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Goetz RL, Vijaykumar K, Solomon GM. Mucus Clearance Strategies in Mechanically Ventilated Patients. Front Physiol 2022; 13:834716. [PMID: 35399263 PMCID: PMC8984116 DOI: 10.3389/fphys.2022.834716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/10/2022] [Indexed: 12/01/2022] Open
Abstract
The use of airway clearance strategies as supplementary treatment in respiratory disease has been best investigated in patients with cystic fibrosis (CF) and non-cystic fibrosis bronchiectasis (NCFBE), conditions which are traditionally characterized by excessive mucus stasis and mucociliary dysfunction. A variety of airway clearance therapies both pharmacological and non-pharmacological have been shown to ameliorate disease progression in this population and have hence been assimilated into routine respiratory care. This self-propagating cycle of mucus retention and airway damage leading to chronic inflammation and infections can also be applied to patients with respiratory failure requiring mechanical ventilation. Furthermore, excessive trachea-bronchial secretions have been associated with extubation failure presenting an opportunity for intervention. Evidence for the use of adjunctive mucoactive agents and other therapies to facilitate secretion clearance in these patients are not well defined, and this subgroup still remains largely underrepresented in clinical trials. In this review, we discuss the role of mucus clearance techniques with a proven benefit in patients with CF and NCFBE, and their potential role in patients requiring mechanical ventilation while highlighting the need for standardization and adoption of mucus clearance strategies in these patient populations.
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Affiliation(s)
- Ryan L. Goetz
- Department of Medicine, Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kadambari Vijaykumar
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - George M. Solomon
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- The Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, United States
- *Correspondence: George M. Solomon,
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2
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Current and Future Treatments in Primary Ciliary Dyskinesia. Int J Mol Sci 2021; 22:ijms22189834. [PMID: 34575997 PMCID: PMC8470068 DOI: 10.3390/ijms22189834] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 01/05/2023] Open
Abstract
Primary ciliary dyskinesia (PCD) is a rare genetic ciliopathy in which mucociliary clearance is disturbed by the abnormal motion of cilia or there is a severe reduction in the generation of multiple motile cilia. Lung damage ensues due to recurrent airway infections, sometimes even resulting in respiratory failure. So far, no causative treatment is available and treatment efforts are primarily aimed at improving mucociliary clearance and early treatment of bacterial airway infections. Treatment guidelines are largely based on cystic fibrosis (CF) guidelines, as few studies have been performed on PCD. In this review, we give a detailed overview of the clinical studies performed investigating PCD to date, including three trials and several case reports. In addition, we explore precision medicine approaches in PCD, including gene therapy, mRNA transcript and read-through therapy.
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3
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Mandru R, Zhou CY, Pauley R, Burkes RM. Considerations for and Mechanisms of Adjunct Therapy in COPD. J Clin Med 2021; 10:jcm10061225. [PMID: 33809583 PMCID: PMC7999347 DOI: 10.3390/jcm10061225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022] Open
Abstract
Inhaled bronchodilators and corticosteroids, when indicated, form the backbone of COPD therapy. However, over the last decade there has been an emergence of adjunct therapies in oral or inhaled form that are now part of the therapeutic approach to COPD. While these therapies have shown to be beneficial when used in the appropriate instances, there are particular considerations that need to be minded when using these therapies. This review article discussed the mechanism of roflumilast, macrolide antibiotics, other chronic antibiotic regimens, vitamin D supplementation, oral corticosteroids, n-acetylcysteine, and nebulized hypertonic saline, the clinical data behind each of these therapies, adverse events associated with therapy, and the expert recommendations for their utilization. Our goal is to provide a brief but informative and clinically useful review of commonly encountered therapies used in advanced COPD.
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Affiliation(s)
- Rachana Mandru
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH 45221, USA;
| | - Christine Y. Zhou
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.Y.Z.); (R.P.)
| | - Rachel Pauley
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.Y.Z.); (R.P.)
| | - Robert M. Burkes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH 45221, USA;
- Correspondence:
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4
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Nagai N, Sakurai S, Seiriki R, Minami M, Yamaguchi M, Deguchi S, Harata E. MPC Polymer Promotes Recovery from Dry Eye via Stabilization of the Ocular Surface. Pharmaceutics 2021; 13:168. [PMID: 33513827 PMCID: PMC7910948 DOI: 10.3390/pharmaceutics13020168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 11/16/2022] Open
Abstract
The polymer that includes 2-methacryloyloxy ethyl phosphorylcholine (MPC) is well-known as an effectively hydrating multifunction agent. In this study, we prepared an MPC polymer (MPCP) using radical polymerization with co-monomers-MPC/Stearyl Methacrylate/N,N-dimethylacrylamide-and evaluated the MPCP's usefulness for dry eye treatment using a rabbit model treated with N-acetylcysteine. The MPCP particle size was 50-250 nm, and the form was similar to that of micelles. The MPCP viscosity (approximately 0.95 mPa·s) was 1.17-fold that of purified water, and a decrease in the transepithelial electrical resistance value (corneal damage) was not observed in the immortalized human corneal epithelial cell line HCE-T cell (HCE-T cell layer). The MPCP enhanced the water maintenance on the cornea, and the instillation of MPCP increased the lacrimal fluid volume and prolonged the tear film breakup time without an increase in total mucin contents in the lacrimal fluid of the normal rabbits. The therapeutic potential of the MPCP for dry eye was evaluated using an N-acetylcysteine-treated rabbit model, and, in our investigation, we found that MPCP enhanced the volume of lacrimal fluid and promoted an improvement in the tear film breakup levels. These findings regarding the creation and characteristics of a novel MPCP will provide relevant information for designing further studies to develop a treatment for dry eyes.
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Affiliation(s)
- Noriaki Nagai
- Faculty of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-Osaka, Osaka 577-8502, Japan; (R.S.); (M.M.); (M.Y.); (S.D.)
| | - Shunsuke Sakurai
- Life Science Products Division, NOF Corporation, Yebisu Garden Place Tower, 20-3 Ebisu 4-chome, Shibuya-ku, Tokyo 150-6019, Japan; (S.S.); (E.H.)
| | - Ryotaro Seiriki
- Faculty of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-Osaka, Osaka 577-8502, Japan; (R.S.); (M.M.); (M.Y.); (S.D.)
| | - Misa Minami
- Faculty of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-Osaka, Osaka 577-8502, Japan; (R.S.); (M.M.); (M.Y.); (S.D.)
| | - Mizuki Yamaguchi
- Faculty of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-Osaka, Osaka 577-8502, Japan; (R.S.); (M.M.); (M.Y.); (S.D.)
| | - Saori Deguchi
- Faculty of Pharmacy, Kindai University, 3-4-1 Kowakae, Higashi-Osaka, Osaka 577-8502, Japan; (R.S.); (M.M.); (M.Y.); (S.D.)
| | - Eiji Harata
- Life Science Products Division, NOF Corporation, Yebisu Garden Place Tower, 20-3 Ebisu 4-chome, Shibuya-ku, Tokyo 150-6019, Japan; (S.S.); (E.H.)
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5
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Li X, Jin F, Lee HJ, Lee CJ. Recent Advances in the Development of Novel Drug Candidates for Regulating the Secretion of Pulmonary Mucus. Biomol Ther (Seoul) 2020; 28:293-301. [PMID: 32133827 PMCID: PMC7327140 DOI: 10.4062/biomolther.2020.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 01/30/2020] [Accepted: 02/17/2020] [Indexed: 12/14/2022] Open
Abstract
Hypersecretion of pulmonary mucus is a major pathophysiological feature in allergic and inflammatory respiratory diseases including asthma and chronic obstructive pulmonary disease (COPD). Overproduction and/or oversecretion of mucus cause the airway obstruction and the colonization of pathogenic microbes. Developing a novel pharmacological agent to regulate the production and/or secretion of pulmonary mucus can be a useful strategy for the effective management of pathologic hypersecretion of mucus observed in COPD and asthma. Thus, in the present review, we tried to give an overview of the conventional pharmacotherapy for mucus-hypersecretory diseases and recent research results on searching for the novel candidate agents for controlling of pulmonary mucus hypersecretion, aiming to shed light on the potential efficacious pharmacotherapy of mucus-hypersecretory diseases.
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Affiliation(s)
- Xin Li
- Department of Pharmacology, School of Medicine, Chungnam National University, Daejeon 35015, Republic of Korea
| | - Fengri Jin
- Department of Pharmacology, School of Medicine, Chungnam National University, Daejeon 35015, Republic of Korea
| | - Hyun Jae Lee
- Smith Liberal Arts College and Department of Addiction Science, Graduate School, Sahmyook University, Seoul 01795, Republic of Korea
| | - Choong Jae Lee
- Department of Pharmacology, School of Medicine, Chungnam National University, Daejeon 35015, Republic of Korea
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6
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Wang S, Gumpper K, Tan T, Luo X, Guo H, Ming C, Jiang H, Fang J, Du G, Zhu H, Ma J, Chen Z, Gong N. A novel organ preservation solution with efficient clearance of red blood cells improves kidney transplantation in a canine model. Cell Biosci 2018; 8:28. [PMID: 29651333 PMCID: PMC5894212 DOI: 10.1186/s13578-018-0226-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/30/2018] [Indexed: 11/15/2022] Open
Abstract
Organ preservation solutions are designed to minimize organ damage during transplantation. A novel preservation solution, WMO-II, was developed to have a low viscosity and to improve microvasculature perfusion for kidneys. In an autologous canine transplantation model, kidney function and recovery were evaluated after organs were flushed and cold-stored with WMO-II or HTK solution, a perfusate currently approved for clinical use. The average number of red blood cells remaining in a single glomerulus after flushing with WMO-II was significantly reduced when compared with HTK solution. Additionally, WMO-II reduced the number of apoptotic bodies in stored kidneys compared to HTK treated tissue after 48 h of cold storage by reducing expression of Caspase-9, BiP, Chop, and Caspase-12. WMO-II solution reduced serum creatinine levels and serum potassium in kidneys stored for 48 h when compared to HTK perfusion. WMO-II preserves kidney function as evidenced by the reduction in serum creatinine and potassium during graft transplantation.
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Affiliation(s)
- Sheng Wang
- 1Institute of Organ Transplantation, Key Laboratory of the Ministry of Health and the Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Kristyn Gumpper
- 2Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH 43210 USA
| | - Tao Tan
- 2Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH 43210 USA
| | - Xianzhang Luo
- 1Institute of Organ Transplantation, Key Laboratory of the Ministry of Health and the Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Hui Guo
- 1Institute of Organ Transplantation, Key Laboratory of the Ministry of Health and the Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Changsheng Ming
- 1Institute of Organ Transplantation, Key Laboratory of the Ministry of Health and the Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Hanying Jiang
- 1Institute of Organ Transplantation, Key Laboratory of the Ministry of Health and the Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China.,4Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Jiangguo Fang
- 4Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Guang Du
- 4Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Hua Zhu
- 2Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH 43210 USA
| | - Jianjie Ma
- 2Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH 43210 USA.,3Department of Molecular and Cellular Biochemistry, The Ohio State University, Columbus, OH 43210 USA
| | - Zhishui Chen
- 1Institute of Organ Transplantation, Key Laboratory of the Ministry of Health and the Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
| | - Nianqiao Gong
- 1Institute of Organ Transplantation, Key Laboratory of the Ministry of Health and the Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030 China
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7
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Zayed MA, Wei X, Park KM, Belaygorod L, Naim U, Harvey J, Yin L, Blumer K, Semenkovich CF. N-Acetylcysteine accelerates amputation stump healing in the setting of diabetes. FASEB J 2017; 31:2686-2695. [PMID: 28280002 DOI: 10.1096/fj.201601348r] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 02/21/2017] [Indexed: 11/11/2022]
Abstract
Over 60% of lower extremity amputations are performed in patients with diabetes and peripheral arterial disease, and at least 25% require subsequent reamputation due to poor surgical site healing. The mechanisms underlying poor amputation stump healing in the setting of diabetes are not understood. N-acetylcysteine (NAC) is known to promote endothelial cell function and angiogenesis and may have therapeutic benefits in the setting of diabetes. We tested the hypothesis that NAC alters the vascular milieu to improve healing of amputation stumps in diabetes using a novel in vivo murine hindlimb ischemia-amputation model. Amputation stump tissue perfusion and healing were evaluated in C57BL/6J adult mice with streptozotocin-induced diabetes. Compared with controls, mice treated with daily NAC demonstrated improved postamputation stump healing, perfusion, adductor muscle neovascularization, and decreased muscle fiber damage. Additionally, NAC stimulated HUVEC migration and proliferation in a phospholipase C β-dependent fashion and decreased Gαq palmitoylation. Similarly, NAC treatment also decreased Gαq palmitoylation in ischemic and nonischemic hindlimbs in vivo In summary, we demonstrate that NAC accelerates healing of amputation stumps in the setting of diabetes and ischemia. The underlying mechanism appears to involve a previously unrecognized effect of NAC on Gαq palmitoylation and phospholipase C β-mediated signaling in endothelial cells.-Zayed, M. A., Wei, X., Park, K., Belaygorod, L., Naim, U., Harvey, J., Yin, L., Blumer, K., Semenkovich, C. F. N-acetylcysteine accelerates amputation stump healing in the setting of diabetes.
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Affiliation(s)
- Mohamed A Zayed
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; .,Department of Surgery, St. Louis Veterans Affairs Health Care System, St. Louis, Missouri, USA
| | - Xiachao Wei
- Division of Endocrinology, Metabolism, and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kyoung-Mi Park
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Larisa Belaygorod
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Uzma Naim
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joseph Harvey
- Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Li Yin
- Division of Endocrinology, Metabolism, and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kendall Blumer
- Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Clay F Semenkovich
- Division of Endocrinology, Metabolism, and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, Missouri, USA
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8
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da Cunha AA, Nuñez NK, de Souza RG, Vargas MHM, Silveira JS, Antunes GL, Schmitz F, de Souza Wyse AT, Jones MH, Pitrez PM. Recombinant human deoxyribonuclease attenuates oxidative stress in a model of eosinophilic pulmonary response in mice. Mol Cell Biochem 2016; 413:47-55. [PMID: 26738487 DOI: 10.1007/s11010-015-2638-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/23/2015] [Indexed: 12/14/2022]
Abstract
The inflammatory cells infiltrating the airways produce several mediators, such as reactive oxygen species (ROS). ROS and the oxidant-antioxidant imbalance might play an important role in the modulation of airways inflammation. In order to avoid the undesirable effects of ROS, various endogenous antioxidant strategies have evolved, incorporating both enzymatic and non-enzymatic mechanisms. Recombinant human deoxyribonuclease (rhDNase) in clinical studies demonstrated a reduction in sputum viscosity, cleaving extracellular DNA in the airways, and facilitating mucus clearance, but an antioxidant effect was not studied so far. Therefore, we evaluated whether the administration of rhDNase improves oxidative stress in a murine model of asthma. Mice were sensitized by two subcutaneous injections of ovalbumin (OVA), on days 0 and 7, followed by three lung challenges with OVA on days 14, 15, and 16. On days 15 and 16, after 2 h of the challenge with OVA, mice received 1 mg/mL of rhDNase in the lungs. Bronchoalveolar lavage fluid and lung tissue were obtained on day 17, for inflammatory and oxidative stress analysis. We showed that rhDNase did not alter the population of inflammatory cells, such as eosinophil cells, in OVA-treated rhDNase group but significantly improved oxidative stress in lung tissue, by decreasing oxygen reactive species and increasing superoxide dismutase/catalase ratio, glutathione peroxidase activity, and thiol content. Our data provide the first evidence that rhDNase decreases some measures of oxidative stress and antioxidant status in a murine model of asthma, with a potential antioxidant effect to be further studied in human asthma.
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Affiliation(s)
- Aline Andrea da Cunha
- Laboratory of Pediatric Respirology, Infant Center, Institute of Biomedical Research, Pontifícia Universidade Católica do Rio Grande do Sul, 6690 Ipiranga Avenue, 2nd Floor, Room 13, Porto Alegre, RS, 90610-000, Brazil.
| | - Nailê Karine Nuñez
- Laboratory of Pediatric Respirology, Infant Center, Institute of Biomedical Research, Pontifícia Universidade Católica do Rio Grande do Sul, 6690 Ipiranga Avenue, 2nd Floor, Room 13, Porto Alegre, RS, 90610-000, Brazil
| | - Rodrigo Godinho de Souza
- Laboratory of Pediatric Respirology, Infant Center, Institute of Biomedical Research, Pontifícia Universidade Católica do Rio Grande do Sul, 6690 Ipiranga Avenue, 2nd Floor, Room 13, Porto Alegre, RS, 90610-000, Brazil
| | - Mauro Henrique Moraes Vargas
- Laboratory of Pediatric Respirology, Infant Center, Institute of Biomedical Research, Pontifícia Universidade Católica do Rio Grande do Sul, 6690 Ipiranga Avenue, 2nd Floor, Room 13, Porto Alegre, RS, 90610-000, Brazil
| | - Josiane Silva Silveira
- Laboratory of Pediatric Respirology, Infant Center, Institute of Biomedical Research, Pontifícia Universidade Católica do Rio Grande do Sul, 6690 Ipiranga Avenue, 2nd Floor, Room 13, Porto Alegre, RS, 90610-000, Brazil
| | - Géssica Luana Antunes
- Laboratory of Pediatric Respirology, Infant Center, Institute of Biomedical Research, Pontifícia Universidade Católica do Rio Grande do Sul, 6690 Ipiranga Avenue, 2nd Floor, Room 13, Porto Alegre, RS, 90610-000, Brazil
| | - Felipe Schmitz
- Laboratory of Neuroprotection and Neurometabolic Disease, Department of Biochemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Angela Terezinha de Souza Wyse
- Laboratory of Neuroprotection and Neurometabolic Disease, Department of Biochemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marcus Herbert Jones
- Laboratory of Respiratory Physiology, Infant Center, Institute of Biomedical Research, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Paulo Márcio Pitrez
- Laboratory of Pediatric Respirology, Infant Center, Institute of Biomedical Research, Pontifícia Universidade Católica do Rio Grande do Sul, 6690 Ipiranga Avenue, 2nd Floor, Room 13, Porto Alegre, RS, 90610-000, Brazil
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9
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van der Hoeven SM, Binnekade JM, de Borgie CAJM, Bosch FH, Endeman H, Horn J, Juffermans NP, van der Meer NJM, Merkus MP, Moeniralam HS, van Silfhout B, Slabbekoorn M, Stilma W, Wijnhoven JW, Schultz MJ, Paulus F. Preventive nebulization of mucolytic agents and bronchodilating drugs in invasively ventilated intensive care unit patients (NEBULAE): study protocol for a randomized controlled trial. Trials 2015; 16:389. [PMID: 26329352 PMCID: PMC4557315 DOI: 10.1186/s13063-015-0865-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/14/2015] [Indexed: 01/09/2023] Open
Abstract
Background Preventive nebulization of mucolytic agents and bronchodilating drugs is a strategy aimed at the prevention of sputum plugging, and therefore atelectasis and pneumonia, in intubated and ventilated intensive care unit (ICU) patients. The present trial aims to compare a strategy using the preventive nebulization of acetylcysteine and salbutamol with nebulization on indication in intubated and ventilated ICU patients. Methods/Design The preventive nebulization of mucolytic agents and bronchodilating drugs in invasively ventilated intensive care unit patients (NEBULAE) trial is a national multicenter open-label, two-armed, randomized controlled non-inferiority trial in the Netherlands. Nine hundred and fifty intubated and ventilated ICU patients with an anticipated duration of invasive ventilation of more than 24 hours will be randomly assigned to receive either a strategy consisting of preventive nebulization of acetylcysteine and salbutamol or a strategy consisting of nebulization of acetylcysteine and/or salbutamol on indication. The primary endpoint is the number of ventilator-free days and surviving on day 28. Secondary endpoints include ICU and hospital length of stay, ICU and hospital mortality, the occurrence of predefined pulmonary complications (acute respiratory distress syndrome, pneumonia, large atelectasis and pneumothorax), and the occurrence of predefined side effects of the intervention. Related healthcare costs will be estimated in a cost-benefit and budget-impact analysis. Discussion The NEBULAE trial is the first randomized controlled trial powered to investigate whether preventive nebulization of acetylcysteine and salbutamol shortens the duration of ventilation in critically ill patients. Trial registration NCT02159196, registered on 6 June 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0865-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophia M van der Hoeven
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Jan M Binnekade
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | | | - Frank H Bosch
- Department of Intensive Care, Rijnstate, Arnhem, The Netherlands.
| | - Henrik Endeman
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology (L E I C A), Amsterdam, The Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology (L E I C A), Amsterdam, The Netherlands.
| | - Nardo J M van der Meer
- Department of Intensive Care, Amphia Hospital, Breda, Oosterhout and Etten-Leur, The Netherlands. .,Tias/Tilburg University, Tilburg, The Netherlands.
| | | | - Hazra S Moeniralam
- Department of Intensive Care, Antonius Hospital, Nieuwegein, The Netherlands.
| | - Bart van Silfhout
- Department of Intensive Care, Antonius Hospital, Nieuwegein, The Netherlands.
| | - Mathilde Slabbekoorn
- Department of Intensive Care, Medical Center Haaglanden and Leidschendam, The Hague, The Netherlands.
| | - Willemke Stilma
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Jan Willem Wijnhoven
- Department of Intensive Care, Amphia Hospital, Breda, Oosterhout and Etten-Leur, The Netherlands.
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology (L E I C A), Amsterdam, The Netherlands.
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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10
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Criner GJ, Bourbeau J, Diekemper RL, Ouellette DR, Goodridge D, Hernandez P, Curren K, Balter MS, Bhutani M, Camp PG, Celli BR, Dechman G, Dransfield MT, Fiel SB, Foreman MG, Hanania NA, Ireland BK, Marchetti N, Marciniuk DD, Mularski RA, Ornelas J, Road JD, Stickland MK. Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest 2015; 147:894-942. [PMID: 25321320 PMCID: PMC4388124 DOI: 10.1378/chest.14-1676] [Citation(s) in RCA: 177] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 09/17/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND COPD is a major cause of morbidity and mortality in the United States as well as throughout the rest of the world. An exacerbation of COPD (periodic escalations of symptoms of cough, dyspnea, and sputum production) is a major contributor to worsening lung function, impairment in quality of life, need for urgent care or hospitalization, and cost of care in COPD. Research conducted over the past decade has contributed much to our current understanding of the pathogenesis and treatment of COPD. Additionally, an evolving literature has accumulated about the prevention of acute exacerbations. METHODS In recognition of the importance of preventing exacerbations in patients with COPD, the American College of Chest Physicians (CHEST) and Canadian Thoracic Society (CTS) joint evidence-based guideline (AECOPD Guideline) was developed to provide a practical, clinically useful document to describe the current state of knowledge regarding the prevention of acute exacerbations according to major categories of prevention therapies. Three key clinical questions developed using the PICO (population, intervention, comparator, and outcome) format addressed the prevention of acute exacerbations of COPD: nonpharmacologic therapies, inhaled therapies, and oral therapies. We used recognized document evaluation tools to assess and choose the most appropriate studies and to extract meaningful data and grade the level of evidence to support the recommendations in each PICO question in a balanced and unbiased fashion. RESULTS The AECOPD Guideline is unique not only for its topic, the prevention of acute exacerbations of COPD, but also for the first-in-kind partnership between two of the largest thoracic societies in North America. The CHEST Guidelines Oversight Committee in partnership with the CTS COPD Clinical Assembly launched this project with the objective that a systematic review and critical evaluation of the published literature by clinical experts and researchers in the field of COPD would lead to a series of recommendations to assist clinicians in their management of the patient with COPD. CONCLUSIONS This guideline is unique because it provides an up-to-date, rigorous, evidence-based analysis of current randomized controlled trial data regarding the prevention of COPD exacerbations.
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Affiliation(s)
| | - Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada
| | | | | | - Donna Goodridge
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kristen Curren
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | | | - Mohit Bhutani
- Division of Respirology, University of Toronto, Toronto, ON, Canada
| | - Pat G Camp
- University of Alberta, Edmonton, AB, Canada
| | - Bartolome R Celli
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Gail Dechman
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Mark T Dransfield
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, AL
| | | | | | | | | | | | - Darcy D Marciniuk
- Division of Respirology, Critical Care and Sleep Medicine, Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
| | | | | | - Jeremy D Road
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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11
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Tam J, Nash EF, Ratjen F, Tullis E, Stephenson A. Nebulized and oral thiol derivatives for pulmonary disease in cystic fibrosis. Cochrane Database Syst Rev 2013; 2013:CD007168. [PMID: 23852992 PMCID: PMC8078644 DOI: 10.1002/14651858.cd007168.pub3] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Cystic fibrosis is an inherited condition resulting in thickened, sticky respiratory secretions. Respiratory failure, due to recurrent pulmonary infection and inflammation, is the most common cause of mortality. Muco-active therapies (e.g. dornase alfa and nebulized hypertonic saline) may decrease sputum viscosity, increase airway clearance of sputum, reduce infection and inflammation and improve lung function. Thiol derivatives, either oral or nebulized, have shown benefit in other respiratory diseases. Their mode of action is likely to differ according to the route of administration. There are several thiol derivatives, and it is unclear which of these may be beneficial in cystic fibrosis. OBJECTIVES To evaluate the efficacy and safety of nebulized and oral thiol derivatives in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches, hand searches of relevant journals, abstract books and conference proceedings.Most recent search: 13 June 2013.We also conducted a PubMed search on 26 February 2013 for relevant published articles. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing nebulized or oral thiol derivatives to placebo or another thiol derivative in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS The authors independently assessed trials for inclusion, analysed risk of bias and extracted data. MAIN RESULTS Searches identified 23 trials; nine trials (255 participants) are included, of these seven trials are more than 10 years old. Three trials of nebulized thiol derivatives were identified (one compared 20% N-acetylcysteine to 2% N-acetylcysteine; another compared sodium-2-mercaptoethane sulphonate to 7% hypertonic saline; and another compared glutathione to 4% hypertonic saline). Although generally well-tolerated with no significant adverse effects, there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments.Six trials of oral thiol derivatives were identified. Three trials compared N-acetylcysteine to placebo; one compared N-acetylcysteine, ambroxol and placebo; one compared carbocysteine to ambroxol; and one compared low and high-dose N-acetylcysteine. Oral thiol derivatives were generally well-tolerated with no significant adverse effects, however there was no evidence of significant clinical benefit in our primary outcomes in participants receiving these treatments. AUTHORS' CONCLUSIONS We found no evidence to recommend the use of either nebulized or oral thiol derivatives in people with cystic fibrosis. There are very few good quality trials investigating the effect of these medications in cystic fibrosis, and further research is required to investigate the potential role of these medications in improving the outcomes of people with cystic fibrosis.
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Affiliation(s)
- Julian Tam
- Division of Respirology, Critical Care, and SleepMedicine. Department ofMedicine, University of Saskatchewan, Saskatoon,
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12
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Pillai K, Akhter J, Chua TC, Morris DL. Potential mucolytic agents for mucinous ascites from pseudomyxoma peritonei. Invest New Drugs 2012; 30:2080-6. [PMID: 22359216 DOI: 10.1007/s10637-012-9797-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 01/20/2012] [Indexed: 11/24/2022]
Abstract
Pseudomyxoma peritonei is a disease characterised by the accumulation of mucinous ascites. Thus far, cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to be effective at eradicating disease. Chemotherapy has been less effective, providing disease stabilization but not demonstrating significant treatment responses. Mucolytic is a potential class of drug that may be exploited in the chemical management of this disease. A variety of potential mucolytic agents are explored in this review providing evidence of basic biochemical evidence of its efficacy with potential translational application.
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Affiliation(s)
- Krishna Pillai
- Department of Surgery Cancer Research Laboratories, University of New South Wales, Sydney, Australia
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Affiliation(s)
- Mark R Elkins
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050, Australia.
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14
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Suk JS, Lai SK, Boylan NJ, Dawson MR, Boyle MP, Hanes J. Rapid transport of muco-inert nanoparticles in cystic fibrosis sputum treated with N-acetyl cysteine. Nanomedicine (Lond) 2011; 6:365-75. [PMID: 21385138 DOI: 10.2217/nnm.10.123] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIMS Sputum poses a critical diffusional barrier that strongly limits the efficacy of drug and gene carriers in the airways of individuals with cystic fibrosis (CF). Previous attempts to enhance particle penetration of CF sputum have focused on either reducing its barrier properties via mucolytics, or decreasing particle adhesion to sputum constituents by coating the particle surface with non-mucoadhesive polymers, including polyethylene glycol (PEG). Neither approach has enabled particles to penetrate expectorated sputum at rates previously observed for non-mucoadhesive nanoparticles in human cervicovaginal mucus. Here, we sought to investigate whether a common mucolytic, N-acetyl cysteine (NAC), in combination with dense PEG coatings on particles, can synergistically enhance particle penetration across fresh undiluted CF sputum. MATERIALS & METHODS We used high-resolution multiple particle tracking to measure the diffusion of uncoated and PEG-coated nanoparticles in native and NAC-treated CF sputum. RESULTS We discovered that 200 nm particles, if densely coated with PEG, were able to penetrate CF sputum pretreated with NAC with average speeds approaching their theoretical speeds in water. Based on the rapid penetration of PEG-coated particles in NAC-treated sputum, we determined that the average spacing between sputum mesh elements was increased from 145 ± 50 nm to 230 ± 50 nm upon NAC treatment. Mathematical models based on particle transport rates suggest as much as 75 and 30% of 200 and 500 nm PEG-coated particles, respectively, may penetrate a physiologically thick NAC-treated CF sputum layer within 20 min. Uncoated particles were trapped in CF sputum pretreated with NAC nearly to the same extent as in native sputum, suggesting that NAC treatment alone offered little improvement to particle penetration. CONCLUSION NAC facilitated rapid diffusion of PEG-coated, muco-inert nanoparticles in CF sputum. Our results provide a promising strategy to improve drug and gene carrier penetration in CF sputum, offering hope for improved therapies for CF.
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Affiliation(s)
- Jung Soo Suk
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, MD, USA
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15
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Chen J, Reheman A, Gushiken FC, Nolasco L, Fu X, Moake JL, Ni H, López JA. N-acetylcysteine reduces the size and activity of von Willebrand factor in human plasma and mice. J Clin Invest 2011; 121:593-603. [PMID: 21266777 DOI: 10.1172/jci41062] [Citation(s) in RCA: 166] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 11/17/2010] [Indexed: 12/18/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease characterized by systemic microvascular thrombosis caused by adhesion of platelets to ultra-large vWF (ULVWF) multimers. These multimers accumulate because of a deficiency of the processing enzyme ADAMTS13. vWF protein forms long multimers from homodimers that first form through C-terminal disulfide bonds and then join through their N termini by further disulfide bonding. N-acetylcysteine (NAC) is an FDA-approved drug that has long been used to treat chronic obstructive lung disease and acetaminophen toxicity and is known to function in the former disorder by reducing mucin multimers. Here, we examined whether NAC could reduce vWF multimers, which polymerize in a manner similar to mucins. In vitro, NAC reduced soluble plasma-type vWF multimers in a concentration-dependent manner and rapidly degraded ULVWF multimer strings extruded from activated ECs. The effect was preceded by reduction of the intrachain disulfide bond encompassing the platelet-binding A1 domain. NAC also inhibited vWF-dependent platelet aggregation and collagen binding. Injection of NAC into ADAMTS13-deficient mice led to the rapid resolution of thrombi produced by ionophore treatment of the mesenteric venules and reduced plasma vWF multimers. These results suggest that NAC may be a rapid and effective treatment for patients with TTP.
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Affiliation(s)
- Junmei Chen
- Puget Sound Blood Center, 921 Terry Ave., Seattle, Washington 98104, USA
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16
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Lai SK, Wang YY, Wirtz D, Hanes J. Micro- and macrorheology of mucus. Adv Drug Deliv Rev 2009; 61:86-100. [PMID: 19166889 PMCID: PMC2736374 DOI: 10.1016/j.addr.2008.09.012] [Citation(s) in RCA: 698] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2007] [Accepted: 09/22/2008] [Indexed: 11/30/2022]
Abstract
Mucus is a complex biological material that lubricates and protects the human lungs, gastrointestinal (GI) tract, vagina, eyes, and other moist mucosal surfaces. Mucus serves as a physical barrier against foreign particles, including toxins, pathogens, and environmental ultrafine particles, while allowing rapid passage of selected gases, ions, nutrients, and many proteins. Its selective barrier properties are precisely regulated at the biochemical level across vastly different length scales. At the macroscale, mucus behaves as a non-Newtonian gel, distinguished from classical solids and liquids by its response to shear rate and shear stress, while, at the nanoscale, it behaves as a low viscosity fluid. Advances in the rheological characterization of mucus from the macroscopic to nanoscopic levels have contributed critical understanding to mucus physiology, disease pathology, and the development of drug delivery systems designed for use at mucosal surfaces. This article reviews the biochemistry that governs mucus rheology, the macro- and microrheology of human and laboratory animal mucus, rheological techniques applied to mucus, and the importance of an improved understanding of the physical properties of mucus to advancing the field of drug and gene delivery.
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Affiliation(s)
- Samuel K. Lai
- Department of Chemical & Biomolecular Engineering (JH Primary Appointment), Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218
| | - Ying-Ying Wang
- Department of Biomedical Engineering, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Denis Wirtz
- Department of Chemical & Biomolecular Engineering (JH Primary Appointment), Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218
- Institute for NanoBioTechnology, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218
| | - Justin Hanes
- Department of Chemical & Biomolecular Engineering (JH Primary Appointment), Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218
- Institute for NanoBioTechnology, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218
- Department of Biomedical Engineering, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21205
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17
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Lai SK, Wang YY, Hanes J. Mucus-penetrating nanoparticles for drug and gene delivery to mucosal tissues. Adv Drug Deliv Rev 2009; 61:158-71. [PMID: 19133304 PMCID: PMC2667119 DOI: 10.1016/j.addr.2008.11.002] [Citation(s) in RCA: 1187] [Impact Index Per Article: 79.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Accepted: 11/21/2008] [Indexed: 12/31/2022]
Abstract
Mucus is a viscoelastic and adhesive gel that protects the lung airways, gastrointestinal (GI) tract, vagina, eye and other mucosal surfaces. Most foreign particulates, including conventional particle-based drug delivery systems, are efficiently trapped in human mucus layers by steric obstruction and/or adhesion. Trapped particles are typically removed from the mucosal tissue within seconds to a few hours depending on anatomical location, thereby strongly limiting the duration of sustained drug delivery locally. A number of debilitating diseases could be treated more effectively and with fewer side effects if drugs and genes could be more efficiently delivered to the underlying mucosal tissues in a controlled manner. This review first describes the tenacious mucus barrier properties that have precluded the efficient penetration of therapeutic particles. It then reviews the design and development of new mucus-penetrating particles that may avoid rapid mucus clearance mechanisms, and thereby provide targeted or sustained drug delivery for localized therapies in mucosal tissues.
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Affiliation(s)
- Samuel K. Lai
- Department of Chemical & Biomolecular Engineering (JH Primary Appointment), Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218
- Institute for NanoBioTechnology, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218
| | - Ying-Ying Wang
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Justin Hanes
- Department of Chemical & Biomolecular Engineering (JH Primary Appointment), Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218
- Institute for NanoBioTechnology, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21205
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18
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Jelic S, Cunningham JA, Factor P. Clinical review: airway hygiene in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:209. [PMID: 18423061 PMCID: PMC2447567 DOI: 10.1186/cc6830] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Maintenance of airway secretion clearance, or airway hygiene, is important for the preservation of airway patency and the prevention of respiratory tract infection. Impaired airway clearance often prompts admission to the intensive care unit (ICU) and can be a cause and/or contributor to acute respiratory failure. Physical methods to augment airway clearance are often used in the ICU but few are substantiated by clinical data. This review focuses on the impact of oral hygiene, tracheal suctioning, bronchoscopy, mucus-controlling agents, and kinetic therapy on the incidence of hospital-acquired respiratory infections, length of stay in the hospital and the ICU, and mortality in critically ill patients. Available data are distilled into recommendations for the maintenance of airway hygiene in ICU patients.
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Affiliation(s)
- Sanja Jelic
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, 630 West 168th Street, New York, NY 10032, USA.
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19
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Gallon AM. Evaluation of nebulised acetylcysteine and normal saline in the treatment of sputum retention following thoracotomy. Thorax 1996; 51:429-32. [PMID: 8733499 PMCID: PMC1090682 DOI: 10.1136/thx.51.4.429] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of acetylcysteine as a mucolytic agent is controversial. In 1962 it was claimed to be "the most effective agent ... for the liquefaction of ... secretions" but was subsequently taken off the market as a respirator solution. Normal saline, on the other hand, is becoming increasingly popular. A study was undertaken to determine which solution is more effective at clearing retained secretions following thoracotomy. METHODS The study included 10 patients and was of single blind, two-way crossover design. Measurements taken before and after each treatment included sputum viscosity, difficulty of expectoration, weight of sputum expectorated, and oxygen saturation. RESULTS Following nebulisation of acetylcysteine, sputum viscosity was reduced, difficulty of expectoration was reduced, the weight of sputum expectorated was increased, and oxygen saturation was increased. There were no changes after nebulisation of normal saline. CONCLUSIONS This study shows that, following thoracotomy, nebulised acetylcysteine reduces sputum viscosity, making expectoration easier and improving oxygenation. Nebulised normal saline has no effect.
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Affiliation(s)
- A M Gallon
- Norfolk and Norwich Health Care NHS Trust, UK
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20
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Krieg DP, Bass JA, Mattingly SJ. Phosphorylcholine stimulates capsule formation of phosphate-limited mucoid Pseudomonas aeruginosa. Infect Immun 1988; 56:864-73. [PMID: 3126146 PMCID: PMC259382 DOI: 10.1128/iai.56.4.864-873.1988] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Production of both alginic acid and lipopolysaccharide by a mucoid strain of Pseudomonas aeruginosa, SRM-3, was studied in a chemostat system during growth under nutrient-limiting conditions chosen to reflect the chronic growth conditions in the lungs of cystic fibrosis patients. Since mucoid strains have been shown to elaborate extracellular proteases and phospholipase C, nitrogen and phosphate limitation were selected for analysis. A modified alginate-promoting medium containing either 1 mM glutamate or 0.05 mM K2HPO4 as limiting nutrient and doubling times of 1.6 to 15.7 h were used. Under nitrogen limitation, strain SRM-3 produced 1.4 mg of uronic acid per mg (dry weight) of cells at all doubling times studied. However, phosphate limitation resulted in the synthesis of only 0.4 mg of uronic acid per mg (dry weight) of cells. The role of phosphate in alginic acid polysaccharide production was further investigated by using phosphorylcholine, a product of phospholipase C activity on phosphatidylcholine, the major lung surfactant. No only were mucoid cells capable of utilizing phosphorylcholine for growth, but a highly specific interaction occurred among phosphorylcholine, alginate, and whole cells, resulting in greatly enhanced culture viscosity. Electron micrographs showed the gradual formation of a capsule during growth on phosphorylcholine, indicating that the mucoid strain has the ability to utilize surfactant not only as a nutrient source but also for constructing a capsule with greatly enhanced adhesive properties.
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Affiliation(s)
- D P Krieg
- Department of Microbiology, University of Texas Health Science Center, San Antonio 78284-7758
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21
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Ratjen F, Wönne R, Posselt HG, Stöver B, Hofmann D, Bender SW. A double-blind placebo controlled trial with oral ambroxol and N-acetylcysteine for mucolytic treatment in cystic fibrosis. Eur J Pediatr 1985; 144:374-8. [PMID: 3908111 DOI: 10.1007/bf00441781] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The therapeutic efficacy of oral N-acetylcysteine (NAC) and ambroxol as compared with the effect of placebos was studied in 36 cystic fibrosis (CF) patients with mild to moderate pulmonary disease. The patients were randomly assigned to one of three regimens, matched on the basis of age and Chrispin-Norman scores. The trial was conducted over a period of 12 weeks. Patients were assessed clinically and by extensive pulmonary function techniques (body-plethysmography, maximal expiratory flow-volume curves, trapped air determination). Although no clinical differences could be observed between the three groups, significant impairment in the placebo group was found for trapped air and FEV1 when compared to the active groups, suggesting a therapeutic effect of ambroxol and NAC in CF.
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22
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Thomson ML, Pavia D, Jones CJ, McQuiston TA. No demonstrable effect of S-carboxymethylcysteine on clearance of secretions from the human lung. Thorax 1975; 30:669-73. [PMID: 769242 PMCID: PMC470344 DOI: 10.1136/thx.30.6.669] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The mucolytic efficacy of S-carboxymethylcysteine has been assessed in a double-blind crossover trial in 16 patients with chronic obstructive bronchitis. No significant difference was found between drug and placebo after four or seven days' treatment in the rate of clearance of secretions from the lung. This was measured by external counting of previously inhaled polystyrene tracer particles tagged with technetium-99m (99mTc). Lateral scans across the right chest after inhaling the aerosol showed equal penetration of particles towards the periphery of the lung in drug and placebo runs; this indicated that the airways had not been cleared of mucus by the drug. There was no significant difference between drug and placebo runs in the number of coughs or the weight and radioactive content of sputum voided or raised at the end of the run by chest percussion and postural drainage. Ventilatory capacity was not significantly changed nor was there any subjective improvement in the patients as a result of taking the drug.
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Obenberger J, Cejková J. Corneal damage following intracorneal injection of N-acetyl-L-cysteine. ALBRECHT VON GRAEFES ARCHIV FUR KLINISCHE UND EXPERIMENTELLE OPHTHALMOLOGIE. ALBRECHT VON GRAEFE'S ARCHIVE FOR CLINICAL AND EXPERIMENTAL OPHTHALMOLOGY 1972; 185:171-6. [PMID: 4115958 DOI: 10.1007/bf00410060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
In vitro and in vivo studies were made on the sputum of chronic bronchitics using a Ferranti-Shirley cone and plate viscometer and a new stress relaxation method. The latter utilized a modified chemical balance and permitted study at very low shear rates. The results from simpler apparatus correlated well with the data obtained with the cone and plate viscometer. Significant reduction in four chosen parameters of viscosity occurred in vitro with N-acetylcysteine and with ascorbic acid-hydrogen peroxide-cupric ion complex (A.A.H.Cu.), but not with 4-molar urea. In vivo studies showed that, using freshly prepared A.A.H.Cu in an efficient hospital nebulizer, a statistically significant reduction in the four viscosity parameters occurred with subjective ease of expectoration. Nebulization of A.A.H.Cu performed with a simpler domestic-type nebulizer did not produce satisfactory reduction of viscosity or ease of expectoration. Rheological methods previously employed to study mucus and mucolytic agent activity are briefly reviewed.
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