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Review
. 2020 Aug 17;24(1):506.
doi: 10.1186/s13054-020-03206-9.

A narrative review on trans-nasal pulmonary aerosol delivery

Affiliations
Free PMC article
Review

A narrative review on trans-nasal pulmonary aerosol delivery

Jie Li et al. Crit Care. .
Free PMC article

Abstract

The use of trans-nasal pulmonary aerosol delivery via high-flow nasal cannula (HFNC) has expanded in recent years. However, various factors influencing aerosol delivery in this setting have not been precisely defined, and no consensus has emerged regarding the optimal techniques for aerosol delivery with HFNC. Based on a comprehensive literature search, we reviewed studies that assessed trans-nasal pulmonary aerosol delivery with HFNC by in vitro experiments, and in vivo, by radiolabeled, pharmacokinetic and pharmacodynamic studies. In these investigations, the type of nebulizer employed and its placement, carrier gas, the relationship between gas flow and patient's inspiratory flow, aerosol delivery strategies (intermittent unit dose vs continuous administration by infusion pump), and open vs closed mouth breathing influenced aerosol delivery. The objective of this review was to provide rational recommendations for optimizing aerosol delivery with HFNC in various clinical settings.

Keywords: Aerosol therapy; Asthma; Chronic obstructive pulmonary disease; High-flow nasal cannula; Jet nebulizer; Oxygen therapy; Pulmonary hypertension; Vibrating mesh nebulizer.

Conflict of interest statement

Dr. Dhand reports remuneration from GSK Pharmaceuticals, Boehringer-Ingelheim, Bayer, Mylan, Teva, and Astra-Zeneca Pharmaceuticals outside the submitted work. Dr. Fink is Chief Science Officer for Aerogen Pharma Corp, San Mateo, CA, USA. Dr. MacLoughlin is the Senior Manager Science for Aerogen Ltd., Galway, Ireland. Dr. Li declares to receive research funding from Fisher & Paykel Healthcare, The Daniel and Ada Rice Foundation. None of the companies had a role in the conception of this review, in the literature search or interpretation, in the writing of the manuscript, or in the decision to publish the results.

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Abstract

Some patients with coronavirus disease (COVID-19) present with severe acute respiratory syndrome, which causes multiple organ dysfunction, besides dysfunction of the respiratory system, that requires invasive procedures. On the basis of the opinions of front-line experts and a review of the relevant literature on several topics, we proposed clinical practice recommendations on the following aspects for physiotherapists facing challenges in treating patients and containing virus spread: 1. personal protective equipment, 2. conventional chest physiotherapy, 3. exercise and early mobilization, 4. oxygen therapy, 5. nebulizer treatment, 6. non-invasive ventilation and high-flow nasal oxygen, 7. endotracheal intubation, 8. protective mechanical ventilation, 9. management of mechanical ventilation in severe and refractory cases of hypoxemia, 10. prone positioning, 11. cuff pressure, 12. tube and nasotracheal suction, 13. humidifier use for ventilated patients, 14. methods of weaning ventilated patients and extubation, and 15. equipment and hand hygiene. These recommendations can serve as clinical practice guidelines for physiotherapists. This article details the development of guidelines on these aspects for physiotherapy of patients with COVID-19.

Conflict of interest statement

No potential conflict of interest was reported.

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Review
. 2019 Dec;32(6):341-351.
doi: 10.1089/jamp.2019.1524. Epub 2019 May 14.

Nasal High-Flow Nebulization for Lung Drug Delivery: Theoretical, Experimental, and Clinical Application

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Review

Nasal High-Flow Nebulization for Lung Drug Delivery: Theoretical, Experimental, and Clinical Application

Jonathan Dugernier et al. J Aerosol Med Pulm Drug Deliv. 2019 Dec.

Abstract

The use of nasal high-flow (NHF) therapy is rapidly spreading across acute care facilities. This raises the question of optimal delivery of inhaled medication to patients undergoing this noninvasive ventilatory support consisting in delivering heated and humidified high gas flow rates through nasal cannulas. In this article, we review experimental and clinical work evaluating the delivery of inhaled medication within the NHF circuit to target the lung without interrupting the ventilatory support. Using vibrating mesh nebulizers placed immediately upstream or downstream of the humidification chamber, with flow rates of 30-45 L/min in adults and 2-6 L/min in children and infants, about 1%-10% of the drug charged in the nebulizer may be delivered to the lungs. Compared with conventional facemask aerosol interfaces, this amount is significantly lower than amounts delivered to adults (i.e., up to 25% of the nominal dose), but similar to amounts delivered to children and infants, the latter having a predominantly nasal breathing. However, significant clinical effects have been shown in both populations when delivering bronchodilators through NHF. This interface is particularly well tolerated and may be useful to improve aerosol therapy tolerance in the pediatric setting. Thus, among patients undergoing NHF therapy, bronchodilators may be delivered through this route. Whereas other drugs may be delivered this way or if there is a patient-centered benefit to specifically use NHF for aerosol therapy among patients without ongoing ventilatory support, requires further evaluation and technological development.

Keywords: bronchodilator agents; cannula; nebulizers and vaporizers; noninvasive ventilation; oxygen inhalation therapy.

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Review
. 2017;18(11):877-882.
doi: 10.2174/1389201019666171219104217.

Aerosol Drug Delivery Through High Flow Nasal Cannula

Affiliations
Review

Aerosol Drug Delivery Through High Flow Nasal Cannula

Arzu Ari. Curr Pharm Biotechnol. 2017.

Abstract

Background: High flow nasal cannula (HFNC) is widely utilized to support critically ill adults, pediatrics and neonates. Through the continuous delivery of oxygen at high flow rates that meet or exceed patients' inspiratory flow, HFNC improves oxygenation, respiratory rates, patient comfort, and tolerance during therapy. As HFNC becomes more widely employed, clinicians have started to consider aerosol drug delivery through HFNC.

Conclusion: Using HFNC along with nebulizers as a potential therapy in aerosol medicine is a new and innovative approach for aerosol drug delivery to patients with pulmonary diseases. The purpose of this paper is to review current in vitro and in vivo studies on aerosol drug delivery through HFNC in adults and children.

Keywords: Aerosols; adults; high flow nasal cannula; nebulizers; neonates.; pediatrics.

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Review
. 2017 Nov 15;11:3257-3271.
doi: 10.2147/DDDT.S135377. eCollection 2017.

Role of nebulized glycopyrrolate in the treatment of chronic obstructive pulmonary disease

Affiliations
Free PMC article
Review

Role of nebulized glycopyrrolate in the treatment of chronic obstructive pulmonary disease

Pierachille Santus et al. Drug Des Devel Ther. .
Free PMC article

Abstract

In the upcoming years, the proportion of elderly patients with chronic obstructive pulmonary disease (COPD) will increase, according to the progressively aging population and the increased efficacy of the pharmacological treatments, especially considering the management of chronic comorbidities. The issue to prescribe an appropriate inhalation therapy to COPD patients with significant handling or coordination difficulties represents a common clinical experience; in the latter case, the choice of an inadequate inhalation device may jeopardize the adherence to the treatment and eventually lead to its ineffectiveness. Treatment options that do not require particular timing for coordination between activation and/or inhalation or require high flow thresholds to be activated should represent the best treatment option for these patients. Nebulized bronchodilators, usually used only in acute conditions such as COPD exacerbations, could fulfill this gap, enabling an adequate drug administration during tidal breathing and without the need for patients' cooperation. However, so far, only short-acting muscarinic antagonists have been available for nebulization. Recently, a nebulized formulation of the inhaled long-acting muscarinic antagonist glycopyrrolate, delivered by means of a novel proprietary vibrating mesh nebulizer closed system (SUN-101/eFlow®), has progressed to Phase III trials and is currently in late-stage development as an option for maintenance treatment in COPD. The present critical review describes the current knowledge about the novel nebulizer technology, the efficacy, safety, and critical role of nebulized glycopyrrolate in patients with COPD. To this end, PubMed, ClinicalTrials.gov, Embase, and Cochrane Library have been searched for relevant papers. According to the available results, the efficacy and tolerability profile of nebulized glycopyrrolate may represent a valuable and dynamic treatment option for the chronic pharmacological management of patients with COPD.

Keywords: COPD; antimuscarinic; device; glycopyrrolate; glycopyrronium; nebulizer.

Conflict of interest statement

Disclosure PS has received financial support for research from Pfizer, Almirall, Chiesi Farmaceutici, and AirLiquide. He has received honoraria for lectures at national meetings from Chiesi Farmaceutici, Novartis, Zambon Italia, AstraZeneca, Almirall, GlaxoSmithKline, Boehringer Ingelheim, Menarini, and Malesci-Guidotti. He has served as consultant for Zambon Italia, AstraZeneca, Novartis, Chiesi Farmaceutici, and Boehringer Ingelheim. DR has received honoraria for lectures from Astra Zeneca and Boehringer Ingelheim. AC, VV, and MR report no conflicts of interest in this work.

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Review
. 2017 Dec;11(12):945-953.
doi: 10.1080/17476348.2017.1391095. Epub 2017 Oct 16.

Aerosol therapy through high flow nasal cannula in pediatric patients

Affiliations
Review

Aerosol therapy through high flow nasal cannula in pediatric patients

Awni M Al-Subu et al. Expert Rev Respir Med. 2017 Dec.

Abstract

High flow nasal cannula (HFNC) is increasingly used in pediatric patients suffering from respiratory failure. In some disease processes, patients may also benefit from aerosol therapy. Therefore, the use of HFNC to deliver aerosolized medications is a convenient and attractive option. Areas covered: This review aims to appraise available evidence concerning the efficiency of aerosol nebulized therapy delivery using HFNC in pediatric patients. Expert commentary: Delivery of aerosol particles is a very complex process and depends on the use of oxygen vs. heliox, nebulizer type and position within the HFNC circuit, patient's breathing effort and pattern, and more importantly cannula size and flow rates. Current in vitro evidence suggests the amount of aerosol delivery is likely to be very low at high flows. Clinical studies are limited in pediatric patients and given the limited clinical data, it is not possible to make recommendations for or against aerosol delivery through HFNC for pediatric patients.

Keywords: HFNC; High flow nasal cannula; aerosol; albuterol; children; gas exchange; hypoxia; nebulized; non-invasive ventilation; pediatrics; respiratory distress.

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Review
. 2015 Jun;60(6):880-91; discussion 891-3.
doi: 10.4187/respcare.04042.

Aerosol Therapy During Noninvasive Ventilation or High-Flow Nasal Cannula

Affiliations
Free article
Review

Aerosol Therapy During Noninvasive Ventilation or High-Flow Nasal Cannula

Dean R Hess. Respir Care. 2015 Jun.
Free article

Abstract

Noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC) are increasingly used for patients with acute respiratory failure. Some patients receiving these therapies might also benefit from inhaled drug delivery. Thus, it is attractive to combine aerosol therapy with NIV or HFNC. The purpose of this paper is to review the available evidence related to the use of inhaled aerosols with NIV or HFNC. Available evidence supports the delivery of aerosols during NIV. Inhaled bronchodilator response might be improved with the use of NIV in acute asthma, but the evidence is not sufficiently mature to recommend this as standard therapy. Evidence does support aerosol delivery without discontinuation of NIV. Clinical studies on aerosol delivery during HFNC are needed, and based on the available in vitro evidence, it is not possible to make a recommendation for or against aerosol delivery during HFNC.

Keywords: aerosol; high-flow nasal cannula; inhaler; nebulizer; noninvasive ventilation.

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Review
. 2014 Jan 3;97(1):23-6.

Going with the flow: respiratory care in the pediatric emergency department

Affiliations
  • PMID: 24400308
Review

Going with the flow: respiratory care in the pediatric emergency department

Therese L Canares et al. R I Med J (2013). .

Abstract

Providers in pediatric emergency departments (ED) frequently encounter a variety of life-threatening respiratory illnesses. This article reviews current updates on the management and unique adjuncts for 3 common respiratory illnesses. Discussed first is bronchiolitis and the impact of high flow nasal cannula on reducing the need for intubation. Next, the current therapy for croup and the adjunctive use of Heliox and finally, the ED approach to asthma and treatment with breath actuated nebulizers.

Keywords: asthma; bronchiolitis; croup; pediatrics; respiratory care.

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Review
. 2012;7(4):e35797.
doi: 10.1371/journal.pone.0035797. Epub 2012 Apr 26.

Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review

Affiliations
Free PMC article
Review

Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review

Khai Tran et al. PLoS One. 2012.
Free PMC article

Abstract

Aerosol generating procedures (AGPs) may expose health care workers (HCWs) to pathogens causing acute respiratory infections (ARIs), but the risk of transmission of ARIs from AGPs is not fully known. We sought to determine the clinical evidence for the risk of transmission of ARIs to HCWs caring for patients undergoing AGPs compared with the risk of transmission to HCWs caring for patients not undergoing AGPs. We searched PubMed, EMBASE, MEDLINE, CINAHL, the Cochrane Library, University of York CRD databases, EuroScan, LILACS, Indian Medlars, Index Medicus for SE Asia, international health technology agencies and the Internet in all languages for articles from 01/01/1990 to 22/10/2010. Independent reviewers screened abstracts using pre-defined criteria, obtained full-text articles, selected relevant studies, and abstracted data. Disagreements were resolved by consensus. The outcome of interest was risk of ARI transmission. The quality of evidence was rated using the GRADE system. We identified 5 case-control and 5 retrospective cohort studies which evaluated transmission of SARS to HCWs. Procedures reported to present an increased risk of transmission included [n; pooled OR(95%CI)] tracheal intubation [n = 4 cohort; 6.6 (2.3, 18.9), and n = 4 case-control; 6.6 (4.1, 10.6)], non-invasive ventilation [n = 2 cohort; OR 3.1(1.4, 6.8)], tracheotomy [n = 1 case-control; 4.2 (1.5, 11.5)] and manual ventilation before intubation [n = 1 cohort; OR 2.8 (1.3, 6.4)]. Other intubation associated procedures, endotracheal aspiration, suction of body fluids, bronchoscopy, nebulizer treatment, administration of O2, high flow O2, manipulation of O2 mask or BiPAP mask, defibrillation, chest compressions, insertion of nasogastric tube, and collection of sputum were not significant. Our findings suggest that some procedures potentially capable of generating aerosols have been associated with increased risk of SARS transmission to HCWs or were a risk factor for transmission, with the most consistent association across multiple studies identified with tracheal intubation.

Conflict of interest statement

Competing Interests: The authors have the following interests: John Conly has received honoraria from the Canadian Agency for Drugs and Technologies in Health for work as an expert reviewer and clinical expert, respectively, for projects on the role of rapid PCR testing for MRSA in hospitalized patients and the use of vancomycin or metronidazole for treatment of Clostridium difficile colitis. He has also received speaker's honoraria related to new anti-bacterial agents from Janssen-Ortho, Pfizer and Astellas Pharma during the past five years. This does not alter the authors' adherence to all the PLoS ONE policies on sharing data and materials.

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Review
. Sep-Oct 1996;43(5):109-15.

[Inhalation therapy in asthma]

[Article in Spanish]
Affiliations
  • PMID: 9005002
Review

[Inhalation therapy in asthma]

[Article in Spanish]
R A Gameros Gardea. Rev Alerg Mex. Sep-Oct 1996.

Abstract

Respiratory therapy, consists in the administration of gases or drugs via airways; it includes: oxygen, humidity, aerosol therapy, IPPB, chest physiotherapy and mechanical ventilation. Asthmatic patients frequently require oxygen support which is delivered by low and high flow systems, for best results, gases must be humidified, either by bubble or wick humidifiers, heat increases usefulness. Spray is produced by nebulizers and metered dose inhalers, the last are cheaper but they need a certain grade of coordination. Powder inhalers are easier to use. IPPB is indicated in patients with severe fatigue, this method is used sporadically. Chest physiotherapy teaches utilization of relaxation and inferior thoracic respiration techniques. Thoracic percussion must be avoided in an asthmatic crisis. Mechanical ventilation is delivered through a large bore canule, its goal is to assure an adequate gas exchange and to avoid respiratory muscular fatigue.

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