Choosing Wisely:

Avoid administering nebulized medications by “blow by,” or placing the mask or nebulizer tubing near the child’s nose and mouth rather than securing the mask properly to the face. A T-piece with mouthpiece or face mask should be used instead.

Rationale and Comments: There are many different formulations of asthma medications for pediatric patients. Accurate delivery of each medication to a pediatric patient is extremely important. There is a high rate of error by caregivers and, unfortunately, by health care workers in health care settings. Small children and infants are especially challenging. During a nebulizer treatment, a well-fitting, properly-placed mask to the face is required in a quietly breathing, younger patient who is not crying. An older, cooperative child may use a T-piece with mouthpiece. If the drug being delivered can be converted to an inhaler and administered using a valved holding chamber with a face mask, this change should be considered. Finally, it is important to note that, if treatment failure is occurring with a nebulized inhaled steroid, it could be secondary to the family administering the medication using the “blow by” method by placing the mask or nebulizer tubing near the child’s nose and mouth rather than securing the mask properly to the face. Studies have shown that there is a 40% to 85% decrease in aerosol delivery when a mask is held 2 cm away from a child’s face while giving a nebulizer treatment.
Sponsoring Organizations:
  • N/A
  • Sources:
  • Expert consensus
  • Disciplines:
  • Pediatric
  • Pulmonary medicine
  • References: • Geller D. Comparing clinical features of the nebulizer, metered-dose inhaler, and dry powder inhaler. Respir Care. 2005;50(10):1313-1322.
    • Geller D. Aerosol delivery of medication. In: Light M, ed. Pediatric Pulmonology. Elk Grove Village, IL: American Academy of Pediatrics; 2011:916-917.
    • Rubin B. Nebulizer therapy for children: the device-patient interface. Respir Care. 2002;47(11):1314-1319.
    • Rubin B. Bye-bye, blow-by. Respir Care. 2007;52(8):981.

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