Performance of different nebulizers in clinical use for Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC)

Objective Technical ex-vivo comparison of commercial nebulizer nozzles used for Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC).Methods The performance of four different commercial nebulizer nozzles (Nebulizer; HurriChemTM; MCR-4 TOPOL (R); QuattroJet) was analysed concerning: i) technical design and principle of operation, ii) operational pressure as function of the liquid flow rate, iii) droplet size distribution via laser diffraction spectrometry, iv) spray cone angle, spray cone form as well as horizontal drug deposition by image-metric analyses and v) chemical resistance via exposing to a cytostatic solution and chemical composition by means of spark optical emission spectral analysis.Results The Nebulizer shows quasi an identical technical design and thus also a similar performance (e.g., mass median droplet size of 29 mu m) as the original PIPAC nozzles (MIP/ CapnoPen). All other nozzles show more or less a performance deviation to the original PIPAC nozzles. The HurriChemTM has a similar design and principle of operation as the Nebulizer, but provides a finer aerosol (22 mu m). The principle of operation of MCR-4 TOPOL (R) and QuattroJet differ significantly from that of the original PIPAC nozzle technology. The MCR-4 TOPOL (R) offers a hollow spray cone with significantly larger droplets (50 mu m) than the original PIPAC nozzles. The QuattroJet generates an aerosol (22 mu m) similar to that of the HurriChemTM but with improved spatial drug distribution.Conclusion The availability of new PIPAC nozzles is encouraging but can also have a negative impact if their performance and efficacy is unknown. It is recommended that PIPAC nozzles that deviate from the current standard should be subject to bioequivalence testing and implementation in accordance with the IDEAL-D framework prior to routine clinical use.