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Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, Khilnani GC, Chaudhary D, Singla R, Koul PA, Mahashur AA, Ghoshal AG, Behera D, Christopher DJ, Talwar D, Ganguly D, Paramesh H, Gupta KB, Kumar T M, Motiani PD, Shankar PS, Chawla R, Guleria R, Jindal SK, Luhadia SK, Arora VK, Vijayan VK, Faye A, Jindal A, Murar AK, Jaiswal A, M A, Janmeja AK, Prajapat B, Ravindran C, Bhattacharyya D, D'Souza G, Sehgal IS, Samaria JK, Sarma J, Singh L, Sen MK, Bainara MK, Gupta M, Awad NT, Mishra N, Shah NN, Jain N, Mohapatra PR, Mrigpuri P, Tiwari P, Narasimhan R, Kumar RV, Prasad R, Swarnakar R, Chawla RK, Kumar R, Chakrabarti S, Katiyar S, Mittal S, Spalgais S, Saha S, Kant S, Singh VK, Hadda V, Kumar V, Singh V, Chopra V, B V. Indian Guidelines on Nebulization Therapy. Indian J Tuberc 2022; 69 Suppl 1:S1-S191. [PMID: 36372542 DOI: 10.1016/j.ijtb.2022.06.004] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/16/2023]
Abstract
Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.
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Affiliation(s)
- S K Katiyar
- Department of Tuberculosis & Respiratory Diseases, G.S.V.M. Medical College & C.S.J.M. University, Kanpur, Uttar Pradesh, India.
| | - S N Gaur
- Vallabhbhai Patel Chest Institute, University of Delhi, Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater NOIDA, Uttar Pradesh, India
| | - R N Solanki
- Department of Tuberculosis & Chest Diseases, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Raj Kumar
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, National Centre of Allergy, Asthma & Immunology; University of Delhi, Delhi, India
| | - G C Khilnani
- PSRI Institute of Pulmonary, Critical Care, & Sleep Medicine, PSRI Hospital, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhary
- Department of Pulmonary & Critical Care Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rupak Singla
- Department of Tuberculosis & Respiratory Diseases, National Institute of Tuberculosis & Respiratory Diseases (formerly L.R.S. Institute), Delhi, India
| | - Parvaiz A Koul
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Ashok A Mahashur
- Department of Respiratory Medicine, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
| | - A G Ghoshal
- National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
| | - D Behera
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepak Talwar
- Metro Centre for Respiratory Diseases, Noida, Uttar Pradesh, India
| | | | - H Paramesh
- Paediatric Pulmonologist & Environmentalist, Lakeside Hospital & Education Trust, Bengaluru, Karnataka, India
| | - K B Gupta
- Department of Tuberculosis & Respiratory Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India
| | - Mohan Kumar T
- Department of Pulmonary, Critical Care & Sleep Medicine, One Care Medical Centre, Coimbatore, Tamil Nadu, India
| | - P D Motiani
- Department of Pulmonary Diseases, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - P S Shankar
- SCEO, KBN Hospital, Kalaburagi, Karnataka, India
| | - Rajesh Chawla
- Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Department of Pulmonary Medicine & Sleep Disorders, AIIMS, New Delhi, India
| | - S K Jindal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Luhadia
- Department of Tuberculosis and Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - V K Arora
- Indian Journal of Tuberculosis, Santosh University, NCR Delhi, National Institute of TB & Respiratory Diseases Delhi, India; JIPMER, Puducherry, India
| | - V K Vijayan
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, University of Delhi, Delhi, India
| | - Abhishek Faye
- Centre for Lung and Sleep Disorders, Nagpur, Maharashtra, India
| | | | - Amit K Murar
- Respiratory Medicine, Cronus Multi-Specialty Hospital, New Delhi, India
| | - Anand Jaiswal
- Respiratory & Sleep Medicine, Medanta Medicity, Gurugram, Haryana, India
| | - Arunachalam M
- All India Institute of Medical Sciences, New Delhi, India
| | - A K Janmeja
- Department of Respiratory Medicine, Government Medical College, Chandigarh, India
| | - Brijesh Prajapat
- Pulmonary and Critical Care Medicine, Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
| | - C Ravindran
- Department of TB & Chest, Government Medical College, Kozhikode, Kerala, India
| | - Debajyoti Bhattacharyya
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, Army Hospital (Research & Referral), New Delhi, India
| | | | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Centre for Research and Treatment of Allergy, Asthma & Bronchitis, Department of Chest Diseases, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Jogesh Sarma
- Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Lalit Singh
- Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - M K Sen
- Department of Respiratory Medicine, ESIC Medical College, NIT Faridabad, Haryana, India; Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mahendra K Bainara
- Department of Pulmonary Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nilkanth T Awad
- Department of Pulmonary Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, M.K.C.G. Medical College, Berhampur, Orissa, India
| | - Naveed N Shah
- Department of Pulmonary Medicine, Chest Diseases Hospital, Government Medical College, Srinagar, Jammu & Kashmir, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care & Sleep Medicine, PSRI, New Delhi, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Parul Mrigpuri
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pawan Tiwari
- School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - R Narasimhan
- Department of EBUS and Bronchial Thermoplasty Services at Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Vijai Kumar
- Department of Pulmonary Medicine, MediCiti Medical College, Hyderabad, Telangana, India
| | - Rajendra Prasad
- Vallabhbhai Patel Chest Institute, University of Delhi and U.P. Rural Institute of Medical Sciences & Research, Safai, Uttar Pradesh, India
| | - Rajesh Swarnakar
- Department of Respiratory, Critical Care, Sleep Medicine and Interventional Pulmonology, Getwell Hospital & Research Institute, Nagpur, Maharashtra, India
| | - Rakesh K Chawla
- Department of, Respiratory Medicine, Critical Care, Sleep & Interventional Pulmonology, Saroj Super Speciality Hospital, Jaipur Golden Hospital, Rajiv Gandhi Cancer Hospital, Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - S Chakrabarti
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sonam Spalgais
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | | | - Surya Kant
- Department of Respiratory (Pulmonary) Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - V K Singh
- Centre for Visceral Mechanisms, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Virendra Singh
- Mahavir Jaipuria Rajasthan Hospital, Jaipur, Rajasthan, India
| | - Vishal Chopra
- Department of Chest & Tuberculosis, Government Medical College, Patiala, Punjab, India
| | - Visweswaran B
- Interventional Pulmonology, Yashoda Hospitals, Hyderabad, Telangana, India
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Li H, Li J, Bodycomb J, Patience GS. Experimental Methods in Chemical Engineering: Particle Size Distribution by Laser Diffraction—PSD. CAN J CHEM ENG 2019. [DOI: 10.1002/cjce.23480] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- He Li
- Department of Chemical EngineeringPolytechnique MontréalMontréal QC Canada
| | - Jingwen Li
- School of ScienceJiangnan UniversityWuxi Jiangsu China
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Abstract
Historically, the inhaled route has been used for the delivery of locally-acting drugs for the treatment of respiratory conditions, such as asthma, COPD, and airway infections. Targeted delivery of substances to the lungs has some key advantages over systemic administration, including a more rapid onset of action, an increased therapeutic effect, and, depending on the agent inhaled, reduced systemic side effects since the required local concentration in the lungs can be obtained with a lower dose. Fortunately, when designed properly, inhaled drug delivery devices can be very effective and safe for getting active agents directly to their site of action.
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Affiliation(s)
| | - Ben Forbes
- King's College London, London, SEI 9NH, UK.
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Mashat M, Clark B, Assi K, Chrystyn H. Assessment of recent nebulizer delivery systems using urinary pharmacokinetics method and aerodynamic characteristics of TOBI ® nebulized dose following inhalation. J Drug Deliv Sci Technol 2017. [DOI: 10.1016/j.jddst.2017.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Coates AL, Wanger J, Cockcroft DW, Culver BH, Carlsen KH, Diamant Z, Gauvreau G, Hall GL, Hallstrand TS, Horvath I, de Jongh FH, Joos G, Kaminsky DA, Laube B, Leuppi JD, Sterk PJ. ERS technical standard on bronchial challenge testing: general considerations and performance of methacholine challenge tests. Eur Respir J 2017; 49:49/5/1601526. [DOI: 10.1183/13993003.01526-2016] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 01/15/2017] [Indexed: 11/05/2022]
Abstract
This international task force report updates general considerations for bronchial challenge testing and the performance of the methacholine challenge test. There are notable changes from prior recommendations in order to accommodate newer delivery devices. Rather than basing the test result upon a methacholine concentration (provocative concentration (PC20) causing a 20% fall in forced expiratory volume in 1 s (FEV1)), the new recommendations base the result upon the delivered dose of methacholine causing a 20% fall in FEV1 (provocative dose (PD20)). This end-point allows comparable results from different devices or protocols, thus any suitable nebuliser or dosimeter may be used, so long as the delivery characteristics are known. Inhalation may be by tidal breathing using a breath-actuated or continuous nebuliser for 1 min (or more), or by a dosimeter with a suitable breath count. Tests requiring maximal inhalations to total lung capacity are not recommended because the bronchoprotective effect of a deep breath reduces the sensitivity of the test.
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Affiliation(s)
- Peter J Barry
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester, Manchester, United Kingdom of Great Britain and Northern Ireland
- Institute of Inflammation and Repair, University of Manchester, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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Abstract
Medications delivered through oral inhalation represent the cornerstone of pharmacotherapy for asthma and chronic obstructive pulmonary diseases. Several options exist as methods of delivering aerosols to the lung, including metered-dose inhalers, metered-dose inhalers attached to spacers or valved holding chambers, dry powder inhalers, and nebulizers. Delivery of aerosols to the lung is affected by numerous factors including characteristics of aerosol particles, patients’ ventilatory patterns, and physical condition of the lung. It has become increasingly clear that the device used to deliver the medication is an important factor in the extent of deposition and the ultimate therapeutic effect. Further, the same therapeutic agent may exhibit differing effects depending on which delivery device is used. Each inhalation device has specific instructions for use, and the techniques for use vary significantly among the available products. In each case, patients should be instructed and observed to ensure that they have the proper technique of use to achieve an optimal effect.
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Affiliation(s)
- Tina Penick Brock
- Beard Hall CB#7360, School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599
| | - Dennis M. Williams
- Division of Pharmacotherapy, School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599,
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Abstract
Gram-negative organisms comprise a large portion of the pathogens responsible for lower respiratory tract infections, especially those that are nosocomially acquired, and the rate of antibiotic resistance among these organisms continues to rise. Systemically administered antibiotics used to treat these infections often have poor penetration into the lung parenchyma and narrow therapeutic windows between efficacy and toxicity. The use of inhaled antibiotics allows for maximization of target site concentrations and optimization of pharmacokinetic/pharmacodynamic indices while minimizing systemic exposure and toxicity. This review is a comprehensive discussion of formulation and drug delivery aspects, in vitro and microbiological considerations, pharmacokinetics, and clinical outcomes with inhaled antibiotics as they apply to disease states other than cystic fibrosis. In reviewing the literature surrounding the use of inhaled antibiotics, we also highlight the complexities related to this route of administration and the shortcomings in the available evidence. The lack of novel anti-Gram-negative antibiotics in the developmental pipeline will encourage the innovative use of our existing agents, and the inhaled route is one that deserves to be further studied and adopted in the clinical arena.
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Affiliation(s)
- Eric Wenzler
- University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois, USA
| | - Dustin R Fraidenburg
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Tonya Scardina
- Loyola University Medical Center, Chicago, Illinois, USA
| | - Larry H Danziger
- University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois, USA University of Illinois at Chicago, College of Medicine, Chicago, Illinois, USA
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Carvalho TC, McConville JT. The function and performance of aqueous aerosol devices for inhalation therapy. ACTA ACUST UNITED AC 2016; 68:556-78. [PMID: 27061412 DOI: 10.1111/jphp.12541] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [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: 04/30/2015] [Accepted: 02/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In this review paper, we explore the interaction between the functioning mechanism of different nebulizers and the physicochemical properties of the formulations for several types of devices, namely jet, ultrasonic and vibrating-mesh nebulizers; colliding and extruded jets; electrohydrodynamic mechanism; surface acoustic wave microfluidic atomization; and capillary aerosol generation. KEY FINDINGS Nebulization is the transformation of bulk liquids into droplets. For inhalation therapy, nebulizers are widely used to aerosolize aqueous systems, such as solutions and suspensions. The interaction between the functioning mechanism of different nebulizers and the physicochemical properties of the formulations plays a significant role in the performance of aerosol generation appropriate for pulmonary delivery. Certain types of nebulizers have consistently presented temperature increase during the nebulization event. Therefore, careful consideration should be given when evaluating thermo-labile drugs, such as protein therapeutics. We also present the general approaches for characterization of nebulizer formulations. SUMMARY In conclusion, the interplay between the dosage form (i.e. aqueous systems) and the specific type of device for aerosol generation determines the effectiveness of drug delivery in nebulization therapies, thus requiring extensive understanding and characterization.
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Affiliation(s)
- Thiago C Carvalho
- Bristol-Myers Squibb, Drug Product Science & Technology, New Brunswick, NJ, USA
| | - Jason T McConville
- Department of Pharmaceutical Sciences, University of New Mexico, Albuquerque, NM, USA
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Mashat M, Clark B, Assi K, Chrystyn H. In vitro aerodynamic characterization of the dose emitted during nebulization of tobramycin high strength solution by novel and jet nebulizer delivery systems. Pulm Pharmacol Ther 2016; 37:37-42. [DOI: 10.1016/j.pupt.2015.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/24/2015] [Accepted: 12/26/2015] [Indexed: 10/22/2022]
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Kamin W, Erdnüss F, Krämer I. Inhalation solutions — Which ones may be mixed? Physico-chemical compatibility of drug solutions in nebulizers — Update 2013. J Cyst Fibros 2014; 13:243-50. [DOI: 10.1016/j.jcf.2013.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 09/16/2013] [Accepted: 09/20/2013] [Indexed: 12/13/2022]
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Najlah M, Vali A, Taylor M, Arafat BT, Ahmed W, Phoenix DA, Taylor KM, Elhissi A. A study of the effects of sodium halides on the performance of air-jet and vibrating-mesh nebulizers. Int J Pharm 2013; 456:520-7. [DOI: 10.1016/j.ijpharm.2013.08.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 08/12/2013] [Accepted: 08/15/2013] [Indexed: 10/26/2022]
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Abstract
BACKGROUND In the adenosine 5'-monophosphate (AMP) bronchial challenge test, AMP is usually administered according to dosing protocols for methacholine. We investigated whether the 2-min tidal breathing challenge test for methacholine is applicable to AMP. Parameters known to affect nebulizer output were studied. Our aim was to determine whether control of additional parameters is needed for currently standardized protocols. METHODS The study was performed with the Sidestream nebulizer from the APS Pro Aerosol Provocation System (CareFusion Respiratory). The effects of AMP concentration, jet pressure, and suction flow rate on nebulizer output rate and aerosol droplet size distribution were determined. RESULTS The volume median diameter for water increased from 5.10 μm to 8.49 μm when the jet pressure was reduced to obtain the prescribed output rate of 0.13 mL/min. The output rate was increased when a suction flow rate was used to remove the aerosol. Increasing the AMP concentration resulted in smaller droplets and a lower output rate when a suction flow was applied. CONCLUSIONS The effects of AMP concentration on nebulizer performance may result in changes in the administered dose and site of deposition of AMP at dose escalation. All of the investigated parameters influence nebulizer performance, hence the outcome of a bronchial challenge test. Therefore, these parameters should not only be specified in challenge testing, but be actively controlled as well.
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Affiliation(s)
- Anne J Lexmond
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen , 9713 AV Groningen, The Netherlands
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Ali R, Mittal G, Sultana S, Bhatnagar A. Ameliorative potential of alpha-ketoglutaric acid (AKG) on acute lung injuries induced by ammonia inhalation in rats. Exp Lung Res 2012; 38:435-44. [PMID: 22978367 DOI: 10.3109/01902148.2012.721859] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Toxicants such as ammonia, if inhaled, can damage respiratory tract leading to acute lung injury and pulmonary edema. Besides being a possible threat for the workers in chemical industry, easy availability and the toxic nature of ammonia may be used by terror groups for inflicting mass casualty among vulnerable population. In the present study, we have evaluated the therapeutic efficacy of alpha-ketoglutarate (AKG) to mitigate acute effects of ammonia on lung structure and antioxidant status in experimental animals. METHODS Acute lung injury (ALI) models were developed by inhalation of aerosols of liquid ammonia in male Sprague Dawley rats. AKG (5%) respiratory fluid was inhaled by nebulization once daily for 5 days. Animals were euthanized and their blood samples were collected for hematology and serum biochemistry analysis. Total cell count, total protein (TP), lactate dehydrogenase (LDH), antioxidant enzyme activity (CAT, SOD, GSH), and malonaldialdehyde (MDA) formation were measured in bronchoalveolar lavage (BAL) fluid. RESULTS Treatment with AKG showed significant lung protection by lowering the levels of total cell count, TP, LDH, superoxide dismutase (SOD), and MDA in BAL fluid. There was a marked increase in catalase (CAT) and glutathione (GSH) content of BAL fluid post-AKG inhalation. Histopathology of lung tissue correlated with cellular and biochemical findings indicate therapeutic efficacy of AKG against ammonia-induced lung injuries. CONCLUSIONS The data suggest a possible therapeutic role of AKG inhalation against ammonia-induced structural and inflammatory changes in the lung.
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Affiliation(s)
- Rashid Ali
- Department of Nuclear Medicine, Institute of Nuclear Medicine and Allied Sciences, Delhi, India
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Sultana S, Singh T, Ahmad FJ, Bhatnagar A, Mittal G. Development of nano alpha-ketoglutarate nebulization formulation and its pharmacokinetic and safety evaluation in healthy human volunteers for cyanide poisoning. Environ Toxicol Pharmacol 2011; 31:436-442. [PMID: 21787714 DOI: 10.1016/j.etap.2011.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 01/09/2011] [Accepted: 02/11/2011] [Indexed: 05/31/2023]
Abstract
Development of nano alpha-ketoglutarate (A-KG) nebulization formulation for neutralization of inhaled cyanide ion toxicity. Objectives of the present study were to (a) develop a novel A-KG nebulization formulation against cyanide poisoning, particularly hydrogen cyanide gas (b) validate its respiratory fraction in vitro and in vivo, and (c) create its pharmacokinetic data in human volunteers. The formulation was optimized on the basis of particle size of aerosolized droplets after nebulization in 6 volunteers. Gamma scintigraphy was used to quantify total and regional lung deposition of nebulized A-KG after radiolabeling it with Technetium-99m. The formulation was optimized using 30% ethanol-saline with particle size in the range of 300-500 nm. In vitro and in vivo studies showed that drug nebulization resulted in a significant respirable fraction of 65 ± 0.6% with whole lung deposition of 13 ± 1%. Human pharmacokinetic data was derived in 6 healthy human volunteers with peak serum concentration (C(max)) of 39 ± 3 μg/ml, while the area under curve (AUC) after inhalation was 376 ± 23 μg × h/ml indicating that the drug was rapidly and completely absorbed when targeted directly to lungs. Significant lung deposition of A-KG was achieved with the developed formulation. The formulation appears to have several advantages, including the potential of neutralizing inhaled CN(-) ions in the lungs themselves. It is a safe and efficacious procedure, suitable for hospital or ambulance use in accidental cyanide poisoning cases, or as a preventive approach for fire-rescue teams.
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Affiliation(s)
- Shaheen Sultana
- Department of Pharmaceutics, Faculty of Pharmacy, Hamdard University, New Delhi 110 062, India
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Heijerman H, Westerman E, Conway S, Touw D. Inhaled medication and inhalation devices for lung disease in patients with cystic fibrosis: A European consensus. J Cyst Fibros 2009; 8:295-315. [DOI: 10.1016/j.jcf.2009.04.005] [Citation(s) in RCA: 187] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 04/05/2009] [Accepted: 04/08/2009] [Indexed: 12/12/2022]
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Okapo SO, Gupta J, Martinez E, Mark R. In vitro deposition properties of nebulized formoterol fumarate: effect of nebulization time, airflow, volume of fill and nebulizer type. Curr Med Res Opin 2009; 25:807-16. [PMID: 19207092 DOI: 10.1185/03007990802708236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to investigate in vitro the delivery of a new long-acting beta2-agonist (LABA) drug formoterol fumarate inhalation solution (20 microg/2 mL) nebulized with and without ipratropium bromide (0.5 mg/2.5 mL) at different administration times (2.5-22.5 min), airflows (5-28.3 L/min), nebulizer fill volumes (2-6 mL),and nebulizer brands (Pari LC+, Ventstream and DeVilbiss). METHOD Formoterol fumarate with and without ipratropium bromide was aerosolized at different administration times, airflows, nebulizer fill volumes, and nebulizer brands. The drug deposited on the throat, filter and stage plates was collected and analyzed by HPLC to determine the aerodynamic profiles of the nebulized drugs under each variable. RESULTS In addition to altering the aerosol characteristics,increasing the nebulizer fill volume including the addition of ipratropium bromide produced a significant(p50.05) increase in the drug output. As expected, sputtering time was significantly longer at low airflows, and vice versa at higher airflows but with a significant loss of drug delivered presumably due to greater solvent evaporation at higher airflows. Airflows between 10 and 28.3 L/min and a nebulization time of approximately 10 min appear sufficient for producing aerosols within the respirable range (1-5 mm MMAD) with the nebulizer/compressor combination used.While the drug output varied significantly (p50.05) among the three brands of nebulizers tested, the LC+ nebulizer appears to produce aerosols (2.7 0.1 microm MMAD) capable of penetrating more deeply into the lung than the other nebulizers evaluated under the current test conditions. This study did not attempt to evaluate different nebulizer/compressor combinations. Also, the cascade impaction data may not necessarily reflect aerosol deposition in the airways in vivo, which may be different depending on the health status of the patient. CONCLUSION The results demonstrated that administration of nebulized formoterol fumarate require proper selection of a delivery system/method for safe and effective therapy of the medication with and without ipratropium bromide.
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Affiliation(s)
- Samuel O Okapo
- Department of Analytical Development, Dey LP, 2751 Napa Valley Corporate Drive, Napa, CA 4558, USA.
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Akapo S, Gupta J, Martinez E, McCrea C, Ye L, Roach M. Compatibility and aerosol characteristics of formoterol fumarate mixed with other nebulizing solutions. Ann Pharmacother 2008; 42:1416-24. [PMID: 18780805 DOI: 10.1345/aph.1l273] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) are often given admixtures of nebulizable drugs to minimize the time of administration in treatment regimens. OBJECTIVE To evaluate the physicochemical compatibility and aerodynamic characteristics of formoterol fumarate 20 microg/2 mL when mixed or sequentially nebulized with budesonide inhalation suspension 0.5 mg/2 mL, ipratropium bromide 0.5 mg/2.5 mL, cromolyn sodium 20 mg/2 mL, or acetylcysteine 10% (100 mg/mL). METHODS The admixtures were prepared in triplicate and analyzed for physicochemical compatibility at 0, 15, 30, and 60 minutes after mixing at room temperature. Physical compatibility was determined by visual examination and measurements of pH, osmolality, and turbidity. Chemical stability was evaluated using compendial or in-house-validated high-performance liquid chromatography (HPLC) assay methods. The aerodynamic characteristics of the admixtures or sequentially nebulized drugs were determined from aerosols generated from a Pari LC Plus nebulizer, using an 8-stage cascade impactor followed by HPLC analysis of the deposited drug. RESULTS The admixtures remained clear, colorless solutions with no precipitation, except for cloudiness observed in the formoterol/budesonide combination due to budesonide suspension. The pH, osmolality, and turbidity for all admixtures were within the initial values (< or = 3%), and there were no significant changes (< or = 2%) in potency of the active components throughout the 1-hour study period. Due to increased drug volume or reconcentration in the nebulizer cup, the respirable fraction/delivered dose increased significantly (p < 0.05) for the mixed or sequentially nebulized drug. However, the fine particle fraction (FPF), mass median aerodynamic diameter, and geometric standard deviation generally remained unchanged for all admixtures, with the exception of FPF for the formoterol/budesonide combination. CONCLUSIONS Our results indicate that admixtures of formoterol with budesonide, ipratropium, cromolyn, or acetylcysteine are physically and chemically compatible. However, admixing or sequential nebulization significantly increased the amount of drug delivered compared with single drug nebulization. The clinical implications of the in vitro data in patients with COPD have not been determined.
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Affiliation(s)
- Samuel Akapo
- Analytical Development, Dey L.P., 2751 Napa Valley Corporate Dr., Napa, CA 94558, USA.
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Abdulhamid I, Wise TL, Andrews S, Biglin K, Lehr VT. Elevated serum tobramycin concentrations after treatment with tobramycin inhalation in a preterm infant. Pharmacotherapy 2008; 28:939-44. [PMID: 18576909 DOI: 10.1592/phco.28.7.939] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
High-dose inhaled tobramycin has been increasingly used for treatment and suppression of Pseudomonas aeruginosa pulmonary infections, especially in patients with cystic fibrosis. The advantage of inhalation over other routes of administration is minimal systemic absorption, which reduces the potential for adverse effects. However, cases of adults who had elevated serum concentrations and experienced systemic adverse effects due to excessive systemic absorption after inhaled tobramycin have been reported. We describe a prematurely born infant with numerous congenital and acquired disorders who required assisted mechanical ventilation and a 60-day stay in the neonatal intensive care unit (NICU). Tracheostomy and mechanical ventilatory support were required throughout the infant's hospital stay. The patient developed several pulmonary infections caused by various bacteria. He was treated with multiple antibiotics, including two different dose preparations of inhaled tobramycin 80 mg and 300 mg, administered through the tracheostomy and the ventilator. The infant was given a total of five preparations of tobramycin 80 mg/dose and three of 300 mg/dose, for a total cumulative dose of 1,300 mg over a 6-day period. His tobramycin concentrations increased, prompting discontinuation of the inhaled tobramycin. The infant died on day 60. To our knowledge, this is the first report of elevated tobramycin concentrations after inhalation in an infant. Although studies have found that tobramycin is safe and effective, certain patient populations are more at risk for toxicity. Tobramycin concentrations should be closely monitored in patients with significant underlying renal disorders, especially those in age-group extremes.
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Affiliation(s)
- Ibrahim Abdulhamid
- Division of Pediatric Pulmonary Medicine, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201, USA
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Coates AL, Green M, Leung K, Chan J, Ribeiro N, Louca E, Ratjen F, Charron M, Tservistas M, Keller M. Rapid pulmonary delivery of inhaled tobramycin for Pseudomonas infection in cystic fibrosis: a pilot project. Pediatr Pulmonol 2008; 43:753-9. [PMID: 18613006 DOI: 10.1002/ppul.20850] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [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: 11/10/2022]
Abstract
BACKGROUND Patients with cystic fibrosis spend as much 30 min a day inhaling tobramycin. Could a new rapid system deposit the equivalent amount of tobramycin faster? METHODS Six healthy adult males inhaled 5 ml (300 mg) of tobramycin from a breath enhanced nebulizer and either 125 mg (n = 3) or 150 mg (n = 3) from a vibrating membrane system with a large or small aerosol mixing chamber respectively. A radiolabel was added to the solution and shown to "track" with the tobramycin. Imaging was done with a dual headed gamma camera. Because the radiolabel will be cleared by mucociliary action during administration, algorithms were developed to allow the comparison of a slower system to a faster one. RESULTS Both formulations were well tolerated. The lung deposition was 16.6 +/- 3.2% (mean +/- SD) of the charge dose delivered in 10.9 +/- 1.0 min for the breath enhanced nebulizer versus 32.0 +/- 5.1% delivered in 2.5 +/- 0.4 min from the vibrating membrane system. The absolute pulmonary delivery of tobramycin was 49.9 +/- 9.6 versus 43.9 +/- 4.8 mg for the two systems respectively, differences that were statistically significant (pair t-test) but unlikely to be clinically significant. There was a similar deposition of tobramycin for the 125 and 150 mg dose. CONCLUSIONS It is possible to deliver an equivalent amount of tobramycin in a shorter period of time with the new vibrating membrane system and a more concentrated formulation. These data will allow the design of a comparison in patients with CF.
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Affiliation(s)
- Allan L Coates
- Division of Nuclear Medicine, Hospital for Sick Children Research Institute, University of Toronto, Toronto, Canada.
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Bello Dronda S, Vilá Justribó M. ¿Seguiremos teniendo antibióticos mañana? Arch Bronconeumol 2007. [DOI: 10.1157/13108785] [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] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Dronda SB, Justribó MV. [Will we still have antibiotics tomorrow?]. Arch Bronconeumol 2007; 43:450-9. [PMID: 17692246 DOI: 10.1016/s1579-2129(07)60102-5] [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] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Since the discovery of antibiotics, it has been generally believed that these antimicrobials are capable of curing almost all bacterial infections. More recently, the appearance of increasing resistance to antibiotics and the emergence of multiresistant microorganisms have given rise to growing concern among physicians, and that concern has now started to filter through to society in general. The problem is further aggravated by a situation that not many people are currently aware of, that is, the limited prospects for future development of new antibiotics in the short to medium term. Appropriate use of available antibiotics based on a thorough understanding of their in vivo activity and the emergence of new forms of administration, such as inhalers, may help to alleviate the problem.
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Ghazanfari T, Elhissi AMA, Ding Z, Taylor KMG. The influence of fluid physicochemical properties on vibrating-mesh nebulization. Int J Pharm 2007; 339:103-11. [PMID: 17451896 DOI: 10.1016/j.ijpharm.2007.02.035] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Revised: 02/20/2007] [Accepted: 02/23/2007] [Indexed: 11/29/2022]
Abstract
In this study, the effect of fluid physicochemical properties and the vibrating-mesh mechanism on the aerosols generated from vibrating-mesh nebulizers have been evaluated using fluids having a range of viscosity, surface tension and ion concentration. Two nebulizers were investigated: the Omron MicroAir NE-U22 (passively vibrating) and the Aeroneb Pro (actively vibrating) mesh nebulizers. For both devices, the total aerosol output was generally unaffected by fluid properties. Increased viscosity or ion concentration resulted in a decrease in droplet volume median diameter (VMD) and an increase in fine particle fraction (FPF). Moreover, increased viscosity resulted in prolonged nebulization and reduced output rate, particularly for the Omron nebulizer. Both nebulizers were unsuitable for delivery of viscous fluids since nebulization was intermittent or completely ceased at >1.92cP. The presence of ions reduced variability particularly for the Aeroneb Pro nebulizer. No clear effect of surface tension was observed on the performance of nebulizers employing a vibrating-mesh technology. However, when viscosity was low, reduced surface tension seemed advantageous in shortening the nebulization time and increasing the output rate, but for the Omron nebulizer this also increased the droplet VMD and decreased the FPF. This study has shown that vibrating-mesh nebulization was highly dependent on fluid characteristics and nebulizer mechanism of operation.
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Affiliation(s)
- Thu Ghazanfari
- Department of Pharmaceutics, School of Pharmacy, University of London, 29-39 Brunswick Square, London WC1N 1AX, United Kingdom
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Abstract
PURPOSE This investigation examined the effects of nebulized hypertonic saline, isotonic saline (IS), and sterile (hypotonic) water on phonation threshold pressure (PTP) and self-perceived phonatory effort (PPE) following a surface laryngeal dehydration challenge. METHOD In a double-blind, randomized experimental trial, 60 vocally healthy women (n = 15 per group) underwent a laryngeal desiccation challenge involving oral breathing for 15 min using medical-grade dry air (RH<1%). Three of the four groups then received nebulized isotonic saline (0.9% NaCl), hypertonic saline (7% NaCl), or sterile (hypotonic) water, respectively; the 4th group served as a nontreatment control. PTP and PPE were estimated for high-pitched productions at baseline, immediately postdesiccation, and at 5, 20, 35, and 50 min postnebulization. RESULTS PTP increased significantly for all groups following the desiccation challenge. PTP values were, on average, 0.5 cm H(2)O greater immediately postdesiccation versus baseline. In contrast, PTP values did not change significantly following the administration of nebulized treatments, although a temporary trend toward a reduction in PTP was observed for the IS group. Unexpectedly, PPE ratings decreased significantly after the desiccation challenge. In general, PPE ratings were poorly correlated with PTP measures. CONCLUSION A laryngeal desiccation challenge (i.e., temporary exposure to extremely low relative humidity while breathing transorally) significantly increased PTP. Although interesting trends emerged, none of the nebulized treatments significantly enhanced recovery from the negative effects of desiccation on PTP. In light of very low correlations between PTP and PPE, serious questions are raised regarding presumed associations between these measures.
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Affiliation(s)
- Kristine Tanner
- Department of Communication Sciences and Disorders, University of Utah, 390 South 1530 East, Room 1201 BEH SCI, Salt Lake City, UT 84112-0252, USA.
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Leung K, Louca E, Munson K, Dutzar B, Anklesaria P, Coates AL. Calculating expected lung deposition of aerosolized administration of AAV vector in human clinical studies. J Gene Med 2007; 9:10-21. [PMID: 17154340 DOI: 10.1002/jgm.987] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive disease affecting approximately 1 in 2500 live births. Introducing the cDNA that codes for normal cystic fibrosis transmembrane conductance regulator (CFTR) to the small airways of the lung could result in restoring the CFTR function. A number of vectors for lung gene therapy have been tried and adeno-associated virus (AAV) vectors offer promise. The vector is delivered to the lung using a breath-actuated jet nebulizer. The purpose of this project was to determine the aerosolized AAV (tgAAVCF) particle size distribution (PSD) in order to calculate target doses for lung delivery. METHODS A tgAAVCF solution was nebulized using the Pari LC Plus (n = 3), and the PSD was determined by coupling laser diffraction and inertial impaction (NGI) techniques. The NGI allowed for quantification of the tgAAVCF at each stage of impaction, ensuring that rAAV-CFTR vector is present and not empty particles. Applying the results to mathematical algorithms allowed for the calculation of expected pulmonary deposition. RESULTS The mass median diameter (MMD) for the tgAAVCF was 2.78 +/- 0.43 microm. If the system works ideally and the patient only receives aerosol on inspiration, the patient would receive 47 +/- 0% of the initial dose placed in the nebulizer, with 72 +/- 0.73% of this being deposited beyond the vocal cords. CONCLUSIONS This technology for categorizing the pulmonary delivery system for lung gene therapy vectors can be adapted for advanced aerosol delivery systems or other vectors.
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Affiliation(s)
- Kitty Leung
- Division of Respiratory Medicine, Hospital for Sick Children, Research Institute, University of Toronto, Toronto, Canada
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Westerman EM, De Boer AH, Le Brun PPH, Touw DJ, Roldaan AC, Frijlink HW, Heijerman HGM. Dry powder inhalation of colistin in cystic fibrosis patients: a single dose pilot study. J Cyst Fibros 2006; 6:284-92. [PMID: 17185047 DOI: 10.1016/j.jcf.2006.10.010] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2006] [Revised: 10/20/2006] [Accepted: 10/24/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Dry powder inhalation (DPI) may be an alternative to nebulisation of drugs in the treatment of chest infections in cystic fibrosis (CF) patients. In a pilot study the feasibility of a colistin dry powder inhaler (prototype Twincer) by a single dose in CF-patients was assessed and compared to nebulised colistin. METHODS Ten CF-patients, chronically infected with P. aeruginosa, participated in a randomised cross over study. On two visits to the outpatient clinic, patients inhaled colistin sulphomethate as 25 mg dry powder (Twincer) or as 158 mg nebulised solution (Ventstream nebuliser, PortaNeb compressor). Pulmonary function tests were performed before, 5 and 30 min after inhalation. Serum samples were drawn prior to each dose and at 15, 45 min, 1.5; 2.5; 3.5 and 5.5 h after inhalation. RESULTS The DPI was well tolerated by the patients: no significant reduction in FEV1 was observed. Relative bioavailability of DPI to nebulisation was approx. 140% based on actual dose and approx. 270% based on drug dose label claim. CONCLUSIONS The colistin DPI (Twincer inhaler) is well tolerated and appreciated by CF-patients. Optimisation with respect to particle size and internal resistance of the inhaler is necessary to attain equivalent pulmonary deposition to liquid nebulisation.
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Affiliation(s)
- E M Westerman
- Apotheek Haagse Ziekenhuizen, P.O. Box 43100, 2504 AC The Hague, The Netherlands.
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Abstract
Although not recommended, co-administration of drugs separately prescribed for nebulization is done in real life. The impact of this practice on drug output and aerosol characteristics is poorly understood. We studied the effect of drug admixtures (DA) on aerosol characteristics and drug output of nebulized albuterol delivered by a continuous output (CONT) and a breath enhanced nebulizer (BEN). Albuterol was nebulized alone (ALB) and combined with cromolyn sodium (A+CRO), ipratropium bromide (A+IB), tobramycin (A+TOB), flunisolide (A+FLU), and n-acetylcysteine (A+NAC). A BEN (PARI LC Plus) and a CONT (Hudson T UP-DRAFT II) were tested at 8 liters per minute (Lpm) for 2 and 5 min, respectively. Albuterol output and aerosol characteristics were determined by impaction and chemical analysis. Mass median aerodynamic diameter (MMAD; microm) A+CRO reduced MMAD from 2.57 (ALB) to 1.29 with CONT. A+FLU increased MMAD from 2.71 (ALB) to 3.40 with BEN. Geometric standard deviation (GSD) A+CRO increased GSD from 2.66 (ALB) to 3.36 with CONT. GSD was 2.33 for ALB and was not changed by DA with BEN. BEN generated a smaller and less heterodisperse aerosol than CONT. Respirable fraction (RF%) was 74% for ALB and was not changed by DA with CON. A+TOB and A+FLU decreased RF% from 75%, to 70% and 67% (respectively) with BEN. Respirable mass (RM; microg) for ALB was 935 and was not changed by DA with CONT. A+IB and A+FLU increased RM from 917 (ALB) to 1172 and 1240, respectively, with BEN. Co-nebulization of albuterol with other drugs can affect its output and aerosol characteristics. In vivo data is needed to asses the clinical implications of our findings.
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Affiliation(s)
- Ariel Berlinski
- Pediatric Pulmonology Section, Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas 72202, USA.
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Abstract
OBJECTIVES Sildenafil, tezosentan, and prostacyclin reduce pulmonary vascular pressures in pulmonary hypertension, but have potential to vasodilate the systemic circulation. Nebulized vasodilators allow targeted drug delivery, high local drug concentrations, less systemic hypotension, and better matching of the lung's ventilation and perfusion. We aimed to estimate pulmonary deposition of these drugs from commonly employed nebulizers using in vitro techniques and to create a mathematical model to predict inspired mass of aerosol. DESIGN Lung deposition was estimated by characterization of drug output and particle size distribution (PSD) of nebulizers using helium-neon laser diffraction techniques. A mathematical model for each device was created to estimate pulmonary deposition using patients' breathing patterns and was verified with a mechanical-breathing model. RESULTS Total output and PSD were similar for the Hudson Updraft II and Whisperjet nebulizers, consisting of half the nebulizer's charge, with (1/4) of particles < or = 5 microm, in the respirable fraction (RF). Drug output increased with inspiratory flow for the Pari LC Star. Differences were noted in device performance, depending on the drug tested. Estimated pulmonary deposition (mean, 95% CI) was 8.1 (7.2, 9.0)% of the initial drug charge for the Hudson Updraft II, 6.4 (5.8, 7.0)% for the Whisperjet, and 33.0 (28.3, 37.9)% for the Pari LC Star. A mechanical model was consistent with our mathematical model. CONCLUSIONS All drugs could be nebulized, but expected pulmonary deposition varied depending on the nebulizer and drug.
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Affiliation(s)
- Sherri L Katz
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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Abstract
Aerosolised antimicrobial agents have been used in clinical practice since the 1950s. The main advantage of this route of administration is the targeted drug delivery to the site of infection in the lung. Exploitation of this targeted delivery can yield high concentrations at the site of infection/colonisation while minimising systemic toxicities. It is important to note that the ability of a drug to reach the target area in the lung effectively is dependent on a number of variables, including the nebuliser, patient technique, host anatomy and disease-specific factors. The most convincing data to support the use of aerosolised antimicrobials has been generated with tobramycin solution for inhalation (TOBI, Chiron Corp.) for maintenance treatment in patients with cystic fibrosis. In addition to cystic fibrosis, the use of aerosolised antimicrobials has also been studied for the treatment or prevention of a number of additional disease states including non-cystic fibrosis bronchiectasis, ventilator-associated pneumonia and prophylaxis against pulmonary fungal infections. Key studies evaluating the benefits and shortcomings of aerosolised antimicrobial agents in these areas are reviewed. Although the theory behind aerosolised administration of antibiotics seems to be sound, there are limited data available to support the routine use of this modality. Owing to the gaps still existing in our knowledge base regarding the routine use of aerosolised antibiotics, caution should be exercised when attempting to administer antimicrobials via this route in situations falling outside clearly established indications such as the treatment of patients with cystic fibrosis or Pneumocystis pneumonia.
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Affiliation(s)
- Jennifer K Hagerman
- Ferris State University, Hurley Medical Center, One Hurley Plaza, Pharmacy Department, Flint, MI 48503, USA.
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Abstract
The pulmonary route is an interesting route for drug administration, both for effective local therapy (asthma, chronic obstructive pulmonary disease or cystic fibrosis) and for the systemic administration of drugs (e.g., peptides and proteins). Well-designed dry powder inhalers are highly efficient systems for pulmonary drug delivery. However, they are also complicated systems, the the performance of which relies on many aspects, including the design of the inhaler (e.g., resistance to air flow and the used de-agglomeration principle to generate the inhalation aerosol), the powder formulation and the air flow generated by the patient. The technical background of these aspects, and how they may be tuned in order to obtain desired performance profiles, is reviewed. In light of the technical background, new developments and possibilities for further improvements are discussed.
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Affiliation(s)
- H W Frijlink
- Groningen University Institute for Drug Exploration (GUIDE), Department of Pharmaceutical Technology and Biopharmacy, A. Deusinglaan 1, 9713 AV Groningen, The Netherlands.
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Abstract
Aerosolized sanitizer was investigated as a potential alternative to aqueous and gaseous sanitizers for produce. Peroxyacetic acid was aerosolized (5.42 to 11.42 microm particle diameter) by a commercially available nebulizer into a model cabinet. Iceberg lettuce leaves were inoculated with three strains each of Escherichia coli O157:H7, Listeria monocytogenes, and Salmonella Typhimurium and then treated with aerosolized peroxyacetic acid for 10, 30, or 60 min in a model aerosol cabinet at room temperature (22 +/- 2 degrees C). After treatment, surviving healthy and injured bacterial cells were enumerated on appropriate selective agars or using the overlay agar method. Inoculated iceberg lettuce leaves exposed to aerosolized peroxyacetic acid for 10 min exhibited a 0.8-log reduction in E. coli O157:H7, a 0.3-log reduction in Salmonella Typhimurium, and a 2.5-log reduction in L. monocytogenes when compared with the control. After 30 min of treatment, the three pathogens were reduced by 2.2, 3.3, and 2.7 log, and after 60 min, the reductions were 3.4, 4.5, and 3.8 log, respectively. Aerosolization may be a new and convenient method for sanitizing produce for storage or shipping.
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Affiliation(s)
- Se-Wook Oh
- Food Safety Research Division, Korea Food Research Institute, Seoul 463-420, Korea
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Abstract
AIMS As a preliminary experiment on new sanitizer delivery tools, the efficacy of aerosolized sanitizer on food-borne pathogens was investigated in larger model chamber system. METHODS Peroxyacetic acid and hydrogen peroxide were aerosolized in a model system against artificially inoculated target micro-organisms on laboratory media. Cultures of four different food-borne pathogens were inoculated and affixed onto three different heights (bottom, wall and ceiling), and three different orientations (face-down, vertical and face-down) inside a commercial semi-trailer cabinet (14.6 x 2.6 x 2.8 m). Sanitizer was aerosolized into 2 microm droplet size fog and treated for 1 h at ambient temperature. RESULTS Populations of Bacillus cereus, Listeria innocua, Staphylococcus aureus, and Salmonella typhimurium were reduced by an average of 3.09, 7.69, 6.93 and 8.18 log units per plate respectively. Interestingly, L. innocua, Staph. aureus, and Salm. typhimurium showed statistically not different (P >/= 0.05) reduction patterns relative to height and orientation that were never expected in a spraying system. CONCLUSIONS Aerosolized sanitizers diffuse like gaseous sanitizers. SIGNIFICANCE AND IMPACT OF THE STUDY Aerosolization has great potential for use in commercial applications.
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Affiliation(s)
- S-W Oh
- Food Safety Research Division, Korea Food Research Institute, Korea
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Abstract
OBJECTIVES To evaluate differences between three new-generation nebulizers-Pari LC Star (Pari Respiratory Equipment; Mississauga, ON, Canada), AeroEclipse (Trudell Medical International, London, ON, Canada), and Halolite (Medic-Aid Limited, West Sussex, UK)-in terms of rate and amount of expected deposition as well as the consistency of the doses delivered. METHODS The in vitro performance characteristics were determined and then coupled to the respiratory pattern of seven patients with cystic fibrosis (age range, 4 to 18 years) in order to calculate expected deposition. The Pari LC Star and AeroEclipse were characterized while being driven by the Pari ProNeb Ultra compressor (Pari Respiratory Equipment) for home use, and by a 50-psi medical air hospital source. The Halolite has its own self-contained compressor. Algorithms for the rate of output for the inspiratory flow were developed for each device. Patient flow patterns were divided into 5-ms epochs, and the expected deposition for each epoch was calculated from the algorithms. Summed over a breath, this allowed the calculation of the estimated deposition for each patient's particular pattern of breathing. RESULTS The rate of deposition was highest for the Pari LC Star and lowest for the Halolite. Rate of deposition was independent of respiratory pattern for the Pari LC Star and AeroEclipse, but proportional to respiratory rate for the Halolite. The differences between the Pari LC Star and AeroEclipse were less when driven by the 50-psi source. The AeroEclipse had the least amount of drug wastage. As designed, the Halolite delivered a predetermined amount of drug very accurately, whereas expected deposition when run to dryness of the other two devices had significant variations. CONCLUSIONS To minimize treatment time, the Pari LC Star would be best. To minimize drug wastage, the AeroEclipse would be best. To accurately deliver a specific drug dose, the Halolite would be best.
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Affiliation(s)
- Kitty Leung
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada
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36
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize modern data pertaining to the use of aerosolized antimicrobials for the treatment of and prophylaxis against pulmonary infections. RECENT FINDINGS Few recent publications have examined the safety and efficacy of nebulized antibiotics. Two well conducted trials have been published that describe the utility of tobramycin solution for inhalation among cystic fibrosis patients. A couple of good reviews have also been published that have summarized the use of aerosolized antibiotics in other patient populations. SUMMARY Data regarding this topic are scarce. At this time, data support the use of aerosolized tobramycin solution for inhalation in cystic fibrosis patients infected or colonized by Pseudomonas aeruginosa. Apart from this situation, widespread aerosolized administration of other agents in cystic fibrosis and non-cystic fibrosis patient populations should not be advocated.
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Affiliation(s)
- Michael E Klepser
- Ferris State University, Big Rapids, and Borgess Medical Center, Kalamazoo, Michigan, USA.
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37
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Abstract
The performance of five different compressors (CR60), Porta-Neb, Pulmo-Aide, TurboBoy and Freeway Freedom) was studied in combination with the widely recommended PARI LC PLUS nebuliser for the aerosolisation of a marketed tobramycin solution (TOBI). The droplet size distribution of the generated aerosol was measured with laser diffraction technique at stationary inspiratory flow rates through the nebuliser cup of 20, 30 and 40l N/min. The different compressors showed a distinct difference in droplet size distribution of the aerosol and nebulisation time till dry running. The finest droplets with a volume (equals mass) median diameter (mmd) of 1.84 microm (which was the same at all flow rates), as well as the narrowest size distribution were obtained with a CR60. The Freeway Freedom generated the largest droplets: mmd ranged between 2.63 and 3.72 microm depending on the inspiratory flow rate. The aerosol produced with this compressor also had the widest size distribution. The differences between the compressors could be explained with differences in the jet flow. A higher jet flow resulted in finer droplets, less dependence on the inspiratory flow rate and a shorter time till dry running. Thus, to obtain the required fineness of the aerosol for peripheral airway deposition of the tobramycin, independent of the inspiratory flow rate, the use of the CR60 compressor is preferred over the use of Porta-Neb, Pulmo-Aide, TurboBoy and Freeway Freedom (in order of decreasing preference). Finally, it was found that careful cleaning with warm water and liquid soap of the nebuliser cup is essential to obtain adequate performance of the LC PLUS.
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Affiliation(s)
- A H de Boer
- Department of Pharmaceutical Technology and Biopharmacy, Groningen University Institute for Drug Exploration, Antonius Deusinglaan 1, Groningen, 9713 AV, The Netherlands.
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38
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Asmus MJ, Stewart BA, Milavetz G, Teresi ME, Han SH, Wang D, Ahrens RC. Tobramycin as a pharmacologic tracer to compare airway deposition from nebulizers. Pharmacotherapy 2002; 22:557-63. [PMID: 12013353 DOI: 10.1592/phco.22.8.557.33202] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To assess the utility of inhaled tobramycin as a pharmacologic tracer for comparing lung deposition from a prototypic breath-actuated jet nebulizer connected to an electronic pressure sensor designed to coordinate nebulization with inspiration with that from a continuously operating standard jet nebulizer. DESIGN Prospective open-label study. SETTING University-affiliated research center. SUBJECTS Six healthy adult volunteers. INTERVENTION All subjects received inhaled tobramycin 80, 160, and 320 mg from each nebulizer during six visits, as well as oral tobramycin 32 mg at a seventh visit to confirm the absence of significant gastrointestinal absorption. During each visit, urine was collected before drug administration and in 12-hour segments throughout the first 48 hours after administration. MEASUREMENTS AND MAIN RESULTS Lung deposition of tracer after each of the seven treatments was quantified by measuring urinary tobramycin excretion over 48 hours with use of an enzyme-multiplied immunoassay technique. The ratio of tobramycin excreted after breath-actuated nebulization to that after standard nebulization, normalized for dose, was used to compare lung deposition by the two devices. Urinary excretion of tobramycin was linear and proportional to dose for both nebulizers. For every 1 mg of tobramycin that the standard nebulizer deposited into the lungs, the breath-actuated nebulizer deposited 1.22 mg (95% confidence interval 1.04-1.43). CONCLUSIONS Tobramycin can be used as a pharmacologic tracer for comparison of relative airway deposition by nebulizers.
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Affiliation(s)
- Michael J Asmus
- College of Pharmacy, University of Florida, Gainesville, USA
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39
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Abstract
The objective of this study was to evaluate relative efficiency in vitro of four reusable breath-enhanced nebulizers (Pari LC Star, Medic-Aid Ventstream, Devilbiss PermaNeb, Salter Ultramist), and to integrate the in vitro performance data of the nebulizers with the respiratory patterns of four cystic fibrosis (CF) patients to compare efficiency in vivo of each device for each individual patient. Six nebulizers of each type were used to nebulize a solution of 2.5 mg (0.5 mL) albuterol with 3.5 mL of 0.9% saline. Total albuterol output and the rate of albuterol output of each device were measured until end-nebulization and for 4 min, respectively, using entrained flows from 0 to 20 L/min through the inspiratory valve of the device. Particle size distributions and the respirable fraction (RF) were evaluated by laser diffraction technique. Regression analysis of the change in rate of output and change in RF values with inspiratory flows was done to characterize each nebulizer's performance over the complete range of interest. Actual breath tracings of four CF patients were integrated with the equations specific to the in vitro performance of each nebulizer and in vivo nebulizer efficiency was calculated. The change in efficiency in vitro from 0 to 20 L/min flow, respectively, was highest for the Star (44-57%) and lowest for the Ultramist (13-15%). The mean predicted efficiency in vivo for the Star was threefold that of the Ultramist. Although all four nebulizers are breath-enhanced in design, clearly there are measurable differences in the performance and efficiency of each type. The Pari LC Star nebulizer has proven to be the nebulizer of choice among the devices tested.
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Affiliation(s)
- S L Ho
- Research Institute, Hospital for Sick Children and the University of Toronto, Ontario, Canada
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40
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Abstract
Aerosolized aminoglycosides have demonstrated their efficacy in the treatment of P. aeruginosa pneumonia in cystic fibrosis (CF) patients. There is wide interpatient variability in the deposited and systemic drug doses that depend on both the nebulization and inhalation conditions and result in a risk of inefficacy or toxicity. We have developed a tool to provide a simple method for individual dose monitoring by estimating the total quantity of amikacin excreted, which corresponds to the dose absorbed systemically. It is based on a single urine assay. Thirty-seven urinary pharmacokinetic time courses in healthy volunteers (groups A and B) or in CF patients (groups C and D) were used. The rules for extrapolating the total dose excreted on the basis of 6-, 8-, 10-, and 12-h urine samples, were determined from group A. The accuracy of these rules was then tested in the other three groups. The total amount excreted was poorly predictable, with a coefficient of variation (CV) of 36 and 30% in the healthy volunteers, and of 48 and 82% in the CF group, whereas the CV of the estimated amount, based on 8- to 12-h samples, was only 10-15% in the healthy volunteers and 4-8% in the CF patients. Collecting a single sample over an 8- to 12-h period requires overnight sampling. The very low circadian variations in renal function, ranging from -2% to +5%, demonstrated the absence of any significant bias resulting from overnight sampling. A single urine assay can therefore be proposed as a simple, noninvasive, low cost, and reliable method for the clinical monitoring of nebulized amikacin in CF patients. Further studies are needed before this method can be extended to aerosol treatments with other aminoglycosides.
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Affiliation(s)
- F Faurisson
- INSERM EMI-V 99 33, Hĵpital Bichat Claude Bernard, Paris, France.
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41
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Standaert TA, Bohn SE, Aitken ML, Ramsey B. The equivalence of compressor pressure-flow relationships with respect to jet nebulizer aerosolization characteristics. J Aerosol Med 2001; 14:31-42. [PMID: 11495483 DOI: 10.1089/08942680152007873] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Manufacturers of aerosolized medications, approved by the Food and Drug Administration, specify the nebulizer(s) and compressor to be used with their product, in an attempt to achieve efficacy comparable to that obtained in the clinical trials. The need to limit the compressor to that used in the trials has not been investigated in detail. We suggest a technique to determine the equivalency of different compressors such that a chosen nebulizer's performance is not significantly altered. Aerosol particle size (MMD) was measured with a laser; compressor flow and pressure were measured with a mass flow meter and pressure gauge, respectively. For all models of nebulizer, increased flow or driving pressure caused a decrease in aerosol MMD. The flow resistance of nebulizer models varied, and the flow output of compressors decreased as imposed nebulizer resistance increased. However, for any specific compressor-nebulizer combination there is a unique flow and pressure, and the nebulizer generates a given MMD. We demonstrate methods to choose alternate compressors that may be used to drive a nebulizer and yet keep the nebulizer's MMD and performance within predetermined limits. Once an acceptable range of variance in a nebulizer's MMD is defined, alternate compressors may be safely chosen. We recommend that these techniques be used by manufacturers of medications and of compressors to safely determine the acceptability of several rather than a single model compressor to drive a chosen nebulizer. The techniques assure consistency of the nebulizer's clinically demonstrated performance characteristics.
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Affiliation(s)
- T A Standaert
- Department of Pediatrics, Cystic Fibrosis Research Center, Children's Hospital and Medical Center, Seattle, Washington, USA.
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42
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Coates AL, Allen PD, MacNeish CF, Ho SL, Lands LC. Effect of size and disease on estimated deposition of drugs administered using jet nebulization in children with cystic fibrosis. Chest 2001; 119:1123-30. [PMID: 11296179 DOI: 10.1378/chest.119.4.1123] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To develop a model that quantified the nebulizer output that was inhaled by subjects with cystic fibrosis (CF) in order to predict the amount of drug likely to enter the upper airway contained in particles small enough to be deposited in the lower respiratory tract of individual patients. DESIGN Forty-three patients (age, 6 to 18 years) with CF, with FEV(1) of 26 to 124% of predicted, breathed through a nebulizer circuit with a pneumotachograph in place at the distal end. Algorithms were developed from the measured flows through the pneumotachograph, allowing partitioning of inspiration into undiluted aerosol and fresh gas. In order to validate the algorithms, argon was added to the nebulizing gas flow and then its concentration was analyzed at the mouth by mass spectrometry. RESULTS Predictions of the concentration of argon at the mouth were concordant with that measured by mass spectrometry, thus validating the model. Combining data from the model with in vitro nebulizer performance data, predictions for estimates for lung deposition for individuals were possible. Total estimate was independent of patient size or FEV(1). The respiratory duty cycle was 0.44 +/- 0.05 (mean +/- SD) and correlated (r = 0.91, p < 0.001) with estimated deposition and minute ventilation (r = 0.60, p < 0.01). However, when expressed in milligrams per kilogram of body weight, the estimated deposition in smaller children was fourfold higher than in larger children. CONCLUSIONS If the effect of patient size and pattern of breathing on estimated drug deposition are not considered when prescribing drugs given by nebulization, the result may be overdosing younger children, underdosing older children, or both.
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Affiliation(s)
- A L Coates
- Division of Respiratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada.
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43
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Abstract
STUDY OBJECTIVES To develop practical ways of nebulizing colistin by determining the rate of drug output, total drug output, and particle-size distribution of two commercially available jet nebulizers, the disposable Hudson 1730 Updraft II (Hudson Respiratory Care; Temecula, CA) and the reusable Pari LC Star breath-enhanced nebulizer (Pari Respiratory Equipment; Midlothian, VA). METHODS The nebulizers contained colistin, 75 mg, in 4 mL of isotonic solution. Particle-size distribution was measured by helium-neon laser diffraction, allowing calculation of the respirable fraction (RF), the mass of aerosol comprised of droplets < 5 microm. RESULTS The mean (95% confidence interval [CI]) total rate of output of the Updraft II was 2.6 mg/min (2.0, 3.1; n = 4) with 1.3 mg/min (1.0, 1.5) mg/min within the RF. The rate of output of the LC Star increased in a quadratic relationship to the inspiratory flow, delivering 1.8 mg/min (0.7, 2.0; n = 4) with 1.4 mg/min (1.3, 1.6) within the RF, and 6.2 mg/min (5.6, 6.8) with 5.3 mg/min (4.8, 5.7) within the RF, at 0 L/min and 20 L/min inspiratory flows, respectively. Efficiency, as the rate of expected pulmonary deposition divided by rate of total output, was then calculated. The LC Star estimated 56% (51, 61) efficiency, with pulmonary delivery of 29% (26, 32) of the charge of the nebulizer, compared to the Updraft II at 22% (22, 23) efficiency and expected pulmonary deposition of 10% (10, 10) of the dose. CONCLUSIONS Colistin can be successfully nebulized with both nebulizers tested. This study provides an estimate of in vivo efficiency and expected pulmonary deposition that may be used in future trials.
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Affiliation(s)
- S L Katz
- Division of Respiratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada
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44
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Prober CG, Walson PD, Jones J. Technical report: precautions regarding the use of aerosolized antibiotics. Committee on Infectious Diseases and Committee on Drugs. Pediatrics 2000; 106:E89. [PMID: 11099632 DOI: 10.1542/peds.106.6.e89] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In 1998, the Food and Drug Administration (FDA) approved the licensure of tobramycin solution for inhalation (TOBI). Although a number of additional antibiotics, including other aminoglycosides, beta-lactams, antibiotics in the polymyxin class, and vancomycin, have been administered as aerosols for many years, none are approved by the FDA for administration by inhalation. TOBI was approved by the FDA for the maintenance therapy of patients 6 years or older with cystic fibrosis (CF) who have between 25% and 75% of predicted forced expiratory volume in 1 second (FEV(1)), are colonized with Pseudomonas aeruginosa, and are able to comply with the prescribed medical regimen. TOBI was not approved for the therapy of acute pulmonary exacerbations in patients with CF nor was it approved for use in patients without CF. Currently, no other antibiotics are approved for administration by inhalation to patients with or without CF. The purpose of this statement is to briefly summarize the data that supported approval for licensure of TOBI and to provide recommendations for its safe use. The pharmacokinetics of inhaled aminoglycosides and problems associated with aerosolized antibiotic treatment, including environmental contamination, selection of resistant microbes, and airway exposure to excipients in intravenous formulations, will be discussed.
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45
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Standaert TA, Vandevanter D, Ramsey BW, Vasiljev M, Nardella P, Gmur D, Bredl C, Murphy A, Montgomery AB. The choice of compressor effects the aerosol parameters and the delivery of tobramycin from a single model nebulizer. J Aerosol Med 2000; 13:147-53. [PMID: 11010595 DOI: 10.1089/089426800418677] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Recent U.S. Phase III trials of the aerosolized delivery of tobramycin to cystic fibrosis (CF) patients demonstrated a significant improvement in pulmonary function and in sputum bacterial density. These trials used the Pari LC Plus nebulizer and DeVilbiss Pulmo-Aide compressor. This compressor is not generally available in Europe, and its power requirements do not match the European power supply. Thus alternate compressors were evaluated, using the LC Plus nebulizer, in preparation for European clinical trials. Aerosol particle size distribution, nebulization time (min), and the respirable dose of tobramycin (mg within 1-5 mu) were obtained for seven compressor models. The respirable quantity delivered by each of the European compressors (240 Volts, 50 Hz) was compared to the LC Plus and PulmoAide compressor (120 Volts, at 60 Hz). The U.S. system delivered 71.4 mg of the 300 mg instilled dose within the respirable range; using the European compressors, between 63.0 and 74.8 mg was delivered. With a 97% confidence that the delivered tobramycin was within 20% of the standard, we conclude that the SystAm 23ST, MedicAid CR50 and CR60, Pari Master and the Pari Boy compressors are equivalent to the U.S. standard; the Hercules and the SystAm 26ST compressors were not statistically equivalent to the standard. Using the LC Plus nebulizer, five European compressors delivered doses of TOBI that are similar to the doses delivered by the DeVilbiss PulmoAide compressors, and thus may be expected to produce clinical results similar to those of the U.S. trials.
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Affiliation(s)
- T A Standaert
- Cystic Fibrosis Research Center, Children's Hospital and Medical Center, Seattle, Washington, USA.
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46
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Abstract
The use of inhaled tobramycin for prophylaxis and treatment of respiratory symptoms in cystic fibrosis (CF) is now widespread. There have been concerns that inhaling the intravenous (I.V.) formulation of tobramycin causes bronchoconstriction. Previous studies using this formulation have either not specified the nebulizing equipment, or studied older, more severely affected patients. This study investigated the incidence of bronchoconstriction with tobramycin inhalation in children with mild to moderate CF. We studied 26 patients between the ages of 7 and 17 years, with mild to moderate CF (20 female). Prior to being placed on prolonged inhaled tobramycin therapy, they underwent a "tobramycin challenge." FEV(1) was measured pre and post challenge. For the test, standard I.V. solution (80 mg/2 mL) diluted with 2 mL of normal saline was nebulized, using the Hudson (Temecula, CA) RCI Updraft II nebulizer. The nebulization lasted 2 min. There was a 3-min "quiet period," following which FEV(1) was measured. A decrease in FEV(1) by at least 10% post-tobramycin inhalation was considered to be a positive test. Results were analyzed using the Pearson Chi-square test. Five of 26 (19%) had a positive reaction to tobramycin. Sixteen of 26 (61.5%) were using salbutamol on a daily basis at the time of testing but not for 48 hr before the challenge, and 16 of 26 (61.5%) had a pre-tobramycin FEV(1) of < or =80%. Neither an FEV(1) of <80% (P = 0.93) nor regular use of salbutamol (P = 0. 34) were associated with a positive tobramycin challenge. This study suggests that, while bronchoconstriction does occur, many patients do not exhibit bronchoconstriction in response to the standard I.V. preparation and, as prior work suggests, this may be reduced further by pretreatment with salbutamol.
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Affiliation(s)
- M Ramagopal
- Department of Respiratory Medicine, Montreal Children's Hospital, Montreal, Province of Quebec, Canada
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47
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Coates AL, MacNeish CF, Allen PD, Ho SL, Lands LC. Do sinusoidal models of respiration accurately reflect the respiratory events of patients breathing on nebulizers? J Aerosol Med 2000; 12:265-73. [PMID: 10724641 DOI: 10.1089/jam.1999.12.265] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The amount of drug that is delivered by nebulization is a combination of the physical properties of the agent being nebulized, the performance of the nebulizer, and the pattern of breathing of the patient. To avoid biological variation, mechanical models of breathing are frequently employed during the evaluation of the performance of a device. For simplicity, many investigators use sinusoidal models of breathing to calculate the expected inhaled mass, although some use square waves and other more complex models. Most assume that the duration of inspiration (Ti) is half of the total respiratory time (Ttot). This study compared the calculated inhaled mass from which the expected pulmonary deposition was estimated from the actual pattern of breathing of 43 children with cystic fibrosis (CF) breathing from an unvented nebulizer with a low dead volume and appropriate particle size distribution with that from a sinusoidal pattern of breathing using the same tidal volume (VT) and respiratory rate. The respiratory duty cycle (Ti/Ttot) was 0.45 +/- 0.05, which meant that less time was spent during inspiration than that found in a pure sinusoidal pattern. The difference between the predicted deposition from the actual pattern of breathing and that calculated from the sinusoidal model was 12 +/- 7%, which correlated with the respiratory rate (r = 0.67, P < 0.001). The degree of lung disease did not influence the discrepancy between the two values. In general, the actual VTs and respiratory rates were less in the patients than those employed in mechanical models of pediatric breathing. Although some patients had respiratory patterns that could be represented accurately with a sinusoidal model, most did not, and there were wide variations from child to child. These results suggest that there are both systematic and random errors arising from the use of a sinusoidal waveform to mimic respiratory events in patients.
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Affiliation(s)
- A L Coates
- Division of Respiratory Medicine, Hospital for Sick Children, University of Toronto, Ontario, Canada.
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48
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Abstract
Inhaled drugs play an important role in asthma management. The correct use of an appropriate delivery device is necessary to achieve the desired therapeutic effects of the drug. Currently, chlorofluorocarbon-propelled metered-dose inhalers, with or without spacers, are the most popular aerosol delivery devices. With the planned phase out of the chlorofluorocarbon metered-dose inhalers, the use of other delivery devices is being emphasized. To achieve optimal therapeutic effects, the drug and the delivery device should be considered a "couple". Aerosol delivery devices should provide an adequate "drug dose to the lung", be cost effective, simple to operate, minimize oropharyngeal deposition and systemic side effects, and match the patient's requirements. A new generation of aerosol delivery devices, incorporating the latest advances in aerosol technology, is likely to fulfill many of the goals mentioned above.
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Affiliation(s)
- R Dhand
- Division of Pulmonary and Critical Care Medicine, Stritch School of Medicine, Loyola University of Chicago, IL, USA
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49
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50
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Abstract
Formulation scientists generate physicochemical data that are used in process modelling and in the prediction of end-product quality. In this respect, contact angles are of particular importance as the surface energy of substances influences their processability and bioavailability. Dynamic contact angle (DCA) analysis represents a straightforward wettability assay. Now fully adapted to powders, DCA analysis also proves to be more efficient than other methods for wettability determination.
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