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Pasteka R, Hufnagl L, Forjan M, Berger A, Werther T, Wagner M. Positive end-expiratory pressure and surfactant administration mode influence function in ex-vivo premature sheep lungs. Acta Paediatr 2024; 113:722-730. [PMID: 38149457 DOI: 10.1111/apa.17083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Abstract
AIM Respiratory distress syndrome often necessitates endotracheal surfactant administration in extremely preterm infants. Our study aimed to explore a multi-modal simulation tool for investigating treatment strategies in ex vivo sheep lungs during spontaneous breathing. METHODS An electromechanical lung simulator (xPULM) mimicking spontaneous breathing was coupled with a non-aerated premature sheep lung, replicating a premature respiratory system. Changes in tidal volume for different positive end-expiratory pressure (PEEP) levels prior to and after either bolus or nebulised surfactant administration were compared. RESULTS In two preterm sheep lungs, we observed a progressive decline in tidal volume with increasing PEEP levels prior to surfactant delivery from 0.30 ± 0.01 mL at zero PEEP to 0.04 ± 0.01 mL at 15 cmH2O PEEP. Our measurements showed that both bolus (p < 0.05) and nebulised (p < 0.05) surfactant administration resulted in a significant increase in tidal volume, with no significant difference (p = 0.71) between the two methods. CONCLUSION The experimental setup demonstrated the feasibility of xPULM for investigating the effectiveness of different PEEP levels and modes of surfactant administration with respect to tidal volume in premature sheep lungs. The lack of adequate lung water resorption in our model warrants further investigations.
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Affiliation(s)
- Richard Pasteka
- Department Life Science Engineering, Competence Centre Medical Engineering & Integrated Healthcare, University of Applied Sciences Technikum Wien, Vienna, Austria
| | - Lisa Hufnagl
- Department of Paediatrics and Adolescent Medicine, Comprehensive Centre for Paediatrics, Division of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Medical University of Vienna, Vienna, Austria
| | - Mathias Forjan
- Department Life Science Engineering, Competence Centre Medical Engineering & Integrated Healthcare, University of Applied Sciences Technikum Wien, Vienna, Austria
| | - Angelika Berger
- Department of Paediatrics and Adolescent Medicine, Comprehensive Centre for Paediatrics, Division of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Medical University of Vienna, Vienna, Austria
| | - Tobias Werther
- Department of Paediatrics and Adolescent Medicine, Comprehensive Centre for Paediatrics, Division of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Wagner
- Department of Paediatrics and Adolescent Medicine, Comprehensive Centre for Paediatrics, Division of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Medical University of Vienna, Vienna, Austria
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2
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Briones-Claudett KH, Briones-Claudett MH, Bajaña Huilcapi CK, Tripul Villamar OE, Ochoa Vásquez R, Rivera Salas CDR, Briones-Zamora KH, Benites Solis J, Briones-Márquez DC, Freire AX, Grunauer M. Surfactant therapy using vibrating-mesh nebulizers in adults with COVID-19-induced ARDS: A case series. SAGE Open Med Case Rep 2024; 12:2050313X241236313. [PMID: 38444695 PMCID: PMC10913513 DOI: 10.1177/2050313x241236313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024] Open
Abstract
Coronavirus adult respiratory distress syndrome, characterized by decreased surfactant due to lysis of type II pneumocytes and hyaline membrane formation, contributes to severe hypoxemia. The administration of surfactant via high-flow nasal cannula (HFNC) may positively affect lung structure and function in this context. In this study, we report on five clinical cases, encompassing patients aged 40-60 years of both sexes, who tested positive for coronavirus disease 2019 via real-time polymerase chain reaction and exhibited significant pulmonary compromise with elevated inflammatory biomarkers. These patients were treated with aerosol therapy using surfactant delivered through vibrating-mesh nebulizers alongside HFNC. Of these patients, four demonstrated positive responses to the treatment, suggesting that aerosol therapy with surfactant through vibrating-mesh nebulizers could be a viable rescue therapy in adults receiving HFNC oxygen therapy for hypoxemic respiratory failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Unfortunately, one patient had a negative outcome and succumbed. The findings from these cases indicate that the use of aerosol therapy with vibrating-mesh nebulizers as rescue therapy might offer an alternative approach for managing adults with hypoxemic respiratory failure due to SARS-CoV-2, as evidenced by the positive outcomes in four out of the five cases presented.
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Affiliation(s)
- Killen H Briones-Claudett
- Facultad de Medicina, Universidad de Las Americas, Quito, Ecuador
- Intensive Care Unit, Ecuadorian Institute of Social Security, Babahoyo, Ecuador
| | | | | | | | | | | | | | | | | | - Amado X Freire
- Division of Pulmonary, Critical Care, and Sleep Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Michelle Grunauer
- School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador
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3
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Hojnicki M, Zapata HA, Kaluarachchi DC, Fort P, Minton S, Albert G, Ross A, Wilding GE, Guthrie SO. Predictors of successful treatment of respiratory distress with aerosolized calfactant. J Perinatol 2023; 43:991-997. [PMID: 37433969 DOI: 10.1038/s41372-023-01722-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/14/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Predictors for successful aerosolized surfactant treatment are not well defined. OBJECTIVE To identify predictors for successful treatment in the AERO-02 trial and the AERO-03 expanded access program. METHODS Neonates receiving nasal continuous positive airway pressure (NCPAP) at the time of first aerosolized calfactant administration were included in this analysis. Associations between demographic and clinical predictors to need for intubation were examined using univariate testing and multivariate logistic regression analyses. RESULTS Three hundred and eighty infants were included in the study. Overall, 24% required rescue by intubation. Multivariate modeling revealed that the predictors of successful treatment were a gestational age ≥31 weeks, a respiratory severity score (RSS) of <1.9, and <2 previous aerosol treatments. CONCLUSION Gestational age, number of aerosols, and RSS are predictive of successful treatment. These criteria will help select patients most likely to benefit from aerosolized surfactant.
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Affiliation(s)
- Michelle Hojnicki
- Johns Hopkins All Children's Hospital, Maternal, Fetal and Neonatal Institute, St. Petersburg, FL, USA
| | - Henry A Zapata
- Department of Pediatrics, Division of Neonatology and Newborn Nursery, University of Wisconsin-Madison, Madison, WI, USA
| | - Dinushan C Kaluarachchi
- Department of Pediatrics, Division of Neonatology and Newborn Nursery, University of Wisconsin-Madison, Madison, WI, USA
| | - Prem Fort
- Johns Hopkins All Children's Hospital, Maternal, Fetal and Neonatal Institute, St. Petersburg, FL, USA
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Ann Ross
- Department of Neonatology, K Hovnanian Children's Hospital, Hackensack Meridian Health, Neptune, NJ, USA
| | - Gregory E Wilding
- Department of Biostatistics, University at Buffalo, Buffalo, NY, USA
| | - Scott O Guthrie
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, TN, USA.
- Jackson-Madison County General Hospital, Jackson, TN, USA.
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Budh HP, Nimbalkar S. Surfactant Replacement Therapy: What’s the New Future? Journal of Neonatology 2022; 36:331-347. [DOI: 10.1177/09732179221136963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Surfactant replacement therapy (SRT) can be lifesaving for preterm babies with respiratory distress because of surfactant deficiency. Attempts have been made over the last two decades to make surfactant administration as smooth and as nontraumatic as possible. Lesser invasive techniques, such as less invasive surfactant administration, minimally invasive surfactant therapy, intrapartum pharyngeal surfactant therapy, and the laryngeal mask airway, are preferred over invasive techniques like intubate surfactant extubation to reduce trauma and peridosing adverse effects. However, at present, aerosolized surfactant (AS) via nebulization remains the only truly noninvasive method of SRT. Many animal and human studies have shown promising results with the use of AS with similar clinical effects to an instilled surfactant with greater safety potential. But still AS has not been adapted to routine neonatal care. There is still scope for studies to further strengthen the role of AS. Also, SRT is a constantly changing field with new innovations revolutionizing and replacing old techniques.
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Affiliation(s)
- Hetal Pramod Budh
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
| | - Somashekhar Nimbalkar
- Department of Neonatology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India
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Howe C, Momin MAM, Aladwani G, Hindle M, Longest PW. Development of a High-Dose Infant Air-Jet Dry Powder Inhaler (DPI) with Passive Cyclic Loading of the Formulation. Pharm Res 2022; 39:3317-3330. [PMID: 36253630 PMCID: PMC10561662 DOI: 10.1007/s11095-022-03409-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/29/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE The objective of this study was to incorporate a passive cyclic loading strategy into the infant air-jet dry powder inhaler (DPI) in a manner that provides high efficiency aerosol lung delivery and is insensitive to powder mass loadings and the presence of downstream pulmonary mechanics. METHODS Four unique air-jet DPIs were initially compared and the best performing passive design (PD) was selected for sensitivity analyses. A single preterm in vitro nose-throat (NT) model, air source, and nasal interface were utilized throughout. While the majority of analyses were evaluated with a model spray-dried excipient enhanced growth (EEG) formulation, performance of a Surfactant-EEG formulation was also explored for the lead DPI design. RESULTS Two devices, PD-2 and PD-3, evaluated in the preterm model achieved an estimated lung delivery efficiency of 60% with the model EEG formulation, and were not sensitive to the loaded dose (10-30 mg of powder). The PD-3 device was also unaffected by the presence of downstream pulmonary mechanics (infant lung model) and had only a minor sensitivity to tripling the volume of the powder reservoir. When using the Surfactant-EEG formulation, increasing the actuation flow rate from 1.7 to 4.0 L/min improved lung delivery by nearly 10%. CONCLUSIONS The infant air-jet DPI platform was successfully modified with a passive cyclic loading strategy and capable of providing an estimated > 60% lung delivery efficiency of a model spray-dried formulation with negligible sensitivity to powder mass loading in the range of 10-30 mg and could be scaled to deliver much higher doses.
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Affiliation(s)
- Connor Howe
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, VA, 23284-3015, USA
| | - Mohammad A M Momin
- Department of Pharmaceutics, Virginia Commonwealth University, 410 N. 12th Street, PO Box 980533, Richmond, VA, 23284, USA
| | - Ghali Aladwani
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, VA, 23284-3015, USA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, 410 N. 12th Street, PO Box 980533, Richmond, VA, 23284, USA
| | - P Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, VA, 23284-3015, USA.
- Department of Pharmaceutics, Virginia Commonwealth University, 410 N. 12th Street, PO Box 980533, Richmond, VA, 23284, USA.
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Nord A, Bianco F, Salomone F, Ricci F, Schlun M, Linner R, Cunha-Goncalves D. Nebulization of High-Dose Poractant Alfa in Newborn Piglets on Nasal Continuous Positive Airway Pressure Yields Therapeutic Lung Doses of Phospholipids. Am J Perinatol 2022; 39:1001-1007. [PMID: 33242911 DOI: 10.1055/s-0040-1721392] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE It is not known how much surfactant must be nebulized to reach a lung dose of phospholipids equivalent to that obtained by the instillation of 200 mg/kg of surfactant. We aimed to assess the feasibility of nebulizing a high-dose of poractant alfa with the eFlow-Neos investigational vibrating-membrane nebulizer in newborn piglets on nasal continuous positive airway pressure (nCPAP) and to determine whether this intervention would yield therapeutic lung doses of phospholipids. STUDY DESIGN Twelve 1-day-old piglets on nCPAP received 600 mg/kg of poractant alfa admixed with technetium-99m via nebulization. Six piglets receiving 200 mg/kg of instilled synthetic surfactant served as controls. Lung deposition (percentage of the nominal dose) was determined by gamma scintigraphy, and the phospholipids' lung dose was calculated. RESULTS The lung dose of phospholipids (mean ± standard deviation [SD]) was 138 ± 96 mg/kg with nebulization, and 172 ± 24 mg/kg with instillation (p = 0.42). Nebulization took 58 ± 12 minutes. The arterial partial pressure of carbon dioxide increased from 6.7 ± 1.1 to 7.2 ± 1.1 kPa during nebulization (p = 0.04). Cerebral oximetry remained stable, and there was no hemodynamic instability. CONCLUSION Nebulization was well tolerated, and the mean lung dose of phospholipids was above 100 mg/kg, that is, not different from the instillation group. These experimental findings suggest that it may be feasible to reach therapeutic lung doses of phospholipids by surfactant nebulization during nCPAP. KEY POINTS · It is not known if effective lung doses of surfactant can be delivered by nebulization.. · Nebulization of high-dose surfactant in newborn piglets on nCPAP was well tolerated.. · A high-dose of nebulized poractant alfa yielded therapeutic lung doses of phospholipids..
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Affiliation(s)
- Anders Nord
- Pediatric Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Federico Bianco
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - Francesca Ricci
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., Parma, Italy
| | | | - Rikard Linner
- Cardiothoracic Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Doris Cunha-Goncalves
- Pediatric Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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7
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Dani C, Talosi G, Piccinno A, Ginocchio VM, Balla G, Lavizzari A, Stranak Z, Gitto E, Martinelli S, Plavka R, Krolak-Olejnik B, Lista G, Spedicato F, Ciurlia G, Santoro D, Sweet D. A Randomized, Controlled Trial to Investigate the Efficacy of Nebulized Poractant Alfa in Premature Babies with Respiratory Distress Syndrome. J Pediatr 2022; 246:40-47.e5. [PMID: 35257740 DOI: 10.1016/j.jpeds.2022.02.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/09/2022] [Accepted: 02/28/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of nebulized poractant alfa (at 200 and 400 mg/kg doses) delivered in combination with nasal continuous positive airway pressure compared with nasal continuous positive airway pressure alone in premature infants with diagnosed respiratory distress syndrome. STUDY DESIGN This randomized, controlled, multinational study was conducted in infants at 280/7 to 326/7 weeks of gestation. The primary outcome was the incidence of respiratory failure in the first 72 hours of life, defined as needing endotracheal surfactant and/or mechanical ventilation owing to prespecified criteria. Secondary outcomes included the time to respiratory failure in the first 72 hours, duration of ventilation, mortality, incidence of bronchopulmonary dysplasia, and major associated neonatal comorbidities. In addition, the safety and tolerability of the treatments were assessed reporting the number and percentage of infants with treatment-emergent adverse events and adverse drug reactions during nebulization. RESULTS In total, 129 infants were randomized. No significant differences were observed for the primary outcome: 24 (57%), 20 (49%), and 25 (58%) infants received endotracheal surfactant and/or mechanical ventilation within 72 hours in the poractant alfa 200 mg/kg, poractant alfa 400 mg/kg, and nasal continuous positive airway pressure groups, respectively. Similarly, secondary respiratory outcomes did not differ among groups. Enrollment was halted early owing to a change in the benefit-risk balance of the intervention. Nebulized poractant alfa was well-tolerated and safe, and no serious adverse events were related to the study treatment. CONCLUSIONS The intervention did not decrease the likelihood of respiratory failure within the first 72 hours of life. TRIAL REGISTRATION ClinicalTrials.gov: NCT03235986.
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Affiliation(s)
- Carlo Dani
- Careggi University Hospital of Florence, Florence, Italy.
| | - Gyula Talosi
- Bács-Kiskun County Teaching Hospital, Kecskemét, Hungary
| | | | | | | | | | - Zbynek Stranak
- Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Eloisa Gitto
- University Hospital Gaetano Martino, Messina, Italy
| | | | - Richard Plavka
- General University Hospital in Prague, Prague, Czech Republic
| | | | | | | | | | | | - David Sweet
- Royal Jubilee Maternity Hospital, Belfast, United Kingdom
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8
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Walther FJ, Waring AJ. Aerosol Delivery of Lung Surfactant and Nasal CPAP in the Treatment of Neonatal Respiratory Distress Syndrome. Front Pediatr 2022; 10:923010. [PMID: 35783301 PMCID: PMC9240419 DOI: 10.3389/fped.2022.923010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/24/2022] [Indexed: 01/06/2023] Open
Abstract
After shifting away from invasive mechanical ventilation and intratracheal instillation of surfactant toward non-invasive ventilation with nasal CPAP and less invasive surfactant administration in order to prevent bronchopulmonary dysplasia in preterm infants with respiratory distress syndrome, fully non-invasive surfactant nebulization is the next Holy Grail in neonatology. Here we review the characteristics of animal-derived (clinical) and new advanced synthetic lung surfactants and improvements in nebulization technology required to secure optimal lung deposition and effectivity of non-invasive lung surfactant administration. Studies in surfactant-deficient animals and preterm infants have demonstrated the safety and potential of non-invasive surfactant administration, but also provide new directions for the development of synthetic lung surfactant destined for aerosol delivery, implementation of breath-actuated nebulization and optimization of nasal CPAP, nebulizer circuit and nasal interface. Surfactant nebulization may offer a truly non-invasive option for surfactant delivery to preterm infants in the near future.
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Affiliation(s)
- Frans J. Walther
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Alan J. Waring
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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9
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Ricci F, Mersanne A, Storti M, Nutini M, Pellicelli G, Carini A, Milesi I, Lombardini M, Dellacà RL, Thomson MA, Murgia X, Lavizzari A, Bianco F, Salomone F. Preclinical Assessment of Nebulized Surfactant Delivered through Neonatal High Flow Nasal Cannula Respiratory Support. Pharmaceutics 2022; 14:pharmaceutics14051093. [PMID: 35631679 PMCID: PMC9146271 DOI: 10.3390/pharmaceutics14051093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022] Open
Abstract
High-flow nasal cannula (HFNC) is a non-invasive respiratory support (NRS) modality to treat premature infants with respiratory distress syndrome (RDS). The delivery of nebulized surfactant during NRS would represent a truly non-invasive method of surfactant administration and could reduce NRS failure rates. However, the delivery efficiency of nebulized surfactant during HFNC has not been evaluated in vitro or in animal models of respiratory distress. We, therefore, performed first a benchmark study to compare the surfactant lung dose delivered by commercially available neonatal nasal cannulas (NCs) and HFNC circuits commonly used in neonatal intensive care units. Then, the pulmonary effect of nebulized surfactant delivered via HFNC was investigated in spontaneously breathing rabbits with induced respiratory distress. The benchmark study revealed the surfactant lung dose to be relatively low for both types of NCs tested (Westmed NCs 0.5 ± 0.45%; Fisher & Paykel NCs 1.8 ± 1.9% of a nominal dose of 200 mg/kg of Poractant alfa). The modest lung doses achieved in the benchmark study are compatible with the lack of the effect of nebulized surfactant in vivo (400 mg/kg), where arterial oxygenation and lung mechanics did not improve and were significantly worse than the intratracheal instillation of surfactant. The results from the present study indicate a relatively low lung surfactant dose and negligible effect on pulmonary function in terms of arterial oxygenation and lung mechanics. This negligible effect can, for the greater part, be explained by the high impaction of aerosol particles in the ventilation circuit and upper airways due to the high air flows used during HFNC.
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Affiliation(s)
- Francesca Ricci
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
| | - Arianna Mersanne
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
| | - Matteo Storti
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
| | - Marcello Nutini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
| | - Giulia Pellicelli
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
| | - Angelo Carini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
| | - Ilaria Milesi
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
| | - Marta Lombardini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
| | - Raffaele L. Dellacà
- TechRes Lab, Dipartimento di Elettronica, Informazione e Bioingegneria (DEIB), Politecnico di Milano University, 20133 Milan, Italy;
| | | | | | - Anna Lavizzari
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Federico Bianco
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 15739 Parma, Italy; (F.R.); (A.M.); (M.S.); (M.N.); (G.P.); (A.C.); (I.M.); (M.L.); (F.B.)
- Correspondence:
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10
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Gemci T, Ponyavin V, Collins R, Corcoran TE, Saha SC, Islam MS. CFD Study of Dry Pulmonary Surfactant Aerosols Deposition in Upper 17 Generations of Human Respiratory Tract. Atmosphere 2022; 13:726. [DOI: 10.3390/atmos13050726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The efficient generation of high concentrations of fine-particle, pure surfactant aerosols provides the possibility of new, rapid, and effective treatment modalities for Acute Respiratory Distress Syndrome (ARDS). SUPRAER-CATM is a patented technology by Kaer BiotherapeuticsTM, which is a new class of efficient aerosol drug generation and delivery system using Compressor Air (CA). SUPRAER-CA is capable of aerosolizing relatively viscous solutions or suspensions of proteins and surfactants and of delivering them as pure fine particle dry aerosols. In this Computational Fluid Dynamics (CFD) study, we select a number of sites within the upper 17 generations of the human respiratory tract for calculation of the deposition of dry pulmonary surfactant aerosol particles. We predict the percentage of inhaled dry pulmonary surfactant aerosol arriving from the respiratory bronchioles to the terminal alveolar sacs. The dry pulmonary surfactant aerosols, with a Mass Median Aerodynamic Diameter (MMAD) of 2.6 µm and standard deviation of 1.9 µm, are injected into the respiratory tract at a dry surfactant aerosol flow rate of 163 mg/min to be used in the CFD study at an air inhalation flow rate of 44 L/min. This CFD study in the upper 17th generation of a male adult lung has shown computationally that the penetration fraction (PF) is approximately 25% for the inhaled surfactant aerosols. In conclusion, an ARDS patient might receive approximately one gram of inspired dry surfactant aerosol during an administration period of one hour as a possible means of further inflating partly collapsed alveoli.
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11
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Bass K, Momin MAM, Howe C, Aladwani G, Strickler S, Kolanjiyil AV, Hindle M, DiBlasi RM, Longest W. Characterizing the Effects of Nasal Prong Interfaces on Aerosol Deposition in a Preterm Infant Nasal Model. AAPS PharmSciTech 2022; 23:114. [PMID: 35441324 DOI: 10.1208/s12249-022-02259-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/20/2022] [Indexed: 11/30/2022] Open
Abstract
The objective of this study was to characterize the effects of multiple nasal prong interface configurations on nasal depositional loss of pharmaceutical aerosols in a preterm infant nose-throat (NT) airway model. Benchmark in vitro experiments were performed in which a spray-dried powder formulation was delivered to a new preterm NT model with a positive-pressure infant air-jet dry powder inhaler using single- and dual-prong interfaces. These results were used to develop and validate a computational fluid dynamics (CFD) model of aerosol transport and deposition in the NT geometry. The validated CFD model was then used to explore the NT depositional characteristic of multiple prong types and configurations. The CFD model highlighted a turbulent jet effect emanating from the prong(s). Analysis of NT aerosol deposition efficiency curves for a characteristic particle size and delivery flowrate (3 µm and 1.4 L/min (LPM)) revealed little difference in NT aerosol deposition fraction (DF) across the prong insertion depths of 2-5 mm (DF = 16-24%) with the exception of a single prong with 5-mm insertion (DF = 36%). Dual prongs provided a modest reduction in deposition vs. a single aerosol delivery prong at the same flow for insertion depths < 5 mm. The presence of the prongs increased nasal depositional loss by absolute differences in the range of 20-70% compared with existing correlations for ambient aerosols. In conclusion, the use of nasal prongs was shown to have a significant impact on infant NT aerosol depositional loss prompting the need for prong design alterations to improve lung delivery efficiency.
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Howe C, Momin MAM, Bass K, Aladwani G, Bonasera S, Hindle M, Longest PW. In Vitro Analysis of Nasal Interface Options for High-Efficiency Aerosol Administration to Preterm Infants. J Aerosol Med Pulm Drug Deliv 2022; 35:196-211. [PMID: 35166601 PMCID: PMC9416545 DOI: 10.1089/jamp.2021.0057] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: An infant air-jet dry powder inhaler (DPI) platform has recently been developed that in combination with highly dispersible spray-dried powder formulations can achieve high-efficiency aerosolization with low actuation air volumes. The objective of this study was to investigate modifications to the nasal interface section of this platform to improve the aerosol delivery performance through preterm nose-throat (NT) models. Methods: Aerosol delivery performance of multiple nasal interface flow pathways and prong configurations was assessed with two in vitro preterm infant NT models. Two excipient-enhanced growth (EEG) dry powder formulations were explored containing either l-leucine or trileucine as the dispersion enhancer. Performance metrics included aerosol depositional loss in the nasal interface, deposition in the NT models, and tracheal filter deposition, which was used to estimate lung delivery efficiency. Results: The best performing nasal interface replaced the straight flexible prong of the original gradual expansion design with a rigid curved prong (∼20° curvature). The prong modification increased the lung delivery efficiency by 5%-10% (absolute difference) depending on the powder formulation. Adding a metal mesh to the flow pathway, to dissipate the turbulent jet, also improved lung delivery efficiency by ∼5%, while reducing the NT depositional loss by a factor of over twofold compared with the original nasal interface. The platform was also found to perform similarly in two different preterm NT models, with no statistically significant difference between any of the performance metrics. Conclusions: Modifications to the nasal interface of an infant air-jet DPI improved the aerosol delivery through multiple infant NT models, providing up to an additional 10% lung delivery efficiency (absolute difference) with the lead design delivering ∼57% of the loaded dose to the tracheal filter, while performance in two unique preterm airway geometries remained similar.
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Affiliation(s)
- Connor Howe
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mohammad A M Momin
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Karl Bass
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ghali Aladwani
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Serena Bonasera
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Philip Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA.,Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
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13
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Jardine L, Lui K, Liley HG, Schindler T, Fink J, Asselin J, Durand D. Trial of aerosolised surfactant for preterm infants with respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed 2022; 107:51-55. [PMID: 34112722 PMCID: PMC8685619 DOI: 10.1136/archdischild-2021-321645] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the safety of an aerosolised surfactant, SF-RI 1, administered via nasal continuous positive airway pressure (nCPAP) and a prototype breath synchronisation device (AeroFact), to preterm infants with respiratory distress syndrome (RDS). DESIGN Multicentre, open-label, dose-escalation study with historical controls. SETTING Newborn intensive care units at Mater Mothers' Hospital, Brisbane, and Royal Hospital for Women, Sydney, Australia. PATIENTS Infants 26 weeks through 30 weeks gestation who required nCPAP 6-8 cmH2O and fraction of inspired oxygen (FiO2) <0.30 at <2 hours of age. INTERVENTIONS In part 1, infants received a single dose of 216 mg/kg of aerosolised surfactant. In part 2, infants could receive up to four doses of aerosolised surfactant. Three historical control infants were matched for each enrolled infant. MAIN OUTCOME MEASURES Treatment failure was defined as Respiratory Severity Score (FiO2×cmH2O nCPAP) >2.4, nCPAP >8 cmH2O, arterial carbon dioxide >65 mm Hg, pH <7.20 or three severe apnoeas within 6 hours during the first 72 hours of life. Other outcomes included tolerance of the AeroFact treatment and complications of prematurity. RESULTS 10 infants were enrolled in part 1 and 21 in part 2 and were compared with 93 historical controls. No safety issues were identified. In part 2, 6 of 21 (29%) AeroFact-treated infants compared with 30 of 63 (48%) control infants met failure criteria. Kaplan-Meier analysis of patients in part 2 showed a trend towards decreased rate of study failure in the AeroFact-treated infants compared with historical controls (p=0.10). CONCLUSION The AeroFact system can safely deliver aerosolised surfactant to preterm infants with RDS who are on nCPAP. TRIAL REGISTRATION NUMBER ACTRN12617001458325.
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Affiliation(s)
- Luke Jardine
- Neonatology, Mater Mothers' Hospital, Brisbane, Queensland, Australia,Faculty of Medicine, Mater Research Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Kei Lui
- Newborn Care, The Royal Hospital for Women Newborn Intensive Care Unit, Randwick, New South Wales, Australia,School of Women's and Children's Health, University of New South Wales School of Women's and Children's Health, Randwick, New South Wales, Australia
| | - Helen G Liley
- Neonatology, Mater Mothers' Hospital, Brisbane, Queensland, Australia,Faculty of Medicine, Mater Research Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Timothy Schindler
- Newborn Care, The Royal Hospital for Women Newborn Intensive Care Unit, Randwick, New South Wales, Australia,School of Women's and Children's Health, University of New South Wales School of Women's and Children's Health, Randwick, New South Wales, Australia
| | - James Fink
- Aerogen Pharma, San Mateo, California, USA
| | | | - David Durand
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
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Cimato A, Facorro G, Martínez Sarrasague M. Budesonide associated with exogenous pulmonary surfactant in a novel formulation to improve the delivery to the lung. Respir Physiol Neurobiol 2021; 296:103825. [PMID: 34808585 DOI: 10.1016/j.resp.2021.103825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/01/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
Lung delivery for glucocorticoids (GCs) is very low and depends on the system used. Exogenous pulmonary surfactant (EPS) is a promising tool to transporting GCs efficiently to the airways. We developed a new formulation of EPS with Budesonide (BUD) incorporated into EPS membranes (EPS-BUD) to improve lung delivery of BUD. We evaluated the biodistribution and pharmacokinetic of the transported BUD by intra-tracheal instillation of EPS-BUD in healthy rats. Aqueous suspension of Budesonide was used as control. Budesonide and its esters present in trachea, kidneys and lungs were determined by HPLC. The delivery of BUD in lung for EPS-BUD group was 75 % of total instilled and only 35 % for the control group. BUD was rapidly internalized in pneumocytes and a high proportion of Budesonide esters and persistent concentrations of active free BUD were found for up to 6 h after instillation. The new EPS-BUD formulation developed significantly improves the deposition and increases the permanence of BUD in lung.
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Affiliation(s)
- Alejandra Cimato
- Cátedra de Física, Departamento de Fisicomatemática, Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Buenos Aires, Argentina.
| | - Graciela Facorro
- Cátedra de Física, Departamento de Fisicomatemática, Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Margarita Martínez Sarrasague
- Cátedra de Física, Departamento de Fisicomatemática, Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Buenos Aires, Argentina
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15
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Gaertner VD, Thomann J, Bassler D, Rüegger CM. Surfactant Nebulization to Prevent Intubation in Preterm Infants: A Systematic Review and Meta-analysis. Pediatrics 2021; 148:peds.2021-052504. [PMID: 34711678 DOI: 10.1542/peds.2021-052504] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Surfactant nebulization (SN) may offer a safe alternative for surfactant administration in respiratory distress syndrome of preterm infants. OBJECTIVE To evaluate the efficacy of SN for the prevention of early intubation. DATA SOURCES Medline, Embase, The Cochrane Library, clinicaltrials.gov, published abstracts, and references of relevant articles were searched through March 23, 2021. STUDY SELECTION Randomized clinical trials of preterm infants <37 weeks' gestation comparing SN with noninvasive respiratory support or intratracheal surfactant application. DATA EXTRACTION Two reviewers extracted data and assessed risk of bias from included studies separately and blinded. Data were pooled by using a fixed-effects model. Subgroups (gestational age, type of nebulizer, surfactant type, and dosage) were evaluated. Primary outcome was intubation rate at 72 hours after birth. RESULTS Nine studies recruiting 1095 infants met inclusion criteria. SN compared with standard care significantly reduced intubation rate at 72 hours after birth (226 of 565 infants [40.0%] vs 231 of 434 infants [53.2%]; risk ratio [RR]: 0.73, 95% confidence interval [CI]: 0.63-0.84; number needed to treat: 8; 95% CI: 5-14]). Prespecified subgroup analysis identified important heterogeneity: SN was most effective in infants ≥28 weeks' gestation (RR: 0.70, 95% CI: 0.60-0.82), with a pneumatically driven nebulizer (RR: 0.52, 95% CI: 0.40-0.68) and in infants receiving ≥200 mg/kg and animal-derived surfactant (RR: 0.63, 95% CI: 0.52-0.75). No differences in neonatal morbidities or mortality were identified. LIMITATIONS Quality of evidence was low owing to risk of bias and imprecision. CONCLUSIONS SN reduced the intubation rate in preterm infants with a higher efficacy for specific subgroups. There was no difference in relevant neonatal morbidities or mortality.
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Affiliation(s)
- Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Switzerland
| | - Janine Thomann
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Switzerland
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Switzerland
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Switzerland
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16
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Howe C, Momin MAM, Farkas DR, Bonasera S, Hindle M, Longest PW. Advancement of the Infant Air-Jet Dry Powder Inhaler (DPI): Evaluation of Different Positive-Pressure Air Sources and Flow Rates. Pharm Res 2021; 38:1615-1632. [PMID: 34462876 DOI: 10.1007/s11095-021-03094-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/05/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE In order to improve the delivery of dry powder aerosol formulations to the lungs of infants, this study implemented an infant air-jet platform and explored the effects of different air sources, flow rates, and pulmonary mechanics on aerosolization performance and aerosol delivery through a preterm nose-throat (NT) in vitro model. METHODS The infant air-jet platform was actuated with a positive-pressure air source that delivered the aerosol and provided a full inhalation breath. Three different air sources were developed to provide highly controllable positive-pressure air actuations (using actuation volumes of ~10 mL for the preterm model). While providing different flow waveform shapes, the three air sources were calibrated to produce the same flow rate magnitude (Q90: 90th percentile of flow rate). Multiple air-jet DPI designs were coupled with the air sources and evaluated with a model spray-dried excipient enhanced growth formulation. RESULTS Compared to other designs, the D1-Single air-jet DPI provided improved performance with low variability across all three air sources. With the tested D1-Single air-jet and Timer air source, reducing the flow rate from 4 to 1.7 L/min marginally decreased the aerosol size and significantly increased the lung delivery efficiency above 50% of the loaded dose. These results were not impacted by the presence of downstream pulmonary mechanics (resistance and compliance model). CONCLUSIONS The selected design was capable of providing an estimated >50% lung delivery efficiency of a model spray-dried formulation and was not influenced by the air source, thereby enabling greater flexibility for platform deployment in different environments.
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Affiliation(s)
- Connor Howe
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, VA, 23284-3015, USA
| | - Mohammad A M Momin
- Department of Pharmaceutics, Virginia Commonwealth University, 410 North 12th Street, P.O. Box 980533, Richmond, VA, 23298-0533, USA
| | - Dale R Farkas
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, VA, 23284-3015, USA
| | - Serena Bonasera
- Department of Pharmaceutics, Virginia Commonwealth University, 410 North 12th Street, P.O. Box 980533, Richmond, VA, 23298-0533, USA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, 410 North 12th Street, P.O. Box 980533, Richmond, VA, 23298-0533, USA
| | - P Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, 401 West Main Street, P.O. Box 843015, Richmond, VA, 23284-3015, USA. .,Department of Pharmaceutics, Virginia Commonwealth University, 410 North 12th Street, P.O. Box 980533, Richmond, VA, 23298-0533, USA.
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Pioselli B, Salomone F, Mazzola G, Amidani D, Sgarbi E, Amadei F, Murgia X, Catinella S, Villetti G, De Luca D, Carnielli V, Civelli M. Pulmonary surfactant: a unique biomaterial with life-saving therapeutic applications. Curr Med Chem 2021; 29:526-590. [PMID: 34525915 DOI: 10.2174/0929867328666210825110421] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/26/2021] [Accepted: 06/29/2021] [Indexed: 11/22/2022]
Abstract
Pulmonary surfactant is a complex lipoprotein mixture secreted into the alveolar lumen by type 2 pneumocytes, which is composed by tens of different lipids (approximately 90% of its entire mass) and surfactant proteins (approximately 10% of the mass). It is crucially involved in maintaining lung homeostasis by reducing the values of alveolar liquid surface tension close to zero at end-expiration, thereby avoiding the alveolar collapse, and assembling a chemical and physical barrier against inhaled pathogens. A deficient amount of surfactant or its functional inactivation is directly linked to a wide range of lung pathologies, including the neonatal respiratory distress syndrome. This paper reviews the main biophysical concepts of surfactant activity and its inactivation mechanisms, and describes the past, present and future roles of surfactant replacement therapy, focusing on the exogenous surfactant preparations marketed worldwide and new formulations under development. The closing section describes the pulmonary surfactant in the context of drug delivery. Thanks to its peculiar composition, biocompatibility, and alveolar spreading capability, the surfactant may work not only as a shuttle to the branched anatomy of the lung for other drugs but also as a modulator for their release, opening to innovative therapeutic avenues for the treatment of several respiratory diseases.
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Affiliation(s)
| | | | | | | | - Elisa Sgarbi
- Preclinical R&D, Chiesi Farmaceutici, Parma. Italy
| | | | - Xabi Murgia
- Department of Biotechnology, GAIKER Technology Centre, Zamudio. Spain
| | | | | | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Antoine Béclère Medical Center, APHP, South Paris University Hospitals, Paris, France; Physiopathology and Therapeutic Innovation Unit-U999, South Paris-Saclay University, Paris. France
| | - Virgilio Carnielli
- Division of Neonatology, G Salesi Women and Children's Hospital, Polytechnical University of Marche, Ancona. Italy
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Walther FJ, Chan H, Smith JR, Tauber M, Waring AJ. Aerosol, chemical and physical properties of dry powder synthetic lung surfactant for noninvasive treatment of neonatal respiratory distress syndrome. Sci Rep 2021; 11:16439. [PMID: 34385559 PMCID: PMC8360972 DOI: 10.1038/s41598-021-95999-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/03/2021] [Indexed: 11/11/2022] Open
Abstract
Inhalation of dry powder synthetic lung surfactant may assist spontaneous breathing by providing noninvasive surfactant therapy for premature infants supported with nasal continuous positive airway pressure. Surfactant was formulated using spray-drying with different phospholipid compositions (70 or 80 total weight% and 7:3 or 4:1 DPPC:POPG ratios), a surfactant protein B peptide analog (KL4, Super Mini-B, or B-YL), and Lactose or Trehalose as excipient. KL4 surfactant underperformed on initial adsorption and surface activity at captive bubble surfactometry. Spray-drying had no effect on the chemical composition of Super Mini-B and B-YL peptides and surfactant with these peptides had excellent surface activity with particle sizes and fine particle fractions that were well within the margins for respiratory particles and similar solid-state properties. Prolonged exposure of the dry powder surfactants with lactose as excipient to 40 °C and 75% humidity negatively affected hysteresis during dynamic cycling in the captive bubble surfactometer. Dry powder synthetic lung surfactants with 70% phospholipids (DPPC and POPG at a 7:3 ratio), 25% trehalose and 3% of SMB or B-YL showed excellent surface activity and good short-term stability, thereby qualifying them for potential clinical use in premature infants.
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Affiliation(s)
- Frans J Walther
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA.
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, 90502, USA.
| | - Holly Chan
- Acorda Therapeutics Inc., Waltham, MA, 02451, USA
| | | | - Mike Tauber
- Acorda Therapeutics Inc., Waltham, MA, 02451, USA
| | - Alan J Waring
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, 90502, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA
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19
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Rey-Santano C, Mielgo V, Gastiasoro E, Bianco F, Salomone F, Gomez-Solaetxe MA. Surfactant nebulization therapy during NIPPV ventilation in surfactant-deficient newborn piglets. Pediatr Pulmonol 2021; 56:2125-2135. [PMID: 33960742 PMCID: PMC8252521 DOI: 10.1002/ppul.25425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND In recent years, nasal intermittent positive pressure ventilation (NIPPV) has been growing in popularity as a form of noninvasive ventilation for respiratory support in the initial treatment of neonates with surfactant (SF) deficiency. The combination of this type of ventilation with noninvasive SF administration (by nebulization) is an attractive treatment option for respiratory distress syndrome (RDS)-associated pathophysiology of the neonatal lungs. In this study, we aimed to test the tolerability and efficacy of SF nebulization during NIPPV for the treatment of neonatal RDS. METHODS Spontaneously-breathing newborn piglets (n = 6/group) with bronchoalveolar lavage (BAL)-induced RDS were assigned to receive during NIPPV (180 min): poractant alfa (400 mg/kg) via an investigational customized vibrating-membrane nebulizer (eFlow-Neos) or poractant alfa (200 mg/kg) as a bolus using the Insure method or no surfactant (controls). MEASUREMENT AND RESULTS We assessed pulmonary, hemodynamic and cerebral effects and performed histological analysis of lung and brain tissue. After repeated BAL, newborn piglets developed severe RDS (FiO2 : 1, pH < 7.2, PaCO2 > 70 mmHg, PaO2 < 70 mmHg, Cdyn < 0.5 ml/cmH2 O/kg). In both SF-treated groups, we observed rapid improvement in pulmonary status and also similar hemodynamic, cerebral behavior, and lung and brain injury scores. CONCLUSION Our results in newborn piglets with severe BAL-induced RDS show the administration of nebulized poractant alfa using the eFlow-Neos nebulizer during NIPPV to be well tolerated and efficacious, suggesting that this noninvasive SF administration option should be explored further.
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Affiliation(s)
- Carmen Rey-Santano
- Animal Research Unit and Experimental Research Department, Biocruces-Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
| | - Victoria Mielgo
- Animal Research Unit and Experimental Research Department, Biocruces-Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
| | - Elena Gastiasoro
- Primary Health Care Department, Biocruces-Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
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20
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Brasher M, Raffay TM, Cunningham MD, Abu Jawdeh EG. Aerosolized Surfactant for Preterm Infants with Respiratory Distress Syndrome. Children (Basel) 2021; 8:children8060493. [PMID: 34200535 PMCID: PMC8228799 DOI: 10.3390/children8060493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022]
Abstract
Currently, the administration of surfactant to preterm infants with respiratory distress syndrome (RDS) mainly relies on intratracheal instillation; however, there is increasing evidence of aerosolized surfactant being an effective non-invasive strategy. We present a historical narrative spanning sixty years of development of aerosolization systems. We also offer an overview of the pertinent mechanisms needed to create and manage the ideal aerosolization system, with a focus on delivery, distribution, deposition, and dispersion in the context of the human lung. More studies are needed to optimize treatment with aerosolized surfactants, including determination of ideal dosages, nebulizer types, non-invasive interfaces, and breath synchronization. However, the field is rapidly evolving, and widespread clinical use may be achieved in the near future.
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Affiliation(s)
- Mandy Brasher
- Department of Pediatrics/Neonatology, College of Medicine, University of Kentucky, Lexington, KY 40506, USA;
- Correspondence: (M.B.); (E.G.A.J.); Tel.: +1-859-323-6117 (E.G.A.J.); Fax: +1-859-257-6066 (E.G.A.J.)
| | - Thomas M. Raffay
- Department of Pediatrics/Neonatology, College of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - M. Douglas Cunningham
- Department of Pediatrics/Neonatology, College of Medicine, University of Kentucky, Lexington, KY 40506, USA;
| | - Elie G. Abu Jawdeh
- Department of Pediatrics/Neonatology, College of Medicine, University of Kentucky, Lexington, KY 40506, USA;
- Correspondence: (M.B.); (E.G.A.J.); Tel.: +1-859-323-6117 (E.G.A.J.); Fax: +1-859-257-6066 (E.G.A.J.)
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21
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Rey-Santano C, Mielgo VE, Gomez-Solaetxe MA, Bianco F, Salomone F, Loureiro B. Nebulized Poractant Alfa Reduces the Risk of Respiratory Failure at 72 Hours in Spontaneously Breathing Surfactant-Deficient Newborn Piglets. Crit Care Med 2020; 48:e523-31. [PMID: 32301841 DOI: 10.1097/CCM.0000000000004318] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Supplemental Digital Content is available in the text. We have setup for the first time a long-term (72 hr) respiratory distress syndrome model in spontaneously breathing surfactant-deficient newborn piglets to investigate the continuous positive airway pressure failure rate with nebulized poractant alfa compared with that with the intubation surfactant extubation technique or continuous positive airway pressure only.
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Bianco F, Salomone F, Milesi I, Murgia X, Bonelli S, Pasini E, Dellacà R, Ventura ML, Pillow J. Aerosol drug delivery to spontaneously-breathing preterm neonates: lessons learned. Respir Res 2021; 22:71. [PMID: 33637075 PMCID: PMC7908012 DOI: 10.1186/s12931-020-01585-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023] Open
Abstract
Delivery of medications to preterm neonates receiving non-invasive ventilation (NIV) represents one of the most challenging scenarios for aerosol medicine. This challenge is highlighted by the undersized anatomy and the complex (patho)physiological characteristics of the lungs in such infants. Key physiological restraints include low lung volumes, low compliance, and irregular respiratory rates, which significantly reduce lung deposition. Such factors are inherent to premature birth and thus can be regarded to as the intrinsic factors that affect lung deposition. However, there are a number of extrinsic factors that also impact lung deposition: such factors include the choice of aerosol generator and its configuration within the ventilation circuit, the drug formulation, the aerosol particle size distribution, the choice of NIV type, and the patient interface between the delivery system and the patient. Together, these extrinsic factors provide an opportunity to optimize the lung deposition of therapeutic aerosols and, ultimately, the efficacy of the therapy. In this review, we first provide a comprehensive characterization of both the intrinsic and extrinsic factors affecting lung deposition in premature infants, followed by a revision of the clinical attempts to deliver therapeutic aerosols to premature neonates during NIV, which are almost exclusively related to the non-invasive delivery of surfactant aerosols. In this review, we provide clues to the interpretation of existing experimental and clinical data on neonatal aerosol delivery and we also describe a frame of measurable variables and available tools, including in vitro and in vivo models, that should be considered when developing a drug for inhalation in this important but under-served patient population.
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Affiliation(s)
- Federico Bianco
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122, Parma, Italy.
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122, Parma, Italy
| | - Ilaria Milesi
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122, Parma, Italy
| | | | - Sauro Bonelli
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122, Parma, Italy
| | - Elena Pasini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122, Parma, Italy
| | - Raffaele Dellacà
- TechRes Lab, Dipartimento Di Elettronica, Informazione E Bioingegneria (DEIB), Politecnico Di Milano University, Milano, Italy
| | | | - Jane Pillow
- School of Human Sciences, University of Western Australia, Perth, Australia
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DiBlasi RM, Kajimoto M, Poli JA, Deutsch G, Pfeiffer J, Zimmerman J, Crotwell DN, Malone P, Fink JB, Ringer C, Uthamanthil R, Ledee D, Portman MA. Breath-Synchronized Nebulized Surfactant in a Porcine Model of Acute Respiratory Distress Syndrome. Crit Care Explor 2021; 3:e0338. [PMID: 33604579 DOI: 10.1097/CCE.0000000000000338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Objectives Effective treatment options for surfactant therapy in acute respiratory distress syndrome and coronavirus disease 2019 have not been established. To conduct preclinical studies in vitro and in vivo to evaluate efficiency, particle size, dosing, safety, and efficacy of inhaled surfactant using a breath-synchronized, nebulized delivery system in an established acute respiratory distress syndrome model. Design Preclinical study. Setting Research laboratory. Subjects Anesthetized pigs. Intervention In vitro analysis included particle size distribution and inhaled dose during simulated ventilation using a novel breath-synchronized nebulizer. Physiologic effects of inhaled aerosolized surfactant (treatment) were compared with aerosolized normal saline (control) in an adult porcine model (weight of 34.3 ± 0.6 kg) of severe acute respiratory distress syndrome (Pao2/Fio2 <100) with lung lavages and ventilator-induced lung injury during invasive ventilation. Measurements and Main Results Mass median aerosol diameter was 2.8 µm. In vitro dose delivered distal to the endotracheal tube during mechanical ventilation was 85% ± 5%. Nebulizers were functional up to 20 doses of 108 mg of surfactant. Surfactant-treated animals (n = 4) exhibited rapid improvement in oxygenation with nearly full recovery of Pao2/Fio2 (~300) and end-expiratory lung volumes with nominal dose less than 30 mg/kg of surfactant, whereas control subjects (n = 3) maintained Pao2/Fio2 less than 100 over 4.5 hours with reduced end-expiratory lung volume. There was notably greater surfactant phospholipid content and lower indicators of lung inflammation and pathologic lung injury in surfactant-treated pigs than controls. There were no peridosing complications associated with nebulized surfactant, but surfactant-treated animals had progressively higher airway resistance post treatment than controls with no differences in ventilation effects between the two groups. Conclusions Breath-synchronized, nebulized bovine surfactant appears to be a safe and feasible treatment option for use in coronavirus disease 2019 and other severe forms of acute respiratory distress syndrome.
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Gaertner VD, Bassler D, Rüegger CM. Does surfactant nebulization prevent early intubation in preterm infants? A protocol for a systematic review and meta-analysis. Syst Rev 2021; 10:9. [PMID: 33407775 PMCID: PMC7786931 DOI: 10.1186/s13643-020-01573-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 12/26/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Respiratory distress syndrome (RDS) is the most common cause of respiratory failure in preterm infants. Treatment consists of respiratory support and exogenous surfactant administration. Commonly, surfactant is administered intratracheally. However, this requires airway instrumentation and subsequent fluid instillation which may be harmful. Surfactant nebulization (SN) may offer a safe and effective alternative for surfactant administration, but the clinical efficacy is not yet established. Thus, this systematic review and meta-analysis of randomized controlled trials will summarize the available evidence to determine the effectiveness and safety of SN for the prevention of intubation and subsequent mechanical ventilation at 72 h after birth. METHODS A systematic literature search in Medline, Embase, and The Cochrane Library will be performed, and all randomized controlled trials (RCTs) and quasi-RCTs from published articles, presentations, and trial registries will be included in this meta-analysis. Titles and abstracts of all records identified in the search will be screened by two reviewers independently. Data on preterm infants (≤ 37 weeks) receiving nebulized surfactant in the first 72 h after birth for the treatment or prevention of RDS will be evaluated. Primary outcome is the intubation rate by 72 h after birth, and secondary outcomes include peridosing safety effects as well as major neonatal morbidities. Risk of bias will be assessed using the revised Cochrane ROB tool, and subgroup analyses will be performed to evaluate potential confounding factors. Publication bias will be assessed by examining a funnel plot. The meta-analysis will be performed using a fixed-effects model. DISCUSSION This review will provide an evidence-based tool for information about surfactant nebulization, illustrating the current knowledge and hopefully revealing potential novel avenues for researchers and clinicians alike. SYSTEMATIC REVIEW REGISTRATION This review is registered with the publicly available resource PROSPERO ( CRD42020175625 ).
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Affiliation(s)
- Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland.
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
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25
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Rong H, Bao Y, Wen Z, Chen X, Chen C, Li F. Nebulized versus invasively delivered surfactant therapy for neonatal respiratory distress syndrome: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23113. [PMID: 33235071 PMCID: PMC7710245 DOI: 10.1097/md.0000000000023113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Pulmonary surfactant (PS) is commonly used for the treatment of neonatal respiratory distress syndrome (NRDS), several randomized controlled trials (RCTs) have evaluated the role of nebulized versus invasively delivered PS, yet the results remained inconsistent. Therefore, we aimed to conduct this meta-analysis to evaluate the effects and safety of nebulized versus invasively delivered PS in the treatment of NRDS. METHODS We searched PubMed et al databases from inception date to May 15, 2020 for RCTs that compared nebulized vs invasively delivered PS. Two authors independently screened the studies and extracted data from the published articles. Summary odd ratios (OR) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated for each outcome by means of fixed- or random-effects model. RESULTS Two RCTs with a total of 95 preterm neonates were identified, with 48 neonates received PS nebulization and 47 neonates undergone invasive PS administration. There was no significant difference in the SpO2 level (MD = -0.44, 95% CI -6.01 to 5.12) and the A/APaO2 level (MD = 0.01, 95% CI -0.02 to 0.05) 1 hour after treatment among 2 groups. But the duration of mechanical ventilation in the nebulization groups was significantly less than that of invasive group (MD = -30.70, 95% CI -41.45 to 19.95). CONCLUSIONS Given the limited evidences, the effects and safety of nebulized versus invasively delivered PS still need further verification.
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Affiliation(s)
| | - Ying Bao
- Nursing department, Children's Hospital of Nanjing Medical University, China
| | - Zunjia Wen
- Nursing department, Children's Hospital of Nanjing Medical University, China
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Cummings JJ, Gerday E, Minton S, Katheria A, Albert G, Flores-Torres J, Famuyide M, Lampland A, Guthrie S, Kuehn D, Weitkamp JH, Fort P, Abu Jawdeh EG, Ryan RM, Martin GC, Swanson JR, Mulrooney N, Eyal F, Gerstmann D, Kumar P, Wilding GE, Egan EA. Aerosolized Calfactant for Newborns With Respiratory Distress: A Randomized Trial. Pediatrics 2020; 146:peds.2019-3967. [PMID: 33060258 DOI: 10.1542/peds.2019-3967] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Exogenous surfactants to treat respiratory distress syndrome (RDS) are approved for tracheal instillation only; this requires intubation, often followed by positive pressure ventilation to promote distribution. Aerosol delivery offers a safer alternative, but clinical studies have had mixed results. We hypothesized that efficient aerosolization of a surfactant with low viscosity, early in the course of RDS, could reduce the need for intubation and instillation of liquid surfactant. METHODS A prospective, multicenter, randomized, unblinded comparison trial of aerosolized calfactant (Infasurf) in newborns with signs of RDS that required noninvasive respiratory support. Calfactant was aerosolized by using a Solarys nebulizer modified with a pacifier adapter; 6 mL/kg (210 mg phospholipid/kg body weight) were delivered directly into the mouth. Infants in the aerosol group received up to 3 treatments, at least 4 hours apart. Infants in the control group received usual care, determined by providers. Infants were intubated and given instilled surfactant for persistent or worsening respiratory distress, at their providers' discretion. RESULTS Among 22 NICUs, 457 infants were enrolled; gestation 23 to 41 (median 33) weeks and birth weight 595 to 4802 (median 1960) grams. In total, 230 infants were randomly assigned to aerosol; 225 received 334 treatments, starting at a median of 5 hours. The rates of intubation for surfactant instillation were 26% in the aerosol group and 50% in the usual care group (P < .0001). Respiratory outcomes up to 28 days of age were no different. CONCLUSIONS In newborns with early, mild to moderate respiratory distress, aerosolized calfactant at a dose of 210 mg phospholipid/kg body weight reduced intubation and surfactant instillation by nearly one-half.
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Affiliation(s)
| | - Erick Gerday
- Utah Valley Regional Medical Center, Provo, Utah
| | | | - Anup Katheria
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
| | | | | | - Mobolaji Famuyide
- Department of Pediatrics, University of Mississippi, Oxford, Mississippi
| | | | - Scott Guthrie
- Jackson-Madison County General Hospital, Jackson, Tennessee
| | - Devon Kuehn
- East Carolina University and Vidant Medical Center, Greenville, North Carolina
| | | | - Prem Fort
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | - Rita M Ryan
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | | | | | | | - Fabien Eyal
- University of South Alabama Children's and Women's Hospital, Mobile, Alabama
| | | | - Praveen Kumar
- Order of St. Francis Children's Hospital of Illinois, Peoria, Illinois
| | - Greg E Wilding
- Department of Biostatistics, University at Buffalo, Buffalo, New York; and
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Rey-Santano C, Mielgo V, Salomone F, Bianco F, Gomez-Solaetxe MA. The authors reply. Pediatr Crit Care Med 2020; 21:927-8. [PMID: 33009317 DOI: 10.1097/PCC.0000000000002554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tarantini F, Milesi I, Murgia X, Bianco F, Dellacà RL. A Compartment-Based Mathematical Model for Studying Convective Aerosol Transport in Newborns Receiving Nebulized Drugs during Noninvasive Respiratory Support. Pharmaceutics 2020; 12:E936. [PMID: 33007894 DOI: 10.3390/pharmaceutics12100936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 12/28/2022] Open
Abstract
Nebulization could be a valuable solution to administer drugs to neonates receiving noninvasive respiratory support. Small and irregular tidal volumes and air leaks at the patient interface, which are specific characteristics of this patient population and are primarily responsible for the low doses delivered to the lung (DDL) found in this application, have not been thoroughly addressed in in vitro and in vivo studies for quantifying DDL. Therefore, we propose a compartment-based mathematical model able to describe convective aerosol transport mechanisms to complement the existing deposition models. Our model encompasses a mechanical ventilator, a nebulizer, and the patient; the model considers the gas flowing between compartments, including air leaks at the patient–ventilator interface. Aerosol particles are suspended in the gas flow and homogeneously distributed. The impact of breathing pattern variability, volume of the nebulizer, and leaks level on DDL is assessed in representative conditions. The main finding of this study is that convective mechanisms associated to air leaks and breathing patterns with tidal volumes smaller than the nebulizer dramatically reduce the DDL (up to 70%). This study provides a possible explanation to the inconsistent results of drug aerosolization in clinical studies and may provide guidance to improve nebulizer design and clinical procedures.
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Howe C, Hindle M, Bonasera S, Rani V, Longest PW. Initial Development of an Air-Jet Dry Powder Inhaler for Rapid Delivery of Pharmaceutical Aerosols to Infants. J Aerosol Med Pulm Drug Deliv 2020; 34:57-70. [PMID: 32758026 DOI: 10.1089/jamp.2020.1604] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Positive-pressure dry powder inhalers (DPIs) have recently been developed that in combination with highly dispersible spray-dried powder formulations can achieve high efficiency aerosolization with low actuation air-volumes (AAVs). The objective of this study was to initially develop the positive-pressure air-jet DPI platform for high efficiency aerosol delivery to newborn infants by using the nose-to-lung route. Methods: Aerosolization performance metrics of six air-jet DPIs were first assessed at AAVs that were consistent with full-term (30 mL) and preterm (10 mL) neonates. Designs of the air-jet DPIs varied based on geometry of the inlet and outlet flow passages and shape of the aerosolization chamber. Aerosolization metrics evaluated at the device outlet were emitted dose (ED) and mass median aerodynamic diameter (MMAD). Designs with the best aerosolization performance were connected to a smoothly expanding nasal interface and full-term infant (3550 g) nose-throat (NT) model with tracheal filter. Results: The three best performing devices had characteristics of a cylindrical and horizontal aerosolization chamber with a flush or protruding outlet orifice. Including multiple air inlets resulted in meeting the aerosolization targets of >80% ED (based on loaded dose) and MMAD <1.8 μm. Reducing the AAV by a factor of threefold from 30 to 10 mL had little effect on aerosol formation. The three leading devices all delivered ∼50% of the loaded dose through a full-term NT in vitro model by using an AAV of 30 mL. Conclusion: With careful selection of design attributes, the air-jet DPI platform is capable of high-efficiency aerosolization of a 10 mg powder mass by using AAVs that are consistent with infant inhalation. The associated infant air-jet DPI system, which forms a seal at the nostril(s) and delivers both the aerosol and a complete inhalation, is capable of rapid and efficient aerosol administration to infant lungs, based on initial testing in a full-term in vitro NT model.
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Affiliation(s)
- Connor Howe
- Department of Mechanical and Nuclear Engineering and Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Serena Bonasera
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Vijaya Rani
- Department of Mechanical and Nuclear Engineering and Virginia Commonwealth University, Richmond, Virginia, USA
| | - P Worth Longest
- Department of Mechanical and Nuclear Engineering and Virginia Commonwealth University, Richmond, Virginia, USA.,Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
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Rey-Santano C, Mielgo V, Gomez-Solaetxe MA, Ricci F, Bianco F, Salomone F, Loureiro B. Dose-Response Study on Surfactant Nebulization Therapy During Nasal Continuous Positive Airway Pressure Ventilation in Spontaneously Breathing Surfactant-Deficient Newborn Piglets. Pediatr Crit Care Med 2020; 21:e456-66. [PMID: 32195907 DOI: 10.1097/PCC.0000000000002313] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The current clinical treatment of neonates with respiratory distress syndrome includes endotracheal intubation and intratracheal instillation of exogenous surfactant. Nebulization of surfactant offers an attractive alternative. The aims of this study were to test nebulization as a noninvasive method of administering surfactant and determine the optimal dose for the treatment of respiratory distress syndrome-associated pathophysiology of the neonatal lungs. DESIGN Prospective, randomized, animal model study. SETTING An experimental laboratory. SUBJECTS Thirty-six newborn piglets. INTERVENTIONS Different doses (100, 200, 400, and 600 mg/kg) of poractant alfa were administered via a vibrating membrane nebulizer (eFlow-Neos; Pari Pharma GmbH, Starnberg, Germany) or a bolus administration using the intubation-surfactant-extubation (Insure) technique (200 mg/kg) to spontaneously breathing newborn piglets (n = 6/group) with bronchoalveolar lavage-induced respiratory distress syndrome during nasal continuous positive airway pressure (180 min). MEASUREMENTS AND MAIN RESULTS Pulmonary, hemodynamic, and cerebral effects were assessed. Histologic analysis of lung and brain tissue was also performed. After repeated bronchoalveolar lavage, newborn piglets developed severe respiratory distress syndrome. Rapid improvement in pulmonary status was observed in the Insure group, whereas a dose-response effect was observed in nebulized surfactant groups. Nebulized poractant alfa was more effective at doses higher than 100 mg/kg and was associated with similar pulmonary, hemodynamic, and cerebral behavior to that in the Insure group, but improved lung injury scores. CONCLUSIONS In newborn piglets with severe bronchoalveolar lavage-induced respiratory distress syndrome, our results demonstrate that the administration of nebulized poractant alfa using an investigational customized eFlow-Neos nebulizer is an effective and safe noninvasive surfactant administration technique.
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Kamga Gninzeko FJ, Valentine MS, Tho CK, Chindal SR, Boc S, Dhapare S, Momin MAM, Hassan A, Hindle M, Farkas DR, Longest PW, Heise RL. Excipient Enhanced Growth Aerosol Surfactant Replacement Therapy in an In Vivo Rat Lung Injury Model. J Aerosol Med Pulm Drug Deliv 2020; 33:314-322. [PMID: 32453638 DOI: 10.1089/jamp.2020.1593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: In neonatal respiratory distress syndrome, breathing support and surfactant therapy are commonly used to enable the alveoli to expand. Surfactants are typically delivered through liquid instillation. However, liquid instillation does not specifically target the small airways. We have developed an excipient enhanced growth (EEG) powder aerosol formulation using Survanta®. Methods: EEG Survanta powder aerosol was delivered using a novel dry powder inhaler via tracheal insufflation to surfactant depleted rats at nominal doses of 3, 5, 10, and 20 mg of powder containing 0.61, 0.97, 1.73, and 3.46 mg of phospholipids (PL), whereas liquid Survanta was delivered via syringe instillation at doses of 2 and 4 mL/kg containing 18.6 and 34 mg of PL. Ventilation mechanics were measured before and after depletion, and after treatment. We hypothesized that EEG Survanta powder aerosol would improve lung mechanics compared with instilled liquid Survanta in surfactant depleted rats. Results and Conclusion: EEG Survanta powder aerosol at a dose of 0.61 mg PL significantly improved lung compliance and elastance compared with the liquid Survanta at a dose of 18.6 mg, which represents improved primary efficacy of the aerosol at a 30-fold lower dose of PL. There was no significant difference in white blood cell count of the lavage from the EEG Survanta group compared with liquid Survanta. These results provide an in vivo proof-of-concept for EEG Survanta powder aerosol as a promising method of surfactant replacement therapy.
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Affiliation(s)
- Franck J Kamga Gninzeko
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael S Valentine
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Cindy K Tho
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sahil R Chindal
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Susan Boc
- Department of Pharmaceutics, and Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sneha Dhapare
- Department of Pharmaceutics, and Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Amr Hassan
- Department of Pharmaceutics, and Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael Hindle
- Department of Pharmaceutics, and Virginia Commonwealth University, Richmond, Virginia, USA
| | - Dale R Farkas
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - P Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Rebecca L Heise
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
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Bianco F, Pasini E, Nutini M, Murgia X, Stoeckl C, Schlun M, Hetzer U, Bonelli S, Lombardini M, Milesi I, Pertile M, Minocchieri S, Salomone F, Bucholski A. Extended Pharmacopeial Characterization of Surfactant Aerosols Generated by a Customized eFlow Neos Nebulizer Delivered through Neonatal Nasal Prongs. Pharmaceutics 2020; 12:pharmaceutics12040319. [PMID: 32252349 PMCID: PMC7238214 DOI: 10.3390/pharmaceutics12040319] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/06/2020] [Accepted: 03/31/2020] [Indexed: 12/17/2022] Open
Abstract
The delivery of nebulized medications to preterm infants during Non-Invasive Ventilation (NIV) remains an unmet clinical need. In this regard, the effective delivery of nebulized surfactant has been particularly investigated in preclinical and clinical studies. In this work, we investigated the feasibility of delivering nebulized surfactant through various commercially available nasal prong types. We first performed a compendial characterization of surfactant aerosols generated by the eFlow Neos nebulizer, customized to be used in neonates, determining the amount of surfactant delivered by the device as well as the aerodynamic characteristics of surfactant aerosols. Additionally, we extended the compendial characterization by testing the effect of different nasal prong types on the estimated lung dose using a realistic Continuous Positive Airway Pressure (CPAP) circuit that included a cast of the upper airways of a preterm neonate. The compendial characterization of surfactant aerosols delivered through different nasal prongs achieved relatively high delivered surfactant doses (in the range 63-74% of the nominal dose), with aerodynamic characteristics displaying mass median aerodynamic diameters ranging between 2.52 and 2.81 µm. Nevertheless, when using a representative in vitro setup mimicking NIV in a clinical setting, significant differences were observed in terms of the estimated lung dose accounting for up to two-fold differences (from 10% to 20% estimated lung deposition of the nominal dose) depending on the chosen nasal prong type. Considering that surfactant lung deposition rates are correlated with therapeutic efficacy, this study points out the relevance of choosing the appropriate NIV interface to maximize the lung dose of nebulized medications.
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Affiliation(s)
- Federico Bianco
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy; (E.P.); (M.N.); (S.B.); (M.L.); (I.M.); (M.P.); (F.S.)
- Correspondence: ; Tel.: +390521279035
| | - Elena Pasini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy; (E.P.); (M.N.); (S.B.); (M.L.); (I.M.); (M.P.); (F.S.)
| | - Marcello Nutini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy; (E.P.); (M.N.); (S.B.); (M.L.); (I.M.); (M.P.); (F.S.)
| | | | - Carolin Stoeckl
- PARI Pharma GmbH, 82319 Starnberg, Germany; (C.S.); (M.S.); (U.H.); (A.B.)
| | - Martin Schlun
- PARI Pharma GmbH, 82319 Starnberg, Germany; (C.S.); (M.S.); (U.H.); (A.B.)
| | - Uwe Hetzer
- PARI Pharma GmbH, 82319 Starnberg, Germany; (C.S.); (M.S.); (U.H.); (A.B.)
| | - Sauro Bonelli
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy; (E.P.); (M.N.); (S.B.); (M.L.); (I.M.); (M.P.); (F.S.)
| | - Marta Lombardini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy; (E.P.); (M.N.); (S.B.); (M.L.); (I.M.); (M.P.); (F.S.)
| | - Ilaria Milesi
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy; (E.P.); (M.N.); (S.B.); (M.L.); (I.M.); (M.P.); (F.S.)
| | - Marisa Pertile
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy; (E.P.); (M.N.); (S.B.); (M.L.); (I.M.); (M.P.); (F.S.)
| | - Stephan Minocchieri
- Division of Neonatology, Cantonal Hospital Winterthur, 8401 Winterthur, Switzerland;
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy; (E.P.); (M.N.); (S.B.); (M.L.); (I.M.); (M.P.); (F.S.)
| | - Albert Bucholski
- PARI Pharma GmbH, 82319 Starnberg, Germany; (C.S.); (M.S.); (U.H.); (A.B.)
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Bianco F, Pasini E, Nutini M, Murgia X, Stoeckl C, Schlun M, Hetzer U, Bonelli S, Lombardini M, Milesi I, Pertile M, Minocchieri S, Salomone F, Bucholski A. In Vitro Performance of an Investigational Vibrating-Membrane Nebulizer with Surfactant under Simulated, Non-Invasive Neonatal Ventilation Conditions: Influence of Continuous Positive Airway Pressure Interface and Nebulizer Positioning on the Lung Dose. Pharmaceutics 2020; 12:E257. [PMID: 32178276 DOI: 10.3390/pharmaceutics12030257] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 11/25/2022] Open
Abstract
Non-invasive delivery of nebulized surfactant has been a long-pursued goal in neonatology. Our aim was to evaluate the performance of an investigational vibrating-membrane nebulizer in a realistic non-invasive neonatal ventilation circuit with different configurations. Surfactant (aerosols were generated with a nebulizer in a set-up composed of a continuous positive airway pressure (CPAP) generator with a humidifier, a cast of the upper airway of a preterm infant (PrINT), and a breath simulator with a neonatal breathing pattern. The lung dose (LD), defined as the amount of surfactant collected in a filter placed at the distal end of the PrINT cast, was determined after placing the nebulizer at different locations of the circuit and using either infant nasal mask or nasal prongs as CPAP interfaces. The LD after delivering a range of nominal surfactant doses (100–600 mg/kg) was also investigated. Surfactant aerosol particle size distribution was determined by laser diffraction. Irrespective of the CPAP interface used, about 14% of the nominal dose (200 mg/kg) reached the LD filter. However, placing the nebulizer between the Y-piece and the CPAP interface significantly increased the LD compared with placing it 7 cm before the Y-piece, in the inspiratory limb. (14% ± 2.8 vs. 2.3% ± 0.8, nominal dose of 200 mg/kg). The customized eFlow Neos showed a constant aerosol generation rate and a mass median diameter of 2.7 μm after delivering high surfactant doses (600 mg/kg). The customized eFlow Neos nebulizer showed a constant performance even after nebulizing high doses of undiluted surfactant. Placing the nebulizer between the Y-piece and the CPAP interface achieves the highest LD under non-invasive ventilation conditions.
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Nord A, Linner R, Salomone F, Bianco F, Ricci F, Murgia X, Schlun M, Cunha-Goncalves D, Perez-de-Sa V. Lung deposition of nebulized surfactant in newborn piglets: Nasal CPAP vs Nasal IPPV. Pediatr Pulmonol 2020; 55:514-520. [PMID: 31833668 DOI: 10.1002/ppul.24603] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 11/26/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Nasal continuous positive airway pressure support (nCPAP) is the standard of care for prematurely born infants at risk of neonatal respiratory distress syndrome (nRDS). However, nasal intermittent positive pressure ventilation (NIPPV) may be an alternative to nCPAP in babies requiring surfactant, and in conjunction with surfactant nebulization, it could theoretically reduce the need for invasive mechanical ventilation. We compared lung deposition of nebulized poractant in newborn piglets supported by nCPAP or NIPPV. METHODS Twenty-five sedated newborn piglets (1.2-2.2 kg) received either nCPAP (3 cmH2 O, n = 12) or NIPPV (3 cmH2 O positive end expiratory pressure+3 cmH2 O inspiratory pressure, n = 13) via custom-made nasal prongs (FiO2 0.4, Servo-i ventilator). Piglets received 200 mg kg-1 of technetium-99m-surfactant mixture continuously nebulized with a customized eFlow-Neos investigational vibrating-membrane nebulizer system. Blood gases were taken immediately before, during, and after nebulization. The deposition was estimated by gamma scintigraphy. RESULTS Mean surfactant deposition in the lungs was 15.9 ± 11.9% [8.3, 23.5] (mean ± SD [95% CI]) in the nCPAP group and 21.6 ± 10% [15.6, 27.6] in the NIPPV group (P = .20). Respiratory rates were similar in both groups. Minute volume was 489 ± 203 [360, 617] in the nCPAP group and 780 ± 239 [636, 924] mL kg-1 min-1 in the NIPPV group (P = .009). Blood gases were comparable in both groups. CONCLUSION Irrespective of the noninvasive ventilatory support mode used, relatively high lung deposition rates of surfactant were achieved with nebulization. The amounts of deposited surfactant might suffice to elicit a pulmonary function improvement in the context of nRDS.
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Affiliation(s)
- Anders Nord
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Rikard Linner
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | | | - Federico Bianco
- Corporate Preclinical R&D, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - Francesca Ricci
- Corporate Preclinical R&D, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - Xabi Murgia
- Department of Drug Delivery, Helmholtz Institute for Pharmaceutical Research Saarland, Saarbrucken, Germany
| | | | | | - Valeria Perez-de-Sa
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Cunha-Goncalves D, Nord A, Bianco F, Salomone F, Ricci F, Schlun M, Linner R, Perez-de-Sa V. Impact of Body Position on Lung Deposition of Nebulized Surfactant in Newborn Piglets on Nasal Continuous Positive Airway Pressure. Neonatology 2020; 117:467-473. [PMID: 32604091 DOI: 10.1159/000508349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/26/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The ideal body position during surfactant nebulization is not known. OBJECTIVE The aim of this study was to determine whether body positioning during surfactant nebulization influences surfactant distribution and deposition in the lungs. METHODS Twenty-four 12- to 36-h-old full-termpiglets (1.3-2.2 kg) on nasal continuous positive airway pressure (nCPAP) were randomized into four groups: lateral decubitus with right or left side up, prone or supine positions (n = 6 each). All animals received 200 mg kg-1 of poractant alfa mixed with 200 MBq of 99mtechnetium-nanocolloid via a customized eFlow-Neos investigational vibrating-membrane nebulizer. Surfactant deposition (percentage of the administered dose) was measured by gamma scintigraphy. RESULTS Comparing all groups, the mean total lung surfactant deposition was significantly higher in the prone position (32.4 ± 7.7%, p = 0.03). The deposition in this group was higher in the right lung (21.0 ± 8.6 vs. 11.3 ± 5.7%, p = 0.04). When nebulization was performed in the lateral decubitus, most of the surfactant was found in the dependent lung, regardless of which side the piglet lay on (right side up 15.3 ± 1.0 vs. 3.4 ± 1.0%, p = 0.06, and left side up 11.2 ± 9.8 vs. 1.8 ± 0.7%, p = 0.04). CONCLUSIONS In spontaneously breathing animals on nCPAP, the prone position yielded the highest lung dose. Higher deposition rates in the dependent lung while on lateral decubitus indicates that deposition was also influenced by gravity.
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Affiliation(s)
- Doris Cunha-Goncalves
- Department of Cardiothoracic Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden, .,Department of Clinical Sciences, Lund University, Lund, Sweden,
| | - Anders Nord
- Department of Pediatric Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Federico Bianco
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici SpA, Parma, Italy
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici SpA, Parma, Italy
| | - Francesca Ricci
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici SpA, Parma, Italy
| | | | - Rikard Linner
- Department of Cardiothoracic Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Valeria Perez-de-Sa
- Department of Pediatric Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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