The Processing Space of the Spray-Dried Mannitol-Leucine System for Pulmonary Drug Delivery.

Designing spray-dried particles for inhalation aims at specific physicochemical properties including a respirable aerodynamic diameter and adequate powder dispersibility. Leucine, an amphiphilic amino acid, has been shown to aid in optimizing bulk powder properties. Mannitol, a model crystalline active and common bulking agent, was co-sprayed with leucine at several excipient ratios, ethanol/water ratios, and spray dryer outlet temperatures in order to experimentally probe the underlying particle formation mechanisms in this binary crystalline system. During the droplet drying of two crystallizing components, the material that nucleates first will preferentially enrich the surface. It is desired to have a completely crystalline leucine shell to improve powder properties, however, mannitol competes with leucine for the surface depending on excipient concentration and manufacturing parameters. The resulting particles were studied initially and at a two-month timepoint via solid state characterization, visual analysis, and particle size analysis in order to detect changes in bulk powder properties. It was determined that, similar to systems where only leucine can crystallize, initial leucine saturation in the formulation dictates powder characteristics.

On the Physical Stability of Leucine-Containing Spray-Dried Powders for Respiratory Drug Delivery.

Carrier-free spray-dried dispersions for pulmonary delivery, for which the demand is growing, frequently require the incorporation of dispersibility-enhancing excipients into the formulations to improve the efficacy of the dosage form. One of the most promising of such excipients, L-leucine, is expected to be approved for inhalation soon and has been studied exhaustively. However, during stability, small fibers protruding from the particles of leucine-containing powders have occasionally been observed. To clarify the origin of these fibers and assess their potential influence on the performance of the powders, three different classes of spray-dried leucine-containing formulation systems were studied over an 8-month accelerated stability program. These systems consisted of a large molecule biologic (bevacizumab) in conjunction with a glass former (trehalose), an amorphous small-molecular mass active (moxidectin), and a crystallizing active (mannitol). It was determined that the appearance of the fibers was due to the presence of small quantities of leucine in higher energy states, either because these were amorphous or present as a less stable crystalline polymorph. It was further shown that the growth of these leucine fibers caused no significant physicochemical instability in the powders. Nor, more importantly, did it decrease their aerosol performance in a dry powder inhaler or reduce the concentration of their active pharmaceutical ingredients.

Simultaneous Spray Drying for Combination Dry Powder Inhaler Formulations.

Spray drying is a particle engineering technique used to manufacture respirable pharmaceutical powders that are suitable for delivery to the deep lung. It is amenable to processing both small molecules and biologic actives, including proteins. In this work, a simultaneous spray-drying process, termed simul-spray, is described; the process involves two different active pharmaceutical ingredient (API) solutions that are simultaneously atomized through separate nozzles into a single-spray dryer. Collected by a single cyclone, simul-spray produces a uniform mixture of two different active particles in a single-unit operation. While combination therapies for dry powder inhalers containing milled small molecule API are commercially approved, limited options exist for preparing combination treatments that contain both small molecule APIs and biotherapeutic molecules. Simul-spray drying is also ideal for actives which cannot withstand a milling-based particle engineering process, or which require a high dose that is incompatible with a carrier-based formulation. Three combination case studies are demonstrated here, in which bevacizumab is paired with erlotinib, cisplatin, or paclitaxel in a dry powder inhaler formulation. These model systems were chosen for their potential relevance to the local treatment of lung cancer. The resulting formulations preserved the biologic activity of the antibody, achieved target drug concentration, and had aerosol properties suitable for pulmonary delivery.

Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery.

OBJECTIVE: To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery. STUDY DESIGN: Retrospective cohort study. SETTING: County hospital otolaryngology practice. METHODS: A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery. This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use. RESULTS: We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 (P < .05) following protocol implementation. Mean MMEs prescribed significantly decreased (P < .05) for each procedure pain tier: mild (107.4 to 40.5), intermediate (112.8 to 48.1), and high (240.4 to 105.0). Mean MMEs prescribed significantly decreased (P < .05) for each procedure type: endocrine (105.6 to 44.4), facial plastics (225.0 to 50.0), general (160.9 to 105.7), head and neck oncology (138.6 to 77.1), laryngology (53.8 to 12.5), otology (77.5 to 42.9), rhinology (142.2 to 44.4), and trauma (288.0 to 24.5). Protocol patients reported a mean 1-week postoperative pain score of 3.4, used opioids for a mean 3.1 days, and used only 39% of their prescribed opioids. CONCLUSION: Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.

Local Treatment of Non-small Cell Lung Cancer with a Spray-Dried Bevacizumab Formulation.

Local delivery of biotherapeutics to the lung holds great promise for treatment of lung diseases, but development of physically stable, biologically active dry powder formulations of large molecules for inhalation has remained a challenge. Here, spray drying was used to manufacture a dry powder pulmonary formulation of bevacizumab, a monoclonal antibody approved to treat non-small cell lung cancer (NSCLC) by intravenous infusion. By reformulating bevacizumab for local delivery, reduced side effects, lower doses, and improved patient compliance are possible. The formulation had aerosol properties suitable for delivery to the deep lung, as well as good physical stability at ambient temperature for at least 6 months. Bevacizumab's anti-VEGF bioactivity was not impacted by the manufacturing process. The formulation was efficacious in an in vivo rat model for NSCLC at a 10-fold decrease in dose relative to the intravenous control.

Water-Induced Phase Separation of Spray-Dried Amorphous Solid Dispersions.

Spray drying is widely used in the manufacturing of amorphous solid dispersion (ASD) systems due to its fast drying rate, enabling kinetic trapping of the drug in amorphous form. Spray-drying conditions, such as solvent composition, can have a profound impact on the properties of spray-dried dispersions. In this study, the phase behavior of spray-dried dispersions from methanol and methanol-water mixtures was assessed using ritonavir and copovidone [poly(vinylpyrrolidone-co-vinyl acetate) (PVPVA)] as dispersion components. The resultant ASDs were characterized using differential scanning calorimetry (DSC), fluorescence spectroscopy, X-ray photoelectron spectroscopy (XPS), as well as surface-normalized dissolution rate (SNDR) measurements. Quaternary phase diagrams were calculated using a four-component Flory-Huggins model. It was found that the addition of water to the solvent system can lead to phase separation during the spray-drying process. A 10:90 H2O/MeOH solvent system caused a minor extent of phase separation. Phase heterogeneity in the 50 and 75% drug loading ASDs prepared from this spray solvent can be detected using DSC but not with other techniques used. The 25% drug loading system did not show phase heterogeneity in solid-state characterization but exhibited a compromised dissolution rate compared to that of the miscible ASD prepared from H2O-free solvent. This is possibly due to the formation of slow-releasing drug-rich phases upon phase separation. ASDs prepared with a 60:40 H2O/MeOH solvent mixture showed phase heterogeneity with all analytical methods used. The surface composition of dispersion particles as measured by fluorescence spectroscopy and XPS showed good agreement, suggesting surface drug enrichment of the spray-dried ASD particles prepared from this solvent system. Calculated phase diagrams and drying trajectories were consistent with experimental observations, suggesting that small variations in solvent composition may cause significant changes in ASD phase behavior during drying. These findings should aid in spray-drying process development for ASD manufacturing and can be applied broadly to assess the risk of phase separation for spray-drying systems using mixed organic solvents or other solvent-based processes.

Solvent-Assisted Secondary Drying of Spray-Dried Polymers.

PURPOSE: The purpose of this work is to introduce solvent-assisted secondary drying, a method used to accelerate the residual solvent removal from spray dried materials. Spray-drying is used to manufacture amorphous solid dispersions, which enhance the bioavailability of active pharmaceutical ingredients (APIs) with low aqueous solubility. In the spray-drying process, API and excipients are co-dissolved in a volatile organic solvent, atomized into droplets through a nozzle, and introduced to a drying chamber containing heated nitrogen gas. The product dries rapidly to form a powder, but small amounts of residual solvent (typically, 1 to 10 wt%) remain in the product and must be removed in a secondary-drying process. For some spray-dried materials, secondary drying by traditional techniques can take days and requires balancing stability risks with process time. METHODS: Spray-dried polymers were secondary dried, comparing the results for three state-of-the-art methods that employed a jacketed, agitated-vessel dryer: (1) vacuum-only drying, (2) water-assisted drying, or (3) methanol-assisted drying. Samples of material were pulled at various time points and analyzed by gas chromatography (GC) and Karl Fischer (KF) titration to track the drying process. RESULTS: Model systems were chosen for which secondary drying is slow. For all cases studied, methanol-assisted drying outperformed the vacuum-only and water-assisted drying methods. CONCLUSIONS: The observation that methanol-assisted drying is more effective than the other drying techniques is consistent with the free-volume theory of solvent diffusion in polymers.

Novel High-Drug-Loaded Amorphous Dispersion Tablets of Posaconazole; In Vivo and In Vitro Assessment.

Amorphous solid dispersions (ASDs) can increase the bioavailability of drugs with poor aqueous solubility. However, concentration-sustaining dispersion polymers (CSPs) incorporated in ASDs can result in low drug loading and, therefore, a large dosage-form size or multiple units to meet dose requirements, potentially decreasing patient compliance. To address this challenge, a high-loaded dosage-form (HLDF) architecture for ASDs was developed, in which a drug is first spray-dried with a high glass-transition temperature (Tg) dispersion polymer to facilitate high drug loading while maintaining physical stability. The ASD is then granulated with a CSP designed to extend supersaturation in solution. The HLDF differs from traditional ASD architectures in which the dispersion polymer inside the ASD acts as the CSP. By strategically combining two different polymers, one "inside" and one "outside" the ASD, solubilization performance, physical stability, and overall drug loading are maximized. This study demonstrates in vivo performance of the HLDF architecture using posaconazole as a model drug. Two sizes of HLDF tablets were tested in beagle dogs, along with traditional ASD architecture (benchmark) tablets, ASD tablets without a CSP, and a commercial crystalline oral suspension (Noxafil OS). HLDF tablets performed equivalently to the benchmark tablets, the smaller HLDF tablet being 40% smaller (by mass) than the benchmark tablet. The HLDF tablets doubled the blood plasma AUC relative to Noxafil OS. In line with the in vivo outcome, in vitro results in a multicompartment dissolution apparatus demonstrated similar area under the curve (AUC) values in the intestinal compartment for ASD tablets. However, the in vitro data underpredicted the relative in vivo AUC of Noxafil OS compared to the ASD tablets. This study demonstrated that the HLDF approach can increase drug loadings while achieving good performance for ASD drug products.

A novel architecture for achieving high drug loading in amorphous spray dried dispersion tablets.

Although Amorphous Solid Dispersions (ASDs) effectively increase bioavailability, tablet mass can be high due to the large fraction of excipients needed to stabilize the amorphous drug in the solid state, extend drug supersaturation in solution and achieve robust manufacturability. The aim of this work was to reduce tablet mass of an ASD tablet comprising a low glass transition temperature (Tg), rapidly crystallizing drug without compromising these key attributes. In this approach, erlotinib (Tg = 42 °C, Tm/Tg = 1.4 K/K) was spray dried with the high Tg polymer poly(methyl methacrylate-co-methacrylic acid) (Eudragit® L100, Evonik) (Tg = 187 °C) to facilitate high drug loading while maintaining physical stability. Hydroxypropyl methylcellulose acetate succinate (HPMCAS) (AQOAT® HF, Shin-Etsu) was granulated with the ASD to extend supersaturation in solution. For comparison, a benchmark ASD was spray dried at a lower drug loading with HPMCAS-H (Tg = 119 °C). This High Loaded Dosage Form (HLDF) approach reduced tablet mass by 40%, demonstrated similar physical stability and in vitro performance as the benchmark and exhibited excellent downstream manufacturability. Strategically combining two different polymers in a tablet to maintain physical stability and sustain supersaturation in solution can decrease tablet mass of some low Tg, rapidly crystallizing amorphous drugs.

Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury.

The decision to intubate acute burn patients is often based on the presence of classic clinical exam findings. However, these findings may have poor correlation with airway injury and result in unnecessary intubation. We investigated flexible fiberoptic laryngoscopy (FFL) as a means to diagnose upper airway thermal and inhalation injury and guide airway management. A retrospective chart review of all burn patients who underwent FFL from 2013 to 2017 was performed. Their charts were reviewed to determine the indications for FFL including the historical data and physical exam findings that indicated airway injury as well as patient age, TBSA, type and depth of burn injury, carboxyhemoglobin level, and clinical course. Fifty-one patients underwent FFL, with an average TBSA of 6.5% (range 0.5-38.0%) and carboxyhemoglobin level of 3.5%. Burn mechanism was flame (35.3%) or flash (51.0%), with 50% occurring in enclosed spaces. In all cases, the decision to perform FFL was based on physical exam findings meeting criteria for intubation, including facial burns, singed nasal hairs, nasal soot, voice change, throat pain or abnormal sensation, shortness of breath, carbonaceous sputum, wheezing, or stridor. Based on FFL, 9 patients (17.7%) were treated with steroids, 28 patients (54.9%) received supportive care, and 6 patients (11.8%) had repeat FFL for monitoring. One patient was intubated after repeat FFL examination. All patients who underwent FFL met traditional criteria for intubation based on exam, however 98% were monitored without issues based on FFL findings. FFL is a valuable tool that can lead to fewer intubations in acute burn patients with a stable respiratory status for whom history and physical exam suggest upper airway injury.

Spontaneous Retropharyngeal and Mediastinal Emphysema.

A 14-year-old girl with no significant medical history presented at Emergency Department with sore throat and odynophagia after one episode of nonviolent coughing. She denied any respiratory distress, voice change, foreign body ingestion, retching, substance abuse, dental procedures, or trauma. She was afebrile with normal oxygen saturation and physical examination including the head and neck was unremarkable with the exception of bilateral neck crepitus without tenderness on palpation. Fiberoptic laryngoscopy revealed a patent laryngeal airway with normal vocal fold movement. Lateral neck X-ray demonstrated a linear air-column in the retropharyngeal space and computed tomography confirmed emphysema involving the retropharyngeal space and mediastinum with no evidence of fluid collection or abscess formation. Spontaneous retropharyngeal and mediastinal emphysema are clinical entities where free air is present within the confines of retropharyngeal space and mediastinum without obvious cause. It is benign and self-limited in nature and allows for conservative management. This case is presented with a review of literature.

Transport and Stability of Laser-Deposited Amorphous Polymer Nanoglobules.

We characterized the transport, i.e., time-of-flight, and nanoscale thermal properties of amorphous polymer nanoglobules fabricated via a laser-deposition technique, Matrix-Assisted Pulsed Laser Deposition (MAPLE). Here, we report the first experimental measurement of the velocity of polymer during MAPLE processing and its connection to nanostructured film formation. A nanoscale dilatometry technique using atomic force microscopy was employed to directly measure the thermal properties of MAPLE-deposited polymer nanoglobules. Similarly to bulk stable polymer glasses deposited by MAPLE, polymer nanoglobules were found to exhibit enhanced thermal stability and low density despite containing only thousands of molecules. By directly connecting the exceptional properties of the nanostructured building blocks to those of bulk stable glasses, we gain insight into the physics of glassy polymeric materials formed via vapor-assisted techniques.

Fragility of an Isochorically Confined Polymer Glass.

We report the effect of isochoric confinement on the dynamic fragility of a polymeric glass-former, that is, polystyrene (PS). Utilizing silica-capped PS nanospheres as a model system, the fictive temperature (Tf) and the isochoric heat capacity (Cv) are measured as a function of diameter via differential scanning calorimetry. By examining Tf as a function of cooling rate for each sample, the isochoric fragility (mv) is obtained, which decreases significantly as the diameter of the nanospheres is reduced from 260 to 129 nm. Hence, the temperature dependence of structural relaxation near the glass transition is weakened with isochoric confinement.

Perioperative steroids in tonsillectomy using electrocautery and sharp dissection techniques.

OBJECTIVE: To determine the effect of preoperative dexamethasone sodium phosphate administration on posttonsillectomy morbidity for electrocautery ("hot") and sharp ("cold") dissection techniques. DESIGN: Prospective, randomized, double-blind study. SETTING: University pediatric hospital and county teaching hospital. Subjects A total of 219 children, aged 9 months to 12 years, undergoing tonsillectomy. Intervention Participants who underwent tonsillectomy were randomly assigned to receive either intravenous dexamethasone sodium phosphate (1 mg/kg) or placebo. OUTCOME MEASURES: Pain scores, oral intake, and emesis on postoperative day (POD) 1. RESULTS: A total of 106 subjects (62 undergoing hot and 44 cold tonsillectomies) received preoperative steroids, and 113 (56 hot and 57 cold tonsillectomies) received placebo. On POD 1, pain scores reported by patients (P =.02), parents (P =.002), and physicians (P<.001) were significantly lower in subjects receiving steroids than in those receiving placebo. Emesis was reduced from a mean of 2.1 (placebo group) to 1.2 episodes (steroid group) (P =.02). Oral intake improved from 24.5% of normal diet (placebo) to 31.7% (steroid group) (P =.004). When all 4 groups were compared (cold placebo, cold steroid, hot placebo, and hot steroid), pain scores reported by physicians and parents were significantly lower in the cold steroid group than in the other groups. CONCLUSIONS: Perioperative dexamethasone use reduces posttonsillectomy morbidity in pediatric patients in the early postoperative period after hot or cold tonsillectomy. The combination of steroid and cold dissection technique provided the greatest advantage in reducing posttonsillectomy subjective pain levels.