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Baker JA. 2022 Year in Review: Pediatric Asthma. Respir Care 2023; 68:1430-1437. [PMID: 37160339 PMCID: PMC10506641 DOI: 10.4187/respcare.10913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Asthma is the most common chronic disease in children. Asthma is a heterogeneous disease characterized by variable, reversible airway obstruction and hyper-responsive airways. There is a high economic burden due to a child having poorly controlled asthma with one or more asthma exacerbations resulting in an emergency department visit or hospitalization in a year. Publications on diagnosis, treatment, and management of pediatric asthma are ongoing with over 2,549 papers published from January-November 2022. The intent of this paper is to summarize 8 key topics that have prompted discussions with local, regional, and national asthma experts due to a shift in clinical practice or lessons learned from the recent pandemic that may have future application.
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Affiliation(s)
- Joyce A Baker
- Breathing Institute, Children's Hospital Colorado, Aurora, Colorado.
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Colaianni-Alfonso N, MacLoughlin R, Espada A, Saa Y, Techera M, Toledo A, Montiel G, Castro-Sayat M. Delivery of Aerosolized Bronchodilators by High-Flow Nasal Cannula During COPD Exacerbation. Respir Care 2023; 68:721-726. [PMID: 37041023 PMCID: PMC10209003 DOI: 10.4187/respcare.10614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND Bronchodilator delivery via a high-flow nasal cannula (HFNC) has generated interest in recent years. The efficacy of in-line vibrating mesh nebulizers with an HFNC during COPD exacerbation is limited. The aim of this study was to evaluate the clinical response of subjects with COPD exacerbation who require bronchodilator therapy (anticholinergic and β-agonist) by using a vibrating mesh nebulizer in line with an HFNC. METHODS This was a prospective single-center study performed in a respiratory intermediate care unit that enrolled patients with a diagnosis of COPD exacerbation who required noninvasive ventilation on admission. All the subjects underwent noninvasive ventilation breaks with an HFNC. After clinical stability, pulmonary function tests were performed to assess changes in FEV1 and clinical parameters before and after bronchodilation by using a vibrating mesh nebulizer in line with an HFNC. RESULTS Forty-six patients with COPD exacerbation were admitted. Five patients who did not use noninvasive ventilation and 10 patients who did not receive bronchodilator treatment with a vibrating mesh nebulizer were excluded. Thirty-one were selected, but 1 subject was secondarily excluded due to loss of data. Finally, 30 subjects were included. The primary outcome was spirometric changes in FEV1. The mean ± SD FEV1 before receiving bronchodilator treatment by using a vibrating mesh nebulizer in line with an HFNC was 0.74 ± 0.10 L, and, after receiving treatment, the mean ± SD FEV1 changed to 0.88 ± 0.12 L (P < .001). Similarly, the mean ± SD FVC increased from 1.75 ± 0.54 L to 2.13 ± 0.63 L (P < .001). Considerable differences were observed in breathing frequency and heart rate after receiving bronchodilator treatment. No relevant changes were observed in the Borg scale or Sp O2 after treatment. The mean clinical stability recorded was 4 d. CONCLUSIONS In subjects with COPD exacerbation, bronchodilator treatment by using a vibrating mesh nebulizer in line with an HFNC showed a mild but significant improvement in FEV1 and FVC. In addition, a decrease in breathing frequency was observed, suggesting a reduction in dynamic hyperinflation.
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Affiliation(s)
- Nicolás Colaianni-Alfonso
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Ronan MacLoughlin
- Dr Research and Development, Science and Emerging Technologies, Aerogen Ltd, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
| | - Ariel Espada
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Yasmine Saa
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mariano Techera
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ada Toledo
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Guillermo Montiel
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mauro Castro-Sayat
- Respiratory Intermediate Care Unit, Hospital General de Agudos Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina
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O'Neil JA, Villasmil-Urdaneta LA. A path forward in the development of new aerosol drug delivery devices for pediatrics. Respir Med 2023; 211:107210. [PMID: 36907367 DOI: 10.1016/j.rmed.2023.107210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/24/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023]
Abstract
Inhaled medications are widely accepted as being the optimal route for treating pediatric respiratory diseases, a leading cause of hospitalization and death. Despite jet nebulizers being the preferred inhalation device for neonates and infants, current devices face performance issues with most of the drug never reaching the target lung location. Previous work has aimed to improve pulmonary drug deposition, yet nebulizer efficiency remains low. The development of an inhalant therapy that is efficacious and safe for pediatrics depends on a well-designed delivery system and formulation. To accomplish this, the field needs to rethink the current practice of basing pediatric treatments on adult studies. The rapidly evolving pediatric patient (i.e. neonates to eighteen) needs to be considered because they are different from adults with respect to airway anatomy, breathing patterns, and adherence. Previous research approaches to improve deposition efficiency have been limited due to the complexity of combining physics, which drives aerosol transport and deposition, and biology, especially within the area of pediatrics. To address these critical knowledge gaps, we need a better understanding of how patient age and disease state affect deposition of aerosolized drugs. The complexity of the multiscale respiratory system makes scientific investigation very challenging. The authors have simplified the complex problem into five components with these three areas as ones to address first: how the aerosol is (i) generated in a medical device, (ii) delivered to the patient, and (iii) deposited inside the lung. In this review, we discuss the technological advances and innovations made from experiments, simulations, and predictive models in each of these areas. In addition, we discuss the impact on patient treatment efficacy and recommend a clinical direction, with a focus on pediatrics. In each area, a series of research questions are posed and steps for future research to improve efficacy in aerosol drug delivery are outlined.
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Affiliation(s)
- Jennifer A O'Neil
- College of Engineering Technology, Department of Manufacturing and Mechanical Engineering Technology, Rochester Institute of Technology, 78 Lomb Memorial Drive, Golisano Hall 1361, Rochester, NY, USA.
| | - Larry A Villasmil-Urdaneta
- College of Engineering Technology, Department of Manufacturing and Mechanical Engineering Technology, Rochester Institute of Technology, Rochester, NY, USA
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Lavelle A, Bonnet JF, O'Sullivan E, Sheil D, MacLoughlin R. Determining optimal gas flow rate and nebuliser position using the Aerogen ® Solo™ vibrating-mesh nebuliser. Anaesthesia 2023; 78:256-258. [PMID: 36378564 DOI: 10.1111/anae.15917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/17/2022]
Affiliation(s)
- A Lavelle
- St James's Hospital, Dublin, Ireland
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Calabrese C, Annunziata A, Mariniello DF, Allocca V, Imitazione P, Cauteruccio R, Simioli F, Fiorentino G. Aerosol delivery through high-flow nasal therapy: Technical issues and clinical benefits. Front Med (Lausanne) 2023; 9:1098427. [PMID: 36743674 PMCID: PMC9889634 DOI: 10.3389/fmed.2022.1098427] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/26/2022] [Indexed: 01/20/2023] Open
Abstract
High-flow nasal cannula (HFNC) therapy is an oxygen delivery method particularly used in patients affected by hypoxemic respiratory failure. In comparison with the conventional "low flow" oxygen delivery systems, it showed several important clinical benefits. The possibility to nebulize drugs via HFNC represents a desirable medical practice because it allows the administration of inhaled drugs, mostly bronchodilators, without the interruption or modification of the concomitant oxygen therapy. HFNC, by itself has shown to exert a small but significant bronchodilator effect and improves muco-ciliary clearance; thus, the nebulization of bronchodilators through the HFNC circuit may potentially increase their pharmacological activity. Several technical issues have been observed which include the type of the nebulizer that should be used, its position within the HFNC circuit, and the optimal gas flow rates to ensure an efficient drug delivery to the lungs both in "quiet" and "distressed" breathing patterns. The aim of this review has been to summarize the scientific evidence coming from "in vitro" studies and to discuss the results of "in vivo" studies performed in adult subjects, mainly affected by obstructive lung diseases. Most studies seem to indicate the vibrating mesh nebulizer as the most efficient type of nebulizer and suggest to place it preferentially upstream from the humidifier chamber. In a quite breathing patterns, the inhaled dose seems to increase with lower flow rates while in a "distressed" breathing pattern, the aerosol delivery is higher when gas flow was set below the patient's inspiratory flow, with a plateau effect seen when the gas flow reaches approximately 50% of the inspiratory flow. Although several studies have demonstrated that the percentage of the loaded dose nebulized via HFNC reaching the lungs is small, the bronchodilator effect of albuterol seems not to be impaired when compared to the conventional inhaled delivery methods. This is probably attributed to its pharmacological activity. Prospective and well-designed studies in different cohort of patients are needed to standardize and demonstrate the efficacy of the procedure.
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Affiliation(s)
- Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy,*Correspondence: Cecilia Calabrese,
| | - Anna Annunziata
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | | | - Valentino Allocca
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Pasquale Imitazione
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | - Rosa Cauteruccio
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | - Francesca Simioli
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
| | - Giuseppe Fiorentino
- Department of Intensive Care, Azienda Ospedaliera di Rilievo Nazionale dei Colli, Naples, Italy
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Amin MA, Taha HK, Hussein RRS, Sarhan RM, Abdelrahim MEA. Effect of oxygen flow on aerosol delivery from a vibrating mesh nebulizer with a holding chamber. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2022. [DOI: 10.1186/s43088-022-00338-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Abstract
Background
A holding chamber (HC) was created to work with a vibrating mesh nebulizer (VMN) to boost the total inhalable dose for patients. In addition to the optional supply of supplemental oxygen, it facilitates intermittent and continuous nebulization. Our goal was to see how well a VMN coupled to a HC with a mouthpiece or valved facemask performed at varied oxygen flows starting at 0–6 L/min. In this study, we used a breathing simulator to simulate adults' spontaneous breathing patterns with a tidal volume of 500 mL and a 1:1 inhalation–exhalation ratio. For the combination of nebulizer and HC adapter with a valved facemask or mouthpiece, five determinations were made. Salbutamol was recovered and evaluated using high-performance liquid chromatography from the inhalation filter connected to the breathing simulator, the nebulizer reservoir chamber, and the HC.
Results
The amount of salbutamol in the nebulizer reservoir chamber and within the HC did not differ significantly when using a mouthpiece or a valved facemask. However, the supplied dose to the inhalation filter was increased until oxygen flow reached 2 and 3 L/min using the mouthpiece and valved facemask as interfaces, respectively. The supplied salbutamol was much higher at this flow than at the other oxygen flows. This was followed by a progressive reduction in the supplied salbutamol until the lowest given dose was reached at 6 L/min oxygen flow, p < 0.005.
Conclusions
The supplied doses of salbutamol to the inhalation filter were variable with the VMN connected to the HC and mouthpiece or valved facemask, with significant improvements until an oxygen flow of 2 L/min with a mouthpiece and 3 L/min with a valved facemask, followed by gradual decreases to lower values at an oxygen flow of 6 L/min. An in vivo investigation is required to further validate the findings.
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Mac Giolla Eain M, Cahill R, MacLoughlin R, Nolan K. Aerosol release, distribution, and prevention during aerosol therapy: a simulated model for infection control. Drug Deliv 2022; 29:10-17. [PMID: 34962221 PMCID: PMC8725970 DOI: 10.1080/10717544.2021.2015482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 10/24/2022] Open
Abstract
Aerosol therapy is used to deliver medical therapeutics directly to the airways to treat respiratory conditions. A potential consequence of this form of treatment is the release of fugitive aerosols, both patient derived and medical, into the environment and the subsequent exposure of caregivers and bystanders to potential viral infections. This study examined the release of these fugitive aerosols during a standard aerosol therapy to a simulated adult patient. An aerosol holding chamber and mouthpiece were connected to a representative head model and breathing simulator. A combination of laser and Schlieren imaging was used to non-invasively visualize the release and dispersion of fugitive aerosol particles. Time-varying aerosol particle number concentrations and size distributions were measured with optical particle sizers at clinically relevant positions to the simulated patient. The influence of breathing pattern, normal and distressed, supplemental air flow, at 0.2 and 6 LPM, and the addition of a bacterial filter to the exhalation port of the mouthpiece were assessed. Images showed large quantities of fugitive aerosols emitted from the unfiltered mouthpiece. The images and particle counter data show that the addition of a bacterial filter limited the release of these fugitive aerosols, with the peak fugitive aerosol concentrations decreasing by 47.3-83.3%, depending on distance from the simulated patient. The addition of a bacterial filter to the mouthpiece significantly reduces the levels of fugitive aerosols emitted during a simulated aerosol therapy, p≤ .05, and would greatly aid in reducing healthcare worker and bystander exposure to potentially harmful fugitive aerosols.
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Affiliation(s)
| | - Ronan Cahill
- School of Medicine, UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Ronan MacLoughlin
- Aerogen Ltd, IDA Business Park, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
| | - Kevin Nolan
- School of Mechanical and Materials Engineering, University College Dublin, Dublin, Ireland
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8
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Otto M, Kropp Y, Kummer L, Thiel M, Tsagogiorgas C. [Can mesh nebulizers improve prehospital aerosol therapy? An in vitro study on simulated prehospital emergency patients suffering from respiratory distress]. DIE ANAESTHESIOLOGIE 2022; 71:758-766. [PMID: 35976418 PMCID: PMC9525251 DOI: 10.1007/s00101-022-01183-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 04/15/2022] [Accepted: 06/19/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nebulizers used to treat prehospital emergency patients should provide a high output efficiency to achieve a fast onset of therapeutic drug effects while remaining unaffected by the presence of supplementary oxygen flow or the patient's breathing pattern. On the other hand, nebulizer performance is directly influenced by differences in device design, gas flow and patients' breathing patterns. Several studies from emergency departments were able to demonstrate an improvement in patient outcome when using a mesh nebulizer instead of a jet nebulizer. Data or bench studies regarding prehospital care are non-existent. OBJECTIVE The aim of the present in vitro study was to evaluate which type of aerosol generator would best address the requirements of a prehospital adult emergency patient suffering from respiratory distress. MATERIAL AND METHODS We evaluated the performance of a jet nebulizer (Cirrus™ 2, Intersurgical®) and two mesh nebulizers (Aerogen Solo® with USB controller, Aerogen Limited and M‑Neb® mobile, NEBU-TEC International med. Produkte Eike Kern GmbH) with the possibility of portable operation in an in vitro model of a spontaneously breathing adult emergency patient. One physiological and three pathological breathing patterns (distressed breathing pattern as well as stable and acute exacerbated chronic obstructive pulmonary disease) were simulated. Nebulizer output and salbutamol lung deposition were measured at different oxygen flow rates using a face mask as the delivery interface. RESULTS The mesh nebulizers produced a significantly higher aerosol output when compared to the jet nebulizer. The M‑Neb® mobile was able to significantly exceed the output of the Aerogen Solo®. Oxygen flow had the largest influence on the output of the jet nebulizer but hardly affected the mesh nebulizers. After a nebulization time of 10 min the M‑Neb® mobile also achieved the highest total salbutamol lung deposition (P < 0.001). Aerosol drug deposition was therefore mainly determined by the nebulizer's drug output per unit time. The deposition could not be improved using a spacer but was strongly influenced by the simulated emergency patients' breathing pattern. CONCLUSION The use of mesh nebulizers might have the potential to improve the aerosol therapy of prehospital emergency patients. In general, mesh nebulizers seem to be superior to jet nebulizers regarding aerosol output per unit time and total lung deposition. The present data suggest that aerosol output and drug deposition to the collection filter in this simulated setting are closely connected and crucial for total salbutamol deposition, as the deposition could not be improved by adding a spacer. Aerosol drug deposition in simulated emergency patients' lungs is therefore mainly determined by the nebulizer's drug output per unit time. The level of oxygen flow used had the largest influence on the output of the jet nebulizer but hardly affected the output of the tested mesh nebulizers. Mesh nebulizers could therefore enable a demand-adapted oxygen therapy due to their consistent performance despite the presence of oxygen flow. A high respiratory rate was associated with a high drug deposition, which is clinically desirable in the treatment of patients in respiratory distress; however, drug underdosing must also be expected in the treatment of bradypneic patients. Further clinical studies must prove whether our findings also apply to the treatment of real prehospital emergency patients.
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Affiliation(s)
- M Otto
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Y Kropp
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - L Kummer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Thiel
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - C Tsagogiorgas
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
- Klinik für Anästhesie und Intensivmedizin, St. Elisabethenkrankenhaus Frankfurt, Frankfurt am Main, Deutschland.
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Quach S. Questions About Fugitive Aerosols: The Answer Is PPE. Respir Care 2022; 67:496-499. [PMID: 35338098 PMCID: PMC9994015 DOI: 10.4187/respcare.10031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Shirley Quach
- School of Rehabilitation SciencesMcMaster UniversityHamilton, Canada
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Gallagher L, Joyce M, Murphy B, Mac Giolla Eain M, MacLoughlin R. The Impact of Head Model Choice on the In Vitro Evaluation of Aerosol Drug Delivery. Pharmaceutics 2021; 14:pharmaceutics14010024. [PMID: 35056920 PMCID: PMC8777612 DOI: 10.3390/pharmaceutics14010024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
There are variations in the values reported for aerosol drug delivery across in vitro experiments throughout the published literature, and often with the same devices or similar experimental setups. Factors contributing to this variability include, but are not limited to device type, equipment settings, drug type and quantification methods. This study assessed the impact of head model choice on aerosol drug delivery using six different adults and three different paediatric head models in combination with a facemask, mouthpiece, and high-flow nasal cannula. Under controlled test conditions, the quantity of drug collected varied depending on the choice of head model. Head models vary depending on a combination of structural design differences, facial features (size and structure), internal volume measurements and airway geometries and these variations result in the differences in aerosol delivery. Of the widely available head models used in this study, only three were seen to closely predict in vivo aerosol delivery performance in adults compared with published scintigraphy data. Further, this testing identified the limited utility of some head models under certain test conditions, for example, the range reported across head models was aerosol drug delivery of 2.62 ± 2.86% to 37.79 ± 1.55% when used with a facemask. For the first time, this study highlights the impact of head model choice on reported aerosol drug delivery within a laboratory setting and contributes to explaining the differences in values reported within the literature.
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Affiliation(s)
- Lauren Gallagher
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Mary Joyce
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Barry Murphy
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Marc Mac Giolla Eain
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
| | - Ronan MacLoughlin
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland; (L.G.); (M.J.); (B.M.); (M.M.G.E.)
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
- Correspondence:
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Bronchodilator Delivery via High-Flow Nasal Cannula: A Randomized Controlled Trial to Compare the Effects of Gas Flows. Pharmaceutics 2021; 13:pharmaceutics13101655. [PMID: 34683948 PMCID: PMC8539308 DOI: 10.3390/pharmaceutics13101655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/13/2021] [Accepted: 09/26/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Aerosol delivery via high-flow nasal cannula (HFNC) has attracted increasing clinical interest. In vitro studies report that the ratio of HFNC gas flow to patient inspiratory flow (GF:IF) is a key factor in the efficiency of trans-nasal aerosol delivery. (2) Methods: In a randomized controlled trial, patients with a history of COPD or asthma and documented positive responses to inhaled bronchodilators in an outpatient pulmonary function laboratory were recruited. Subjects were randomized to receive inhalation at gas flow ratio settings of: GF:IF = 0.5, GF:IF = 1.0, or GF = 50 L/min. Subjects were assigned to inhale saline (control) followed by salbutamol via HFNC with cumulative doses of 0.5 mg, 1.5 mg, 3.5 mg, and 7.5 mg. Spirometry was performed at baseline and 10-12 min after each inhalation. (3) Results: 75 subjects (49 asthma and 26 COPD) demonstrating bronchodilator response were enrolled. Per the robust ATS/ERS criteria no difference was observed between flows, however using the criteria of post-bronchodilator forced expiratory volume in the first second (FEV1) reaching the screening post-bronchodilator FEV1 with salbutamol, a higher percentage of subjects receiving GF:IF = 0.5 met the criteria at a cumulative dose of 1.5 mg than those receiving GF:IF = 1.0, and GF = 50 L/min (64% vs. 29% vs. 27%, respectively, p = 0.011). Similarly at 3.5 mg (88% vs. 54% vs. 46%, respectively, p = 0.005). The effective dose at GF:IF = 0.5 was 1.5 mg while for GF = 50 L/min it was 3.5 mg. (4) Conclusions: During salbutamol delivery via HFNC, cumulative doses of 1.5 mg to 3.5 mg resulted in effective bronchodilation. Applying the robust ATS/ERS criteria no difference was observed between the flows, however using the more sensitive criteria of subjects reaching post screening FEV1 to salbutamol via HFNC, a higher number of subjects responded to the doses of 0.5 mg and 1.5 mg when HFNC gas flow was set at 50% of patient peak inspiratory flow.
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Li J, Tu M, Yang L, Jing G, Fink JB, Burtin C, Andrade ADD, Gong L, Xie L, Ehrmann S. Worldwide Clinical Practice of High-Flow Nasal Cannula and Concomitant Aerosol Therapy in the Adult ICU Setting. Respir Care 2021; 66:1416-1424. [PMID: 33824172 PMCID: PMC9993868 DOI: 10.4187/respcare.08996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND High-flow nasal cannula (HFNC) oxygen therapy has been broadly used. However, no consensus has been achieved on the practical implementation of HFNC and how to provide aerosol delivery during HFNC therapy in adult patients. METHODS An online anonymous questionnaire survey endorsed by 4 academic societies from America, Europe, mainland China, and Taiwan was administered from May to December 2019. Clinicians who had worked in adult ICUs for > 1 year and had used HFNC to treat patients within 30 days were included. RESULTS A total of 2,279 participants clicked on the survey link, 1,358 respondents completed the HFNC section of the questionnaire, whereas 1,014 completed the whole survey. Postextubation hypoxemia and moderate hypoxemia were major indications for HFNC. The initial flow was mainly set at 40-50 L/min. Aerosol delivery via HFNC was used by 24% of the participants (248/1,014), 30% (74/248) of whom reported reducing flow during aerosol delivery. For the patients who required aerosol treatment during HFNC therapy, 40% of the participants (403/1,014) reported placing a nebulizer with a mask or mouthpiece while pursuing HFNC whereas 33% (331/1,014) discontinued HFNC to use conventional aerosol devices. A vibrating mesh nebulizer was the most commonly used nebulizer (40%) and was mainly placed at the inlet of the humidifier. CONCLUSIONS The clinical utilization of HFNC was variable, as were indications, flow settings, and criteria for adjustment. Many practices associated with concomitant aerosol therapy were not consistent with available evidence for optimal use. More efforts are warranted to close the knowledge gap.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois.
| | - Meilien Tu
- Department of Respiratory Care, Chang Gung University of Science and Technology, Taiwan
| | - Lei Yang
- Hongli Hospital, Xinxiang, Henan, China
| | - Guoqiang Jing
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois
- Aerogen Pharma Corp, San Mateo, California
| | - Chris Burtin
- Universiteit Hasselt - Campus Diepenbeek, Hasselt, Belgium
| | | | - Lingyue Gong
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois
| | - Lixin Xie
- Department of Respiratory and Critical Care Medicine, People's Liberation Army General Hospital, Beijing, China.
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC Institut National de la Santé et de la Recherche Médicale 1415, CRICS-TriggerSEP F-CRIN Research Network, Tours, France
- Institut National de la Santé et de la Recherche Médicale, Centre d'étude des pathologies respiratoires, U1100, Université de Tours, Tours, France
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13
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Brennan LC, O’Sullivan A, MacLoughlin R. Cellular Therapy for the Treatment of Paediatric Respiratory Disease. Int J Mol Sci 2021; 22:ijms22168906. [PMID: 34445609 PMCID: PMC8396271 DOI: 10.3390/ijms22168906] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 12/12/2022] Open
Abstract
Respiratory disease is the leading cause of death in children under the age of 5 years old. Currently available treatments for paediatric respiratory diseases including bronchopulmonary dysplasia, asthma, cystic fibrosis and interstitial lung disease may ameliorate symptoms but do not offer a cure. Cellular therapy may offer a potential cure for these diseases, preventing disease progression into adulthood. Induced pluripotent stem cells, mesenchymal stromal cells and their secretome have shown great potential in preclinical models of lung disease, targeting the major pathological features of the disease. Current research and clinical trials are focused on the adult population. For cellular therapies to progress from preclinical studies to use in the clinic, optimal cell type dosage and delivery methods need to be established and confirmed. Direct delivery of these therapies to the lung as aerosols would allow for lower doses with a higher target efficiency whilst avoiding potential effect of systemic delivery. There is a clear need for research to progress into the clinic for the treatment of paediatric respiratory disease. Whilst research in the adult population forms a basis for the paediatric population, varying disease pathology and anatomical differences in paediatric patients means a paediatric-centric approach must be taken.
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Affiliation(s)
- Laura C. Brennan
- College of Medicine, Nursing & Health Sciences, National University of Ireland, H91 TK33 Galway, Ireland;
| | - Andrew O’Sullivan
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland;
| | - Ronan MacLoughlin
- Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland;
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- Correspondence:
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14
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Luo Z, Fink JB. Demystifying medical aerosols in acute and critical care. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:587. [PMID: 33987285 DOI: 10.21037/atm-21-964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zhe Luo
- Deputy Director, Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - James B Fink
- Chief Science Officer, Aerogen Pharma Corp. San Mateo, CA, USA.,Adjunct Faculty, Graduate College Division of Health Sciences, Rush University, Chicago, IL, USA.,Visiting Professor, Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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15
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Li J, Fink JB. Narrative review of practical aspects of aerosol delivery via high-flow nasal cannula. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:590. [PMID: 33987288 DOI: 10.21037/atm-20-7383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Using high-flow nasal cannula (HFNC) as a "vehicle" to administer aerosolized medication has attracted clinicians' interest in recent years. In this paper, we summarize the current evidence to answer the common questions raised by clinicians about this new aerosol delivery route and best practices of administration. Benefits of trans-nasal aerosol delivery include increased comfort, ability to speak, eat, and drink for patients while meeting a range of oxygen requirements, particularly for those who need to inhale aerosolized medication for long periods. Aerosol administration via HFNC has been shown to be well tolerated by children and adults, with comparable or better delivery efficacy than other interfaces, ranging from 2-20%. In vitro and in vivo scintigraphy studies among pediatric and adult populations reported that the inhaled dose delivered via a vibrating mesh nebulizer is 2 to 3 fold greater than that via a jet nebulizer. For adults, placement of nebulizer at the inlet of humidifier increases inhaled dose while reducing rainout obstructing nasal prongs. When HFNC gas flow is set below patient inspiratory flow, aerosol deposition is higher than when the gas flow exceeds patient inspiratory flow; thus, if tolerated, titrating down HFNC gas flow during trans-nasal aerosol delivery, with close monitoring and the use of unit dose with high concentration are recommended. Trans-nasal pulmonary aerosol delivery has not been shown to increase bioaerosols generated by patients, but gas flow may disperse aerosols. Placement of a surgical or procedure mask over HFNC might reduce aerosol dispersion.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
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16
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O’Toole C, Joyce M, McGrath JA, O’Sullivan A, Byrne MA, MacLoughlin R. Fugitive aerosols in the intensive care unit: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:592. [PMID: 33987290 PMCID: PMC8105852 DOI: 10.21037/atm-20-2280] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/10/2020] [Indexed: 12/20/2022]
Abstract
The risk of unintended inhalation of fugitive aerosols is becoming a topic of increasing interest in the healthcare arena. These fugitive aerosols may be bioaerosols, generated by the patient themselves through cough or sneeze, or they may be therapeutic medical aerosols, generated by therapeutic medical aerosol generators with the intent of delivery to a specific patient's respiratory tract. This review focus' on therapeutic aerosols in the intensive care unit (ICU) only, those typically generated by nebulisers. In the intensive care environment, patients are generally in receipt of ventilatory support, and the literature suggests that these different support interventions influence fugitive therapeutic medical aerosol emissions in a variety of ways. Predominant ventilatory support interventions include, but are not limited to, invasive mechanical ventilation (MV), non-invasive mechanical ventilation (NIV), high flow nasal therapy (HFNT), and supplemental oxygen delivery in spontaneously breathing patients. Further, factors such as nebuliser type, patient interface, patient breathing pattern, nebuliser position in the patient breathing circuit and medication formulation characteristics also have been shown to exert influence on aerosol concentrations and distance from the source. Here we present the state of the art knowledge in this, as yet, poorly described field of research, and identify the key risks, and subsequently, opportunities to mitigate the risks of unintended exposure of both patients and bystanders during and for periods following the administration of therapeutic aerosols.
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Affiliation(s)
- Ciarraí O’Toole
- School of Physics & Ryan Institute’s Centre for Climate & Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | - Mary Joyce
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
| | - James A. McGrath
- School of Physics & Ryan Institute’s Centre for Climate & Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | | | - Miriam A. Byrne
- School of Physics & Ryan Institute’s Centre for Climate & Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | - Ronan MacLoughlin
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
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17
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Mac Giolla Eain M, Joyce M, O'Sullivan A, McGrath JA, MacLoughlin R. An in vitro investigation into the release of fugitive medical aerosols into the environment during manual ventilation. J Hosp Infect 2020; 108:135-141. [PMID: 33296706 DOI: 10.1016/j.jhin.2020.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND During manual resuscitation, nebulizer therapy may be used to deliver therapeutics to patients in respiratory distress. However, the devices used to generate and deliver these medical aerosols have the potential to release these therapeutics into the local environment and expose caregivers to unwanted medical aerosols. AIM To quantify the levels of fugitive medical aerosol released into the environment during aerosol drug delivery using a manual resuscitation bag with and without filtration. METHODS Time-varying fugitive aerosol concentrations were measured using an aerodynamic particle sizer placed at a position designed to mimic a caregiver. Two nebulizer types were assessed, a vibrating mesh nebulizer and a jet nebulizer. The aerosol dose delivered to the simulated patient lung was also quantified. FINDINGS Filtration of the exhalation port of the manual resuscitation bag was seen to reduce fugitive medical aerosols to ambient levels for both nebulizer types. The vibrating mesh nebulizer delivered the greatest quantity of aerosol to the simulated adult patient (18.44 ± 1.03% versus 3.64 ± 0.26% with a jet nebulizer). CONCLUSIONS The results highlight the potential for exposure to fugitive medical aerosols released during the delivery of aerosol therapy with a manual resuscitation bag and also the potential for significant variation in patient lung dose depending on nebulizer type.
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Affiliation(s)
| | - M Joyce
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
| | - A O'Sullivan
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
| | - J A McGrath
- School of Physics & Ryan Institute's Centre for Climate and Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | - R MacLoughlin
- Aerogen, IDA Business Park, Dangan, Galway, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland; School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland.
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18
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Martini V, Hinchcliffe M, Blackshaw E, Joyce M, McNee A, Beverley P, Townsend A, MacLoughlin R, Tchilian E. Distribution of Droplets and Immune Responses After Aerosol and Intra-Nasal Delivery of Influenza Virus to the Respiratory Tract of Pigs. Front Immunol 2020; 11:594470. [PMID: 33193445 PMCID: PMC7653178 DOI: 10.3389/fimmu.2020.594470] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/07/2020] [Indexed: 11/13/2022] Open
Abstract
Recent evidence indicates that local immune responses and tissue resident memory T cells (TRM) are critical for protection against respiratory infections but there is little information on the contributions of upper and lower respiratory tract (URT and LRT) immunity. To provide a rational basis for designing methods for optimal delivery of vaccines to the respiratory tract in a large animal model, we investigated the distribution of droplets generated by a mucosal atomization device (MAD) and two vibrating mesh nebulizers (VMNs) and the immune responses induced by delivery of influenza virus by MAD in pigs. We showed that droplets containing the drug albuterol, a radiolabel (99mTc-DTPA), or a model influenza virus vaccine (S-FLU) have similar aerosol characteristics. 99mTc-DTPA scintigraphy showed that VMNs deliver droplets with uniform distribution throughout the lungs as well as the URT. Surprisingly MAD administration (1ml/nostril) also delivered a high proportion of the dose to the lungs, albeit concentrated in a small area. After MAD administration of influenza virus, antigen specific T cells were found at high frequency in nasal turbinates, trachea, broncho-alveolar lavage, lungs, tracheobronchial nodes, and blood. Anti-influenza antibodies were detected in serum, BAL and nasal swabs. We conclude that the pig is useful for investigating optimal targeting of vaccines to the respiratory tract.
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Affiliation(s)
- Veronica Martini
- Department of Enhanced Host Responses, The Pirbright Institute, Pirbright, United Kingdom.,Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Elaine Blackshaw
- Radiological Sciences, School of Medicine, Queen's Medical Centre, University of Nottingham, Nottingham, United Kingdom
| | | | - Adam McNee
- Department of Enhanced Host Responses, The Pirbright Institute, Pirbright, United Kingdom.,School of Veterinary Medicine, Daphne Jackson Road, University of Surrey, Guildford, United Kingdom
| | - Peter Beverley
- National Heart and Lung Institute, St Mary's Campus, Imperial College, London, United Kingdom
| | - Alain Townsend
- Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Elma Tchilian
- Department of Enhanced Host Responses, The Pirbright Institute, Pirbright, United Kingdom
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19
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Woods N, MacLoughlin R. Defining a Regulatory Strategy for ATMP/Aerosol Delivery Device Combinations in the Treatment of Respiratory Disease. Pharmaceutics 2020; 12:E922. [PMID: 32993197 PMCID: PMC7601063 DOI: 10.3390/pharmaceutics12100922] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/13/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022] Open
Abstract
Advanced Therapeutic Medicinal Products (ATMP) are a heterogenous group of investigational medicinal products at the forefront of innovative therapies with direct applicability in respiratory diseases. ATMPs include, but are not limited to, stem cells, their secretome, or extracellular vesicles, and each have shown some potential when delivered topically within the lung. This review focuses on that subset of ATMPs. One key mode of delivery that has enabling potential in ATMP validation is aerosol-mediated delivery. The selection of the most appropriate aerosol generator technology is influenced by several key factors, including formulation, patient type, patient intervention, and healthcare economics. The aerosol-mediated delivery of ATMPs has shown promise for the treatment of both chronic and acute respiratory disease in pre-clinical and clinical trials; however, in order for these ATMP device combinations to translate from the bench through to commercialization, they must meet the requirements set out by the various global regulatory bodies. In this review, we detail the potential for ATMP utility in the lungs and propose the nebulization of ATMPs as a viable route of administration in certain circumstances. Further, we provide insight to the current regulatory guidance for nascent ATMP device combination product development within the EU and US.
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Affiliation(s)
- Niamh Woods
- College of Medicine, Nursing & Health Sciences, National University of Ireland, H91 TK33 Galway, Ireland;
| | - Ronan MacLoughlin
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
- Aerogen Ltd., Galway Business Park, H91 HE94 Galway, Ireland
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20
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Li J, Fink JB, MacLoughlin R, Dhand R. A narrative review on trans-nasal pulmonary aerosol delivery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:506. [PMID: 32807226 PMCID: PMC7430014 DOI: 10.1186/s13054-020-03206-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/27/2020] [Indexed: 01/21/2023]
Abstract
The use of trans-nasal pulmonary aerosol delivery via high-flow nasal cannula (HFNC) has expanded in recent years. However, various factors influencing aerosol delivery in this setting have not been precisely defined, and no consensus has emerged regarding the optimal techniques for aerosol delivery with HFNC. Based on a comprehensive literature search, we reviewed studies that assessed trans-nasal pulmonary aerosol delivery with HFNC by in vitro experiments, and in vivo, by radiolabeled, pharmacokinetic and pharmacodynamic studies. In these investigations, the type of nebulizer employed and its placement, carrier gas, the relationship between gas flow and patient’s inspiratory flow, aerosol delivery strategies (intermittent unit dose vs continuous administration by infusion pump), and open vs closed mouth breathing influenced aerosol delivery. The objective of this review was to provide rational recommendations for optimizing aerosol delivery with HFNC in various clinical settings.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, 1620 W Harrison St, Tower LL1202, Chicago, IL, 60612, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
| | | | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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21
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Hibbitts AJ, Ramsey JM, Barlow J, MacLoughlin R, Cryan SA. In Vitro and In Vivo Assessment of PEGylated PEI for Anti-IL-8/CxCL-1 siRNA Delivery to the Lungs. NANOMATERIALS 2020; 10:nano10071248. [PMID: 32605011 PMCID: PMC7407419 DOI: 10.3390/nano10071248] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 06/19/2020] [Accepted: 06/24/2020] [Indexed: 12/16/2022]
Abstract
Inhalation offers a means of rapid, local delivery of siRNA to treat a range of autoimmune or inflammatory respiratory conditions. This work investigated the potential of a linear 10 kDa Poly(ethylene glycol) (PEG)-modified 25 kDa branched polyethyleneimine (PEI) (PEI-LPEG) to effectively deliver siRNA to airway epithelial cells. Following optimization with anti- glyceraldehyde 3-phosphate dehydrogenase (GAPDH) siRNA, PEI and PEI-LPEG anti-IL8 siRNA nanoparticles were assessed for efficacy using polarised Calu-3 human airway epithelial cells and a twin stage impinger (TSI) in vitro lung model. Studies were then advanced to an in vivo lipopolysaccharide (LPS)-stimulated rodent model of inflammation. In parallel, the suitability of the siRNA-loaded nanoparticles for nebulization using a vibrating mesh nebuliser was assessed. The siRNA nanoparticles were nebulised using an Aerogen® Pro vibrating mesh nebuliser and characterised for aerosol output, droplet size and fine particle fraction. Only PEI anti-IL8 siRNA nanoparticles were capable of significant levels of IL-8 knockdown in vitro in non-nebulised samples. However, on nebulization through a TSI, only PEI-PEG siRNA nanoparticles demonstrated significant decreases in gene and protein expression in polarised Calu-3 cells. In vivo, both anti-CXCL-1 (rat IL-8 homologue) nanoparticles demonstrated a decreased CXCL-1 gene expression in lung tissue, but this was non-significant. However, PEI anti-CXCL-1 siRNA-treated rats were found to have significantly less infiltrating macrophages in their bronchoalveolar lavage (BAL) fluid. Overall, the in vivo gene and protein inhibition findings indicated a result more reminiscent of the in vitro bolus delivery rather than the in vitro nebulization data. This work demonstrates the potential of nebulised PEI-PEG siRNA nanoparticles in modulating pulmonary inflammation and highlights the need to move towards more relevant in vitro and in vivo models for respiratory drug development.
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Affiliation(s)
- Alan J. Hibbitts
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin D02 YN77, Ireland; (A.J.H.); (J.M.R.); (R.M.)
- Trinity Centre for Biomedical Engineering, Trinity College, Dublin D02 R590, Ireland
| | - Joanne M. Ramsey
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin D02 YN77, Ireland; (A.J.H.); (J.M.R.); (R.M.)
| | - James Barlow
- Department of Chemistry, Royal College of Surgeons in Ireland, Dublin D02 YN77, Ireland;
| | - Ronan MacLoughlin
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin D02 YN77, Ireland; (A.J.H.); (J.M.R.); (R.M.)
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin D02 PN40, Ireland
- Aerogen Ltd. Galway Business Park, Galway H91 HE94, Ireland
| | - Sally-Ann Cryan
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin D02 YN77, Ireland; (A.J.H.); (J.M.R.); (R.M.)
- Trinity Centre for Biomedical Engineering, Trinity College, Dublin D02 R590, Ireland
- Correspondence: ; Tel.: +353-14022741
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22
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Li J, Wei W, Fink JB. In vitro comparison of unit dose vs infusion pump administration of albuterol via high-flow nasal cannula in toddlers. Pediatr Pulmonol 2020; 55:322-329. [PMID: 31782914 DOI: 10.1002/ppul.24589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/10/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Transnasal pulmonary aerosol delivery using high-flow nasal cannula (HFNC) devices has become a popular route of aerosol administration in toddlers. Clinically, albuterol is administered using an infusion pump or unit doses. However, little evidence is available to compare the two administration strategies. METHODS A toddler manikin (15 kg) with appropriate anatomic airway was connected with collecting filter to a simulator of distressed breathing. HFNC device with mesh nebulizer placed at the inlet of a humidifier at 37°C, with the gas flow set at 25 and 3.75 L/min. Five milligrams of albuterol was delivered in all experiments. With infusion pump administration, albuterol concentrations of 5 and 1 mg/mL were delivered at 4 and 20 mL/hr for 15 minutes. With unit dose administration, 1 mL (5 mg/mL) and 2 mL (2.5 mg/mL) of albuterol were nebulized. Additional tests with mouth open and nebulizers via mask were using 5 mg/1 mL for mesh nebulizer and 5 mg/3 mL for jet nebulizer (n = 3). The drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). RESULTS The inhaled dose was higher with unit dose than infusion pump administration with gas flows of 25 L/min (2.66 ± 0.38 vs 1.16 ± 0.28%; P = .004) and 3.75 L/min (10.51 ± 1.29 vs 8.58 ± 0.68%; P = .025). During unit dose administration, compared with closed-mouth breathing, open-mouth breathing generated a higher inhaled dose at 3.75 L/min and lower inhaled dose at 25 L/min. Compared to the nebulizers via mask with both open and closed-mouth breathing, nebulization via HFNC at 3.75 L/min generated greater inhaled dose, while HFNC at 25 L/min generated lower inhaled dose. CONCLUSIONS During transnasal aerosol delivery, the inhaled dose was higher with medication administrated using unit dose than using an infusion pump.
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Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois
| | - Wu Wei
- Department of Critical Care Medicine, Shanghai Zhongshan Hospital, Fu Dan University, Shanghai, China
| | - James B Fink
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois.,Aerogen Pharma Corp, San Mateo, California
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23
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Alcoforado L, Ari A, Barcelar JDM, Brandão SCS, Fink JB, de Andrade AD. Impact of Gas Flow and Humidity on Trans-Nasal Aerosol Deposition via Nasal Cannula in Adults: A Randomized Cross-Over Study. Pharmaceutics 2019; 11:pharmaceutics11070320. [PMID: 31284680 PMCID: PMC6680424 DOI: 10.3390/pharmaceutics11070320] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Trans-nasal pulmonary aerosol delivery using high flow nasal cannula (HFNC) devices is described with the administration of high gas flows exceeding patient inspiratory flow (HF) and with lower flows (LF). The aim of this pilot clinical trial was to compare deposition and distribution of radiolabeled aerosol via nasal cannula in healthy adults across three rates of gas flow delivered with active heated humidification, and to further identify the impact of aerosol administration without heated humidity. Methods: Twenty-three (23) healthy adults (16F) were randomized to receive aerosol with active heated humidification or unheated oxygen at gas flows of 10 L/min (n = 8), 30 L/min (n = 7), or 50 L/min (n = 8). Diethylenetriaminepentaacetic acid labeled with 1 millicurie (37 MBq) of Technetium-99m (DTPA-Tc99m) was mixed with NaCl to a fill volume of 1 mL, and administered via mesh nebulizer placed at the inlet of the humidifier. Radioactivity counts were performed using a gamma camera and the regions of interest (ROIs) were delimited with counts from the lungs, upper airways, stomach, nebulizer, circuit, and expiratory filter. A mass balance was calculated and each compartment was expressed as a percentage of the total. Results: Lung deposition (mean ± SD) with heated humidified gas was greater at 10 L/min than 30 L/min or 50 L/min (17.2 ± 6.8%, 5.71 ± 2.04%, and 3.46 ± 1.24%, respectively; p = 0.0001). Using unheated carrier gas, a lung dose of aerosol was similar to the active heated humidification condition at 10 L/min, but greater at 30 and 50 L/min (p = 0.011). Administered gas flow and lung deposition were negatively correlated (r = −0.880, p < 0.001). Conclusions: Both flow and active heated humidity inversely impact aerosol delivery through HFNC. Nevertheless, aerosol administration across the range of commonly used flows can provide measurable levels of lung deposition in healthy adult subjects (NCT 02519465).
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Affiliation(s)
- Luciana Alcoforado
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife 50740-560, PE, Brazil
| | - Arzu Ari
- Department of Respiratory Therapy, Texas State University, Round Rock, TX 78665, USA
| | | | | | - James B Fink
- Department of Respiratory Therapy, Texas State University, Round Rock, TX 78665, USA
- Aerogen Pharma Corp, San Mateo, CA 94402, USA
| | - Armele Dornelas de Andrade
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife 50740-560, PE, Brazil.
- Avenida Jornalista Aníbal Fernandes, SN-Cidade Universitária, CEP, Recife 50740-560, PE, Brazil.
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