Dos and don’ts to optimize transnasal aerosol drug delivery in clinical practice

ABSTRACT

Introduction

Transnasal aerosol drug delivery has become widely accepted for treating acutely ill infants, children, and adults. More recently aerosol administration to wider populations receiving high and low-flow nasal oxygen has become common practice.

Areas Covered

Skepticism of insufficient aerosol delivery to the lungs has been tempered by multiple in vitro explorations of variables to optimize delivery efficiency. Additionally, clinical studies demonstrated comparable clinical responses to orally inhaled aerosols. This paper provides essential clinical guidance on how to improve transnasal aerosol delivery based on device-, settings-, and drug-related optimization to serve as a resource for educational initiatives and quality enhancement endeavors at healthcare institutions.

Expert Opinion

Transnasal aerosol delivery is proliferating worldwide, but indiscriminate use of excessive-high flows poor selection and placement of aerosol devices and circuits can greatly reduce aerosol delivery and efficacy, potentially compromising treatment to acute and critically ill patients. Attention to these details can improve inhaled dose by an order of magnitude, making the difference between effective treatment and the progression to more invasive ventilatory support, with greater inherent risk and cost. These revelations have prompted specific recommendations for optimal delivery, driving advancements in aerosol generators, formulations, and future device designs to administer aerosols and maximize treatment effectiveness.

KEYWORDS:

• Aerosols
• Transnasal
• High flow nasal cannula
• Drug delivery
• Flow rate
• Children
• Adults
• And nebulizers

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Article highlights

• Transnasal aerosol administration benefits many patients requiring aerosol doses lasting longer than 15 – 30 minutes as well as aerosol administration during high-flow nasal oxygen (HFNO). A range of treatment scenarios have employed continuous aerosol administration over extended periods with low-flow carrier gases:

  1. Delivery of overnight aerosol hypertonic saline for cystic fibrosis (CF) patients,

  2. Continuous bronchodilator administration in children and adults with severe asthma,

  3. Inhaled continuous low-dose prostacyclins for treatment of pulmonary hypertension in the critical care environment,

  4. Inhaled surfactant to low birthweight preterm infants via nasal continuous positive airway pressure, and

  5. Inhaled medication delivery during high-flow nasal oxygen without interruption of vital oxygen and pressure applied to the airway.

• With proper device, setup, and techniques, the clinical responses to aerosols delivered by transnasal administration are similar to that of conventional nebulizers and interfaces, but without the barriers of poor tolerance, discomfort, and inconvenience. As optimal techniques are more uniformly applied, further development of devices, circuits, and formulations will proliferate to more efficiently adapt transnasal aerosol drug delivery to a broader range of drugs, patients, and indications.

Declaration of interest

A Ari discloses relationships with the CHEST Foundation, COPD Foundation, Fisher and Paykel Healthcare, Aerogen Ltd, and the US Department of Labor. J Fink is the chief science officer of Aerogen Pharma. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Table 2. Dos and Don’ts in Setting-related Optimization during Transnasal Aerosol Drug Delivery in Clinical Practice

Additional information

Funding

This paper was not funded.