Pediatric Pulmonology 48:1026–1034 (2013) Albuterol Delivery via Metered Dose Inhaler in a Spontaneously Breathing Pediatric Tracheostomy Model Ariel Berlinski, MD 1,2 * 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 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 Albuterol and other inhaled aerosols are frequently 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 for Medical Sciences, Little Rock, Arkansas. 2 Pediatric Aerosol Research Laboratory, Arkansas Children’s Hospital Research Institute, Little Rock, Arkansas. 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 pediatric pulmonary fellow at University of Arkansas for Medical Scien- ces at the time the study was performed. Partial data were presented in abstract format at 2010 American Thoracic Society Meeting by Dr. Chavez. *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.