Drug delivery interfaces: A way to optimize inhalation therapy in spontaneously breathing children

Table 1 Descriptions, advantages and disadvantages of each interface used for aerosol drug delivery to spontaneously breathing neonates and pediatrics

Interface	Description	Advantages	Disadvantages	Suggestions for the best practice
Blow-by	A technique that directs aerosol plume towards the patient’s face by placing a jet nebulizer within a distance from the child that ranges from 1 to 30 cm	Easy to use Comfortable and easy to tolerate by the patient A mask-free aerosol delivery technique Used with fussing, crying and uncooperative children	Inefficient aerosol drug delivery to children Drug delivery with blow-by is 50%-85% less than the facemask Cannot be used with pMDIs, breath- actuated nebulizers and mesh nebulizers	Inhalation therapy with blow-by is not efficient; therefore, it should not be used for aerosol drug delivery to neonates and pediatrics
Mouthpiece	A cylindrical tube that extends between the lips so that aerosol can pass through the oropharynx to reach lower respiratory tract	Efficient inhalation therapy in children Aerosol drug delivery with a mouthpiece is two-fold more than that with a face mask	Children less than 3 yr of age cannot use a mouthpiece An adequate consistent seal is needed during inhalation therapy	The mouthpiece should not be used for children who are less than 3 yr old When using a mouthpiece child should be encouraged to keep it in their mouth during therapy If a child cannot keep the mouthpiece in his mouth with an adequate seal during aerosol drug delivery, another interface should be used for inhalation therapy
Facemask	An interface that covers the nose and mouth. It is kept in place through an elastic band that extends beyond the back of the head or neck	Can be used in children all years of age Can be used with nebulizers and pMDIs to deliver aerosolized medications to neonates and pediatrics	A good facemask seal is needed for optimum aerosol drug delivery Is frequently associated with crying, intolerance and rejection of the mask Crying and leaks between face and mask decrease aerosol drug delivery to children	Select a lightweight and flexible facemask with anatomic contours to increase tolerability of face mask by children during therapy Choose a facemask with small dead space and have a good face-mask seal to increase delivery efficiency of inhalation therapy Use another interface if the patient starts to fuss, and cry during aerosol drug delivery with a facemask
Pacifier mask	A face mask with the attachment of the infant’s own pacifier	A new and innovative facemask design that eliminates fear, discomfort and cry with the standard facemask A children-oriented drug delivery interface designed to achieve therapeutic lung deposition in children Improves compliance to inhalation therapy in infants		May be a good option for children who fuss, cry and does not tolerate other interfaces used for aerosol drug delivery in neonates and pediatrics
Nasal mask	An interface that covers the nose to allow aerosol to pass through the nasopharynx to reach the lower respiratory tract	Easy to use Better tolerance than the facemask	Aerosol delivery with the nasal mask is less than that with the standard facemask
High flow nasal cannula	A tubing with two small prongs that are inserted into the nares to allow aerosol pass through the nasopharynx and reach the lower respiratory tract	Efficient delivery of aerosolized medications to neonates and pediatrics Children may tolerate HFNC better than the facemask	More information about the safety and efficacy of aerosol drug delivery though HFNC is needed Cannot be used with pMDIs	When using mesh nebulizers for aerosol drug delivery to neonates and pediatrics, place the nebulizer prior to the heated humidifier
Hood	An enclosure that covers the head and neck of a neonate or small children to deliver aerosol to the lungs while isolating it from ambient air	A good option for aerosol delivery to children who cannot use a mouthpiece and tolerate the facemask Likelihood of agitating infants and making them cry is low Aerosol delivery with the hood is the same as the facemask Parents prefer the hood over the mask	User may need additional training and practice to provide proper inhalation therapy with the hood More time and parts may be needed for the set-up	Use the hood for aerosol drug delivery to children who cannot use a mouthpiece and tolerate the facemask Put the infant in the face-side position when using the hood for inhalation therapy because it has less facial-ocular deposition than face-up position
Valved holding chamber	A chamber shaped interface with a one-way valve that allows aerosols to be contained in the chamber during aerosol therapy	Reduces oropharyngeal deposition Minimize hand-breath coordination during inhalation therapy Improves efficiency of aerosol therapy	Electrostatic charge and large volume VHCs result in a decrease in aerosol drug delivery to children	Wash the VHC with detergent and air dry before inhalation therapy in order to eliminate static charge and improve aerosol delivery to neonates and pediatrics Choose small volume VHCs for aerosol therapy Actuate one-dose at a time into VHC instead of multiple doses

VHC: Valved holding chambers; pMDIs: Pressurized metered-dose inhalers.