Scientific letter
In Vitro and In Vivo Comparison of Two Nebulizers Used for Inhaled Pentamidine Delivery
Comparación in vitro e in vivo de dos nebulizadores utilizados para administrar pentamidina inhalada
Nicolas Audaga,b,
, Giuseppe Liistrob,c, Dimitri Van der lindend, Françoise Smetse, Teresinha Lealf, Gregory Reychlera,b,c
Corresponding author
a Service de Médecine Physique et Réadaptation, Cliniques universitaires Saint-Luc, Brussels, Belgium
b Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL & Dermatologie, Université Catholique de Louvain, Brussels, Belgium
c Service de Pneumologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
d Pediatric Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium
e Pediatric Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Brussels, Belgium
f Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
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"referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Giuseppe" "apellidos" => "Liistro" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Dimitri" "apellidos" => "Van der linden" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "Françoise" "apellidos" => "Smets" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" 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Brussels, Belgium" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Service de Pneumologie, Cliniques universitaires Saint-Luc, Brussels, Belgium" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Pediatric Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Pediatric Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Brussels, Belgium" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comparación in vitro e in vivo de dos nebulizadores utilizados para administrar pentamidina inhalada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 897 "Ancho" => 2500 "Tamanyo" => 130768 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Schematic diagram of experimental devices used in the in vitro study.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pneumocystis jirovecii pneumonia (PJP) represents a significant cause of morbidity and mortality in immunosuppressed patients.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2</span></a> Pentamidine, used in secondary prevention of PJP, is administered via inhalation and requires a specific nebulizer.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,4</span></a> In the recent ERS/ISAM Task Force Consensus Statement, the RespirgardII<span class="elsevierStyleSup">®</span> (Vital Signs) was considered as the reference nebulizer to deliver pentamidine.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> Nebulizers with comparable properties are required because RespirgardII<span class="elsevierStyleSup">®</span> is no longer available since its recent withdrawal from the market in some countries.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Most of the nebulizers compared previously to the RespirgardII were ultrasonic nebulizers.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> In this study, we compared a jet nebulizer (ISO-NEB<span class="elsevierStyleSup">®</span>, Teleflex) to RespirgardII<span class="elsevierStyleSup">®</span> for pentamidine delivery. Both nebulizers possess one-way valves on the inspiratory and on the expiratory way and an expiratory filter as recommended.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,4</span></a> Both were driven by a similar air flow (8<span class="elsevierStyleHsp" style=""></span>L/min) and deliver particles with similar size (MMAD: 1–2<span class="elsevierStyleHsp" style=""></span>μm).<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,7,8</span></a> In vitro, nebulizers were connected to a dual chamber lung model (5600i Dual Adult Test Lung<span class="elsevierStyleSup">®</span>, Michigan Instrument Inc.) driven by a ventilator (SERVO-I<span class="elsevierStyleSup">®</span>, Maquet) in volume-controlled mode simulating an adult breathing pattern (Vt<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>mL; RF<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>15 breaths/min; I/E ratio<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1:2; no end-inspiratory pause) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Artificial lung compliance and resistance were set to 70<span class="elsevierStyleHsp" style=""></span>mL/cmH<span class="elsevierStyleInf">2</span>O and 5cmH<span class="elsevierStyleInf">2</span>O, respectively. Nebulizations of a pentamidine solution (300<span class="elsevierStyleHsp" style=""></span>mg/6<span class="elsevierStyleHsp" style=""></span>mL sterile water) were performed in triplicate for each model in accordance with manufacturer's and guidelines recommendations until one minute after the appearance of the sputtering point.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2,7,9</span></a> Inhaled dose, expressed in percentage of the nominal dose (ND), corresponding to the nebulized doses deposited on the filter interposed between nebulizer and lung model (weighed before the nebulization and after drying for 24<span class="elsevierStyleHsp" style=""></span>h) multiplied by the relative mass of pentamidine. The residual volume was also quantified.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">In the in vivo part, after ethical approval (2013/27JUI/375) and registration of the trial (NCT02277808), five non-smoker healthy male volunteers were recruited and signed a written inform consent. Each subject performed a spirometry according to the ATS/ERS guidelines.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> This was a randomized cross-over study based on CONSORT statement for clinical trials. Nebulizations of amikacin sulfate (Amukin<span class="elsevierStyleSup">®</span>, Bristol-Myers Squibb) dissolved in 4<span class="elsevierStyleHsp" style=""></span>mL of normal saline (125<span class="elsevierStyleHsp" style=""></span>mg/mL) were made during 10<span class="elsevierStyleHsp" style=""></span>min with both devices. During nebulization, tidal volume (Vt; L), respiratory frequency (RF; min<span class="elsevierStyleSup">−1</span>) and minute ventilation (VE; L<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span>) were monitored by inductance plethysmography (Respitraces<span class="elsevierStyleSup">®</span>, Ambulatory Monitoring Inc.). Participants were requested (1) to empty their bladder before nebulization, (2) to inhale spontaneously through the mouthpiece with a nose clip in a sitting position, (3) to collect their urine for 24<span class="elsevierStyleHsp" style=""></span>h following nebulization and (4) to observe a wash-out period of one week between both nebulizations. Then comparison was performed by sampling the daily urinary excretion of nebulized amikacin following the technique previously described by Dequin et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> and analyzed by High Performance Liquid Chromatography. The total daily amount of amikacin excreted in the urine (Cu max) was calculated from cumulating amikacin amount measured at each micturition (Cu) and represents the lung dose. The elimination constant (<span class="elsevierStyleItalic">K</span><span class="elsevierStyleInf">e</span>) was calculated from the fitted curve of the cumulated amount of amikacin excreted in the urine plotted versus the time. The equation is Cu=Cu max(1−e−Ket).</p><p id="par0015" class="elsevierStylePara elsevierViewall">Inhaled dose was similar between devices, 28.7% (22.7; 33.5) vs 29.3% of ND (26.3; 33.1) for ISO-NEB<span class="elsevierStyleSup">®</span> and for RespirgardII<span class="elsevierStyleSup">®</span> (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.792). Residual volume was 0.9313<span class="elsevierStyleHsp" style=""></span>g (0.9270; 0.9382) and 1.4087<span class="elsevierStyleHsp" style=""></span>g (1.3845; 1.4416) for ISO-NEB<span class="elsevierStyleSup">®</span> and for RespirgardII<span class="elsevierStyleSup">®</span>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In vivo, all volunteers (23.5<span class="elsevierStyleHsp" style=""></span>+/−<span class="elsevierStyleHsp" style=""></span>1.3 years) had spirometric values in the normal range. Cu max was similar between devices with 3.5% (3.1; 3.6) and 3.6% of ND (2.2; 4.2), (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.893) for ISO-NEB<span class="elsevierStyleSup">®</span> and RespirgardII<span class="elsevierStyleSup">®</span>, respectively. Urine volume was 1.37<span class="elsevierStyleHsp" style=""></span>L (0.80; 1.72) and 1.30<span class="elsevierStyleHsp" style=""></span>L (0.75; 2.10) for ISO-NEB<span class="elsevierStyleSup">®</span> and RespirgardII<span class="elsevierStyleSup">®</span>, respectively (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.686). Elimination constant (<span class="elsevierStyleItalic">K</span><span class="elsevierStyleInf">e</span>) of the drug following nebulization was similar for both devices (0.159 (0.078; 0.208) vs 0.130 (0.085; 0.162) for ISO-NEB<span class="elsevierStyleSup">®</span> and for RespirgardII<span class="elsevierStyleSup">®</span>, respectively (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.225)). There was no significant difference in RF, Vt and VE. Our results were in the range of previous studies even if the comparison is difficult because there were no data for ISO-NEB<span class="elsevierStyleSup">®</span> and the previous studies on RespirgardII<span class="elsevierStyleSup">®</span> presented many differences in protocols and measurements techniques.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6,9,12,13</span></a> We used the most frequent dosage reported in the previous studies and in the manufacturer's recommendations (300<span class="elsevierStyleHsp" style=""></span>mg pentamidine in 6<span class="elsevierStyleHsp" style=""></span>mL sterile water).<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2,7,9</span></a> The airflow rate (8<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span>) to produce aerosolized pentamidine was in the range of the rate described in previous studies about RespirgardII<span class="elsevierStyleSup">®</span> (about 6–10<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span> for RespirgardII<span class="elsevierStyleSup">®</span>) or recommended by the manufacturer for ISO-NEB<span class="elsevierStyleSup">®</span> (from 5 to 9<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span>). The total amount of drug reaching the lungs was similar and lower than 5% of ND for both devices. Our results are in line with those obtained with pentamidine in prior studies (2–6.74% of ND).<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4,6,9,12</span></a> Some methodological conditions need to be discussed. In vitro, we used the residual gravimetric technique even though it was not validated for pentamidine. However previous studies validated this process for different drugs.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> In vivo, we used amikacin sulfate because pentamidine has not been previously considered as a valid pharmacological marker of pulmonary deposition.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">11,15</span></a> For a methodological consideration, we recruited only male subjects because it is easier for a man to collect his urine without loss and to prevent potential fetal risk ototoxicity in pregnant female subjects. Finally, we did not measure the particle sizes for both nebulizers, but according to previous studies and manufacturer's data we can consider that they were similar (1–2<span class="elsevierStyleHsp" style=""></span>μm). It is important to notice that the two nebulizers are in the same price range. In conclusion, this in vitro and in vivo study demonstrated that ISO-NEB<span class="elsevierStyleSup">®</span> and RespirgardII<span class="elsevierStyleSup">®</span> have similar properties in the conditions study. Further clinical studies are needed to confirm that ISO-NEB<span class="elsevierStyleSup">®</span> is a valuable alternative to the reference nebulizer recommended by guidelines for pentamidine delivery. Altogether these data suggest that the performance of both devices is similar in the conditions of this in vitro and in vivo study.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 897 "Ancho" => 2500 "Tamanyo" => 130768 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Schematic diagram of experimental devices used in the in vitro study.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumocystis pneumonia in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V. 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