = 0.02, 0.05, P < 0.005) and obesity (0.07, 95% CI = 0.03, 0.10, P < 0.001). There was no association between the closing index and asthma control. CONCLUSION Our findings confirm that airway closure in response to methacholine occurs in a large, diverse population of asthmatic participants, and that increased airway closure is associated with older age and obesity. These findings suggest that therapies targeting airway closure may be important in patients with a high closing index.
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Affiliation(s)
- David A Kaminsky
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - David G Chapman
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Translational Airways Group, School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia.,Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Janet T Holbrook
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Robert J Henderson
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth A Sugar
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - John Mastronarde
- Division of Pulmonary Medicine, Providence Portland Medical Center, Portland, OR, USA
| | - William G Teague
- Division of Pediatric Respiratory Medicine and Allergy, University of Virginia, Charlottesville, VA, USA
| | - Michael Busk
- Division of Pulmonary Medicine, St. Vincent Hospital and Health Care Center, Inc., Indianapolis, IN, USA
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, MO, USA
| | - Anne E Dixon
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Charles G Irvin
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA
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Inhalation Techniques Used in Patients with Respiratory Failure Treated with Noninvasive Mechanical Ventilation. Can Respir J 2018; 2018:8959370. [PMID: 29973963 PMCID: PMC6008820 DOI: 10.1155/2018/8959370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/02/2018] [Indexed: 11/18/2022] Open
Abstract
The administration of aerosolized medication is a basic therapy for patients with numerous respiratory tract diseases, including obstructive airway diseases (OADs), cystic fibrosis (CF), and infectious airway diseases. The management and care for patients requiring mechanical ventilation remains one of the greatest challenges for medical practitioners, both in intensive care units (ICUs) and pulmonology wards. Aerosol therapy is often necessary for patients receiving noninvasive ventilation (NIV), which may be stopped for the time of drug delivery and administered through a metered-dose inhaler or nebulizer in the traditional way. However, in most severe cases, this may result in rapid deterioration of the patient's clinical condition. Unfortunately, only limited number of original well-planned studies addressed this problem. Due to inconsistent information coming from small studies, there is a need for more precise data coming from large prospective real life studies on inhalation techniques in patients receiving NIV.
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Fink JB, Molloy L, Patton JS, Galindo-Filho VC, de Melo Barcelar J, Alcoforado L, Brandão SCS, de Andrade AD. Good Things in Small Packages: an Innovative Delivery Approach for Inhaled Insulin. Pharm Res 2017; 34:2568-2578. [DOI: 10.1007/s11095-017-2215-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
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Albuquerque IMD, Cardoso DM, Masiero PR, Paiva DN, Resqueti VR, Fregonezi GADF, Menna-Barreto SS. Effects of positive expiratory pressure on pulmonary clearance of aerosolized technetium-99m-labeled diethylenetriaminepentaacetic acid in healthy individuals. J Bras Pneumol 2016; 42:404-408. [DOI: 10.1590/s1806-37562015000000320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 04/19/2016] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: To evaluate the effects of positive expiratory pressure (PEP) on pulmonary epithelial membrane permeability in healthy subjects. Methods: We evaluated a cohort of 30 healthy subjects (15 males and 15 females) with a mean age of 28.3 ± 5.4 years, a mean FEV1/FVC ratio of 0.89 ± 0.14, and a mean FEV1 of 98.5 ± 13.1% of predicted. Subjects underwent technetium-99m-labeled diethylenetriaminepentaacetic acid (99mTc-DTPA) radioaerosol inhalation lung scintigraphy in two stages: during spontaneous breathing; and while breathing through a PEP mask at one of three PEP levels-10 cmH2O (n = 10), 15 cmH2O (n = 10), and 20 cmH2O (n = 10). The 99mTc-DTPA was nebulized for 3 min, and its clearance was recorded by scintigraphy over a 30-min period during spontaneous breathing and over a 30-min period during breathing through a PEP mask. Results: The pulmonary clearance of 99mTc-DTPA was significantly shorter when PEP was applied-at 10 cmH2O (p = 0.044), 15 cmH2O (p = 0.044), and 20 cmH2O (p = 0.004)-in comparison with that observed during spontaneous breathing. Conclusions: Our findings indicate that PEP, at the levels tested, is able to induce an increase in pulmonary epithelial membrane permeability and lung volume in healthy subjects.
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Greenblatt EE, Winkler T, Harris RS, Kelly VJ, Kone M, Katz I, Martin A, Caillibotte G, Hess DR, Venegas JG. Regional Ventilation and Aerosol Deposition with Helium-Oxygen in Bronchoconstricted Asthmatic Lungs. J Aerosol Med Pulm Drug Deliv 2016; 29:260-72. [PMID: 26824777 DOI: 10.1089/jamp.2014.1204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Theoretical models suggest that He-O2 as carrier gas may lead to more homogeneous ventilation and aerosol deposition than air. However, these effects have not been clinically consistent and it is unclear why subjects may or may not respond to the therapy. Here we present 3D-imaging data of aerosol deposition and ventilation distributions from subjects with asthma inhaling He-O2 as carrier gas. The data are compared with those that we previously obtained from a similar group of subjects inhaling air. METHODS Subjects with mild-to-moderate asthma were bronchoconstricted with methacholine and imaged with PET-CT while inhaling aerosol carried with He-O2. Mean-normalized-values of lobar specific ventilation sV* and deposition sD* were derived and the factors affecting the distribution of sD* were evaluated along with the effects of breathing frequency (f) and regional expansion (FVOL). RESULTS Lobar distributions of sD* and sV* with He-O2 were not statistically different from those previously measured with air. However, with He-O2 there was a larger number of lobes having sV* and sD* closer to unity and, in those subjects with uneven deposition distributions, the correlation of sD* with sV* was on average higher (p < 0.05) in He-O2 (0.84 ± 0.8) compared with air (0.55 ± 0.28). In contrast with air, where the frequency of breathing during nebulization was associated with the degree of sD*-sV* correlation, with He-O2 there was no association. Also, the modulation of f on the correlation between FVOL and sD*/sV* in air, was not observed in He-O2. CONCLUSION There were no differences in the inter-lobar heterogeneity of sD* or sV* in this group of mild asthmatic subjects breathing He-O2 compared with patients previously breathing air. Future studies, using these personalized 3D data sets as input to CFD models, are needed to understand if, and for whom, breathing He-O2 during aerosol inhalation may be beneficial.
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Affiliation(s)
- Elliot Eliyahu Greenblatt
- 1 Massachusetts Institute of Technology , Boston, Massachusetts.,2 Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Tilo Winkler
- 2 Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Robert Scott Harris
- 2 Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Vanessa Jane Kelly
- 2 Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Mamary Kone
- 2 Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Ira Katz
- 3 R & D Medical, Air Liquide Santé International , Les-Loges-en-Josas, France .,4 Department of Mechanical Engineering, Lafayette College , Easton, Pennsylvania
| | - Andrew Martin
- 5 Delaware Research and Technology Center , American Air Liquide, Newark, Delaware.,6 Department of Mechanical Engineering, University of Alberta , Edmonton, Alberta, Canada
| | - George Caillibotte
- 3 R & D Medical, Air Liquide Santé International , Les-Loges-en-Josas, France
| | - Dean R Hess
- 2 Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Jose G Venegas
- 2 Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
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de Albuquerque IM, Cardoso DM, Masiero PR, Paiva DN, Resqueti VR, Fregonezi GADF, Menna-Barreto SS. Effects of positive expiratory pressure on pulmonary clearance of aerosolized technetium-99m-labeled diethylenetriaminepentaacetic acid in healthy individuals. J Bras Pneumol 2016. [PMID: 28117469 PMCID: PMC5344088 DOI: 10.1590/s1806-37562016000000320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE: To evaluate the effects of positive expiratory pressure (PEP) on pulmonary epithelial membrane permeability in healthy subjects. METHODS: We evaluated a cohort of 30 healthy subjects (15 males and 15 females) with a mean age of 28.3 ± 5.4 years, a mean FEV1/FVC ratio of 0.89 ± 0.14, and a mean FEV1 of 98.5 ± 13.1% of predicted. Subjects underwent technetium-99m-labeled diethylenetriaminepentaacetic acid (99mTc-DTPA) radioaerosol inhalation lung scintigraphy in two stages: during spontaneous breathing; and while breathing through a PEP mask at one of three PEP levels-10 cmH2O (n = 10), 15 cmH2O (n = 10), and 20 cmH2O (n = 10). The 99mTc-DTPA was nebulized for 3 min, and its clearance was recorded by scintigraphy over a 30-min period during spontaneous breathing and over a 30-min period during breathing through a PEP mask. RESULTS: The pulmonary clearance of 99mTc-DTPA was significantly shorter when PEP was applied-at 10 cmH2O (p = 0.044), 15 cmH2O (p = 0.044), and 20 cmH2O (p = 0.004)-in comparison with that observed during spontaneous breathing. CONCLUSIONS: Our findings indicate that PEP, at the levels tested, is able to induce an increase in pulmonary epithelial membrane permeability and lung volume in healthy subjects. OBJETIVO: Avaliar os efeitos da pressão expiratória positiva (PEP) na permeabilidade da membrana epitelial pulmonar em indivíduos saudáveis. MÉTODOS: Foi avaliada uma coorte de 30 indivíduos saudáveis (15 homens e 15 mulheres), com média de idade de 28,3 ± 5,4 anos, média da relação VEF1/CVF de 0,89 ± 0,14 e média de VEF1 de 98,5 ± 13,1% do previsto. Os indivíduos foram submetidos a cintilografia pulmonar por inalação de radioaerossol de ácido dietilenotriaminopentacético marcado com tecnécio-99m (99mTc-DTPA em inglês) em dois estágios: durante respiração espontânea e durante respiração com uma máscara de PEP de 10 cmH2O (n = 10), 15 cmH2O (n = 10) ou 20 cmH2O (n = 10). O 99mTc-DTPA foi nebulizado por 3 min, e sua depuração foi registrada por cintilografia por um período de 30 min durante respiração espontânea e por um período de 30 min durante a respiração com uma máscara de PEP. RESULTADOS: A depuração pulmonar do 99mTc-DTPA foi significativamente menor quando PEP foi aplicada a 10 cmH2O (p = 0,044), 15 cmH2O (p = 0,044) e 20 cmH2O (p = 0,004), em comparação com a observada durante a respiração espontânea. CONCLUSÕES: Nossos achados indicam que o uso de PEP nos níveis testados pode induzir um aumento na permeabilidade da membrana epitelial pulmonar e no volume pulmonar em indivíduos saudáveis.
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Affiliation(s)
- Isabella Martins de Albuquerque
- . Departamento de Fisioterapia e Reabilitação, Programa de Pós-Graduação em Reabilitação Funcional, Universidade Federal de Santa Maria, Santa Maria (RS) Brasil
| | - Dannuey Machado Cardoso
- . Departamento de Educação Física e Saúde, Universidade de Santa Cruz do Sul, Santa Cruz do Sul (RS) Brasil
| | - Paulo Ricardo Masiero
- . Serviço de Medicina Nuclear, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil
| | - Dulciane Nunes Paiva
- . Programa de Pós-Graduação em Promoção da Saúde, Departamento de Educação Física e Saúde, Universidade de Santa Cruz do Sul, Santa Cruz do Sul (RS) Brasil
| | - Vanessa Regiane Resqueti
- . Departamento de Fisioterapia, Laboratório de Desempenho Pneumocardiovascular e Músculos Respiratórios, Universidade Federal do Rio Grande do Norte, Natal (RN) Brasil
| | - Guilherme Augusto de Freitas Fregonezi
- . Departamento de Fisioterapia, Laboratório de Desempenho Pneumocardiovascular e Músculos Respiratórios, Universidade Federal do Rio Grande do Norte, Natal (RN) Brasil
| | - Sérgio Saldanha Menna-Barreto
- . Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil
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Albertson TE, Schivo M, Gidwani N, Kenyon NJ, Sutter ME, Chan AL, Louie S. Pharmacotherapy of critical asthma syndrome: current and emerging therapies. Clin Rev Allergy Immunol 2015; 48:7-30. [PMID: 24178860 DOI: 10.1007/s12016-013-8393-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.
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Affiliation(s)
- T E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA,
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13
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Albertson TE, Sutter ME, Chan AL. The acute management of asthma. Clin Rev Allergy Immunol 2015; 48:114-25. [PMID: 25213370 DOI: 10.1007/s12016-014-8448-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients presenting to the emergency department (ED) or clinic with acute exacerbation of asthma (AEA) can be very challenging varying in both severity and response to therapy. High-dose, frequent or continuous nebulized short-acting beta2 agonist (SABA) therapy that can be combined with a short-acting muscarinic antagonist (SAMA) is the backbone of treatment. When patients do not rapidly clinically respond to SABA/SAMA inhalation, the early use of oral or parenteral corticosteroids should be considered and has been shown to impact the immediate need for ICU admission or even the need for hospital admission. Adjunctive therapies such as the use of intravenous magnesium and helium/oxygen combination gas for inhalation and for driving a nebulizer to deliver a SABA and or SAMA should be considered and are best used early in the treatment plan if they are likely to impact the patients' clinical course. The use of other agents such as theophylline, leukotriene modifiers, inhaled corticosteroids, long-acting beta2 agonist, and long-acting muscarinic antagonist currently does not play a major role in the immediate treatment of AEA in the clinic or the ED but is an important therapeutic option for physicians to be aware of and to consider initiating at the time of discharge from clinic, hospital, or ED to reduce later clinical worsening and readmission to the ED and hospital. A comprehensive summary is provided of the currently available respiratory pharmaceuticals approved for asthma and other airway syndromes. Clinicians must be prepared to use the entire spectrum of medications available for the treatment of acute asthma exacerbations and the agents that should be initiated to prevent worsening or additional exacerbations. They need to be familiar with the major potential drug toxicities associated with their use.
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Affiliation(s)
- Timothy E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, PSSB 3400, 4150 V Street, Sacramento, CA, 95817, USA,
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Barbas CSV, Ísola AM, Farias AMDC, Cavalcanti AB, Gama AMC, Duarte ACM, Vianna A, Serpa A, Bravim BDA, Pinheiro BDV, Mazza BF, de Carvalho CRR, Toufen C, David CMN, Taniguchi C, Mazza DDDS, Dragosavac D, Toledo DO, Costa EL, Caser EB, Silva E, Amorim FF, Saddy F, Galas FRBG, Silva GS, de Matos GFJ, Emmerich JC, Valiatti JLDS, Teles JMM, Victorino JA, Ferreira JC, Prodomo LPDV, Hajjar LA, Martins LC, Malbouisson LMS, Vargas MADO, Reis MAS, Amato MBP, Holanda MA, Park M, Jacomelli M, Tavares M, Damasceno MCP, Assunção MSC, Damasceno MPCD, Youssef NCM, Teixeira PJZ, Caruso P, Duarte PAD, Messeder O, Eid RC, Rodrigues RG, de Jesus RF, Kairalla RA, Justino S, Nemer SN, Romero SB, Amado VM. Brazilian recommendations of mechanical ventilation 2013. Part I. Rev Bras Ter Intensiva 2015; 26:89-121. [PMID: 25028944 PMCID: PMC4103936 DOI: 10.5935/0103-507x.20140017] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Indexed: 12/19/2022] Open
Abstract
Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumonia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.
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Affiliation(s)
- Carmen Sílvia Valente Barbas
- Corresponding author: Carmen Silvia Valente Barbas, Disicplina de
Pneumologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São
Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, Zip code - 05403-900 - São Paulo
(SP), Brazil. E-mail:
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Abstract
Perspectives on invasive and noninvasive ventilatory support for critically ill
patients are evolving, as much evidence indicates that ventilation may have positive
effects on patient survival and the quality of the care provided in intensive care
units in Brazil. For those reasons, the Brazilian Association of Intensive Care
Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and
the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e
Tisiologia - SBPT), represented by the Mechanical Ventilation Committee
and the Commission of Intensive Therapy, respectively, decided to review the
literature and draft recommendations for mechanical ventilation with the goal of
creating a document for bedside guidance as to the best practices on mechanical
ventilation available to their members. The document was based on the available
evidence regarding 29 subtopics selected as the most relevant for the subject of
interest. The project was developed in several stages, during which the selected
topics were distributed among experts recommended by both societies with recent
publications on the subject of interest and/or significant teaching and research
activity in the field of mechanical ventilation in Brazil. The experts were divided
into pairs that were charged with performing a thorough review of the international
literature on each topic. All the experts met at the Forum on Mechanical Ventilation,
which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to
collaboratively draft the final text corresponding to each sub-topic, which was
presented to, appraised, discussed and approved in a plenary session that included
all 58 participants and aimed to create the final document.
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El-Khatib MF, Jamaleddine G, Kanj N, Zeineddine S, Chami H, Bou-Akl I, Husari A, Alawieh M, Bou-Khalil P. Effect of heliox- and air-driven nebulized bronchodilator therapy on lung function in patients with asthma. Lung 2014; 192:377-83. [PMID: 24643901 DOI: 10.1007/s00408-014-9570-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 03/02/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study compares the effect of heliox-driven to that of air-driven bronchodilator therapy on the pulmonary function test (PFT) in patients with different levels of asthma severity. METHODS One-hundred thirty-two participants were included in the study. Participants underwent spirometry twice with bronchodilator testing on two consecutive days. Air-driven nebulization was used one day and heliox-driven nebulization the other day in random order crossover design. After a baseline PFT, each participant received 2.5 mg of albuterol sulfate nebulized with the randomized driving gas. Post bronchodilator PFT was repeated after 30 min. The next day, the exact same protocol was repeated, except that the other driving gas was used to nebulize the drug. Participants were subgrouped and analyzed according to their baseline FEV(1) on day 1: Group I, FEV(1) ≥80 %; Group II, 80 % > FEV(1) > 50 %; Group III, FEV(1) ≤50 %. The proportion of participants with greater than 12 % and 200-mL increases from their baseline FEV(1) and the changes from baseline in PFT variables were compared between heliox-driven versus air-driven bronchodilation therapy. RESULTS The proportion of participants with >12 % and 200-mL increases from their baseline FEV(1) with air- or heliox-driven bronchodilation was not different with respect to the proportion of participants with baseline FEV(1) ≥80 % (20 vs. 18 %, respectively) and 80 % > FEV(1) > 50 % (36 vs. 43 %, respectively), but it was significantly greater with heliox-driven bronchodilation in participants with FEV(1) ≤50 % (43 vs. 73 %, respectively; p = 0.01). Changes from baseline FVC, FEV(1), FEV(1)/FVC, FEF(25-75) %, FEF(max), FEF(25) %, FEF(50) %, and FEF(75) % were significantly larger with heliox-driven versus air-driven bronchodilation in participants with baseline FEV(1) ≤50 %. CONCLUSION Improvements in PFT variables are more frequent and profound with heliox-driven compared to air-driven bronchodilator therapy only in asthmatic patients with baseline FEV(1) ≤50 %.
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Affiliation(s)
- Mohamad F El-Khatib
- Department of Anesthesiology, American University of Beirut, Beirut, Lebanon
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Katz I, Pichelin M, Montesantos S, Majoral C, Martin A, Conway J, Fleming J, Venegas J, Greenblatt E, Caillibotte G. Using helium-oxygen to improve regional deposition of inhaled particles: mechanical principles. J Aerosol Med Pulm Drug Deliv 2014; 27:71-80. [PMID: 24383961 DOI: 10.1089/jamp.2013.1072] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Helium-oxygen has been used for decades as a respiratory therapy conjointly with aerosols. It has also been shown under some conditions to be a means to provide more peripheral, deeper, particle deposition for inhalation therapies. Furthermore, we can also consider deposition along parallel paths that are quite different, especially in a heterogeneous pathological lung. It is in this context that it is hypothesized that helium-oxygen can improve regional deposition, leading to more homogeneous deposition by increasing deposition in ventilation-deficient lung regions. METHODS Analytical models of inertial impaction, sedimentation, and diffusion are examined to illustrate the importance of gas property values on deposition distribution through both fluid mechanics- and particle mechanics-based mechanisms. Also considered are in vitro results from a bench model for a heterogeneously obstructed lung. In vivo results from three-dimensional (3D) imaging techniques provide visual examples of changes in particle deposition patterns in asthmatics that are further analyzed using computational fluid dynamics (CFD). RESULTS AND CONCLUSIONS Based on analytical modeling, it is shown that deeper particle deposition is expected when breathing helium-oxygen, as compared with breathing air. A bench model has shown that more homogeneous ventilation distribution is possible breathing helium-oxygen in the presence of heterogeneous obstructions representative of central airway obstructions. 3D imaging of asthmatics has confirmed that aerosol delivery with a helium-oxygen carrier gas results in deeper and more homogeneous deposition distributions. CFD results are consistent with the in vivo imaging and suggest that the mechanics of gas particle interaction are the source of the differences seen in deposition patterns. However, intersubject variability in response to breathing helium-oxygen is expected, and an example of a nonresponder is shown where regional deposition is not significantly changed.
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Affiliation(s)
- I Katz
- 1 R&D Medical Gases Group , Air Liquide Santé International, Les-Loges-en-Josas, France
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