MODIFLOW

1. MODIFLOW A FLOW MODIFICATION DEVICE

2. CONTENTS • Asthma and other respiratory illnesses • Inhalable medications • Forms of delivery to the lungs • Spacer devices • Fractal geometry • Fractality in living systems • Turbulence • How do the biological systems deal with it? • ModiFlow • The Patent • CIP • FDA regulation • Testing • Financing • Future developments

3. ASTHMA STATS • The number of people with asthma continues to grow. One in 12 people (about 25 million, or 8% of the U.S. population) had asthma in 2009, compared with 1 in 14 (about 20 million, or 7%) in 2001.2• More than half (53%) of people with asthma had an asthma attack in 2008. More children (57%) than adults (51%) had an attack. 185 children and 3,262 adults died from asthma in 2007.2• About 1 in 10 children (10%) had asthma and 1 in 12 adults (8%) had asthma in 2009. Women were more likely than men and boys more likely than girls to have asthma.2• In 2010, 3 out of 5 children who have asthma had one or more asthma attacks in the previous 12 months.6

4. COST • Asthma cost the US about $3,300 per person with asthma each year from 2002 to 2007 in medical expenses, missed school and work days, and early deaths.2• Asthma costs in the US grew from about $53 billion in 2002 to about $56 billion in 2007, about a 6% increase.2• More than half (59%) of children and one-third (33%) of adults who had an asthma attack missed school or work because of asthma in 2008. On average, in 2008 children missed 4 days of school and adults missed 5 days of work because of asthma.2

5. MORBIDITY • More than half (53%) of people with asthma had an asthma attack in 2008. More children (57%) than adults (51%) had an attack. 185 children and 3,262 adults died from asthma in 2007.2• Asthma was linked to 3,447 deaths (about 9 per day) in 2007.

6. INTERNATIONAL • The prevalence of asthma in different countries varies widely, but the disparity is narrowing due to rising prevalence in low and middle income countries and plateauing in high income countries.3• An estimated 300 million people worldwide suffer from asthma, with 250,000 annual deaths attributed to the disease.1• It is estimated that the number of people with asthma will grow by more than 100 million by 2025.1• Workplace conditions, such as exposure to fumes, gases or dust, are responsible for 11% of asthma cases worldwide.1• About 70% of asthmatics also have allergies.1• Approximately 250,000 people die prematurely each year from asthma. Almost all of these deaths are avoidable.1• Occupational asthma contributes significantly to the global burden of asthma, since the condition accounts for approximately 15% of asthma amongst adults.

7. OTHER RESPIRATORY ILLNESSES • Chronic lung disease • Bronchiolitis • Bronchitis • COPD • Cystic fibrosis • Croup • Pneumoconioses • Others

8. INHALABLE MEDICATIONS • Bronchodilators • Steroids • Anti-allergics • Antimicrobials • Insulin • Vitamins (LeWhif) • Chemotherapy • Anti-migrain (Levadex) • Anti-tuberculosis • Pain medications • Gene therapy • Anti-Parkinson’s (levodopa)

9. FORMS OF DELIVERY • Nebulizer machines • Pressurized metered dose inhalers (pMDI) • Dry powder discs (DPI) • MDI’s with Spacers

10. SPACER DEVICES • ACE® (Aerosol Cloud Enhancer) • Aerochamber® • Azmacort® • Easivent® • Ellipse® • Babyhaler • Volumatic • NebuChamber • Inspirease • Fisonair • 500ml modified plastic bottle • Coffee cup

11. DPI • Turbohaler • Diskhaler • Accuhaler • Rotahaler Activated by inspiration

12. Lung deposition of aerosol—a comparison of different spacers • Arch Dis Child 2000;82:495-498 doi:10.1136/adc.82.6.495 • Methodology • H J Zar, E G Weinberg, H J Binns, F Gallie, M D Mann • Abstract • AIMS To investigate (1) aerosol lung deposition obtained from two small volume conventional spacers (Babyhaler and Aerochamber) and a home made spacer (modified 500 ml plastic cold drink bottle); (2) the effect of using a face mask or mouthpiece; and (3) the relation between age and pulmonary deposition. • METHODS Lung deposition of aerosolised technetium-99m DTPA inhaled via spacer was measured in 40 children aged 3–7 years with stable asthma. Each patient performed sequential randomly assigned inhalations using two spacers. Three studies were performed: Babyhaler compared to Aerochamber (with facemasks); Babyhaler with facemask compared to Babyhaler with mouthpiece; and Babyhaler with mouthpiece compared to a 500 ml bottle. • RESULTS Median lung aerosol deposition from a Babyhaler and Aerochamber with masks were similar (25% v 21%, p = 0.9). Aerosol lung deposition from a Babyhaler with mask compared to a Babyhaler with mouthpiece was equivalent (26% v 26%, p = 0.5). Lung deposition was higher from a 500 ml bottle compared to a Babyhaler in both young (25% v 12.5%, p = 0.005) and older children (42% v22.5%, p = 0.003). A notable reduction in pulmonary deposition occurred at 50 months of age. • CONCLUSION A Babyhaler or Aerochamber produce equivalent lung deposition of aerosol. There is no difference in lung deposition when a mask or mouthpiece is used. A modified 500 ml plastic bottle produces greater pulmonary aerosol deposition than a conventional small volume spacer.

13. Volume varies from tube spacers <50ml to holding chambers 750ml • The higher the volume, the better efficiency • Minimize coordination difficulties • Reduce oropharyngeal deposition • Increase lung deposition

14. Metered-dose inhalers with spacers produced outcomes that were at least equivalent to nebulizer delivery

15. Adrenal suppression in asthmatic children receiving low-dose inhaled budesonide: comparison between dry powder inhaler and pressurized metered-dose inhaler attached to a spacer Treatment of asthmatic children with budesonide 400 mcg daily given via a DPI for 1 month was associated with hypothalamic-pituitary-adrenal axis suppression. This effect was not observed with the same dose of budesonide administered via pMDI + spacer. This indicates that systemic absorption might be reduced with pMDI + spacer therapy

16. Randomized trial of spacers in asthma

17. Electrostatics and inhaled medications: influence on delivery via pressurized metered-dose inhalers and add-on devices • Mitchell JP, Coppolo DP, Nagel MW.Trudell Medical International, 725 Third Street, London, Ontario N5V5G4 Canada. jmitchell@trudellmed.com • Abstract • The movement of inhaler-generated aerosols is significantly influenced by electrostatic charge on the particles and on adjacent surfaces. Particle charging arises in the aerosol formation process. Since almost all inhalers contain nonconducting components, these surfaces can also acquire charge during manufacture and use. Spacers and valved holding chambers used with pressurized metered-dose inhalers to treat obstructive lung diseases are particularly prone to this behavior, which increases variability in the amount of medication available for inhalation, and this is exacerbated by low ambient humidity. This may result in inconsistent medication delivery. Conditioning the device by washing it with a conductive surfactant (detergent) or using devices made of charge-dissipative/conducting materials can mitigate electrostatic charge. This review discusses sources of electrostatic charge, the processes that influence aerosol behavior, methods to mitigate electrostatic charge, and potential clinical implications.

18. The importance of nonelectrostatic materials in holding chambers for delivery of hydrofluoroalkanealbuterol HCs made from electrically conductive materials emit significantly greater fine-particle mass, with either a 2-s or 5-s delay, than do HCs made from nonconducting materials, even with wash/rinse pretreatment.

19. Comparison of the bronchodilating effects of albuterol delivered by valved vs. non-valved spacers in pediatric asthma In stable asthmatic children, albuterol administered through MDI using a non-valved spacer produces a bronchodilator response similar to that of a spacer with a valve that requires an inhalatory opening pressure (with flows between 2 and 32 l/min) that even toddlers with bronchial obstruction can easily generate.

20. FRACTAL GEOMETRY • Fractal dimension • Iteration • Self-similarity • Appear the same on different scales • Can fit a large surface area in a small volume • Widespread in the nature, especially in living organisms

24. MANDELBROT SET

28. FRACTALS IN LIVING SYSTEMS • Lungs • Vascular system • Nervous system • Bones • Cell membranes • Parenchimal organs • Plants • Viruses

29. [A three dimensional fractal simulation of the lung bronchial tree] The lungs are naturally irregular and asymmetrical organ in anatomy. The conducting bronchial trees in the lungs display complex self-similar structure. We have established the host mesh coordinates of the right lung on the basis of the anatomical data from the literature. A three-dimensional fractal model of the conducting airways was set up by calculating the coordinates of the mass centers of the divided blocks, searching the branch direction and determining branch lengths with the use of the drawing tool OpenGL. Specific data of the lengths at various grades, branching angles, and capillary diameters were obtained. As a result, the computed data were identical with those of the existing statistical data. The fractal covering dimensionality obtained in the computation of this model was 2.19, which is very close to the ideal dimensionality, 2.17, from the literature. The present model has laid the foundation for further research of the gas diffusion and transfer performance in the lungs using the fractal concept, and furthermore, it helps to save the computer memories and fastening the graphic transfer.

30. Emergence of matched airway and vascular trees from fractal rules The bronchial, arterial, and venous trees of the lung are complex interwoven structures. Their geometries are created during fetal development through common processes of branching morphogenesis. Insights from fractal geometry suggest that these extensively arborizing trees may be created through simple recursive rules. Mathematical models of Turing have demonstrated how only a few proteins could interact to direct this branching morphogenesis. Development of the airway and vascular trees could, therefore, be considered an example of emergent behavior as complex structures are created from the interaction of only a few processes. However, unlike inanimate emergent structures, the geometries of the airway and vascular trees are highly stereotyped. This review will integrate the concepts of emergence, fractals, and evolution to demonstrate how the complex branching geometries of the airway and vascular trees are ideally suited for gas exchange in the lung. The review will also speculate on how the heterogeneity of blood flow and ventilation created by the vascular and airway trees is overcome through their coordinated construction during fetal development.

31. On the asymmetry of bifurcations in the bronchial tree. The branching pattern of the conducting airways is significantly asymmetrical in the human, and even more so in other species. Although this asymmetry is believed to have an important effect on air flow and other transport processes in the bronchial tree, both experimental and theoretical studies have predominantly employed symmetrical model bifurcations. In this paper, published morphometric data for four species (human, dog, rat and hamster) is used to calculate the frequencies with which different degrees of asymmetry occur, and to examine the relationships between four of its manifestations, asymmetry of the cross-sectional areas, the lengths, the branching angles and the flow rates of the daughter branches. The observed characteristics are compared with some of the theoretical 'branching laws' which have been proposed. Quantification of the correlations between the different manifestations of asymmetry allows the geometrical characteristics to be specified for a range of realistic asymmetrical bifurcations, for use in either theoretical or experimental studies of transport in the bronchial tree.

32. Fractal nature of regional ventilation distribution High-resolution measurements of pulmonary perfusion reveal substantial spatial heterogeneity that is fractally distributed. This observation led to the hypothesis that the vascular tree is the principal determinant of regional blood flow. Recent studies using aerosol deposition show similar ventilation heterogeneity that is closely correlated with perfusion. We hypothesize that ventilation has fractal characteristics similar to blood flow. We measured regional ventilation and perfusion with aerosolized and injected fluorescent microspheres in six anesthetized, mechanically ventilated pigs in both prone and supine postures. Adjacent regions were clustered into progressively larger groups. Coefficients of variation were calculated for each cluster size to determine fractal dimensions. At the smallest size lung piece, local ventilation and perfusion are highly correlated, with no significant difference between ventilation and perfusion heterogeneity. On average, the fractal dimension of ventilation is 1.16 in the prone posture and 1. 09 in the supine posture. Ventilation has fractal properties similar to perfusion. Efficient gas exchange is preserved, despite ventilation and perfusion heterogeneity, through close correlation. One potential explanation is the similar geometry of bronchial and vascular structures.

33. Fractal geometry of airway remodeling in human asthma. • RESULTS: • Nonasthma control casts had smooth walls and dichotomous branching patterns with nontapering segments. Asthmatic casts showed many abnormalities, including airway truncation from mucous plugs, longitudinal ridges, and horizontal corrugations corresponding to elastic bundles and smooth muscle hypertrophy, respectively, and surface projections associated with ectatic mucous gland ducts. Fractal dimensions were calculated from digitized images using an information method. The average fractal dimensions of the airways of both the fatal asthma (1.72) and nonfatal asthma (1.76) groups were significantly (p<0.01 and p=0.032, respectively) lower than that of the nonasthma control group (1.83). The lower fractal dimension of asthmatic airways correlated with a decreased overall structural complexity and pathologic severity of disease. • CONCLUSION: • Fractal analysis is a simple and useful technique for quantifying the chronic structural changes of airway remodeling in asthma.

34. TURBULENCE "the most important unsolved problem of classical physics“ Richard Feynman

35. TURBULENT FLOW • Unsteady vortices appear on many scales and interact with each other • Increased resistance to flow • Unpredictable, chaotically disorganized • Deterministic chaos • Extreme sensitivity to initial conditions: “a butterfly in Korea can cause a tsunami in the US”

36. LAMINAR FLOW • Dies out due to molecular viscosity • Orderly, organized • Follows rules and equations • Very small lateral force unable to break the flow, reflects from one edge to the other, iterates multiple times, and grows until it is strong enough to break the flow – turbulence sets in

38. HOW DO THE BIOLOGICAL SYSTEMS DEAL WITH IT?

39. BRONCHIAL TREE

40. the total alveolar volume is the size of a tennis ball.. but the total alveolar surface area is the size of a tennis court

41. VASCULAR TREE

42. the entire vascular system comprises only 3% of the total volume of the body.. yet it bleeds if you puncture anywhere in the body !

43. LYMPHATIC TREE

44. if you put together the lengths of all the blood vessels in the body including the tiniest capillaries, they would line up from Earth to the Moon.. yet the heart is able to pump the blood through them for 100 years !

45. Subdivision of the main flow into two sub-flows iterated multiple times (a tree) seems to disrupt the cycle of growth of the lateral force, preventing the emergence of a high Reynolds number turbulence.

46. At the same time it allows for a large “exchange” surface area to be fitted into a relatively small volume, making the exchange of substances, energy, information extremely efficient.

47. A distribution to a large number of elements without major losses is best achieved via a fractal tree-like hierarchic structure.

48. For the flow in the tree to remain continuous and relatively laminar, and for the turbulence not to emerge at every subdivision, it is important for certain “preservation” rules to be employed.

49. The total cross-sectional area of the sub-flows should be equal to the cross-sectional area of the preceding flow. That area should in fact remain constant throughout the entire tree structure and at every cross-sectional level

50. ModiFlow A NEW GENERATION SPACER DEVICE