Bronchodilator delivery during simulated pediatric noninvasive ventilation

Noninvasive ventilation (NIV) is usually applied using bi-level positive airway pressure devices, and many of these devices use a single-limb patient circuit with an integrated leak port to purge the circuit of exhaled carbon dioxide. Sometimes bronchodilator therapy is indicated in pediatric patients, but there have been no studies of the optimal nebulizer position, with respect to leak, during pediatric NIV. We hypothesized that there would be no differences in albuterol delivery with a vibrating-mesh nebulizer between 3 different positions/exhalation leak valve combinations in the patient circuit during simulated pediatric NIV.

A simulated upper airway model was attached to a lung model that simulated spontaneous breathing. A noninvasive ventilator equipped with heated wire circuit and heated humidifier was attached to the lung model via a pediatric oronasal mask. Albuterol (5 mg) was delivered with a vibrating-mesh nebulizer, at 3 different circuit position/leak condition combinations: prior to the humidifier and leak valve; between the humidifier and leak valve; and integrated within the mask and after the leak. Albuterol was captured on a filter and quantified with chromatography.

Greater albuterol mass was delivered to the filter with the nebulizer integrated into the mask than at any other testing condition (P < .001). In the conditions where the nebulizer was placed prior to the exhalation leak valve, greater drug delivery was observed when the nebulizer was placed proximal to the mask (position 2) than when placed prior to the humidifier (position 3, P = .002).

Albuterol delivery during simulated pediatric NIV was affected by the position of the nebulizer in relation to the expiratory leak valve and the nebulizer's distance from the filter. A vibrating-mesh nebulizer placed intra-mask may provide a better alternative for medication delivery than those previously used during pediatric NIV.