AU2005244079A1 - The use of inhaled gaseous nitric oxide as a mucolytic agent or expectorant - Google Patents

Description

WO 2005/110052 PCT/US2005/016428 THE USE OF INHALED GASEOUS NITRIC OXIDE AS A MUCOLYTIC AGENT OR EXPECTORANT FIELD OF THE INVENTION 5 [00011 The field of the present invention relates to methods and systems for treating, preventing, or mitigating mucus accumulation and mucociliary dyskinesia in the airways of mammals, and in particular, to the inhaled use of gaseous Nitric Oxide (gNO) for mucolysis. 10 BACKGROUND OF THE INVENTION [00021 Mucus is comprised of high molecular weight proteins. It is a heterogeneous mix of primarily water, electrolytes, lipids, and proteins in a gel matrix. Goblet cells and submucosal glands that are located along the tracheobronchial tree produce it. Mucus is secreted in response to irritation of the airways and is elicited by 15 viral, bacterial, and of major import, environmental contamination, primarily small particulates and allergens. [0003] Airway hygiene and integrity also depends on mucociliary clearance (MCC), which in turn depends upon the movement of viscoelastic mucus along the tracheobronchial tree by the beating of the ciliary appendages of airway epithelial cells. 20 However, because mucus secretions are viscous and thick, it is difficult for the ciliary appendages to move them, and excess accumulation further burdens the mucociliary functions. Conditions that encumber MCC result in an inflammatory response to the airway and increase the risk of colonization by microorganisms, such as pathogens, which if chronic, up regulate mucus production. Encumbered MCC may thus result in a 25 vicious cycle of inflammatory damage with the potential for future damage to both the upper and lower airway. See e.g., Cole P., Minerva Anestesiol. 2001 Apr; 67(4):206-9, "Pathophysiology and treatment of airway mucociliary clearance. A moving tale." Additionally, mucociliary dyskinesia, a condition of impaired mucociliary movement in the airways, is derived from a number of similar vectors, including environmental, and 1 WO 2005/110052 PCT/US2005/016428 likewise result in impaired mucociliary clearance times of respiratory secretions. See e.g., Pedersen M. Lung. 1990; 168 Suppl: 368-76, "Ciliary Activity and Pollution." [00041 In equine mammals, for example, excessive mucus accumulation and the resulting inflammation prevalence may be present in as great as 33% of the population. 5 Excessive mucus accumulation is a significant risk factor for poor performance in racehorses. See e.g., S.J. Holcombe, N.E. Robinson, F.J. Derksen, et. al. 50th Annual Convention of the American Association of Equine Practitioners, 2004 (www.ivis.org) , 4-Dec-2004; P1441.1204, "Trachea Mucus Is Associated With Poor racing Performance In Thoroughbred Horses." 10 [0005] Furthermore, excessive mucus accumulation often manifests into Inflammatory Airway Disease (LAD). In humans, mucus accumulation also accompanies several respiratory diseases and conditions, such as acute bronchitis, chronic pulmonary disease, Bronchiectasis and Cystic Fibrosis. [00061 Attempts at treating these airway derangements have focused on a wide 15 range of interventions (antimicrobials, mucolytics, etc,) with limited success, particularly as it applies to the performance horse. Thus, there exists a need for more effective treatment methods for treating and preventing excess mucus accumulation and related pathology. 20 SUMMARY OF INVENTION [0007] The Applicants have unexpectedly found that gaseous NO when inhaled is an effective mucolytic agent that can break down thick mucus aiding in mucociliary clearance in the respiratory tract of mammals. Using an equine model as an example, the Applicants have demonstrated that the administration through inhalation of nitric oxide 25 containing gas is an effective treatment of mucus accumulation, including the treatment of secondary mucociliary dyskinesia via increased mucociliaiy clearance in mammals. By breaking down the mucus to a less viscous liquid, mucociliary clearance is increased. Additionally, the administration of gNO further protects the respiratory airways from the vicious cycle of inflammatory damage and colonization by microbes because of its anti 2 WO 2005/110052 PCT/US2005/016428 infective activity. Thus, gaseous nitric oxide (gNO) can be administered by inhalation as a novel methodology for reducing the severity and pathology of excess mucus residence in a mammal's respiratory airway, and in particular as an mucolytic agent or expectorant. [0008] In one aspect of the present invention, mammals exhibiting excess mucus 5 accumulation are identified and diagnosed. A source of gNO is provided, preferably in a pressurized cylinder coupled to flow control valves and pressure regulators. gNO may also be diluted with other gases such as N 2 , air, or 02 to form a nitric oxide containing gas at a therapeutically effective amount of nitric oxide sufficient to reduce the presence of mucus in the mammal's airways by at least about 20%, preferably by at least about 10 50%, and more preferably by about at least about 75%. The nitric oxide containing gas is administered to the mammal, preferably through nasal delivery, but may also include oral delivery, for example, through a face mask or an endotracheal tube. [0009] Preferably, the flow rate of gaseous nitric oxide is regulated dependent on the mammal's respiratory tidal volume and the administration is repeated over several 15 breaths. The target concentration of nitric oxide in the mammal's airways preferably ranges from 80 ppm to 400 ppm, and more preferably 160 ppm to 220 ppm. The administration of the inhaled nitric oxide containing gas may also coincide with a synchronous parameter of the mammal's respiratory cycle. [0010] Another aspect of the present invention includes prevention of excess 20 mucus accumulation in a mammal's airway. Mammals that are at risk of excess mucus accumulation may be identified and diagnosed. Therapeutic effective concentration of nitric oxide may then be nasally or orally administered in an amount sufficient to prevent excess mucus accumulation, inflammation, and eventually colonization by microbes. [00111 In another aspect of the invention, apparatuses and systems for treating or 25 preventing excess mucus accumulation in a mammal's airway are provided. For example, the system may comprise an endoscope for determining an amount of mucus accumulation in a mammal's airway using a scoring system such as a discrete scale of 0 to 5, representing the absence of mucus to high levels of mucus, respectively. A nitric 3 WO 2005/110052 PCT/US2005/016428 oxide delivery device may be provided that include a source of nitric oxide containing gas, preferably from a pressurized source of gaseous NO such as a canister or cylinder, and a delivery interface for interfacing with the mammal's mouth or nares. The nitric oxide delivery device is preferably controlled by a control unit such as a microprocessor 5 based computer or analog controller wherein, depending on the scoring input representing the level of mucus accumulation, a distinct gNO therapeutic profile is selected and delivered to the mammals. Such therapeutic profile may be pre-determined or may be programmed by the user. The control unit then controls a flow meter arid/or a control valve that regulates the flow of nitric oxide containing gas, either diluted or 10 flowing directly from the pressurized source of gaseous NO. [0012] Preferably, the apparatus delivers a quantity of the nitric oxide containing gas by regulating the flow rate depending on the mammal's respiratory tidal volume for a selected number of breaths at a certain concentration for the inputted score. [00131 In another aspect of the invention, an system for treating mucus 15 accumulation and/or mucociliary dyskenesia is provided. The system may comprise a pressurized source (e.g., canister or cylinder) of nitric oxide containing gas and a visible label affixed to the container, wherein the label indicates that the nitric oxide containing gas is suitable as a mucolytic agent or expectorant for reducing mucus accumulation and/or treating mucociliary dyskenesia in a mammal's airway. The system may further 20 comprise instructions for delivery of the nitric oxide containing gas and/or instructions for therapeutic amounts or dosages of nitric oxide. Preferably, the concentration of nitric oxide in the pressurized source ranges from about 160 ppm to about 400 ppm, but may also be in excess of that amount such as 800 ppm to 10,000 ppm that may need to be diluted with other gases before use. 25 [00141 In a preferred embodiment, the pressurized source of nitric oxide containing gas is portable and can be carried by the mammal prior to initiation of treatment. The pressurized source may also include a release valve for controllably releasing the nitric oxide containing gas into a channel, tube or nozzle adaptable to direct 4 WO 2005/110052 PCT/US2005/016428 the nitric oxide containing gas to a nostril or mouth of the mammal. The release valve can be actuated to release the nitric oxide containing gas. BRIEF DESCRIPTION OF THE DRAWINGS 5 [0015] FIG. 1 illustrates an electromechanical gas delivery device; [0016] FIG. 2 represents the device described in FIG. 1. [0017] FIG. 3 illustrates a method of delivery of the gas to a horse; [0018] FIG. 4 illustrates an overall delivery system; [0019] FIG. 5 illustrates a J-tube used in conjunction with the device to induce gas into 10 the nostril of a horse. DETAILED DESCRIPTION OF THE INVENTION 10020] Before the present compositions and methods are described, it is to be understood that this invention is not limited to the particular devices, compositions, 15 methodologies or protocols described, as these may vary. It is also to be understood that the terminology used in the description is for the purpose of describing the particular versions or embodiments only, and is not intended to limit the scope of the present invention which will be limited only by the appended claims. [0021] Although any methods, devices, and materials similar or equivalent to 20 those described herein can be used in the practice or testing of embodiments of the present invention, the preferred methods, devices, and materials are now described. All publications mentioned herein are incorporated by reference. Nothing herein is to be construed as an admission that the invention is not entitled to antedate such disclosure by virtue of prior invention. 25 [00221 As used herein, terms such as "subject," "patient," and "mammal" may be used interchangeable. As used herein, a mammal's "airway" or "airways" refer to any of the various parts of the respiratory tract through which air passes during breathing, including, but not limited to the lungs and the trachea. As used herein, "treating excess mucus accumulation" encompasses one or more of the following: reducing mucus 5 WO 2005/110052 PCT/US2005/016428 accumulation, preventing excess mucus accumulation, mitigating and/or preventing mucociliaiy dyskinesia, and increasing mucociliary transport in the airway. As used herein, "therapeutically effective amount" refers to an amount sufficient: (1) to increase mucociliary transport in the mammal's airway by about at least 50%; (2) to increase 5 MMC in the mammal by at least about 50%; and/or (3) to reduce the presence of mucus in the mammal's airways by about at least 20%. [00231 Using an equine model, the Applicants have demonstrated that the administration of gaseous NO to mammals exhibiting excess mucus accumulation is effective in the treatment thereof. Specifically, nitric oxide containing gas was inhaled 10 by six (6) equine exhibiting excessive mucus accumulation, and immediately, within 10 30 minutes, non-viscous liquids starts to flow out of the horses' nares, resulting in reductions of mucus to trace levels in all subjects. While gaseous nitric oxide has been utilized in other therapeutic applications such as to treat pulmonary vasocontrictions, pulmonary infections, it is believed that effectiveness of gaseous NO as a mucolytic 15 agent in treating excess mucus accumulation is novel and unexpected. [00241 Delivering exogenous nitric oxide gas is an ideal mucolytic therapy because gaseous NO diffuses readily and uniformly into the respiratory airway to reach the mucus. Once absorbed, its biological activity is limited by avid binding to hemoglobin, rendering its activity short lived. Nevertheless, the short duration of its 20 activity is preferred because it limits the untoward side effects of other systemic agents or drugs. [0025] In a preferred embodiment, the administration of gaseous nitric oxide is performed using a gated flow system, and the concentration of gNO is dilutionally derived based on the mammal's inspiratory phase of the respiratory cycle. To achieve an 25 inspiratory nitric oxide concentration of 160-220 ppm, for example, the mammal may need to receive a pre-determined higher concentration of nitric oxide and therefore a derived fl-action of the mammal's tidal volume. The tidal volume of the mammal may be measured and determined using techniques well known in the art. The required 6 WO 2005/110052 PCT/US2005/016428 flow/concentration (e.g. 160 or 220 ppm of nitric oxide) may then be calculated based on the mammal's tidal volume. [0026] For example, a sample calculation for a horse having a tidal volume (Vt) of 7 liters per breath is as follows. Target NO dose concentration is 200 ppm. Source 5 tank NO concentration is 10,000 ppm. Therefore, 0.02 x 700 (100 brs x Vt 7 liters) = 14 ltrs. Duration of NO gas at Equine respiratory rate (rr) of 12 / min. = 8.3 mins. Total inspiratory time @ I:E ratio of 1:2 = 2.76 mins. Therefore NO gas flow needed @ rr of 12/min = 14ltrs. / 2.76 = 5.07 ltrs/min. [00271 The following example describes the manner and process of 10 administration of gaseous nitric oxide to equines that reduces excess mucus accumulation and increases mucocoliary clearance according to the present invention. The following example should not be construed as limiting. EXAMPLE 15 [0028] Six (6) Thoroughbred racehorses at a major racing jurisdiction were quarantined for two weeks, and each horse had evidence of excessive mucus production as surveyed by clinical presentation and by endoscopic exam. The horses were isolated from each other and were being medicated daily in series with several broad-spectrum antimicrobials routinely employed for respiratory infections in Equids. The results 20 before the administration with-gaseous NO had been unremarkable. Further physical exam revealed all other systems were within normal limits. All six horses were included in the study using gaseous NO. Intervention / Methods: 25 [0029] The horses were brought individually to the veterinary hospital barn for further evaluation over the course of five days. An fiberoptic endoscope was passed to the level of the bifurcation of the trachea (carina-airway) with images recorded on videotape. A scoring system was used to indicate the presence or absence of mucus, as well as its severity, if present. This scoring system has been described by Dixon et. al., 7 WO 2005/110052 PCT/US2005/016428 "Equine Pulmonary Disease: Ancillary Diagnostic Findings," Equine Vet. Journal 27, 428-435, 1995, herein incorporated by reference in its entirety. A score of zero indicates the absence of mucus, while a score of I to 5 indicates increasing amounts of mucus observed endoscopically in the trachea. The attending Veterinarian conducting the 5 examination did the scoring. All of the six horses scored 4 or higher before the initiation of the treatments. [0030] Treatment intervention of inhaled gaseous Nitric Oxide was administered to all six horses during a five-day period. Five of the horses (#2 - #6) received 100 breaths of 10,000 ppm resulting in, based on pulmonary mechanics, a lung concentration 10 of approximately 160 ppm. Horse #1 received 100 breaths of 5000 ppm resulting in 80 ppm on Day #1 and a second administration of 100 breaths of 10,000 ppm on Day #5. Horse #5 received 100 breaths of 10,000 ppm on Day #3 and a second administration of 100 breaths of 10,000 ppm on Day #4. [0031] It was observed that immediately following the administration of gaseous 15 NO to the horses that non-viscous liquids started to flow, out of the nares of the horses. The liquids appear to be mucus that has been hydrolyzed and thinned,i and Applicants postulate that gaseous NO hydrolyzes the mucus by breaking down disulfide bonds in the mucus gel matrix. [0032] The method of the inhaled NO administration was uneventful to other 20 physiological systems and no untoward side effects were observed. An outline of the treatment results is provided below in Table No. 1 (with scores when available). At Day #1, all subjects had a score of 4 or greater. On a day where a measurement and a treatment occur, such as Day #4 for Horse #5, the measurement was taken before the administration of the second dosage. 25 Table No. 1 Day #1 Day #2 Day #3 Day #4 Day #5 Day #6 Horse #1 Tx, 5k Clear(0) 25 % rtn. NG NG, Tx 10k Trace (1) Horse #2 Tx, 10k Clear(0) 25 % rtn. NG NG NA Horse #3 NA Tx, 10k Clear(0) NG Trace (2) NA Horse #4 NA NA Tx, 10k Clear (0) 25% rtn. NA 8 WO 2005/110052 PCT/US2005/016428 Horse #5 NA NA Tx, 10k Clear (0), Trace (2) Trace (1) Tx, 10k Horse #6 NA NA NA NA Tx, 10k Trace (2) Legend: NA = Not applicable, not available for review NG = No change in status 5 25% rtn = A return of 25% of the previous amount of mucus (amount before administration of gNO), not scored Tx, 5 k = A treatment using 100 breaths at 5000 ppm Tx, 10k = A treatment using 100 breaths at 10,000 ppm (0-2) = Numerical scoring system 10 [0033] Although, not scored for the horses in which 25% of the mucus returned (Horses # 2 and #4), a 75% reduction in mucus from Day #1 was observed in these horses. In Horses #1, #3, #5 and #6, a reduction in mucus scores of 4 and 5 to trace amounts (score I and 2) demonstrates a reduction of about 40% to about 80% of mucus 15 present in the airways. [00341 Preliminary experiments with bovine show similar effectiveness with mucus being hydrolyzed and excreted from the nares within 10-30 minutes. Anecdotal studies with human volunteers with cold show similar effectiveness. Thus, the Applicants believe that inhaled gaseous NO as an effective treatment to excess mucus 20 accumulation in the airways of mammals. [0035] It is believed that the observed reduction in the presence of mucus was through the immediate mucolytic activity of gNO in breaking down the mucus gel matrix. While the NO molecule has been studied for many purposes, it is believed that the use of inhaled gaseous NO as a suitable mucolytic therapy is novel. Once liquefied, 25 the ciliary appendages in the respiratory epithelial cells may then more easily transport and move the mucus to clear the respiratory airway. [0036] Moreover, delivery of gaseous NO may increase the local bioavailability of nitric oxide that may regulate and increase the ciliary beat frequency of the respiratory epithelial cells. This leads to further ameliorating of mucociliary dyskinesis with 30 subsequent decreased mucociliary transit time Further, because of the anti-infective 9 WO 2005/110052 PCT/US2005/016428 activity of gaseous NO, longer duration and treatment profiles may be beneficial in removing the microbes or virus that may be causing the excess mucus secretion and accumulation. [00371 Determining the treatment eligibility of an individual may be based upon 5 the clinical presentation of excessive mucus accumulation in the upper lower airway. The excessive mucus accumulation may be observed with an endoscope. A therapeutic amount of nitric oxide containing gas may be administered to a mammal to reduce the amount of mucus in the airways by at least about 20%, preferably at least about 50%, and more preferably, at least about 75%. The scoring system described by Dixon et al. 1995 10 provides a qualitative measure of the presence or absence of mucus, using a scale of 0-5. Thus, a therapeutic amount of nitric oxide containing gas inhaled by a subject may be effective in decreasing this mucus score by at least 1 point, or by about 20%. Other means of quantifying mucus in the airways are also possible. [0038] Additionally, inhaled nitric oxide containing gas may act as a preventative 15 measure in the accumulation of mucus in the airways. Mammals may be selected that exhibit a risk of mucus accumulation. Such a risk may be associated with recent infection and/or contact with other infected mammals. Preliminary experiments with healthy bovine show that delivery of inhaled gNO results in 'the prevention of mucus accumulation. Additionally, in the equine study, the delivery of gNO did not result in 20 any irritation, inflammation or abnormal side effects. The delivery of inhaled nitric oxide containing gas may be administered to these risk mammals in order to prevent mucus accumulation in the airway. Effective therapeutic amounts may also refer to an amount sufficient to break down the viscoelastic mucus and increase mucociliary transport in the mammal's airway and to increase MMC in the mammal. Therefore, treating mucus 25 accumulation in the airways of a mammal comprises reducing mucus accumulation, preventing mucus accumulation, reducing mucociliary dyskinesia, and/or preventing mucociliary dyskinesia. 10 WO 2005/110052 PCT/US2005/016428 Examples of Delivery Methods and Devices [0039] Various methods and devices may be used to administer a therapeutically effective amount of nitric oxide containing gas to a mammal's airways. While preferred examples are provided herein, they are not intended to be limiting. 5 [0040] Effective therapeutics may include an administration of nitric oxide containing gas in a defined concentration of parts per million for a finite duration. Preferably, the target concentration of nitric oxide mammal's airways ranges from about 80 ppm to 400 ppm, and more preferably from about 160 ppm to about 220 ppm. [0041] Delivery of nitric oxide gas to the airway may be achieved through 10 delivery that coincides with the inhalation of the subject. In one embodiment for use with humans, gNO may be contained within portable pressurized canisters such as those used with portable inhalers that are well known in the art. Examples of inhaler designs are discussed in, for example, U.S. Pat. Nos. 5,823,180; 5,570,683; 4,667,668; 4,592,348; 4,534,343; and 4,852,561, each of which patents is herein incorporated by 15 reference. Other inhaler designs are described in the Physicians' Desk Reference, 45th Edition, Edward R. Barnhart, Publisher (1991). Each of these and other aerosol-type inhalers can be adapted to accommodate the delivery of NO gas. This embodiment is especially suited for use by individuals suffering from, for example, common colds or allergy, congestive cough, and flu. 20 [00421 In use, the pressurized canister includes a release valve that can be manually actuated to controllably release gNO into a chanel or tube adapted for insertion into the mouth or nostril of the mammal. Coincident with, or immediately before the inhalation by the mammal, the release valve can be actuated so as to release the gNO into the oral or nasal cavity and inhaled into the respiratory airway. Successive 25 treatments and release of gNO coincident with the inspiration can be made depending on the therapeutic dosage. The amount of gNO release preferably ranges from about 0.5 ml to about 8 ml at a canister concentration of about 5000 or 10,000 ppm. [00431 A visible label can also be affixed to the pressurized canister indicating 11 WO 2005/110052 PCT/US2005/016428 that gNO is used as a mucolytic agent to treat excess mucus accumulation or as an expectorant. Additionally, the pressurized canister can be included in a kit that also includes instruction for its use to treat excess mucus accumulation in the airway. Preferably, the instruction instructs the user that exhibits excess mucus accumulation to 5 insert the channel into his mouth or nostril and to actuate the release valve substantially coincident with the inhalation by the user. [00441 In another embodiment envisioned for use in a hospital or clinical setting, breathable air from any source (e.g., ambient room air or ventilator carrying oxygen containing gas) may be directed to a nasal interface using techniques well known in the 10 art. The inspiration and expiration flow rates of a spontaneous breathing of a mammal may be monitored using a flow sensor or flow meter known in the art and, inspiration flow profiles can be determined for the mammal's breathing. Inspiration flow profile of the breathable gas is the flow rate of the gas as a function of inspiration time. Delivery of the NO containing gas, preferably added to the breathable gas stream through a Y-piece 15 connector, may be timed to coincide with the mammal's inspiration. [0045] In the emhodiments described to deliver the nitric oxide containing gas coincident with inspiration, the concentration of the gas delivered is dilutionally derived and is based on the individual's tidal volume. Thus, the final concentration of nitric oxide gas at the treatment site is a function of arbitrary flow rates and starting 20 concentration. Accordingly, starting concentrations of gNO that are higher than the desired concentration for therapeutic effectiveness may be needed to account for the dilution by the breathable air flowing into the airway, and flow rates may be regulated flow rates may be regulated [0046] For example, in humans, if the desired therapeutic concentrations of nitric 25 oxide in the nitric oxide containing gas is about 160 ppm to about 220 ppm in the lungs, then the source gas may need to contain concentrations of nitric oxide of about 5000 ppm to about 10,000 ppm. In order to meet the therapeutic level in certain embodiments, a delivery concentration of the nitric oxide may need to be decreased by about 80-90 12 WO 2005/110052 PCT/US2005/016428 percent to account for dilution with breathable gas in a human patient. These values of nitric oxide containing gas may be delivered to a patient during their inspiration, wherein for example, a human patient is breathing at a flow rate of about 1 liter per minute. Under this example, delivered nitric oxide containing gas having a concentration of about 5 5000 ppm at 1 liter per minute would be reduced to a concentration of about 65 ppm in the lungs when diluted by the breathable air. If the flow rate is changed to 2 liter per minute, then the delivered nitric oxide containing gas should have a concentration of about 5000 ppm to maintain the same concentration of about 130 ppm at the treatment site (therapeutic concentration). As another example, a pulse of about 1 to 1.5 seconds of 10 nitric oxide would deliver 100 to 150 milliliters of nitric oxide into the airway and the lungs. [0047] These calculations in humans may be recalculated using any concentration of source gas, using the tidal volume of human, which is about 0.5 mL per breath. If a source gas of 10,000 ppm is used and a target therapeutic concentration is 200 ppm, 15 knowing that the tidal volume is 0.5 mL/bth, I liter of the gNO may be delivered over 100 breaths. A typical respiratory rate of a human is 12 bth/min, resulting in a treatment time of about 8.33 minutes. As another example, if a source gas of 10,000 ppm is used and a target therapeutic concentration is 100 ppm, about 0.5 liter of the gNO may be delivered over about 100 breaths. Calculations may be based on total minute ventilation 20 of a patient, which is respiratory rate multiplied by tidal volume, for example is 0.5 L/bth x 12 bth/min = 6 L/min. An inspiratory ratio of 1:2 may be used with a human patient, resulting in a inspiratory time ratio of 0.33. A total inspiratory time per treatment may then be calculated multiplying the inspiratory time ratio by the treatment time, or 8.33 min x 0.33 = 2.78 min, in this example. An inspiratory gNO flow rate from device may 25 be calculated by dividing the source gNO required per treatment by the total inspiratory time, or 0.5 L / 2.78 min = 0.18 L/min. [00481 In the equine model, flow rates of nitric oxide containing gas will be greater than in the human model to account for greater tidal volume of the horse (about 7 13 WO 2005/110052 PCT/US2005/016428 liter per breath). However, horses take about the same number of breaths per minute as humans, about 12 per minute at rest. The flow values outlined below in Table No. 2 provide a guide that allows for effective delivery of near optimal concentrations of the gas using a source cylinder concentration of 10,000 ppm of gaseous NO. 5 Table No. 2 Subject tidal volume Target Nitric Oxide NO Inspiratory Flow from Flow (7-8 ltrs) Delivery (ppm) device (100 brs.) At rest 160 4.0 ltrs/min At rest 200 5.07 ltrs/min [00491 As alluded to above, the nitric oxide containing gas may be inhaled over a finite period of consecutive breaths. In equine, nitric oxide containing gas may be 10 combiried and delivered to about 100 consecutive nasal breaths. For example, using a 10,000 ppm nitric oxide gas source delivered coincident with the inspiratory flow of the horse in 100 breaths results in, based on pulmonary mechanics, a lung concentration of approximately 160 ppm. Using 5,000 ppm nitric oxide gas source in 100 breaths results in about 80 ppm. 15 [0050] With a source gas of 5000 ppm and a target therapeutic delivery concentration of 200 ppm, 28 liters of NO gas should be delivered over 100 breaths. The deliver treatments would delivered over 8.33 minutes. Total minute ventilation for a horse would be tidal volume (7 L/bth).multiplied by respiratory rate (12 bth/min), or 84 L/min. An inspiratory ratio of 1:2 may be used with a horse, resulting in a inspiratory 20 time ratio of 0.33. A total inspiratory time per treatment may then be calculated multiplying the inspiratory time ratio by the treatment time, or 8.33 min x 0.33 = 2.78 min, in this example. An inspiratory gNO flow rate from device may be calculated by dividing the source gNO required per treatment by the total inspiratory time, or 28 L / 2.78 min = 10.08 L/min. 25 [0051] In yet another embodiment, triggering of the NO flow into the breathable 14 WO 2005/110052 PCT/US2005/016428 gas stream may also be accomplished by measuring and modeling the mammal's inspiration profile for a number of previous breaths. NO flow is then initiated on a subsequent breath based upon a predicted timing of the mammal's breathing to flow NO during inspiration. Yet another alternative method of determining the point to initiate the 5 NO flow is by measuring the volume inspired by the mammal, which can be calculated based on the flow rate and elapsed time of flow of the breathable gas. [00521 Those in the respiratory art, and particularly those familiar with ventilation methods, recognize the respiratory cycle of the mammal. The respiratory cycle is synchronous, defined by the inhalation and exhalation of the mammal. There are 10 several synchronous parameters that may be observed to determine the inhalation and exhalation phases of the cycle. Examples of these parameters include the rate of flow of gas directed toward the mammal's airway, pressure change at the initiation of a breath, the synchronous movement of the laryngeal, and the synchronous motion of the chest wall. One or more of these parameters may be used as an indicator of the timing of 15 mammal inhalation and exhalation. Thus, a synchronous parameter may be used to determine the initiation of a breath, and delivery of gNO may be timed according to the synchronous parameter to coincide with the inspiration of the mammal. This parameter may not be applicable to all mammals as anatomy will vary. [00531 The above methods are preferably perfonned through the use of a control 20 module, preferably a controller such as a computer microprocessor with associated logic (firmware or software), that may time the administering of the nitric oxide containing gas to the mammal's airway. The timing may be during the mammal's inspiration, at a predetermined or premeasured time. Alternatively, the mammal's inspiratory flow or volume may be measured and thus delivery will coincide with this measurement. This 25 volume may be monitored or adjusted based on successive breaths. [00541 In another embodiment, a pulse dose delivery or a bolus injection delivery of the NO containing gas may be used. The timing of the bolus injection may be correlated to the detection or observation of a mammal breath. For example, a bolus 15 WO 2005/110052 PCT/US2005/016428 injection of the NO containing gas may be delivered nasally or orally substantially coincident with the inhalation. [0055] Systems and apparatus for delivery of nitric oxide containing gas have been described, for example, in U.S. Patent Application No. 10/315,539 (Publication No. 5 2003/0150457), which is herein incorporated by reference in its entirety. In that application, a nitric gas dispenser is described, which gates the flow rate of the gNO to the inspiratory phase of the respiratory cycle. The dispenser may also include a pressure sensor and a valve mechanism for controllably delivering the nitric oxide gas in connection with the subject's breathing. Synchronous inspiratory application may be 10 advantageous and necessary in order to quantify inhalant nitric oxide administration and minimize inadvertent human and/or mechanical error. [00561 With reference to the FIGs., which describe a delivery method to a horse, FIG. 1 illustrates a block diagram representation of the device 12. With reference to FIG. 1, the device 12 has a power source 100. The power source can be an electrical outlet if 15 the user of the device is going to work out on a treadmill or a battery if the user will be working away from a confined environment like a track. The power source 100 provides sufficient voltage and charge to properly operate the device 12. The device 12 also has a controller that comprises main microprocessor 14 that controls the operation of a solenoid valve 16, also within the device 12. The solenoid valve 16 operates in 20 conjunction with operating parameters that are entered via a data entry keypad 2 and the input from a pressure sensor 18. [0057] The operating parameters and the operating status of the device 12 are displayed on an LCD display 1. Along with the LCD display 1, the device 12 has a nitric oxide gas supply 3, preferably a cylinder. In that cylinder is nitric oxide having a 25 pressure of 1800 to 2200 pounds per square inch (psi). [0058] The device 12 also has a pressure regulator 6. The pressure regulator 6 reduces the pressure of the nitric oxide to less than 100 psi so it can be administered to the mammal, such as a horse, without damaging the mammal's organs from too much 16 WO 2005/110052 PCT/US2005/016428 pressure. [0059] Calibrating the flow through the solenoid valve 16 is obtained by selecting the pressure of the pressure regulator 6 and controlling the time that the solenoid valve 16 is open. Thereby, the valve 16 allows a precise amount of nitric oxide to be delivered 5 through a gas delivery line 4, which delivers the nitric oxide to the mammal, preferably a horse. The pressure sensor 18 is designed to detect a drop in pressure in the gas delivery line 4, when the horse initiates a breath. This pressure drop signals the main processor 14 to open the solenoid valve 6 for a pre-programmed period of time. Among the parameters that are programmed into the device are: Total Breaths, Start Delay, Pulse 10 Time, Pulse Delay, and Re-trigger Lock. [0060] The programmable parameters are defined as follows: [0061] Total Breaths: This parameter is the number of breaths programmed into a run. Each time a breath is detected as identified above, a pulse of nitric oxide gas is injected into the breath of mammal. Breaths that occur during a locked out time of the 15 run are not counted as breaths. After the programmed number of breaths are counted, the run stops automatically and nitric oxide gas is no longer injected into any breaths of the mammal. This number can be set anywhere from 0 to 100 breaths. If the number is set at 0 then the auto shutoff is disabled and breaths will be injected with nitric oxide until the user stops the run. 20 [0062] Start Delay: This parameter is the programmed delay time in minutes that the user can set. The injection of nitric oxide gas into each breath will begin automatically after "Start Delay" minutes. It will then continue for the number of Total Breaths and then the device 12 stops automatically. [0063] Pulse Time: This parameter is the length of time that the solenoid valve 25 16 will open for delivery of nitric oxide gas. The resolution is 0.1 seconds and the range is 0.1 sec to 0.9 seconds. If the regulator is set at 50 psi then each second of the solenoid valve 16 opening 31 cc of nitric oxide gas. If the regulator pressure is set at 30 psi then each 0.1 sec solenoid valve 16 opening represents 21 cc of nitric oxide gas. For example, 17 WO 2005/110052 PCT/US2005/016428 if the regulator is set at 50 psi and the pulse time is set at 0.3 seconds then each detected breath will be injected with a pulse of 0.3 seconds or about 90 cc of nitric oxide gas. [0064] Pulse delay: This parameter is the length of time that the machine waits after detecting the beginning of a breath before opening the solenoid valve 16 to inject a 5 pulse of nitric oxide gas. This allows the user to control the position of the bolus of nitric oxide gas in the breath. For example, if the user sets the solenoid valve 16 at 0.4 seconds, then 0.4 seconds after the beginning of the breath is detected the solenoid valve 16 will open to inject the nitric oxide pulse. [0065] Retrigger Lock: This parameter is the total time that the machine will 10 ignore new breaths beginning at the detection of a new breath. If this parameter is set at 4.5 seconds then the device 12 will wait, after detecting a breath, for 4.5 seconds before recognizing a new breath. Full or half breaths that are initiated by the animal during this lockout time will not be counted and no nitric oxide will be injected. If the breath is initiated before the lockout expires and the animal is still inhaling when the lockout 15 expires then it will be recognized as a new breath and it will be counted and injected with nitric oxide. [00661 With reference to FIG. 2, the data entry keypad 2 contains five active button switches defined as follows: [0067] START/PULSE KEY 30: This key is used to start a run. The user is 20, required to confirm the start by pressing an UP key 32 or to cancel by pressing a DOWN key 34. When a run is in progress, pressing this key will cause the run to pause. The run is then resumed by pressing the UP key 32 or stopping the run by pressing the DOWN key 34. [0068] UP key 32: This key is used to confirm the start of the run, to resume a 25 paused run and also to increment valve changes. [0069] DOWN key 34: This key is used to cancel a started run, end a paused run and also to decrement valve changes. [0070] NEXT key 36: This key is used to switch screen pages on the LCD display 18 WO 2005/110052 PCT/US2005/016428 1. [00711 PURGE key 38: This key is used to open the solenoid valve 16 for two seconds to purge the line. This key is not active during a run. The LCD display 1 displays four screen pages, defined as follows: 5 [0072] Each screen page displays a status line. The status variations include NOT RUNNING, WAITING, RUNNING, PAUSED, PURGING and START Pressed. [0073] The main screen page has a row of asterisks on the top line. This is the only screen available when the KEY switch is in the locked position. This screen displays the total breaths detected and also the total breaths that will cause the run to stop. 10 [00741 The second page shows two valves. The first is the START DELAY valve. When the screen first appears the blinking cursor shows the value, which can be changed by pressing either the UP or DOWN key. Pressing the NEXT key switches, the cursor to the second value on the screen which is TOTAL BREATHS. [0075] The third page allows the user to change the PULSE DELAY and the 15 PULSE TIME. [0076] The fourth page allows the user to change the RETRIGGER LOCK. [0077] With reference to FIG. 2, a capped port 5 is depicted. This is an alternate input port fir nitric oxide and is utilized if the device is not used with the small gas cylinder as depicted in FIG. 2. The cap is typically replaced with a quick-connect style 20 fitting for attachment to a standard regulators on a large gas cylinder. [00781 In one embodiment, the controller may also comprise logic such as firmware or software for selection of a therapeutic profile for the administration of gaseous nitric oxide based on an input value representing a level of severity of mucus accumulation in the mammal's airway. The level of severity may be determined by an 25 attending physician or veterinarian using, for example, a fiberoptic endoscope, as described in the study with horses. As an example, the input value may be 0, 1, 2, 3, 4, and 5, wherein 5 indicates a most severe condition of excess mucus accumulation, while 0 represents only a trace amount of mucus. It should be understand that there are many 19 WO 2005/110052 PCT/US2005/016428 variations on the types of input value, (e.g., A, B, C, et seq. or High Medium, Low, et seq., Most Severe, Severe, Medium, Trace, None), and these variations are considered as equivalents to a numerical scale. [0079] The controller may further comprise a memory device such as a RAM, 5 ROM, EPROM, hard disk, removable storage medium or other removable known in the art, wherein the memory device stores a number of therapeutic profiles each corresponding to a level of severity of mucus accumulation in the mammal's airways. The therapeutic profiles can be pre-determined or programmable by the user. The parameters that make up the therapeutic profiles may include, but is not 10 limited to, flow rate of nitric oxide containing gas, duration of administration of nitric oxide containing gas, number of breaths for which nitric oxide containing gas is to be administered, and concentration of therapeutic NO delivered to the airways. [00801 In use, an attending physician or veterinarian makes a diagnosis of the severity of excess mucus accumulation in the mammalian's airway. The attending 15 physician or veterinarian then input a value into the device 12 or select a value from a set of presented values by the device 12 via the data entry keypad 2. The device 12 via the controller is then instructed to execute the delivery of a certain therapeutic profile corresponding to the value inputted or selected. Table 3 illustrates a sample set of therapeutic profiles based on a nitric oxide gas source at 10,000 ppm for delivery to an 20 equine. It should be understand that this example is not intended to be limiting, and other types of therapeutic profiles may be programmed into the device and delivered to the mammal. 25 Table No. 3 Time Dose Profiling (10% reduction steps on No Breaths) Input flow rate duration of No. of breaths Pre-Diagnosis Value administration 0 1 4.0 ltrs./min 8.30 mins. 100 (160 ppm) Mucus Score 1 2 5.07 ltrs./min 2.07mins. 25 (200 ppm) Mucus Score 2 20 WO 2005/110052 PCT/US2005/016428 3 5.07 ltrs./min. 4.15mins. 50 (200 ppm) Mucus Score 3 4 5.07 ltrs. min. 6.23 mins. 75 (200 ppm) Mucus Score 4 5 5.07 Itrs/min 8.30 mins. 100 (200 ppm) Mucus Score 5 [0081] FIG. 3 and 5 illustrate the method of delivering nitric oxide to the horse. 5 A J-tube 7 made of semi rigid plastic such as styrene is attached to the horses' halter 9 by two hook and loop fabric fasteners. A small clip 10 also secures the delivery line 11 to the halter 9. The delivery tube 11 is typically a clear plastic flexible tubing. The delivery line connects to port 4 shown in FIG. 2. [00821 FIG. 4 shows a typical application in its complete form. The delivery 10 device 12 is shown in a cradle 14 which attaches to a surcingle 13. This provides a convenient method of attaching the device to a horse. [0083] Other delivery systems which may administer inhaled nitric oxide containing gas may include the delivery systems described in U.S. Patent No. 5,765,548, which is herein incorporated by reference in its entirety. As such, several delivery 15 devices may nasally administer the inhaled nitric oxide containing gas. The devices may administer a therapeutic level of nitric oxide gas, such as an inhale nitric oxide containing gas having a concentration of about 160 ppm to about 220 ppm nitric oxide. One apparatus for treating mucus accumulation in a mammal's airway may include a transportable container comprising a nitric oxide containing gas, such as the transportable 20 delivery device 12, attached to the subject in FIG. 4. The apparatus may also include a nozzle in fluid flow communication with the container, wherein the nozzle is operable to deliver the nitric oxide containing gas to one or both nostrils of a mammal. An example of the nozzle is the J-shaped nozzle 7 shown in FIG. 4 in fluid communication with the delivery device 12. 25 [0084] The apparatus may also include means including a flow meter for determining a physiological acceptable quantity of the nitric oxide containing gas to be delivered into the mammal's airway from the nozzle. Such a flow meter may be used to deliver nitric oxide containing gas having a concentration of about 160 ppm to about 220 21 WO 2005/110052 PCT/US2005/016428 ppm nitric oxide. The physiological acceptable quantity of the nitric oxide containing gas may correspond to the mammal's respiratory tidal volume, as described in the delivery mechanics described in FIGs. 1-4. The apparatus may also include an endoscope for determining the presence of mucus accumulation in the airway. This 5 endoscope may communicate with the flow meter in order to deliver the nitric oxide containing gas when it detects a sufficient level of mucus accumulation. [0085] In yet another embodiment of the invention, a kit or system may be provided for the treatment of mucus accumulation would comprise the a pressurized cylinder or canister containing gNO source and a label affixed to the cylinder or canister 10 indicating that use of gNO as a mucolytic agent for the treatment of excess mucus accumulation. [0086] Thus, a system may be assembled including a container comprising a nitric oxide containing gas and a visible label affixed to the container. The label may indicate that the nitric oxide containing gas is suitable for reducing mucus accumulation 15 in a manual's airway. Thus, a nitric oxide containing gas may be packaged and sold for the therapeutic use of reducing mucus accumulation in a mammal's airway. The label may also provide instructions for delivery of the nitric oxide containing gas and/or instructions for therapeutic treatments of mucus accumulation. As explained with reference to the human and equine models, the nitric oxide containing gas may have a 20 concentration of about 160 ppm to about 10,000 ppm nitric oxide. [0087] The example and figures describe the manner and process of nasal administration of gNO to an equine to reduce excess mucus accumulation according to the present invention. While embodiments of the present invention have been shown and described, various modifications may be made without departing from the scope of the 25 invention. The invention, therefore, should not be limited, except to the following claims, and their equivalents. 22

Claims (20)

1. A method of treating excess mucus accumulation in a mammal's airway comprising the steps of: providing a pressurized source of nitric oxide containing gas; and administering a therapeutically effective amount of nitric oxide containing gas to a mammal exhibiting excess mucus accumulation in the mammal's airway, wherein the nitric oxide containing gas is administered substantially coincident with the inspiration of the mammal.

2. The method of claim 1, further comprising the step of regulating a flow rate of the nitric oxide containing gas depending on the mammal's respiratory tidal volume.

3. The method of claim 2, wherein the concentration of nitric oxide containing gas in the mammal's airway ranges from about 160 ppm to about 220 ppm.

4. The method of claim 1, wherein the administration of the nitric oxide containing gas is timed according to a synchronous parameter of the mamma's respiratory cycle.

5. The method of claim 4, wherein the synchronous parameter is selected from a group consisting of rate of flow of gas directed toward the mammal's airway, pressure change at the initiation of a breath, the synchronous movement of the laryngeal, and the synchronous motion of the chest wall.

6. The method of claim 1, wherein the therapeutically effective. amount of nitric oxide containing gas is sufficient to reduce an amount of mucus in the mammal's airways by at least about 50%.

7. The method of claim 1, wherein the therapeutically effective amount of nitric oxide containing gas is sufficient to effect mucolysis within thirty minutes.

8. A method of treating excess mucus accumulation in a mammal's airway comprising the steps of: identifying a mammal exhibiting excess mucus accumulation; determining the severity of mucus accumulation in the mammal; providing a source of nitric oxide containing gas; administering the nitric oxide containing gas using a distinct therapeutic profile corresponding to the severity of mucus accumulation in the mammal. 23 WO 2005/110052 PCT/US2005/016428

9. The method of claim 8, wherein the severity of mucus accumulation is scored from 0 to 5, with 5 indicating a most severe condition.

10. The method of claim 8, wherein the distinct therapeutic profile is selected from a pre-determined set of therapeutic profiles.

11. The method of claim 10, wherein the distinct therapeutic profile comprises therapeutic parameters selected from a group consisting of flow rate of nitric oxide containing gas, duration of administration of nitric oxide containing gas, number of breaths for which nitric oxide containing gas is to be administered, and concentrations of therapeutic NO delivered to the airways.

12. A portable inhaler comprising: a pressurized canister comprising gaseous nitric oxide; a channel adapted for insertion into a mammal's mouth or nostril; a release valve for controllably releasing the gaseous nitric oxide into the chapel; and a label indicating suitable use of gaseous nitric oxide as a mucolytic agent or expectorant.

13. A packaged kit comprising: the portable inhaler of claim 12; and an instruction sheet instructing a user having mucus accumulation to insert the channel into his mouth or nostril and to actuate the release valve substantially coincident with inhalation.

14. A nitric oxide delivery apparatus for treating excess mucus accumulation in a mammal's airway, the apparatus comprising: a source of gaseous nitric oxide; a delivery interface adapted to deliver gaseous nitric oxide to the mammal's airway; a flow control valve positioned downstream of the source of gaseous nitric oxide and upstream of the delivery interface; and a controller in communication with and controlling the flow control valve to regulate a flow rate of the gaseous nitric oxide from the source to the delivery interface; wherein the controller comprises logic for selection of a therapeutic profile of gaseous nitric oxide based on an input value representing a level of severity of mucus accumulation in the mammal's airway. 24 WO 2005/110052 PCT/US2005/016428

15. The nitric oxide delivery apparatus of claim 14, wherein the controller further comprises a memory device that stores a number of therapeutic profiles of gaseous nitric oxide each corresponding to a level of severity of mucus accumulation in the mammal's airways.

16. The nitric oxide delivery apparatus of claim 14, wherein the input value is selected from a group consisting of 0, 1, 2, 3, 4, and 5.

17. The nitric oxide delivery apparatus of claim 15, wherein the therapeutic profiles are pre-determined and comprises therapeutic parameters selected from a group consisting of flow rate of nitric oxide containing gas, duration of administration of nitric oxide containing gas, number of breaths for which nitric oxide containing gas is to be administered, and concentrations of therapeutic NO delivered to the airways.

18. The nitric oxide delivery apparatus of claim 14, further comprising an input device for entering the input value into the controller.

19. An system for treating mucus accumulation, the system comprising: a pressurized cylinder comprising nitric oxide gas; and a visible label affixed to the container, wherein the label indicates that the nitric oxide containing gas is suitable as a mucolytic agent or expectorant.

20. The system of claim 19, further comprising an instruction sheet instructing delivery of nitric oxide gas from the pressurized cylinder to a mammal exhibiting excess mucus accumulation substantially coincident with inhalation of the mammal. 25