Pediatric Pulmonology 48:1026–1034 (2013)

Albuterol Delivery via Metered Dose Inhaler in a

Spontaneously Breathing Pediatric Tracheostomy Model
Ariel Berlinski, MD1,2* and Alma Chavez, MD, MPH
3

Summary. Rationale: Little data are available regarding efficiency of drug delivery devices
and techniques despite their widespread use in spontaneously breathing tracheostomized
patients. We compared patient dose achieved with different devices, inhalation techniques,
tracheostomy tube sizes and breathing patterns using a spontaneously breathing tracheostom-
ized pediatric model. Methods: A tracheostomy model was connected in series to a breathing
simulator with a filter interposed (patient dose). Breathing patterns of a 16-month-old and a 6-
and 12-year-old child with tracheostomy with internal diameters (mm) of 3.5, 4.5, and 5.5 were
used. Albuterol HFAp MDI was used. Aerotrach Plus, MediBag, Aerochamber MV, Aerocham-
ber Mini, and inline adapter with 6-inch tubing were tested. The latter 3 devices were also
tested with assisted technique. Albuterol was analyzed via spectrophotometry. Results: Aero-
trach Plus outperformed almost all devices tested. Aerochamber MV with unassisted technique
was the second best and the adapter was the worst. Comparison of efficiency between best
and worst performer ranged from 3- to 17.2-fold. The 16-month-old breathing pattern and the
3.5 mm tracheostomy tube had the lowest patient dose. The use of assisted technique de-
creased patient dose by 18–67% for the 4.5 and 5.5 mm but not for 3.5 mm tracheostomy
tubes. A median of 7.4% of the nominal dose was deposited in the tracheostomy tubes. Con-
clusions: Aerotrach Plus and the adapter were the most and least efficient devices respectively.
Tracheostomy size and breathing pattern affected drug delivery. The use of assisted technique
reduced aerosol delivery. Pediatr Pulmonol. 2013; 48:1026–1034. ß 2012 Wiley Periodicals, Inc.

Key words: tracheostomy; metered dose inhaler; spacer; delivery device; children.

Funding source: James H. Hamlen II Chair Funds.

BACKGROUND Albuterol and other inhaled aerosols are frequently

Improvement in neonatal care and health technolo-
gy has lead to an increase in number of spontaneously
breathing tracheostomized pediatric patients. The
most common indications for tracheostomy in
children include pulmonary insufficiency, upper air-
way obstruction and craniofacial malformations.1
administered to spontaneously breathing tracheostom-
ized children.2 A recent survey revealed considerable
differences in aerosol delivery devices and techniques
used.2 A consensus statement regarding care of chil-
dren with tracheostomy provided no guidance regard-
ing best practices to deliver inhaled medications to
this population.3

1
Department of Pediatrics, Pulmonology Section, University of Arkansas pediatric pulmonary fellow at University of Arkansas for Medical Scien-
for Medical Sciences, Little Rock, Arkansas. ces at the time the study was performed.

2
Pediatric Aerosol Research Laboratory, Arkansas Children’s Hospital Partial data were presented in abstract format at 2010 American Thoracic
Research Institute, Little Rock, Arkansas. Society Meeting by Dr. Chavez.

3
McClane Children’s Hospital at Scott and White, Temple, Texas.
Conflict of interest: Dr. Berlinski served as Principal Investigator in clini-
cal trials sponsored by Johnson & Johnson, MPEX Pharmaceutical,
Gilead, Philips and was recipient of an unrestricted educational grant
from S&T Technologies. None of their products are discussed in this
manuscript. Alma Chavez have no conflict of interest do declare.
The study was performed at the Pediatric Aerosol Research Laboratory
(Arkansas Children’s Hospital Research Institute). Dr. Chavez was a
*Correspondence to: Ariel Berlinski, MD, Associate Professor, Depart-
ment of Pediatrics, Pulmonary Medicine, University of Arkansas for
Medical Sciences, 1 Children’s Way, Slot 512-17, Little Rock, AR
72202. E-mail: berlinskiariel@uams.edu
Received 19 July 2012; Accepted 3 October 2012.
DOI 10.1002/ppul.22715
Published online 5 November 2012 in Wiley Online Library
(wileyonlinelibrary.com).

ß 2012 Wiley Periodicals, Inc.

 Aerosol Delivery via Pediatric Tracheostomy 1027

Different delivery devices including pressurized metered with internal diameter (ID)/external diameters of 3.5/
dose inhalers (pMDI), nebulizers and dry powder 5 mm, 4.5/6.3 mm, and 5.5/7.6 mm were used.
inhalers have been adapted to deliver inhaled medica-
tions through tracheostomies.4–13 Few in vitro studies Breathing Patterns
using adult models have provided some insight into the
complexity of aerosol delivery through tracheosto- Three different breathing patterns corresponding to a
mies.14–16 These studies, mainly involving nebulizers, 16-month-old (Vt ¼ 80 ml, RR ¼ 30 bpm, I:E ¼ 1:3),
reported that interface, tracheostomy size, type of add-on 6 years old (Vt ¼ 155 ml, RR ¼ 25 bpm, I:E ¼ 1:2)
device and its configuration, use of assisted technique and 12 years old (Vt ¼ 310 ml, RR ¼ 20 bpm,
and presence of bias flow significantly affected drug de- I:E ¼ 1:2) were used.
livery. However these studies used models that by design
could have overestimated drug delivery. In addition, Devices and Delivery Technique
making extrapolations from adult data it is not accurate
Devices were operated with either unassisted or
because children use smaller size artificial airways and
assisted technique. The latter involves the use of
have smaller tidal volumes (Vts).17,18 Some animal data
a resuscitation bag as a means to increase the Vt.
comparing device/delivery techniques are available.19
The following devices were tested with unassisted
Despite the widespread use of pMDIs in spontane-
technique: Aerotrach Plus; Aerochamber Mini,
ously breathing tracheostomized patients little data are
Aerochamber MV (all 3 from Monaghan Medical,
available regarding the efficiency of different delivery
Plattsburgh, NY), and an inline adapter (RTC
devices.2 There is an imperative need to have data to
22-D, Instrumentation Industries, Inc., Bethel Park,
support different strategies when delivering aerosols to
PA) with a 6-in. corrugated tubing (110 ml) inter-
spontaneously breathing pediatric patients. In this in
posed between the tracheostomy and the adapter
vitro study we compared the amount of drug reaching
the carina (patient dose) of a spontaneously breathing
tracheostomized pediatric model using different deliv-
ery devices and techniques, different breathing patterns
and tracheostomies of different sizes.
We hypothesize: (1) that different devices will deliver
different patient doses; (2) that the addition of assisted
breaths will increase patient dose; (3) that increasing
tracheostomy size will increase patient dose; and (4)
that breathing patterns of younger children will deter-
mine smaller patient dose.

MATERIALS AND METHODS

Tracheostomy Model
A tracheal model corresponding to a 6 year child was
built (Fig. 1).20 The model consisted of a superior filter
holder with a one way valve (PARI Respiratory Equip-
ment Inc, Midlothian, VA) connected to a plastic tube,
8 cm height and 1.2 cm internal diameter, then con-
nected to a low dead space lower filter (patient dose).
A circular incision was made 2 cm below the upper
section of the plastic tube to allow placement of
the tracheostomy. This system was connected in series
to a breathing simulator (PARI Compass, Munich,
Germany) (Fig. 1). The distance between the tip of the
tracheostomy tube and the lower filter was 2.8 cm, 3 cm,
and 2 cm for the 3.5, 4.5, and 5.5 mm, respectively.

Tracheostomy Tubes
Three different sizes of uncuffed tracheostomies Fig. 1. Spontaneously breathing tracheostomized pediatric
(Tracoe, Boston Medical Products, Westborough, MA) model.

Pediatric Pulmonology
1028 Berlinski and Chavez

(Fig. 2). The Aerotrach Plus is a 149 ml holding

Fig. 2. Devices used with unassisted technique. From top to
bottom: Aerotrach Plus, Aerochamber MV, Aerochamber Mini,
and inline adapter with 6-in. extension.
chamber made of anti-static material. The chamber
has a 15 mm connector and has built in inspiratory
and expiratory valves and allows the use of the pMDI
without removing the canister from the plastic actua-
tor. The Aerochamber Mini is a 110 ml chamber
made of anti-static material. The chamber has a
15 mm connector and has an exhalation channel with
a one-way valve. These two devices are marketed for
use with tracheostomies. The Aerochamber MV is a
145 ml plastic chamber that connects to either an en-
dotracheal tube (ETT) or a tracheostomy tube and
either be used with resuscitation bag or placed inline
in the inspiratory limb of a ventilator. The Aerocham-
ber Mini, Aerochamber MV, and inline adapter re-
quire removal of the pMDI canister from the plastic
actuator for its use. The following devices were tested
with synchronous assisted technique: Ambu MediBag
(Ambu, Copenhagen, Denmark); Aerochamber MV,
Aerochamber Mini, inline adapter with 6-in. tubing
(Fig. 3). The former is a single patient use resuscitator
bag (450 ml) that has a built in pMDI adapter at the
outlet of the bag, and it uses the volume of the bag
to deliver the drug.21 All other devices were assisted
with a self-inflating resuscitation bag (Pediatric Ambu
Spur II, Ambu) with stroke volume of 450 ml.

Fig. 3. Devices used with assisted technique. Top row: Aerochamber MV and Aerochamber
Mini. Bottom row: MediBag and inline adapter with 6-in. extension. All devices except Medi-
Bag are connected to a self-inflating resuscitation bag.

Pediatric Pulmonology

Procedure
1 significant.
Albuterol pMDI in HFA formulation (ProAir 90
micrograms, IVAX Pharmaceuticals, Waterford, Ireland)
was primed with four puffs at the beginning of each
testing day. A new lower filter (PARI Respiratory
Equipment, Inc., Midlothian, VA) was placed at the be-
ginning of every procedure. Then the accuracy of the
Vt delivered by the breathing simulator was verified
with a mass flowmeter (model 4043, TSI, Shoreview,
MN) and its associated software.
The pMDI was shaken for 30 sec and fired at the
beginning of the inspiration. The breathing simulator
ran for a total of six breaths. When the synchronous
assisted technique was used, the resuscitation bag was
used right after actuating the pMDI and at the begin-
ning of the following five breaths. This was repeated
for nine more times. Each scenario was run five times.
The lower filter (patient dose) was change before each
repeat (10 puffs) and the upper filter was changed after
each scenario was completed (50 puffs). Devices and
pMDi plastic booth were washed with distilled water
and let dry after each scenario was completed. Filters
were diluted with ultrapure water and analyzed by
spectrophotometry (Biomate 3 UV–Vis Spectrophotom-
eter, Thermo Electron Corporation, Waltham, MA) at
276 nm.18 The tracheostomy tube was washed with ul-
trapure water after each scenario and albuterol concen-
tration was measured. The results were reported as
percentage of nominal dose (4,500 mg).
Study Design
All devices were tested with three different breathing
patterns and three different tracheostomy sizes except
for inline adapter with 6-in. tubing that was not tested
with the 5.5 mm ID tracheostomy. Five different units
of each device/configuration were tested (n ¼ 5).
Statistical Analysis
Data were compared as delivery efficiency (mg of
albuterol captured in the lower filter/900 mg
100).
Intra-device comparison for tracheostomy size and
breathing pattern was done with analysis of variance
(ANOVA) for repeated measures. Inter-device for each
scenario (breathing pattern/tracheostomy size) was
done with ANOVA. Tukey test was used when multi-
ple comparison analysis was required after ANOVA.
Two-tailed paired T-test was use for the comparison
of delivery techniques (assisted vs. unassisted). The
variation in patient dose between both techniques
was calculated as follows: [(assisted  unassisted)/
unassisted]
100. Statistical software packages were
used for data analysis (MDAS 2.0, EsKay Software,
Silver Springs, MD and Kaleidagraph 4.1, Reading,
Aerosol Delivery via Pediatric Tracheostomy 1029
PA). A P-value < 0.05 was considered statistically
RESULTS
Device Comparison
Aerotrach Plus outperformed all other devices with
all breathing patterns using a tracheostomy 5.5 mm
(P < 0.0001). Aerochamber MV with unassisted tech-
nique was the second best for all breathing patterns
(P < 0.0001). MediBag was similar to Aerochamber
MV (P ¼ 0.72) with unassisted technique when the
oldest breathing pattern was used (Fig. 4).
Aerotrach Plus outperformed all other devices with
all breathing patterns using a tracheostomy 4.5 mm
(P < 0.0001) except for Aerochamber MV with unas-
sisted technique using the oldest child breathing pattern
(P ¼ 0.068). Aerochamber MV with unassisted tech-
nique was the second best for the 16-month-old and
6 years old breathing patterns (P < 0.0001) (Fig. 4).
Aerotrach Plus outperformed all other devices with
all breathing patterns using a tracheostomy 3.5 mm
(P < 0.0001) except for Aerochamber Mini with unas-
sisted technique using the youngest child breathing pat-
tern (P ¼ 0.99) (Fig. 4).
The difference in device performance between the
best and the worst varied from 17.2-fold (4.5 mm tra-
cheostomy with 16 months old breathing pattern) to 3-
fold (5.5 mm tracheostomy with 12 years old breathing
pattern). Breathing patterns of younger children with
4.5 and 5.5 mm had a higher difference between best
and worst performers. The opposite was seen with the
3.5 mm tracheostomy (Table 1).
Delivery Techniques
The use of assisted technique produced a reduction
of the patient dose that ranged from 40% to 67% and
from 18% to 47% for the Aerochamber MV and Aero-
chamber Mini, respectively, when using a 5.5 mm tra-
cheostomy tube (Fig. 5).
The use of assisted technique produced a reduction
of the patient dose that ranged from 46% to 54%, from
28% to 46%, and from 24% to 44% for the
Aerochamber MV, Aerochamber Mini, and inline adapt-
er, respectively, when using a 4.5 mm tracheostomy
tube. The reduction in patient dose was not statistically
significant for the Inline adapter using the oldest child
breathing pattern (P ¼ 0.06) (Fig. 5).
Effects of using assisted technique were mixed when a
3.5 mm tracheostomy tube was used. Variation in patient
dose was not statistically significant for Aerochamber MV
with any breathing pattern and the Aerochamber Mini
with Inline adapter with the oldest child breathing pattern.
Assisted technique increased delivery efficiency from
1.9% to 4.7% (P ¼ 0.0006) (Fig. 5).
Pediatric Pulmonology
1030 Berlinski and Chavez
TABLE 1— Efficiency Variation Between Best and Worst
Performers

Tracheostomy
size (ID) Breathing Most Least
(mm) pattern efficient efficient Difference1

3.5 16 mo ATþ and A mini AD 7.7-fold

3.5 6 yo ATþ AD assisted 9.6-fold
3.5 12 yo ATþ AD 10.4-fold
4.5 16 mo ATþ AD assisted 17.2-fold
4.5 6 yo ATþ AD assisted 13.2-fold
4.5 12 yo ATþ AD assisted 8.1-fold
5.5 16 mo ATþ A Mini assisted 5.4-fold
5.5 6 yo ATþ A Mini assisted 3.4-fold
5.5 12 yo ATþ A MV assisted 3-fold

ATþ, Aerotrach Plus; A Mini, Aerochamber Mini; A MV,

Aerochamber MV; AD, inline adapter.
1
Difference between most and least efficient devices.

Tracheostomy Size
For devices using the unassisted technique patient
dose achieved with the 4.5 mm tracheostomy tube was
similar to that obtained with a 5.5 mm tracheostomy
tube for all breathing patterns with the exception of
Aerochamber MV/12-year-old breathing pattern (Fig. 4
and Table 2). The patient dose achieved by the 3.5 mm
tracheostomy tube was lower than the others for all
breathing patterns (Fig. 4 and Table 2).
In general devices using the assisted technique
showed no differences in patient dose among different
tracheostomy tube sizes (Fig. 4 and Table 2). The
Medibag/6-year-old breathing pattern scenario had
a similar pattern than the unassisted devices
(4.5 mm ¼ 5.5 mm > 3.5 mm). Other scenarios (Med-
iBag and Aerochamber Mini with assisted technique/
12-year-old breathing pattern) showed the following

Fig. 4. A: Comparison of patient dose obtained with combina-

tion of different devices, different sizes of tracheostomy tubes
and 16-month-old breathing pattern. Top 2 performers and #2
bottom performers. B: Comparison of patient dose obtained
with combination of different devices, different sizes of trache-
ostomy tubes and 6-year-old breathing pattern. Top 2 per-
formers and #2 bottom performers. C: Comparison of patient
dose obtained with combination of different devices, different
sizes of tracheostomy tubes and 12-year-old breathing pattern.

Top 2 performers and #2 bottom performers.
Fig. 5. Effect of using assisted delivery technique on patient
dose.

Pediatric Pulmonology
 Aerosol Delivery via Pediatric Tracheostomy 1031

TABLE 2— P Values for Comparison of Patient Dose Among Tracheostomy Tubes of Different Sizes

Technique Unassisted Assisted

BP Size (mm) ATþ A MV A Mini AD MB A MV A Mini AD

16 mo 3.5 vs. 4.5 <0.0001 <0.0001 0.014 0.0008 0.02 0.025 0.19 0.0002
3.5 vs. 5.5 <0.0001 <0.0001 0.012 — 0.46 0.19 0.19 —
4.5 vs. 5.5 0.35 0.28 0.99 — 0.12 0.002 0.19 —
6 yo 3.5 vs. 4.5 <0.0001 0.0005 <0.0001 0.022 0.0001 0.13 0.15 0.97
3.5 vs. 5.5 0.0001 0.002 <0.0001 — <0.0001 0.13 0.15 —
4.5 vs. 5.5 0.72 0.41 0.85 — 0.96 0.13 0.15 —
12 yo 3.5 vs. 4.5 0.005 <0.0001 <0.0001 0.036 0.6 0.097 0.08 0.07
3.5 vs. 5.5 0.0005 0.0005 <0.0001 — 0.09 0.097 0.79 —
4.5 vs. 5.5 0.17 0.0028 0.85 — 0.022 0.097 0.033 —

BP, breathing pattern; ATþ, Aerotrach Plus; A MV, Aerochamber MV; A Mini, Aerochamber Mini; AD, inline adapter; MB, MediBag.
Bold font represents statistically significant differences.

P values obtained with ANOVA for repeated measures followed by Tukey test when multiple comparison was required.

behavior: 3.5 mm ¼ 4.5 mm and 3.5 mm ¼ 5.5 mm
with 5.5 mm > 4.5 mm. The 16-month-old breathing
pattern showed responses in different directions.
The MediBag showed that 4.5 mm > 3.5 mm, and
3.5 mm ¼ 5.5 mm with 4.5 mm ¼ 5.5 mm; and
Aerochamber MV with assisted technique showed that
4.5 mm > 3.5 mm ¼ 5.5 mm, while the inline adapter
with assisted technique showed a higher patient dose
for the 3.5 mm than for the 4.5 mm.
Breathing Pattern
The older child breathing pattern had the highest pa-
tient dose for all tested devices with the tracheostomy
5.5 mm except for the Aerotrach Plus and
Aerochamber MV with assisted breathing (P ¼ 0.44
and P ¼ 0.99 when compared to the 6-year-old breath-
ing pattern). The latter pattern led to higher patient
doses than for the 16-month-old breathing for all tested
devices.
The older child breathing pattern had a higher patient
dose than the youngest breathing pattern for all tested
devices with the tracheostomy 4.5 mm except for the
Aerotrach Plus (P ¼ 0.072). The older breathing pat-
tern had similar patient dose than the 6-year-old breath-
ing pattern except for Aerochamber MV with
unassisted and assisted technique and inline adapter
with assisted technique (P < 0.0001, P ¼ 0.0034, and
P ¼ 0.01, respectively). The 6 years breathing pattern
led to higher patient doses than for the 16-month-old
breathing for all tested devices except for Aerochamber
MV with assisted technique and inline adapter
with assisted technique (P ¼ 0.14, and P ¼ 0.65,
respectively).
The older child breathing pattern had the highest pa-
tient dose for all tested devices with the tracheostomy
3.5 mm except for inline adapter with assisted and
unassisted technique Aerochamber MV (compared to
6 years old breathing pattern P ¼ 0.11, P ¼ 0.054, and
P ¼ 0.99, respectively. The 6-year breathing led to
higher patient doses than for the 16-month-old breath-
ing pattern for all tested devices except MediBag, Aero-
chamber Mini with assisted and unassisted technique,
and inline adapter with assisted technique (P ¼ 0.97,
P ¼ 0.16, P ¼ 0.99, P ¼ 0.06, respectively).
Drug Deposited in the Tracheostomy Tube
A median amount of 7.4% was deposited in the tra-
cheostomy tube. When data were pooled and analyzed
by tracheostomy tube size no differences were found
(5.2  5.6%, 6.2  4.4%, and 8.9  3.5% for 3.5, 4.5,
and 5.5 mm, respectively; P ¼ 0.15). No differences
were found when data were pooled for breathing pat-
terns either (6.7  5%, 7.1  4%, 8.1  5% for the
16-month-old, 6 years old, and 12 years old, respective-
ly, P ¼ 0.61). When data were pooled and analyzed by
device the inline adapter (0.7  0.6%) had the lowest
amount of drug deposited in the tracheostomy tube ex-
cept for Aerochamber MV with unassisted technique
(5.8  3.9%, P ¼ 0.11) and inline adapter with assisted
technique (3.1  2.2%, P ¼ 0.96). The Aerochamber
MV with assisted technique (10.1  6%, P ¼ 0.0006)
had the highest amount followed by Aerochamber Mini
with assisted technique (9.3  1.6%, P ¼ 0.002), Aero-
chamber Mini with unassisted technique (7.5  2.5%,
P ¼ 0.03), Aerotrach Plus (7.4  5.5%, P ¼ 0.03), and
Medibag (6.7  3.5%, P ¼ 0.01).
DISCUSSION
Little data are available regarding efficiency of drug
delivery devices and techniques despite their wide-
spread use in spontaneously breathing tracheostomized
Pediatric Pulmonology
1032 Berlinski and Chavez
2
patients. In this study we compared patient dose Assisted Delivery
achieved with different devices, inhalation techniques,
We found that the use of assisted technique signifi-
tracheostomy tube sizes, and breathing patterns using a
cantly decreased drug delivery thus rejecting our second
spontaneously breathing tracheostomized pediatric
hypothesis. Piccuito et al.14 in an adult type tracheoto-
model. We found that a valved holding chamber made
my model found that the addition of flow and humidity
of anti-static material that does not require removal of
decreased drug delivery when using pMDIs. One
pMDI canister from the plastic actuator and the inline
could speculate that the presence of additional flow
adapter were the most and least efficient devices respec-
was responsible for the decrease in drug delivery. How-
tively. We also found that tracheostomy size and breath-
ever, one cannot ignore the data showing that in me-
ing pattern affected drug delivery. Finally, the use of
chanically ventilated patients the presence of humidity
assisted technique was found to reduce aerosol delivery.
decreases drug delivery by 50%.27 O’Callaghan et al.19
in an animal study found that the use of assisted tech-
Delivery Device nique decreased drug delivery to the lungs by 30%.
In their study they used radiolabeled beclomethasone
We found that a valved holding chamber made of a
delivered to spontaneously breathing tracheostomized
non-electrostatic material was the most efficient deliv-
(ID ¼ 3 mm) rabbits. These data are in agreement with
ery device. That device was the only one that did not
our findings. Conversely, Cole et al.28 and Diblasi
require removal the canister from the plastic booth.
et al.29 found in a neonatal model that the assisted tech-
Also, the device has an inspiratory valve placed proxi-
nique enhanced drug delivery. There are several impor-
mal to the tracheostomy. We think that these three ele-
tant differences between theirs and our setups. The
ments are responsible for the superior performance of
stroke volume used was not reported in one study and
the device. These data are in agreement with those of
was 250–500 ml in the other. They used very small Vts
Dubus et al.,22 who compared albuterol delivery via
(8–11.6 ml and 6–60 ml, respectively) and used smaller
pMDI in spontaneously breathing rabbits intubated with
ETTs (2.5 mm, and 2–4 mm, respectively). In addition
an ETT with an ID ¼ 3 mm. They found that the
tracheostomies are shorter than ETTs and length of the
valved holding chamber made of non-electrostatic ma-
tube has been previously inversely correlated with drug
terial was the most efficient one. Our data are also in
output.15,30 Interestingly, Ari et al.15 in an adult type
agreement with in vitro studies using spontaneously
tracheostomy model using a jet nebulizer found that
breathing models without artificial airways.23 We also
drug delivery was significantly enhanced with the use
found that the adapter was the worse delivery device.
of assisted technique. We speculate that the difference
These data are in agreement with previously published
with our study is due to the different nature of drug
data involving pMDIs delivering drugs in a ventilator
delivery device (pMDI vs. nebulizer) and the use of an
circuit.24 In our study a large spacer was the second
adult type model that had a tight connection between
most effective device delivering more drug than the
the tracheostomy tube and the filter. The former is sup-
small volume/shorter device made of anti-static materi-
ported by our own data when using nebulizers with the
al. We speculate that the larger length allowed for more
same tracheostomy model.31 Our model allowed for
deceleration of particles therefore decreasing extra-pul-
expiration of drug that remained in the airways that did
monary deposition.25,26 Piccuito et al. in an in vitro
not deposit while the one from Ari et al. did not.
study using an adult scenario (Vt ¼ 400 ml, RR ¼ 20,
I:E ¼ 1:2) compared albuterol delivery of a nebulizer
Tracheostomy Size
and a pMDI. They used a cuffed tracheostomy tube
with ID of 8 mm and a filter placed at the end of the We found that the influence of tracheostomy size on
tube. The authors used a spacer (Aerovent, Monaghan drug delivery is affected by the use of assisted tech-
Medical, Plattsburgh, NY) with pMDI under four differ- nique. The latter eliminated most size differences by
ent configurations: high flow heated humidity with making the systems less efficient. Patient dose was
either t-piece or tracheostomy mask and no additional similar between the 4.5 and 5.5 mm tracheostomy
flow with t-piece and one-way valve placed either distal tube and higher than the 3.5 mm. Our results partially
or proximal to the spacer. The latter was found to be confirm our third hypothesis. Our data are in
the most efficient one. These data are in agreement agreement with data from other studies that evaluated
with ours showing that different devices/configurations the effect of ETT characteristics on drug delivery.19,32
significantly affect drug delivery thus confirming our More recently, Pitance et al.16 using an in vitro
first hypothesis. adult tracheostomy model (Vt ¼ 440 ml, RR ¼ 20,
Practitioners need to be aware of the several-fold dif- I:E ¼ 1:2) found that a reduction of ID led to a reduc-
ference in efficiency found in this and other studies to tion of delivered drug when using different configura-
avoid either under-dosing or overdosing their patients. tions of a nebulizer.
Pediatric Pulmonology

Breathing Patterns
We found that breathing patterns of younger children
led to lowest patient dose thus confirming our fourth
hypothesis. Conversely, the breathing patterns of an
older child children lead to higher patient dose. These
findings are in agreement with in vivo studies and with
in vitro studies using spontaneously breathing pediatric
models.18,33 Interestingly, the differences between the
12-year-old and the 6-year-old breathing patterns were
not significant. We also found that the use of assisted
technique removed the difference in patient dose among
breathing patterns by making delivery less efficient.
This phenomenon increased as the tracheostomy size
decreased.
It is important to keep in mind that the selected
breathing patterns might overestimate those of a child
with chronic lung disease. A practical approach would
be to measure spontaneous tidal volume through the
tracheostomy with a Wright spirometer before making
recommendations for a specific patient.
Drug Deposited in the Tracheostomy Tubes
We found that a median amount of drug of 7.4% of
the nominal dose was deposited in the tracheostomy
tube without difference among sizes. These results are
in agreement with previously published data using neb-
ulizers in mechanically ventilated adults that found that
around 10% of the drug is deposited in the tube.34
One limitation of our study is its in vitro nature espe-
cially the fact that this setup overestimates the amount
deposited in the lower airways because the drug is
trapped in the filter and cannot be exhaled. In addition,
in this study we did not measure particle size of the
aerosols leaving the tracheostomy tube. Another limita-
tion is the fact that only one size ‘‘trachea’’ was used
for all the tested scenarios. Despite these limitations the
current data advances the present knowledge on how to
deliver inhaled drugs via pMDI in tracheostomized pe-
diatric patients.
CONCLUSIONS
Several conclusions regarding the use of pMDI to de-
liver drugs through tracheostomy tubes can be reached
from this in vitro study. The valved holding chamber
made of anti-static material that does not require remov-
al of pMDI canister from the plastic booth and the
adaptor were the most and least efficient devices.
Tracheostomy size and breathing pattern significantly af-
fected drug delivery. Assisted technique reduced aerosol
delivery. The findings in this study underscore the need
of pediatric specific data for current and new delivery
devices. Our data also demonstrate that data from one
type of device cannot be extrapolated to another one.
Aerosol Delivery via Pediatric Tracheostomy 1033
ACKNOWLEDGMENTS
This study was supported in part by James H.
Hamlen II Chair Funds. The Pediatric Aerosol Research
Laboratory at Arkansas Children’s Hospital Research
Institute was partially established and receives partial
support from the George Endowment for Asthma.
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