A narrative review on trans-nasal pulmonary aerosol delivery

Li, Jie; Fink, James B.; MacLoughlin, Ronan; Dhand, Rajiv

doi:10.1186/s13054-020-03206-9

Cited by 32 publications

(39 citation statements)

References 64 publications

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“…This ratio also plays a part in the delivered aerosol dose, as well as the levels of fugitive emissions to the local environment, which is a key, but often forgotten consideration for healthcare professionals or bystanders during aerosol therapy [46][47][48][49]. A recent review of aerosol delivery during HFNT by Li and colleagues provides additional insight into the factors at play [50].…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis

et al. 2021

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Lung disease is the main cause of morbidity and mortality in cystic fibrosis (CF). CF patients inhale antibiotics regularly as treatment against persistent bacterial infections. The goal of this study was to investigate the effect of clinical intervention on aerosol therapy during the escalation of care using a bench model of adult CF. Droplet size analysis of selected antibiotics was completed in tandem with the delivered aerosol dose (% of total dose) assessments in simulations of various interventions providing oxygen supplementation or ventilatory support. Results highlight the variability of aerosolised dose delivery. In the homecare setting, the vibrating mesh nebuliser (VMN) delivered significantly more than the jet nebuliser (JN) (16.15 ± 0.86% versus 6.51 ± 2.15%). In the hospital setting, using VMN only, significant variability was seen across clinical interventions. In the emergency department, VMN plus mouthpiece (no supplemental oxygen) was seen to deliver (29.02 ± 1.41%) versus low flow nasal therapy (10 L per minute (LPM) oxygen) (1.81 ± 0.47%) and high flow nasal therapy (50 LPM oxygen) (3.36 ± 0.34%). In the ward/intensive care unit, non-invasive ventilation recorded 19.02 ± 0.28%, versus 22.64 ± 1.88% of the dose delivered during invasive mechanical ventilation. These results will have application in the design of intervention-appropriate aerosol therapy strategies and will be of use to researchers developing new therapeutics for application in cystic fibrosis and beyond.

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Section: Discussionmentioning

confidence: 99%

Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis

et al. 2021

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“…Since 2018, trans-nasal aerosol delivery to the lungs has attracted clinicians’ interest, and iEPO delivery via HFNC has been proven to be effective [ 15 ]. The feasibility of iEPO delivery via HFNC offered the option of extubating patients directly from invasive ventilation to HFNC with continuation of iEPO administration, which may allow patients capable of weaning from the ventilation without weaning off iEPO during invasive ventilation.…”

Section: Discussionmentioning

confidence: 99%

In-vitro and in-vivo comparisons of high versus low concentrations of inhaled epoprostenol to adult intubated patients

Augustynovich

Gurnani

et al. 2021

Respir Res

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Background Inhaled epoprostenol (iEPO) has been shown to reduce pulmonary artery pressure and improve oxygenation. iEPO is mainly delivered via a syringe pump with feed tubing connected to a vibrating mesh nebulizer with high or low formulation concentration delivery. Methods An in vitro study and a two-period retrospective case–control study were implemented. The in vitro study compared iEPO delivery via invasive ventilation at low concentrations of 7.5, and 15 mcg/mL and high concentration at 30 mcg/mL, to deliver the ordered dose of 30 and 50 ng/kg/min for three clinical scenarios with predicted body weight of 50, 70 and 90 kg. While in the clinical study, adult patients receiving iEPO via invasive ventilation to treat refractory hypoxemia, pulmonary hypertension, or right ventricular failure were included. 80 patients received low concentration iEPO at multiple concentrations (2.5, 7.5, and 15 mcg/mL, depending on the ordered dose) from 2015 to 2017, while 84 patients received high concentration iEPO at 30 mcg/mL from 2018 to 2019. Results In the in vitro study, there were no significant differences in aerosol deposition between high vs low concentrations of iEPO at a dose of 50 ng/kg/min. In the clinical study, age, gender, ethnicity, and indications for iEPO were similar between high and low concentration groups. After 30–120 min of iEPO administration, both delivery strategies significantly improved oxygenation in hypoxemic patients and reduced mean pulmonary arterial pressure (mPAP) for patients with pulmonary hypertension. However, no significant differences of the incremental changes were found between two delivery groups. Compared to low concentration, high concentration delivery group had better adherence to the iEPO weaning protocol (96% vs 71%, p < 0.001), fewer iEPO syringes utilized per patient (5 [3, 10] vs 12 [6, 22], p = 0.001), and shorter duration of invasive ventilation (6 [3, 12] vs 9 [5, 18] days, p = 0.028). Intensive care unit length of stay and mortality were similar between two groups. Conclusion Compared to low concentration delivery of iEPO, high concentration iEPO via a vibrating mesh nebulizer maintained clinical benefits and increased clinician compliance with an iEPO weaning protocol, required less medication preparation time, and shortened duration of invasive ventilation.

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“…When aerosol therapy is administered, titrating ow to 15-20 L/min for stable subjects and 25-30 L/min for subjects with distressed breathing could increase the delivery e ciency. 10 Notably, reducing ow to optimize aerosol delivery might cause desaturation and increase work of breathing, for subjects who rely on high gas ow and high oxygen concentration. For these patients, administration of small volumes of solution may reduce dosing time to shorten the periods of ow reduction.…”

Section: Discussionmentioning

confidence: 99%

“…For these patients, administration of small volumes of solution may reduce dosing time to shorten the periods of ow reduction. 10,26 If reduced ow is not tolerated, or long term continuous inhalation is needed, higher nominal dose might be necessary.…”

Section: Discussionmentioning

confidence: 99%

“…9 More recently HFNC has been utilized as a vehicle to administer inhaled medication to the lower airways. 10 Due to the comfort of the nasal cannula interface with heated humidity, HFNC seems to be better tolerated by small children who are sensitive to gas temperature and noise and resist the use of masks, 11 as well as patients who need to inhale aerosolized medication for extended periods of time, such as inhaled bronchodilators for severe asthmatics 12 or inhaled prostacyclin for patients with pulmonary hypertension 13 and/or refractory hypoxemia. 13,14 In the COVID-19 pandemic, this delivery route has become more popular, 15 as patients can wear surgical mask over the nasal cannula to reduce the dispersion of fugitive aerosol particles into the surrounding environment, 16 resulting in lower opportunities of virus transmission.…”

Section: Introductionmentioning

confidence: 99%

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Inhaled Bronchodilator Delivery via High-Flow Nasal Cannula for COPD and Asthma Patients: A Randomized Controlled Trial to Compare the Bronchodilation Effects of Gas Flow Rates

Chen

Ehrmann

et al. 2020

Preprint

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BackgroundAerosol delivery via high-flow nasal cannula (HFNC) has attracted increasing clinician interest. In vitro studies report that the ratio of HFNC gas flow to patient inspiratory flow (GF:IF) is a key factor in the efficiency of trans-nasal aerosol delivery. This randomized controlled trial was aimed to validate this finding, and to explore the effective dose of inhaled bronchodilator to be given to patients via HFNC. Methods Patients with a history of COPD or asthma and documented positive response to inhaled bronchodilators in an outpatient pulmonary function laboratory were recruited. Subjects were randomized to receive inhalation at gas flow ratio/settings of : GF:IF=0.5, GF:IF=1.0, or GF=50L/min. Patients were assigned to inhale saline (control) followed by salbutamol via HFNC with an escalating dose sequence (0.5mg, 1.0mg, 2.0mg and 4.0mg). Spirometry was performed at baseline and after each inhalation. Results Seventy-five subjects (49 asthma and 26 COPD) demonstrating bronchodilator response (ATS/ERS) were enrolled. Using the criteria of post-bronchodilator FEV1 returning to screening post-bronchodilator FEV1 with salbutamol, a higher percentage of subjects receiving GF:IF=0.5 met criteria at cumulative dose of 1.5mg, than those receiving GF:IF=1.0, and GF=50L/min (64% vs 29% vs 27%, respectively, p=0.011). Similarly at 3.5mg (88% vs 54% vs 46%, respectively, p=0.005). The effective dose at GF:IF=0.5 was 1.5mg while for GF=50 L/min it was 3.5mg. Conclusion Dose response to salbutamol via HFNC was greater when administered with gas flow set at 50% of patient inspiratory flow, than with higher gas flow rates. Trial registration: www.clinicaltrials.gov: NCT03739359. Registered 13 November 2018, https://clinicaltrials.gov/ct2/show/NCT03739359?term=03739359&draw=2&rank=1

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A narrative review on trans-nasal pulmonary aerosol delivery

Cited by 32 publications

References 64 publications

Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis

Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis

In-vitro and in-vivo comparisons of high versus low concentrations of inhaled epoprostenol to adult intubated patients

Inhaled Bronchodilator Delivery via High-Flow Nasal Cannula for COPD and Asthma Patients: A Randomized Controlled Trial to Compare the Bronchodilation Effects of Gas Flow Rates

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