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Background: Drug inhalation is common mode of treatment for chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate the efficiency of aerosol devices in a simulated COPD adult lung model using five commercially available hand-held mesh nebulizers. Materials and Methods: Five nebulizers (PARI VELOX®, Omron NE-U22, Aeroneb® Go, APEX PY001, and Pocket Air®) were tested with a unit dose of 5.0 mg/2.5 mL salbutamol. An in vitro lung model (compliance: 0.06 L/cm H2O, resistance: 20 cm H2O/L/sec) was constructed to simulate parameters (tidal volume of 500 mL, respiratory rate of 15 breaths/min, inspiratory time of 1 second) of an adult patient with COPD. A bacterial filter was attached at the bronchi level for drug collection, referring as inhaled mass. After nebulization, the inhaled mass (%), dose remaining on each component (%), particle size characteristics, and nebulizer performances were analyzed. Particle size characteristics were analyzed using an 8-stage Anderson Cascade Impactor. The salbutamol particles deposited were eluted and analyzed using a spectrophotometer at 276 nm. The inhaled mass (%), dose remaining on each component (%), particle size distribution, and nebulizer performance were statistically analyzed using analysis of variance (ANOVA) with Sheffee post hoc tests. Results: Pocket Air and APEX PY001 showed the greatest inhaled mass and the lowest dose in the mouthpiece connection. The largest and smallest mass median aerodynamic diameters were found with Omron NE-U22 and PARI VELOX, respectively. In addition, the output rate and inhaled aerosol rate (IAR) of PARI VELOX were higher than those of other nebulizers. Conclusions: This study showed that the performance of commercially available mesh nebulizers varied. Aerosol particles deposited on different auxiliary equipment directly influenced the output rate and IAR of the mesh nebulizer. Clinical validation of the drug IAR is necessary to avoid overdose and reduce drug wastage.

Bronchospasm is a common respiratory adverse event in pediatric anesthesia. First line treatment commonly includes inhaled salbutamol. This review focusses on the current best practice to deliver aerosolized medications to awake as well as anesthetized pediatric patients and discusses the advantages and disadvantages of various administration techniques. Additionally, we detail the differences between various airway devices used in anesthesia. We highlight the unmet need for innovation of orally inhaled drug-products to deliver aerosolized medications during pediatric respiratory critical events such as bronchospasm. It is therefore important that clinicians remain up to date with the best clinical practice for aerosolized drug delivery in order to prevent and efficiently treat pediatric patients experiencing life-threatening respiratory emergencies.

Asthma is a common childhood condition. Its prevalence in Saudi Arabia is high, increasing, and could exceed 20% at the current trajectory. Asthma is a syndrome with different clinical presentations and phenotypes. Many conditions are often misdiagnosed as asthma because they share the same symptoms, particularly coughing and shortness of breath; physical findings, such as wheezing; radiological findings, such as hyperinflation on chest X-ray; or even responses to asthma therapies, as in some patients with bronchiolitis. When treating the younger age group (>5 years old), there should be a high degree of suspicion of alternative causes when evaluating patients presenting with clinical features suggestive of asthma or patients who do not respond well to asthma therapies. This study will highlight common conditions that may mimic asthma and, as a result of incorrect treatment, unnecessarily expose patients to steroids and other therapies for extended periods. Furthermore, we seek to alert healthcare providers to common symptoms and signs that suggest a cause other than asthma and suggest when to refer the patient to subspecialists.

BACKGROUND: Methacholine bronchoprovocation or challenge testing (MCT) is commonly performed to assess airway hyper-responsiveness in the setting of suspected asthma. Nebulization is an aerosol-generating procedure, but little is known about the risks of MCT in the context of the ongoing coronavirus disease 2019 (COVID-19) pandemic. We aimed to quantify and characterize aerosol generation during MCT by using different delivery methods and to assess the impact of adding a viral filter. METHODS: Seven healthy subjects performed simulated MCT in a near particle-free laboratory space with 4 different nebulizers and with a dosimeter. Two devices continuously sampled the ambient air during the procedure, which detected ultrafine particles, from 0.02–1 μm, and particles of sizes 0.3, 0.5, 1.0, 2.0, 5.0, and 10 µm, respectively. Particle generation was compared among all the devices, with and without viral filter placement. RESULTS: Ultrafine-particle generation during simulated MCT was significant across all the devices. Ultrafine-particle (0.02–1 μm) concentrations decreased 77%–91% with the addition of a viral filter and varied significantly between unfiltered (P < .001) and filtered devices (P < .001). Ultrafine-particle generation was lowest when using the dosimeter with filtered Hudson nebulizer (1,258 ± 1,644 particle/mL). Ultrafine-particle concentrations with the filtered nebulizer devices using a compressor were higher than particle concentrations detected when using the dosimeter: Monaghan (3,472 ± 1,794 particles/mL), PARI (4,403 ± 2,948), Hudson (6,320 ± 1,787) and AirLife (9,523 ± 5,098). CONCLUSIONS: The high particle concentrations generated during MCT pose significant infection control concerns during the COVID-19 pandemic. Particle generation during MCT was significantly reduced by using breath-actuated delivery and a viral filter, which offers an effective mitigation strategy.

Objective: Conventional inhaler devices have a low efficacy in targeting small airways. Smart nebulizers can be used to increase deposition to small airways by adjusting the flow and depth of each inhalation based on patients ‘individual inspiratory capacity. We investigated whether targeting of high dose inhaled corticosteroids (ICS) to small airways with a smart nebulizer could reduce exacerbation rate in children with severe asthma (SA). Methods: We conducted a retrospective study in children with SA using a smart nebulizer (Akita® Jet nebulizer) for the administration of high dose ICS in our outpatient clinic at the Erasmus MC — Sophia Children’s Hospital. Clinical data before and after start of treatment were collected. The primary outcome was exacerbation rate, defined as: number of asthma exacerbations for which oral corticosteroid courses (OCS) were prescribed. The exacerbation rate 1 year before treatment was compared with the exacerbation rate 1 year after start of treatment. Secondary outcomes were changes in spirometry parameters, hospital admissions and medication use. Results: Data on OCS use was available for 28/31 patients. Median number of asthma exacerbations requiring OCS courses 1 year before decreased from 2 (interquartile range(IQR) 2) to 0.5 (IQR 3) 1 year after treatment (p = 0.021). Hospital admission decreased from 1 (IQR 3) to 0 (IQR 1)(p = 0.028). FEV1, FEF25-75 and FEF75 were not significantly improved after one year of treatment with the smart nebulizer (p = 0.191; p = 0.248; p = 0.572). Conclusion: Targeting small airways with high dose ICS using a smart nebulizer resulted in a significant reduction in exacerbations requiring OCS after one year of treatment.

Introduction: Fugitive aerosol concentrations generated by different nebulizers and interfaces in vivo, and mitigation of aerosol dispersion into the environment with various commercially available devices are not known. Methods: Nine healthy volunteers were given 3 mL saline with a small volume nebulizer (SVN) or vibrating mesh nebulizer (VMN) with a mouthpiece, a mouthpiece with an exhalation filter, an aerosol mask with open ports for SVN and a valved facemask for VMN, and a facemask with a scavenger (Exhalo) in random order. Five of the participants received treatments using a face tent scavenger (Vapotherm) and a mask with exhalation filter with SVN and VMN in a random order. Treatments were performed in an ICU room, with 2 particle counters positioned 1 and 3 feet from participants measuring aerosol concentrations at sizes of 0.3-10 µm at baseline, before, during and after each treatment. The Ethics Committee at Rush University approved this study. Results: Fugitive aerosol concentrations were higher with SVN than VMN and higher with a facemask than a mouthpiece. Adding an exhalation filter to a mouthpiece reduced aerosol concentrations of 0.3-1.0 µm in size for VMN and 0.3-3.0 µm for SVN (all p

Background An airway-associated fire in an operating room can have devastating consequences for patients. Breathing circuit warmers (BCWs) are widely used to provide heated and humidified anesthetic gases and eventually prevent hypothermia during general anesthesia. Herein, we describe a case of a BCW-related airway fire. Case presentation In this case, an electrical short within a BCW wire caused a fire inside the circuit. Simultaneously, the fire was extinguished, ventilation was stopped, and the endotracheal tube was disconnected from the BCW. The patient was exposed to the fire for less than 10 s, resulting in burns to the trachea and bronchi. Immediately after airway burn, bronchoscopy showed no edema or narrowing except for soot in the trachea and both main bronchus. After the inhalation burn event, prophylactic antibiotics, bronchodilator, mucolytics nebulizer, and corticosteroid nebulizer were started. On bronchoscopy 3 days after the inhalation burn, mucosal erythematous edema was observed and the inflammatory reaction worsened. The inflammatory reaction showed aggravation for up to 2 weeks, and then gradually recovered, and the epithelium and mucous membrane of the upper respiratory tract returned to normal after 4 weeks. Eventually, the patient recovered without long-term complications and was successfully discharged. Conclusions This is the first report of a fire caused by BCW. We wanted to share our experience of how we responded to an airway-related fire in an OR and treated the patient. It cannot be overemphasized that the electrical medical appliance associated with the airways are fatal to the patient in the event of a fire, so caution should always be exercised.

Background Both non-invasive ventilation and high flow oxygen therapy are preferred over low flow oxygen therapy in many conditions. Nebulizers, for aerosol delivery, can be used within them without interrupting the circuit. The present study aimed to compare the efficiency of drug delivery within high flow nasal cannula (HFNC) and biphasic positive airway pressure (BiPAP) ventilation mode using two different inspiratory positive airway pressures. The aerosol delivery was examined in HFNC system at low flow, 5 L min−1, and BiPAP non-invasive ventilation under 2 different pressures [high pressure; inspiratory positive airway pressure/expiratory positive airway pressure (IPAP/EPAP) of 20/5 cm water, and low pressure; IPAP/EPAP of 10/5 cm water]. The total inhalable dose (TID) was measured by inserting an Aerogen Solo nebulizer installed with 1 mL salbutamol respiratory solution (5000 μg mL−1) within the circuit, and the salbutamol was collected on an inhalation filter placed in a filter holder connected to a breathing simulator. The breathing simulator was adjusted at a tidal volume of 500 mL, respiratory rate of 15 breaths min−1, and inhalation to exhalation (I:E) ratio of 1:1 for the adult setting. In each technique of the three (HFNC, and low, and high-pressures BiPAP), TID was determined 5 times (n = 5). For particle size characterization, cooled Anderson Cascade Impactor (ACI) was inserted instead of the inhalation filter and the breathing simulator with the same scheme. In each technique of the three, particle size characterization was determined 3 times (n = 3). Results The BiPAP mode at low inspiratory pressure had the highest TID, followed by HFNC at flow 5 L min−1, then BiPAP mode at high inspiratory pressure. There was a significant difference only between low and high inspiratory pressure modes of BiPAP mode. Low-inspiratory pressure BiPAP delivered the highest mean ± SD fine particle dose (FPD). It was significantly higher than that delivered in high inspiratory pressure BiPAP, and HFNC. Also, FPD in HFNC was significantly higher than that in high inspiratory pressure BiPAP. HFNC system had the smallest mass median aerodynamic diameter (MMAD) and the highest FPF followed by low then high inspiratory pressure BiPAP. Conclusions Increasing the inspiratory positive airway pressure in BiPAP, from 10 to 20 cm water, decreased the total inhalable dose and FPF nearly by half. Low inspiratory pressure BiPAP delivered the highest TID and FPD. The HFNC system at low oxygen flow resulted in the least MMAD, and the highest FPF. Using HFNC delivered a TID that was non-significant from that delivered by low inspiratory pressure BiPAP. Graphical Abstract

BACKGROUND: Aerosol delivery via high-flow nasal cannula (HFNC) has been increasingly used in recent years. However, the effects of different HFNC devices, nebulizer types, and placement on aerosol deposition remain largely unknown. METHODS: An adult manikin with anatomically correct upper airway was used with a collection filter placed between the manikin’s trachea and a breathing simulator, composed of a dual-chamber model lung driven by a critical care ventilator. Three HFNC device configurations were compared, with vibrating mesh nebulizer and small-volume nebulizer placed at the humidifier (inlet for Optiflow and outlet for Airvo 2) and proximal to the nasal cannula at gas flows of 10, 20, 40 and 60 L/min, in quiet and distressed breathing patterns. Albuterol (2.5 mg) was nebulized for each condition (no. = 3). The drug was eluted from the collection filter and assayed with ultraviolet spectrophotometry (276 nm). RESULTS: At all settings, except when a nebulizer was placed proximal to the nasal cannula with the Optiflow and when the HFNC flow was set at 60 L/min, the vibrating mesh nebulizer generated a higher inhaled dose than did the small-volume nebulizer (all P CONCLUSIONS: During transnasal aerosol delivery, the vibrating mesh nebulizer generated a higher inhaled dose than did the small-volume nebulizer when the nebulizer was placed at the humidifier. With the vibrating mesh nebulizer placed at the humidifier and an HFNC flow > 10 L/min, the inhaled dose was higher than with the vibrating mesh nebulizer placed proximal to the nasal cannula, and the inhaled dose was higher with Optiflow than with Airvo 2.

Background/aim Use of topical anesthesia before flexible bronchoscopy for the evaluation of the upper airways prevents cough and stridor during and after the procedure while reducing the need for sedation. In practice, lidocaine is the medication of choice before bronchoscopy. There various types of nebulizers used for inhalation treatments. In this study, we compared the respiratory tract symptoms after flexible bronchoscopy between children who received pre-procedure topical lidocaine with mesh or jet nebulizers. Materials and methods We enrolled 4–18 years old subjects that underwent flexible bronchoscopy due to treatment-resistant asthma in this retrospective case-control study. Twenty subjects received topical lidocaine with jet nebulizers while 20 received it with mesh nebulizers. Age, sex, duration of bronchoscopy, duration of anesthesia, time to awaken, and time to recovery were recorded as well as cough and laryngospasm scores after flexible bronchoscopy. Results Severe cough after flexible bronchoscopy was not encountered in the mesh nebulizers group but was seen in 10% of the jet nebulizers group (p = 0.027). On the other hand, age, sex, duration of bronchoscopy, duration of anesthesia, time to awaken, and time to recovery were not significantly different between the mesh and jet nebulizer groups (p = 0.44, 0.34, 0.51, 0.88, 0.88, and 0.22, respectively). Moreover, croup and laryngospasm scores between the two groups were similar (p = 0.62, 0.50 respectively). Cough score was significantly worse jet nebulizers group (p = 0.03). Conclusion Topical lidocaine application with mesh nebulizers decreases the most common complication, cough, after flexible bronchoscopy in children more effectively compare to jet nebulizers. Thus, mesh nebulizers may be a faster way of nebulization before flexible bronchoscopy as an alternative to jet nebulizers.

Asthma is the most common noncommunicable chronic childhood disease, affecting more than 5 million children in the United States. Asthma is the leading cause of school absenteeism. Treatments for asthma are divided into fast-acting medications that are used to relieve symptoms and slower acting (controller) medications that prevent symptoms. Albuterol is the most common fast acting medication for asthma, and it exists in multiple forms, including metered-dose inhaler and nebulized therapy. The use of spacers and holding chambers can further improve medication deposition in the airway. The cornerstone controller therapy for asthma is inhaled corticosteroid. Other medications for asthma include long-acting beta agonists, long-acting antimuscarinics, and antileukotrienes. The newest agents for controller asthma therapies are biologics.

Ribavirin is an inosine monophosphate dehydrogenase inhibitor with demonstrated activity against coronaviruses, including SARS-CoV-2. Five hospitalized patients with COVID-19 (confirmed by positive tests for SARS-CoV-2) received treatment with ribavirin for inhalation solution (ribavirin aerosol) as part of a compassionate use program. Patients included four men and one woman, with an age range of 29–72years. Patients were managed according to international and Italian treatment guidelines for COVID-19. In addition, therapy with ribavirin aerosol 100mg/mL was administered for 30min twice daily for 6days (i.e., 12 doses) in all patients. In order to address concerns about a possible increase in viral dispersal with the use of a nebulizer, healthcare providers remained outside the patient room during ribavirin aerosol administration. Pretreatment chest computed tomography (CT) scans showed pseudonodular areas of parenchymal thickening in the upper right lobe with associated ground glass opacities, multiple areas of parenchymal consolidation in both lower lobes with associated ground glass opacities, bilateral parenchymal thickening and multiple associated ground glass areas, or focal ground glass areas in the upper lobes bilaterally, which were almost completely resolved (three patients) or moderately cleared (one patient) on imaging at the end of ribavirin treatment. For a fifth patient, CT scans showed a stable pulmonary picture at the end of ribavirin treatment. No adverse reactions to ribavirin treatment were observed in any of the five patients. All patients recovered fully, and nasopharyngeal swabs obtained after hospital discharge tested negative for SARS-CoV-2. Ribavirin aerosol appears to be efficacious in the treatment of patients with COVID-19. A controlled trial of ribavirin aerosol is ongoing and will provide additional data across a broader patient population.

The article presents data on the course of inhalations with a native surfactant administered in two patients (66 and 53 years old) at the late respiratory phase of the new coronavirus infection of COVID-19 (the 22nd and the 19th days from the disease onset) who received non-invasive artificial lung ventilation.Subjects and methods.For inhalations, an AeroNeb™ micropump nebulizer was used; for one inhalation, 75 mg of surfactant-BL was dissolved in 5 ml of isotonic sodium chloride solution. The treatment course included 5 days with 2 inhalations a day.Results.In both patients, upon the end of this therapy with the native surfactant, regression of respiratory failure was noted, the level of respiratory support was reduced to insufflation with humidified oxygen, and rehabilitation measures were started with subsequent discharge from the hospital.

Aim: Glycopyrrolate (GLY) has been widely used to treat chronic obstructive pulmonary disease (COPD). Recent technical advancement significantly improves the drug delivery efficiency. In a clinical dose-range determination study via electronic nebulizer, the starting dose was as low as 3-μg, thus, a bioanalytical method capable of measuring down to sub-pg/ml or fg/ml level was required to characterize pharmacokinetics of GLY. Methods: A straightforward solid-phase extraction coupled with reversed-phase LC-MS/MS method was successfully developed to quantify plasma GLY concentrations of 0.500–250 pg/mL. MS/MS detection was at ESI+ by monitoring m/z 318.3→116.1 for GLY and 321.3→119.1 for the internal standard GLY-d3. Results and Conclusion: The method was validated with adequate selectivity, intra- and inter-assay precision and accuracy, dilution linearity, and sufficient stability for measuring GLY in human plasma. This method has been used for sample analysis of a clinical dose-range finding study (3–50 µg twice daily doses via an electronic nebulizer). The assay exhibited good precision, accuracy, and robustness. Pharmacokinetic analysis showed good dose proportionality over the studied dose range, where Cmax was found to be Y = 1.354*X + 1.968 (r2 = 0.9984), and AUC0-12 h was Y = 4.661*X + 23.32 (r2 = 0.9976). The study clearly demonstrated the importance of an ultrasensitive (500 fg/ml LLOQ) method.

BACKGROUND: High-flow nasal cannula (HFNC) has been used in the treatment of pediatric asthma, although high-quality data comparing HFNC to aerosol mask nebulizer are lacking. We hypothesized that HFNC would perform similarly to the aerosol mask for meaningful clinical outcomes in children with critical asthma. METHODS: We retrospectively reviewed the medical records of children with critical asthma (age 2–17 y) with a modified pulmonary index score (MPIS) ≥ 8 admitted to our pediatric ICU as part of a quality improvement project. Patients were managed with our MPIS-based, respiratory therapist-driven protocol. Subjects were divided into 2 cohorts by initial respiratory support: HFNC or aerosol mask. Data included demographics, initial respiratory support, and MPIS over time. Primary outcome was hospital length of stay (LOS). Secondary outcome was difference in MPIS over time. RESULTS: We included 171 subjects, with 104 in the HFNC group and 67 in the aerosol mask group. Median (interquartile range [IQR]) age was lower in the HFNC group (5 [IQR 4–9] vs 7 [IQR 5–10] y, P = .006)], while other demographic characteristics were similar. Initial MPIS was similar between HFNC and aerosol mask groups (11 [IQR 9–12] vs 10 [IQR 9–12], P = .15). There were no significant differences for hospital LOS (2.9 [IQR 2.1–3.9] vs 3.0 [IQR 2.3–4.4] d, P = .47), pediatric ICU LOS (1.9 [IQR 1.4–2.8] vs 1.8 [IQR 1.5–3.0] d, P = .92), or time to MPIS CONCLUSIONS: HFNC performed similarly to aerosol mask in pediatric patients with critical asthma.

Nebulizers generate aerosols and may potentially transmit respiratory viral particles including SARS-CoV-2. There is a great concern about the use of a nebulizer in the treatment of asthma exacerbations in the hospital or home setting during the COVID-19 pandemic and its use is not recommended unless essential. However, aerosol therapy should not be avoided in obligatory indications. Therefore, indications of nebulizer use during the pandemic should be evaluated on an individual basis in case of a severe asthma attack, and infection control recommendations should be followed by clinicians while using nebulizers. In this article, we aimed to assess the safety in addition to the “pro” and “con” sides of nebulizer treatment in asthma exacerbation during the COVID-19 pandemic. Keywords: Asthma, coronavirus disease 2019, COVID-19, SARS-CoV-2, nebulizers

BACKGROUND The American Thoracic Society (ATS) guideline for methacholine challenge testing (MCT) recommended using the English Wright (EW) nebuliser. However, other brands of nebulisers are also indicated to be acceptable for this technique, but further validation of nebuliser performance is recommended. OBJECTIVE To compare the methacholine provocation concentration causing a 20% fall in forced expiratory volume in 1 second (PC20 -FEV1 ) measured by using EW nebuliser and DV 646 nebuliser. METHODS Subjects were randomly assigned to undergo 2-min tidal breathing methacholine challenge with either EW or DV 646 nebuliser on two separate days, which were at least 24 hours but not more than 7 days apart. The above procedure was repeated for each subject in 1 month, but the nebulisers were selected in a reverse order. RESULTS The study includes 15 mild and stable asthmatic patients. The geometric means (SD) of methacholine PC20 measured with using EW and DV 646 nebulisers were 1.82 (6.38) mg/mL versus 0.83 (1.82) mg/mL, respectively in the initial two visits and 2.56 (6.29) mg/mL versus 0.78 (1.40) mg/mL in the following two visits (both P < 0.05). There are well correlations between PC20-EW1 and PC20-EW2 (r = 0.99, P

BACKGROUND: Aerosol therapy is commonly used by intensivists during invasive mechanical ventilation. More information is needed to optimize outcomes. The first aim of this study was to assess the deposition of salbutamol on components of a closed mechanical ventilation system, both in the presence and absence of biofilm generated by Acinetobacter baumannii. The second aim was to evaluate the deposition of salbutamol, using a single dose and a double dose, delivered via a jet nebulizer placed between the flexible tube and the heat and moisture exchanger. METHODS: A mechanical ventilator was connected to a standard system, and a jet nebulizer was placed between the heat and moisture exchanger and the flexible tube. Clinical isolates of A.baumanii were used to generate a biofilm layer on the endotracheal tube. Two amounts of salbutamol were delivered via the jet nebulizer. An analytical liquid chromatography tandem mass spectrometry method was developed to evaluate salbutamol deposition. RESULTS: The presence of a biofilm on the endotracheal tube had no impact on salbutamol deposition (P = .83). There was no difference in surface deposition of salbutamol on component parts of the closed system in a comparison of a single dose and a double dose delivered via a jet nebulizer. CONCLUSIONS: Our findings indicate that an A.baumannii biofilm had no impact on the extent of salbutamol deposition. Salbutamol deposition was comparatively low and could be delivered without removal of the heat and moisture exchanger.

BACKGROUND: High-flow nasal cannula (HFNC) oxygen therapy has been broadly used. However, no consensus has been achieved on the practical implementation of HFNC and how to provide aerosol delivery during HFNC therapy in adult patients. METHODS: An online anonymous questionnaire survey endorsed by 4 academic societies from America, Europe, mainland China, and Taiwan was administered from May to December 2019. Clinicians who had worked in adult ICUs for > 1 year and had used HFNC to treat patients within 30 days were included. RESULTS: A total of 2,279 participants clicked on the survey link, 1,358 respondents completed the HFNC section of the questionnaire, whereas 1,014 completed the whole survey. Postextubation hypoxemia and moderate hypoxemia were major indications for HFNC. The initial flow was mainly set at 40–50 L/min. Aerosol delivery via HFNC was used by 24% of the participants (248/1,014), 30% (74/248) of whom reported reducing flow during aerosol delivery. For the patients who required aerosol treatment during HFNC therapy, 40% of the participants (403/1,014) reported placing a nebulizer with a mask or mouthpiece while pursuing HFNC (a method shown to reduce inhaled dose), whereas 33% (331/1,014) discontinued HFNC to use conventional aerosol devices. A vibrating mesh nebulizer was the most commonly used nebulizer (40%) and was mainly placed at the inlet of the humidifier. CONCLUSIONS: The clinical utilization of HFNC was variable, as were indications, flow settings, and criteria for adjustment. Many practices associated with concomitant aerosol therapy were not consistent with available evidence for optimal use. More efforts are warranted to close the knowledge gap.

SUMMARY Background During manual resuscitation, nebulizer therapy may be used to deliver therapeutics to patients in respiratory distress. However, the devices used to generate and deliver these medical aerosols have the potential to release these therapeutics into the local environment and expose caregivers to unwanted medical aerosols. Aim To quantify the levels of fugitive medical aerosol released into the environment during aerosol drug delivery using a manual resuscitation bag with and without filtration. Methods Time-varying fugitive aerosol concentrations were measured using an aerodynamic particle sizer placed at a position designed to mimic a caregiver. Two nebulizer types were assessed, a vibrating mesh nebulizer and a jet nebulizer. The aerosol dose delivered to the simulated patient lung was also quantified. Findings Filtration of the exhalation port of the manual resuscitation bag was seen to reduce fugitive medical aerosols to ambient levels for both nebulizer types. The vibrating mesh nebulizer delivered the greatest quantity of aerosol to the simulated adult patient (18.44 ± 1.03% versus 3.64 ± 0.26% with a jet nebulizer). Conclusions The results highlight the potential for exposure to fugitive medical aerosols released during the delivery of aerosol therapy with a manual resuscitation bag and also the potential for significant variation in patient lung dose depending on nebulizer type.

Background Efficient methods for the detection and repair of pleural defects are crucial for preventing postoperative air leaks; however, there are few studies on sealing test methods. We developed a new sealing test method that involves the administration of aerosolized indocyanine green into the airway. This experimental study aimed to confirm whether this method could identify alveolar-pleural fistulas. Methods Thoracotomy was performed on 6 beagles under general anesthesia. Pleural defects accompanying air leaks were created in the cranial and caudal lobes. Using a pediatric jet nebulizer kit, 5 mL of 2.5 mg/mL aerosolized indocyanine green solution was administered to the entire lung through a catheter placed in the trachea. Pleural defects were observed using a near-infrared light scope, and the time until confirmation of the defect sites was measured. Results Of the 25 pleural defect sites created, 24 could be identified under a near-infrared light camera. The average time required for confirming the site of pleural defect was 13.8 seconds (95% confidence interval, 7.32-16.8 seconds). Conclusions By administering aerosolized indocyanine green into the airway, the site of alveolar-pleural fistula could be identified with a near-infrared light camera in a canine pleural defect model. This method could be a valid sealing test and is suitable for video-assisted thoracic surgery, as it allows for observation of the lung in a collapsed state with a long observation time. Further studies are needed to determine the optimal dose of indocyanine green and to confirm the method’s applicability and efficacy in humans.

Purpose . Show the significance of helium heated to 95°C (as part of Thermogeliox) in reducing the surface tension of water, including the liquid and cellular fraction of blood, which normalizes the movement of red blood cells in the capillaries and preserves the physiological function of the alveolar — capillary space, improving gas exchange in the alveoli. Materials and methods . The data on the dynamics of complaints and anamnesis, clinical symptoms, results of laboratory and instrumental studies, the results of pathological, pathomorphological and histological manifestations of severe coronavirus pneumonia (CVP) complicated by acute respiratory distress syndrome (ARDS) were analyzed. Results and its discussion . In the complex treatment of severe coronavirus infection (CVI), it is proposed to use the modern innovative medical technology «SIMT», which includes a modern device «Ingalit B2–01», inhaling a respiratory gas mixture heated to 90–100°C — thermogeliox, consisting of oxygen 20–30% and helium 70–80%, alternating with inhalation of pulmonary surfactant by a nebulizer. It is advisable to inject the anticoagulant under the skin. It has been shown that the development of ARDS in CEP is associated with acute coronavirus alveolitis. A quick positive systemic therapeutic effect — the prevention of ARDS in patients with severe CVP when using our proposed «SIMT» is due to a number of physicochemical and physiological effects of thermal helium.

Inhalation therapy is the cornerstone of chronic obstructive pulmonary disease (COPD) management. However, for many COPD patients who are managed at home, nebulization therapy offers an effective alternative treatment and fulfills the gap of catering to the specific population of patients who are unable to use handheld inhaler devices appropriately. The present review highlights key aspects, namely selection of the right beneficiaries for home nebulization, available drugs in nebulized formulations for the treatment of COPD, and the importance of care, cleaning, and maintenance, which are prerequisites for ensuring successful nebulization therapy.

Purpose: Pharmacotherapy is one cornerstone of chronic obstructive pulmonary disease (COPD) management. Published U.S. data seldom includes patient-reported COPD medication use and adherence. We add this patient perspective to the commonly reported administrative prescribing and fill data. Methods: This survey study used inhaler and nebulizer pictures and lists of oral COPD medications to query members of the COPD Foundation Patient-Powered Research Network, a national, self-reported online registry. Medications used, adherence, inhaler education, cost concerns, previous exacerbations, and COPD Assessment Test scores were assessed and summarized using simple descriptive statistics and hazard ratios controlling for age, gender, and disease burden. Results: Respondents mean age was 68 years, 60% were women, >69% had COPD Assessment Test (CAT) scores >15, and >50% reported 2 or more exacerbations in the past 12 months. Overall, >98% used 1 or more inhaled COPD medications, 7.6% used a rescue inhaler only, 17.8% used long-acting bronchodilator only therapy (11.1% dual), and 72.8% used corticosteroid therapies, including 53% who were on triple therapy. Nebulizers were used by 59.4% and 34.8% used oral COPD medications. Reported adherence rates were high (80.1%), but 41% reported trouble paying for medications, with 20.1% reporting missing medications due to cost. Conclusions: In this population, COPD had a high burden with >50% of respondents using triple therapy, and 1 in 8 using maintenance oral corticosteroids. Self-reported adherence was high, but with significant cost concerns reported, resulting in missed medications.

COVID-19 can cause serious respiratory complications resulting in the need for invasive ventilatory support and concurrent aerosol therapy. Aerosol therapy is considered a high risk procedure for the transmission of patient derived infectious aerosol droplets. Critical-care workers are considered to be at a high risk of inhaling such infectious droplets. The objective of this work was to use noninvasive optical methods to visualize the potential release of aerosol droplets during aerosol therapy in a model of an invasively ventilated adult patient. The noninvasive Schlieren imaging technique was used to visualize the movement of air and aerosol. Three different aerosol delivery devices: (i) a pressurized metered dose inhaler (pMDI), (ii) a compressed air driven jet nebulizer (JN), and (iii) a vibrating mesh nebulizer (VMN), were used to deliver an aerosolized therapeutic at two different positions: (i) on the inspiratory limb at the wye and (ii) on the patient side of the wye, between the wye and endotracheal tube, to a simulated intubated adult patient. Irrespective of position, there was a significant release of air and aerosol from the ventilator circuit during aerosol delivery with the pMDI and the compressed air driven JN. There was no such release when aerosol therapy was delivered with a closed-circuit VMN. Selection of aerosol delivery device is a major determining factor in the release of infectious patient derived bioaerosol from an invasively mechanically ventilated patient receiving aerosol therapy.

Astım tedavisinde inhale yolla kullanılan ilaçlar direkt olarak solunum yollarına ulaşır, lokal olarak daha yüksek konsantrasyon oluşturur ve sistemik yan etki oluşturma riski diğer yollarla kullanılan ilaçlara nazaran belirgin olarak daha düşüktür. Astımlı çocuk hastaların takip ve tedavi süreci erişkin hastalardan pek çok yönden farklıdır. Çocuk hastalar inhalasyon tekniği ile ilişkili zorlukları yetişkinlerden daha sık yaşamaktadırlar. Yanlış inhaler cihaz kullanma tekniği hastalık kontrolünün sağlanamamasına, alevlenme riskinde artışa ve ilaç yan etkilerinin artmasına neden olur. İnhalasyon tekniğinin düzeltilmesinin hastalık kontrolünün sağlanması, acil servis başvurularının azaltılması, semptomların seyrekleşmesi ve okul devamsızlığının azalması ile ilişkili olduğu bilinmektedir.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory coronavirus- 2 syndrome (SARS-CoV-2) were first reported by officials in Wuhan City, China, in December 2019 COVID-19 patients have a symptom of respiratory pneumonia diseases which have difficulties in breathing normally Previously, the nebulizer machine commonly used to treat respiratory pneumonia diseases However, the usage for this machine was not suggested during this COVID-19 period because the virus will be spread off easily To overcome these shortcomings, the uses of Metered-Dose Inhaler (MDI) with MDI disposable inhaler spacer is preferable Besides, it had been known that the used of MDI disposable inhaler spacer helps to increase the uptaking of the drug into the lung Besides that, the high demand for the MDI Disposable Inhaler Spacer in the hospital, causing a shortage of supply in Malaysia Thus, this study aims to produce a new design of this spacer to full fill the market need This new design of MDI Disposable Inhaler Spacer (AeroCup) was designed by using Solid Work 2018 Then, the parameters for flow characteristic such as particle velocity magnitude, velocity, Eddy viscosity, turbulence Eddy dissipation and turbulence kinetic energy (TKE) was successfully characterized and compared with commercial design A using ANSYS Fluent Version 19 2 The result showed that new design (AeroCup) had the desired characteristic, which was almost similar to commercial design A This study can provide a piece of information to produce the low-cost metered-dose inhaler (MDI) disposable inhaler spacer to enlighten the burden shouldered by front liners, especially during the pandemic and also can scale-up the economic viability © 2020 PENERBIT AKADEMIA BARU - All rights reserved

Objective: It is not known how much surfactant must be nebulized to reach a lung dose of phospholipids equivalent to that obtained by the instillation of 200 mg/kg of surfactant. We aimed to assess the feasibility of nebulizing a high-dose of poractant alfa with the eFlow-Neos investigational vibrating-membrane nebulizer in newborn piglets on nasal continuous positive airway pressure (nCPAP) and to determine whether this intervention would yield therapeutic lung doses of phospholipids. Study Design: Twelve 1-day-old piglets on nCPAP received 600 mg/kg of poractant alfa admixed with technetium-99m via nebulization. Six piglets receiving 200 mg/kg of instilled synthetic surfactant served as controls. Lung deposition (percentage of the nominal dose) was determined by gamma scintigraphy, and the phospholipids' lung dose was calculated. Results: The lung dose of phospholipids (mean ± standard deviation [SD]) was 138 ± 96 mg/kg with nebulization, and 172 ± 24 mg/kg with instillation (p = 0.42). Nebulization took 58 ± 12 minutes. The arterial partial pressure of carbon dioxide increased from 6.7 ± 1.1 to 7.2 ± 1.1 kPa during nebulization (p = 0.04). Cerebral oximetry remained stable, and there was no hemodynamic instability. Conclusion: Nebulization was well tolerated, and the mean lung dose of phospholipids was above 100 mg/kg, that is, not different from the instillation group. These experimental findings suggest that it may be feasible to reach therapeutic lung doses of phospholipids by surfactant nebulization during nCPAP. Key Points It is not known if effective lung doses of surfactant can be delivered by nebulization. Nebulization of high-dose surfactant in newborn piglets on nCPAP was well tolerated. A high-dose of nebulized poractant alfa yielded therapeutic lung doses of phospholipids. (Less)

The simplicity of converting medicinal solutions and suspensions into aerosols using mechanical and thermal energy, convenient delivery to the airways allows nebulizers to take a worthy place in the treatment of hospitalized and outpatient patients. Different types of nebulizers are available for use in the home and in medical settings (jet, ultrasound, membrane), and researches show that the performance and characteristics of the aerosol vary between different devices and manufacturers. Jet nebulizers are still the most used devices that do not require coordination of inhale and delivery of aerosol to the respiratory tract. To reduce the consumption of medicinal aerosol and optimize the air flow, virtual valve technology (V.V.T.) is being improved, and breath-actuated nebulizers are being created. The advantage of nebulizer therapy is the ability to apply large doses of medications, use substances that exist only in inhaled form. The choice falls on the nebulizer in cases where the patient can not use other delivery devices, for example, if the patient is unable to coordinate the inhalation and intake of the drug into the respiratory tract, with a severe exacerbation of obstructive disease, in the presence of motor disorders. The optimal delivery device for children of any age, including newborns, is a nebulizer. The most common indication for nebulizer therapy is the delivery of bronchodilators and inhaled corticosteroids for asthma or chronic obstructive pulmonary disease, as well as the treatment of upper respiratory tract diseases, in particular croup in children. An important place is given to nebulizers when it is necessary to prescribe certain mucolytics and antibiotics. In the treatment of emergency conditions, inhalation administration of drugs may be required, including situations when the patient is on mechanical ventilation or has a tracheostomy installed. The significance of nebulizers in the treatment of cystic fibrosis, pulmonary arterial hypertension, and alpha-1-antitrypsin deficiency is being studied. The possibilities of endobronchial delivery of heparin, insulin, and monoclonal antibodies are evaluated.

The article presents a comparative retrospective analysis of clinical, laboratory data and outcomes in 39 patients with severe COVID-19 complicated by acute respiratory distress syndrome, who received high-flow oxygen therapy Of which, 19 patients additionally received 75 mg of inhaled surfactant BL twice daily for 5 days using a nebulizer As a result, mortality rate in the group of patients receiving surfactant was 10 5%, while in the standard therapy group — 50%;the number of patients transferred to the mechanical ventilation was 21% and 70%, respectively As the patients receiving the surfactant were injected with COVID-19 hyperimmune convalescent plasma and monoclonal antibodies to interleukin-6 receptors more often than those from the control group, we recalculated the results regardless of these patients However, a significant difference between the mechanical ventilation rate (2 5 times less often in the surfactant group) and mortality rate (3 5 times less in the surfactant group) was observed The duration of hospitalization and stay at the intensive care unit was not significantly different between patients with and without surfactant treatment Inhalation therapy with surfactant BL was well tolerated even by patients with chronic obstructive pulmonary disease In no case did therapy have to be stopped due to side effects, the most common of which was coughing during inhalation This retrospective analysis shows that the prescription of an inhaled surfactant prior to transferring patients to mechanical ventilation can prevent the progression of respiratory failure, put down mechanical ventilation, and improve survival © 2020, Remedium Group Ltd All rights reserved

BACKGROUND: Continuous nebulization of prostacyclins and albuterol by infusion pump during mechanical ventilation evolved as a popular off-label treatment for severe hypoxemic respiratory failure and asthma. Most institutions use a vibrating mesh nebulizer. A new breath-enhanced jet nebulizer is a potential alternative. This study was designed to compare these devices to better define factors influencing continuous infusion aerosol delivery. Device function, ventilator settings, and infusion pump flow were studied in vitro. METHODS: Using a bench model of adult mechanical ventilation, radiolabeled saline was infused at 6 flows (1.5−12 mL/h) into test nebulizers; 4 examples of each were used in rotation to test device reproducibility. Four breathing patterns with duty cycles (percentage of inspiratory time) ranging from 0.13 to 0.34 were tested. The vibrating mesh nebulizer was installed on the “dry” side of the heated humidifier (37°C). The breath-enhanced jet nebulizer, installed on the “wet” side, was powered by air at 3.5 L/min and 50 psi. Infusion time was 1 h. Inhaled mass of aerosol was collected on a filter at the airway opening. Inhaled mass was expressed as the percentage of the initial syringe radioactivity delivered per hour. Radioactivity deposited in the circuit was measured with a gamma camera. Data were analyzed with multiple linear regression. RESULTS: Variation in inhaled mass was significantly explained by pump flow and duty cycle (R2 0.92) and not by nebulizer technology. Duty cycle effects were more apparent at higher pump flow. Vibrating mesh nebulizers failed to nebulize completely in 20% of the test runs. Mass balance indicated that vibrating mesh nebulizers deposited 15.3% in the humidifier versus 0.2% for breath-enhanced jet nebulizer. CONCLUSIONS: Aerosol delivery was determined by infusion pump flow and ventilator settings with comparable aerosol delivery between devices. The breath-enhanced jet nebulizer was more reliable than the vibrating mesh nebulizer; 10−12 mL/h was the maximum infusion flow for both nebulizer technologies.

Porównano bronchodylatacyjną odpowiedź oskrzeli po podaniu kombinacji salbutamolu z bromkiem ipratropium vs sam salbutamol inhalowanych z nebulizatora siateczkowego u dzieci w wieku 6–11 lat z cechami klinicznymi i spirometrycznymi zaostrzenia astmy. Wykazano porównywalny efekt bronchodylatacyjny obu terapii w 15. min po podaniu leku.

BACKGROUND: Aerosol transport during noninvasive ventilation follows the flow of pressurized gas through the noninvasive ventilation circuit, vented via leak port and face mask, and inhaled by the patient. Recommendations for nebulizer placement are based on in vitro models that have focused primarily on aerosol losses via the leak port; face mask leaks have been avoided. This study tested aerosol delivery in the setting of controlled face mask leak. METHODS: Three nebulizer technologies were studied on a bench model using a lung simulator with a face mask placed onto a manikin head. Radiolabeled aerosol delivery (ie, inhaled mass) was determined by mass balance using filters and a gamma camera that tested the effects of nebulizer location and face mask leak. Low (15–20 L/min) and high (55–60 L/min) mask leaks were used to mimic realistic clinical conditions. RESULTS: Inhaled mass (% nebulizer charge) was a function of nebulizer technology (with the nebulizer at ventilator outlet position: Aerogen 22.8%, InspiRx 11.1%, and Hudson 8.1%; P = .001). The location of the nebulizer before or after the leak port was not important (P = 0.13 at low leak and P = 0.38 at high leak). Aerosol delivery was minimal with high mask leak (inhaled mass 1.5–7.0%). Aerosol losses at the leak port at low mask leak were 28–36% versus 9–24% at high mask leak. Aerosol losses via the mask leak were 16–20% at low mask leak versus 46–72% at high mask leak. Furthermore, high face mask leak led to significant deposition on the mask and face (eg, up to 50% of the nebulizer charge with the Aerogen mask). CONCLUSIONS: During noninvasive ventilation, nebulizer placement at the ventilator outlet, which is a more practical position, is effective and minimizes deposition on face and mask. Aerosol therapy should be avoided when there is high face mask leak.

Background: A well-known disease, Acute Respiratory Distress Syndrome (ARDS) presents a daunting challenge to the medical community with alarmingly high mortality rates. Initiation of hypertonic saline (HTS) nebulization therapy for patients with early ARDS appears to be tolerable and may be beneficial. However, using a nebulizer is cumbersome and less efficient. This study aims to assess the efficacy of using HTS3% in a nebulizer in comparison with intravenously injecting it to attenuate the manifestation of ARDS. The study analyses factors such as the severity of the disease, need and duration of mechanical ventilation (MV), ICU stay, and mortality rate in the comparative analysis. Materials and Methods: The randomized, comparative, and controlled study included patients of both genders from an age bracket of 18-60 years. The patients fulfilled the Berlin definition of ARDS. Additionally, the whole sample was divided into four groups (26 patients each): Group A received standard pharmacotherapy [methylprednisolone 1mg/kg/day intravenously and salbutamol nebulizer 2.5 mg (1 ml) + 3 ml normal saline/8hr] and normal saline 0.9% (5ml) nebulizer /8hr: Group B received standard pharmacotherapy + HTS2.7% (5ml) nebulizer/8hr: Group C also received standard pharmacotherapy and 500ml normal saline intravenously over 24 hours: Group D received standard pharmacotherapy and 500 ml HTS 3% intravenously over 24 hours. The following parameters were recorded: Lung injury score (Murray Score, calculated every 24 hours), the incidence of the need for MV, duration of MV, length of ICU stay, and mortality rate. Results: Group B (HTS nebulizer group) and group D (HTS IV group) showed the most rapid improvement in the Murray score with a 50% decrease in the score from its initial value (D50%) by day 4 with P-values of 0.013 and 0.022 respectively. Subjects from Group D (HTS IV) and Group B (HTS Nebulizer) were the least in need of MV as only 38.5% needed MV with a P-value 0.05). Conclusion: The use of hypertonic saline 3% intravenously has a comparable effect as the use of hypertonic saline 3% via nebulizer to attenuate the manifestations of (ARDS) and even superior in the mechanically ventilated patient.

Introduction.Chronic obstructive pulmonary disease (COPD) remains one of the major health problems nowadays. The aim of the research was to increase the treatment efficiency for COPD group B patients by using antibiotics, mucolytics, topical nebulizer therapy and halotherapy sessions in combination therapy. The study enrolled 70 COPD group B patients, the average age of patients was 59.6±2.2 years. The diagnosis was made in accordance with the Order of the Ministry of Public Health of Ukraine as of June 27, 2013 № 555.Patients were divided into two groups. Patients of the first group (control, n=35) received basic therapy - azitrox 500 mg once day, acetylcysteine 200 mg - 2 times daily and combination bronchodilator therapy in the form of dose inhalercontaining fenoterol hydrobromide 50 mcg and ipratropium bromide 20 mcg (berodual H) - 2 times a day, anti-inflammatory therapy in the form of turbuhaler budesonide (pulmicort) 100 mcg twice a day for 7 days. Patients of the second group (main group, n=35) in addition to the basic therapy were prescribed double nebulizer therapy with the compressor nebulizer NEB-10 "Microlife" 2 times a day containing combined broncholytic agent fenoterol hydrobromide with ipratropium bromide (2 Freimid) diluted in 2 ml of saline; solution of budesonide (Pulmicort) nebulized 2 x 0.5 ml mg / mL=1.0 mg, dissolved in 2 ml of saline - 2 times a day №7; and additionally, starting on day 4, halotherapy sessions. Thus, the proposed combined therapy of COPD group B patients is more advanced and rational, it improves the effectiveness of basic medical therapy by optimizing the recovery and rehabilitation process, which has a positive effect on the improvement of the seven components of QOL, it is well tolerated and does not cause side effects.

Background : Asthma Bronchiale is an obstruction of the respiratory tract due to narrowing of the airways that are reversible (narrowing can disappear by itself). But there are times when this reversible trait can be lost after getting treatment. Disorders arising from asthma bronchiale itself are shortness of breath, phlegm buildup, and spasms in the respiratory muscles. The therapy used in this case provides a nebulizer modality that helps relieve tightness and thin the sputum, infrared tries to relax reducing muscle spasm, and chest physiotherapy used to decrease breathlesness. Research Methods : This research method is experimental, research design uses case studies, and data collection techniques use Pre and Post Test. The sampling technique uses accidental sampling. Examination of breathlesness by using the respiratory rate, thorax expansion by using midline and functional activity by using modified RPE. Result : The results obtained from this study can be concluded after 4 times intervention the breathlessness was decrease, expantion of thorax was increase and there are improve of index functional. Conclution : Nebulizer, Infra red, and chest physiotherapy that give into the patient could minimaze the breathless, increase thorax expantion and inprove functional activity.

BACKGROUND: This study compared 3 nebulizer technologies for inter- and intradevice reproducibility, humidification, and fill volume sensitivity during mechanical ventilation: a breath-enhanced jet nebulizer, a vibrating mesh nebulizer, and a jet nebulizer. The breath-enhanced jet nebulizer featured a new design located on the wet side of the humidifier to reduce aerosol loss and potential humidifier contamination. The vibrating mesh nebulizer and the jet nebulizer were placed on the dry side. METHODS: Aerosol delivery was measured using multiple ventilator settings (inspiratory time = 0.45–1.01 s). Using radiolabeled saline and a gamma camera, bench studies were performed using a ventilator to test 4 breathing patterns. Four scenarios were assessed during testing: 3 mL and 6 mL fill volumes with and without heated wire humidification. Measurements included inhaled mass (as a percentage of the nebulizer charge), nebulizer residual, mass balance, and aerosol particle size distribution. Statistics were determined using Mann-Whitney and linear regression. RESULTS: The inhaled mass for the breath-enhanced jet nebulizer was 10.5–29.2% and was affected by fill volume (P = .004) but not by humidity. The inhaled mass for the vibrating mesh nebulizer was 0.9–33% and was unaffected by fill volume and humidity. The inhaled mass for the jet nebulizer was 2.5–25.9% and was affected by both fill volume (P = .009) and humidity (3 mL, P = .002). The inhaled mass for the vibrating mesh nebulizer was more variable due to random failures to achieve complete nebulization, and inhaled mass correlated closely with residual mass: IM% = –0.233(Residual%) + 24.3, r2 = 0.67, P CONCLUSIONS: Nebulization with the breath-enhanced jet nebulizer was less sensitive to humidification than the jet nebulizer. Delivery via the vibrating mesh nebulizer was not predictable, with random failure to empty (55% experimental runs). All devices delivered similar particle distributions. Wet-side aerosol delivery avoids humidifier contamination, and breath-enhanced technology can ensure better control of drug delivery.

Purpose To assess clinical characteristics and device satisfaction of patients with chronic obstructive pulmonary disease (COPD) treated with glycopyrrolate/eFlow® Closed System (CS) nebulizer (further referred to as eFlow) under real-world conditions. Participants and Methods Patients with COPD currently using eFlow were identified by the study sponsor. Consenting patients who met study inclusion criteria completed a cross-sectional survey that included a device satisfaction questionnaire. Means, medians, and standard deviations were calculated. Results Sixty-six patients met inclusion criteria and completed the survey. Participants' mean ± standard deviation age was 64.9 ± 11.9 years and the majority were white (86.4%) and female (59.1%). Almost two-thirds were former smokers. Thirty-nine (59.1%) reported their COPD to be severe/very severe and 38 (57.6%) reported a COPD exacerbation resulting in a hospitalization, ER visit, or medication modification over the past 12 months. Among 55 participants who had previously used another type of nebulizer, 44 (80%) were overall "much more"/"somewhat more" satisfied with the eFlow compared with their previous nebulizer(s). Regardless of prior nebulizer use, 60 (90.9%) participants were "satisfied"/"very satisfied" overall with the eFlow. Assembly and disassembly, operation, and cleaning were perceived as being "easy"/"very easy" by at least 65% of participants. Among all participants, 57 (86.4%) were "confident"/"very confident" of glycopyrrolate administration. On a Likert scale of 1 ("I don't like it") to 7 ("I like it a lot"), mean scores were at least 5.9 for portability, ease of cleaning, size, weight, short administration time, and relative silence of the device. Over 80% of participants said they "probably"/"definitely" would continue to use eFlow. Conclusion Based on this real-world study, the majority of patients were highly satisfied with, and confident in, using eFlow.

Introduction: Today, chronic polypous rhinosinusitis (CPR) occupies a special place among otolaryngological diseases, the incidence rate of which increases every year. To date, the main causes of chronic polypous rhinosinusitis are Staphylococcus aureus and anatomical abnormalities. Diagnostics: Knowledge of a universal algorithm for the diagnosis of this disease, consisting of the collection of anamnesis, endoscopic examination of the nasal cavity, computed tomography of the paranasal sinuses, anterior active rhinomanometry and bacteriological determination of the microbial spectrum, allows diagnosing chronic polyposis rhinosinusitis in time, and, as a consequence, to prescribe a treatment. Treatment: This review describes conservative therapies, including antibiotics and glucocorticosteroids. Today, the main task of doctors is to find the most effective method of administration of glucocorticosteroids to achieve the maximum effect. One of these methods is the introduction of the drug with the help of nebulizer, as in this case, the drug will remain in the perirhinal cavity for a long time and have the maximum effect due to the directed action only in the area of the pathological process. Features of chronic polypous rhinosinusitis in childhood: It should be noted that children under 12 years of age due to the formation of the paranasal sinuses at different stages of ontogenesis will be characterized by different forms of chronic polyposis rhinosinusitis. That is why they should be known and taken into account when making a diagnosis and prescribing a treatment. Conclusion: Today, the frequency of chronic rhinosinusitis increases exponentially, which makes the question of the modern approach to its treatment the most relevant. It is possible that additional research in this area will solve the issue of searching for both the optimal path of therapy and treatment of CPR in children.

Transient tachypnea of the newborn (TTN) is a chest disease found in neonates. It varies from mild to severe and is accompanied by neonatal morbidity and respiratory complications. This is a prospective placebo-controlled study, identification number is TCTR20200513005, which was done in the neonatal unit of Tanta University Hospital between June 2016 and March 2018. This study comprised 100 neonates with TTN, which were divided into two groups. The first group (inhaled steroid group) consisted of 50 neonates with TTN who were exposed to inhalation of corticosteroids (budesonide 2 ml, 0.25 mg/ml suspension for nebulizer, AstraZeneca AB, Sodertalje, Sweden), the first dose was administered within 6 h of birth and the second dose was given 12 h later. The second group (placebo group) consisted of 50 neonates with TTN who were exposed to placebo inhalation (2 ml of distilled sterile water). There was significant difference between both groups regarding Down score (P = 0.001), TTN clinical score (P = 0.001) and Saturation of Peripheral Oxygen (SpO2) measured by pulse oximeter (P = 0.008), while there was nonsignificant difference between both groups regarding PH (P = 0.573), and this showed that clinically the inhaled steroid group is significantly better than the placebo group. Hence, this study concludes that since administration of inhaled budesonide showed improvement in TTN cases, it could be a recommended line of treatment for neonatal TTN.

Background This study compares an endoscopic microcatheter and a nebulizer for delivering Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC). Methods This is an in vitro and ex vivo study in an established model (inverted bovine urinary bladder). Four parameters were compared to determine the performance of a micro-perforated endoscopic spray catheter vs. state-of-the art, nozzle technology: (1) surface coverage and pattern with methylene blue on blotting paper at three different distances; (2) median aerodynamic diameter (MAD) of aerosol droplets with three different solutions (H2O, Glc 5% and silicon oil); (3) depth of tissue penetration of doxorubicin (DOX) and (4) tissue concentration of cisplatin (CIS) and DOX using standard clinical solutions. Results The spray area covered by the microcatheter was larger (p p = 0.002). Conclusions This investigation has revealed that microcatheter technology generates larger aerosol droplet size, less drug tissue penetration and lower drug tissue concentration than the current nozzle technology. In the absence of clinical studies, use of microcatheters for delivering PIPAC can not be recommended at this stage.

Background: In volunteers with idiopathic pulmonary fibrosis (IPF), inhaled Interferon-γ (IFN-γ) is safe and may improve pulmonary function. However, coughing, associated with upper airway deposition, is often reported. To address this problem, a small-particle, breath-enhanced jet nebulizer (i-NEB Mini; InspiRx, Inc., Somerset, NJ) was developed. Using gamma scintigraphy, this device was tested in healthy individuals and subjects with IPF to determine efficiency and regional deposition in lung and airways. Methods: Four healthy individuals and nine subjects with IPF were enrolled. The nebulizer was filled with 2 mL of saline with 99m Tc bound to diethylenetriaminepentaacetic acid (DTPA) powered continuously with 3.4 L/min of compressed air. Mass median aerodynamic diameter (MMAD) was measured by cascade impactor. To maximize deposition in alveoli, inspiratory flow was limited by an inspiratory resistance incorporated into the nebulizer, resulting in a deep inspiration ∼6 seconds. The treatment was run to completion (10 minutes), and each subject underwent deposition imaging. Mass balance and regions of interest determined upper airway (measured by calibrated stomach activity) and regional lung deposition as a percent of pretreatment nebulizer charge. Results: Subjects tolerated the device with no complaints. MMAD (mean [geometric standard deviation]) = 1.04 [1.92] μm. Lung deposition (mean ± standard error, % nebulizer charge) in healthy subjects was 26.2% ± 1.83 and in IPF individuals 23.4% ± 1.60 (p = 0.414). Upper airway deposition was 1.4% ± 0.83 and 2.3% ± 0.48, respectively (p = 0.351), and 20.1% was lost during expiration. Central/Peripheral ratios were consistent in both groups, showing high peripheral deposition (1.32 ± 0.050, vs. 1.28 ± 0.046, p = 0.912). Conclusion: The i-NEB Mini jet nebulizer with breath enhancement produced small particles, resulting in minimal upper airway deposition. Using slow and deep breathing, more than half of the emitted dose deposited in the peripheral lung in normal subjects and individuals with IPF. These data indicate that, for future clinical trials, controlled lung doses of small particles, designed to avoid coughing, are possible even in subjects with advanced disease.

BACKGROUND: Nebulizer therapy is an important treatment component for patients with cystic fibrosis (CF). Nebulizer manufacturers’ guidelines advocate thorough nebulizer drying after washing. The aim of this study, therefore, was to examine the microbiology associated with nebulizer drying, particularly related to Pseudomonas control, and to examine microbiologically non-adherence to the recommended drying procedures. METHODS: Four aspects of nebulizer drying were examined in 3 common nebulizers, including examination of the drying profile, improvement to the drying profile of assembled nebulizers, survival of Pseudomonas aeruginosa in tap water and in tap water plus 0.5% (v/v) dishwashing detergent, and the effect of drying of P. aeruginosa in tap water and tap water plus residual sputum (1%v/v, 10%v/v). Microbiologic examination was performed by using P. aeruginosa (5 clinical CF strains plus 1 National Collection of Type Cultures Reference strain). RESULTS: There were differences in the time to complete dryness between disassembled and fully assembled nebulizers. Vigorous repeated shaking was unable to drive off all residual water on assembled nebulizers. P. aeruginosa counts did not decrease significantly in either tap water or in tap water plus detergent after 24 h storage at ambient temperature. In contrast, all Pseudomonas organisms were killed when nebulizers were dried for 24 h, even when contaminated with 1% and 10% sputum. Dishwashing detergent did not demonstrate any antibacterial activity. CONCLUSIONS: This study demonstrated that nebulizer drying, if applied properly, had the ability to reduce counts of P. aeruginosa to non-detectable levels. Equally, this study showed that, if the device was not dried thoroughly and moisture remained, then the device was able to support the survival of P. aeruginosa at high numbers, which constituted an infection risk to the patient with CF. This information may help educate and inform the patient with CF about the importance of proper nebulizer drying for Pseudomonas control to improve patient awareness and safety.

BACKGROUND: The present study tested a novel nebulizer and circuit that use breath enhancement and breath actuation to minimize ventilator influences. The unique circuit design incorporates “wet-side” jet nebulization (the nebulizer connected to the humidifier outlet port) to prevent unpredictable aerosol losses with active humidification. The system was studied using several ventilator brands over a wide range of settings, with and without humidification. METHODS: During treatment, a 2-position valve directed all ventilator flow to the nebulizer, providing breath enhancement during inspiration. Aerosol was generated by air 50 psi 3.5 L/m triggered during inspiration by a pressure-sensitive circuit. Particles were captured on an inhaled mass filter. Testing was performed by using active humidification or bypassable valved heat and moisture exchanger (HME) over a range of breathing patterns, ventilator modes, and bias flows (0.5-5.0 L/m). The nebulizer was charged with 6 mL of radiolabeled saline solution. Mass balance was performed by using a gamma camera. Tidal volume was monitored by ventilator volume (exhaled VT) and test lung volume. The Mann-Whitney test was used. RESULTS: A total of 6 mL was nebulized within 1 h. Inhaled mass (% neb charge): mean ± SD (all data) 31.1% ± 6.45; no. = 83. Small significant differences were seen with humidification for all modes (humidified 36.1% ± 5.60, no. = 26; bypassable valved HME 28.8% ± 5.51, no. = 57 [P CONCLUSIONS: Breath enhancement with breath actuation provided a predictable dose at any ventilator setting or type of humidification. Preservation of drug delivery during active humidification is a new finding, compared with previous studies. The use of wall gases and stand alone breath actuation standardizes conditions that drive the nebulizer independent of ventilator design. Wet-side nebulizer placement at the humidifier outlet allows delivery without introducing aerosol into the humidification chamber.

Objective: to study the effectiveness of compressor nebulizers in the treatment of respiratory tract respiratory infections in children of different age groups. Material and methods : the main group consisted of 57 children - the average age was 9,7 ± 4,3 years, who were treated with nebulizer therapy using the compressor nebulizer during treatment, 32 children were included in the control group - the average age was 10,8 ± 4,7 years who have not been administered inhalation therapy. Along with conventional therapy, children of the main group underwent inhalation therapy using the compressor nebulizer in two modes, depending on the clinical symptoms of the patient: for bronchitis, the course was 5-6 days, for pneumonia - up to 8-9 days. Using the compressor nebulizer, physiological saline, ipratropium bromide, berodual, pulmicort, lasolvan were injected in a constant flow mode, and in cases of diagnosed rhinosinusitis, a pulsed aerosol delivery regime was used. Results: when analyzing the clinical picture, it was revealed that in all patients the process took a torpid course with prolonged unproductive cough, viscous sputum and persistently retained auscultatory data with insignificant changes in the general blood test. Analysis of the obtained data on the use of various treatment regimens for nosological forms of diseases in the examined children showed that in the patients of the main group the clinical symptoms of a combination of pulmonary diseases and rhino-sinusitis were stopped when applying the pulsating delivery regimen in terms of 6,1 ± 0,7 days (p

Background: Short acting s2-agonist is considered the main stay of therapy in acute asthma episodes, but it could not completely relieve the bronchospasm and reduce dyspnea. One of the other treatments is magnesium sulphate (MgSO4). Nebulized MgSO4 effect has been less evaluated in asthmatics. Aim of the Work is to compare the effects of nebulized MgSO4 in higher doses versus salbutamol nebulization in severe asthmatic attacks. Patients and Methods: Two hundreds asthmatic patients with severe attacks were included in an interventional study. Following initial clinical evaluation and spirometric measurements especially peak expiratory flow (PEF) and Forced expiratory volume in the first second (FEV1) measurements (after control), patients were divided into two equal groups; group I: nebulized salbutamol and group II: nebulized MgSO4. Salbutamol group received salbutamol (2.5 ml)+saline (2.5 ml) while MgSO4 group received MgSO4 (500mg), 7.5 ml (2 mmol vial), through a jet nebulizer. The nebulizations were given 3 times for the first hour, 20 minutes apart, then hydrocortisone and oxygen if not improved then every hour for the remaining 4 hours. Clinical reevaluation, PEF and FEV1 remeasurement were done. Results: The pre-nebulizer clinical parameters, PEF and FEV1 were nearly similar between groups I and II: (PEF: 376.45±49.88 versus 388.46±43.22, respectively), (FEV1: 57.06±9.03 versus 56.51±9.18, respectively). The post-nebulizer PEF and FEV1 values between groups I and II were also nearly similar: (PEF: 410.98±273.82 versus 391.24±39.81, respectively, with p value 0.47), (FEV1: 62.22±9.52 versus 61.78±9.41, respectively, with p value 0.74); indicating the nearly equal effectiveness of both medications. However, the clinical parameters post-nebulization were different: group I developed tachycardia, palpitation and tremors as side effects while group II side effects included nausea, taste changes, numbness and dizziness. Conclusion: Nebulized magnesium sulphate provides nearly equal response as compared to salbutamol in the treatment of acute asthmatic attacks in adults.

Background; Aerosol therapy is a common intervention done on mechanically ventilated patients in intensive care unit all over the world. The agents used by this route include bronchodilators, anti-inflammatory, antibiotics, mucolytics, prostacyclins etc. Objective; The position of nebulizer device is very important for effective drug delivery, so we decided to conduct this study. Method; This is a prospective observation study conducted on adult patients over a period of 6 months who were on invasive mechanical ventilation and nebulization therapy in intensive care unit of a tertiary health care hospital. Results; 160 patients were on nebulization therapy, 100 patients were male and 60 female.146 patients were having endotracheal tube insitu and 14 patients were having tracheotomy tube insitu. Total nebulization events were 9840. 69.20% of the patients were nebulized in ideal way, rest were in a inefficient way. Conclusion; Given the challenges of effective aerosol treatment of the critically ill patient on invasive mechanical ventilation, cost of treatment and better patient outcome, it is necessary to optimize as many factors as possible for effective drug delivery. Hence, guidelines for effective aerosol therapy should be developed and appropriate training and education of the nursing staff is of utmost importance.

Inhaled milrinone administered before cardiopulmonary bypass (CPB) reduces the severity of pulmonary hypertension during cardiac surgery. However, milrinone pharmacokinetics has not been determined for this route of administration. The objective of this study was to investigate inhaled milrinone dosing in vitro and early plasma concentrations in vivo after jet and mesh nebulization. Twelve pulmonary hypertensive patients scheduled for cardiac surgery were randomized to receive milrinone (5 mg) by inhalation before CPB using a jet or mesh nebulizer. In vitro experiments were conducted to determine the inhaled dose delivered with either jet or mesh nebulization. In vivo experiments involved hemodynamic monitoring and blood samples drawn from patients for the first 15 min after the end of inhalation to determine early plasma concentrations. After mesh nebulization, the mean in vitro inhaled dose was almost 3-fold higher compared to jet nebulization (46.4% vs 16.6% for mesh and jet, respectively; mean difference, 29.8%; 95% CI, 14.1 to 45.5; P = 0.006). Consistent with this, the early plasma concentrations in vivo were also 2–3 fold higher after mesh nebulization (P = 0.002–0.005). After inhalation (jet or mesh nebulization), milrinone early plasma concentrations remained within the therapeutic range. No systemic hypotension was reported in our patients.