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Survey of Aerosol Delivery Techniques to Spontaneously Breathing Tracheostomized Children

BACKGROUND: Therapeutic inhaled aerosols are often delivered to spontaneously breathing tracheostomized children. Although aerosol delivery can be affected by several factors, no recommendations for device/drug formulation choice are available. We hypothesized that practice modalities will vary among different institutions. METHODS: The respiratory care departments in institutions in the United States that train pediatric pulmonologists were surveyed regarding their practices of delivering aerosols to spontaneously breathing tracheostomized children. Characteristics of the institution; use of metered-dose inhalers (MDIs), nebulizers, and dry powder inhalers; use of a resuscitation bag to aid aerosol delivery (assisted); types of medication used; and factors affecting choice of delivery method were recorded. RESULTS: Of the invited institutions, 81% (38/47) participated, with 68% of them being freestanding children's hospitals. MDIs were used by 92% of the institutions surveyed, with similar use of unassisted (32%, with 83% of them using spacers), assisted (34%, with 100% of them using non-valved spacers), and both techniques (34%). Nebulizers were used by 97% of the institutions surveyed, with all using unassisted and 32% also using assisted technique. Tracheostomy aerosol mask was the most commonly used interface (89%). Assisted technique for either MDI or nebulizer was used by 68% of the institutions surveyed, with similar use of flow-inflating bag, self-inflating bag, and both devices. Types of inhaled medications utilized by surveyed institutions included aerosolized antibiotics (82%), corticosteroids (100%), short-acting β agonists (100%), combination therapy (32%), and mucolytics (84%). Dry powders were not used. Patient cooperation was the most frequent and single most important factor influencing the choice of delivery method. CONCLUSIONS: A wide variation in practice of delivering aerosols to spontaneously breathing tracheostomized children was noted. In-vivo and in-vitro studies are needed to support clinical recommendations.