Custom-made 3D printed masks for children using non-invasive ventilation: a feasibility study of production method and testing of outcomes in adult volunteers

Mask interfaces and devices for home noninvasive ventilation in children

Home noninvasive ventilation (NIV), including continuous (CPAP) and bilevel (BPAP) positive airway pressure, is increasingly used in children worldwide. In this narrative review, we present a comprehensive summary of the equipment available for home NIV in pediatrics, excluding neonates. NIV may be challenging in young children, as the majority of the equipment has been developed for adults. Regarding the interfaces, only a few masks have been specifically developed for young children in recent years, while older children may benefit from a large variety of interfaces. Even though much progress has been made, skin injuries are still present, and need to be managed rapidly. Several studies addressed the management of the side effects, but recent studies are lacking regarding orofacial anomalies. No recent study reported the available interfaces for young children and the strategies for an optimal mask fit. Regarding the devices, an adapted NIV device to pediatrics that allows an adequate patient's breathing detection should guarantee optimal ventilatory efficiency and monitoring of NIV. A close follow-up and regular monitoring should be mandatory to rule out the potential issues, optimize NIV therapy and ascertain the efficacy of NIV. However, studies are lacking to guide the choice of devices in young children and the optimal management of home NIV in pediatrics. We summarized the characteristics of the different interfaces available for young children and the limitations of NIV devices. We finally addressed potential areas for future research on long-term home NIV in children.

Development of personalized non-invasive ventilation masks for critically ill children: a bench study

BACKGROUND

Obtaining a properly fitting non-invasive ventilation (NIV) mask to treat acute respiratory failure is a major challenge, especially in young children and patients with craniofacial abnormalities. Personalization of NIV masks holds promise to improve pediatric NIV efficiency. As current customization methods are relatively time consuming, this study aimed to test the air leak and surface pressure performance of personalized oronasal face masks using 3D printed soft materials. Personalized masks of three different biocompatible materials (silicone and photopolymer resin) were developed and tested on three head models of young children with abnormal facial features during preclinical bench simulation of pediatric NIV. Air leak percentages and facial surface pressures were measured and compared for each mask.

RESULTS

Personalized NIV masks could be successfully produced in under 12 h in a semi-automated 3D production process. During NIV simulation, overall air leak performance and applied surface pressures were acceptable, with leak percentages under 30% and average surface pressure values mostly remaining under normal capillary pressure. There was a small advantage of the masks produced with soft photopolymer resin material.

CONCLUSION

This first, proof-of-concept bench study simulating NIV in children with abnormal facial features, showed that it is possible to obtain biocompatible, personalized oronasal masks with acceptable air leak and facial surface pressure performance using a relatively short, and semi-automated production process. Further research into the clinical value and possibilities for application of personalized NIV masks in critically ill children is needed.

What Circuits, Masks and Filters Should Be Used in Home Non-Invasive Mechanical Ventilation

Most of the published reviews about non-invasive home ventilation mainly reflect the technical aspects of ventilators. There is much less information about the consumables most used at home. However, the choice of a good interface or tubing system can lead to physiological changes in the patient–ventilator interaction that the clinician should be aware of. These physiological changes may affect the performance of the ventilator itself, the reliability of monitoring and, of course, the comfort of the patient. The use of different circuits, masks or filters is therefore related to the concepts of rebreathing, compressible volume, instrumental dead space or leak estimation and tidal volume. Through certain bench experiments, it is possible to determine the implications that each of these elements may have in clinical practice.

Changes in UK paediatric long-term ventilation practice over 10 years

OBJECTIVES

To provide up-to-date information on the use of long-term ventilation (LTV) in the UK paediatric population and to compare the results with data collected 10 and 20 years previously.

DESIGN

A single timepoint census completed by LTV centres in the UK, carried out via an online survey.

SETTING AND PATIENTS

All patients attending paediatric LTV services in the UK.

RESULTS

Data were collected from 25 LTV centres in the UK. The total study population was 2383 children and young people, representing a 2.5-fold increase in the last 10 years. The median age was 9 years (range 0-20 years). Notable changes since 2008 were an increase in the proportion of children with central hypoventilation syndrome using mask ventilation, an increase in overall numbers of children with spinal muscular atrophy (SMA) type 1, chronic lung disease of prematurity and cerebral palsy being ventilated, and a 4.2-fold increase in children using LTV for airway obstruction. The use of 24-hour ventilation, negative pressure ventilation and tracheostomy as an interface had declined. 115 children had received a disease-modifying drug. The use of ataluren and Myozyme did not influence the decision to treat with LTV, but in 35% of the children with SMA type 1 treated with nusinersin, the clinician stated that the use of this drug had or may have influenced their decision to initiate LTV.

CONCLUSION

The results support the need for national database for children and young people using LTV at home to inform future recommendations and assist in resource allocation planning.

The right interface for the right patient in noninvasive ventilation: a systematic review

INTRODUCTION

Research in the field of noninvasive ventilation (NIV) has contributed to the development of new NIV interfaces. However, interface tolerance plays a crucial role in determining the beneficial effects of NIV therapy.

AREAS COVERED

This systematic review explores the most significant scientific research on NIV interfaces, with a focus on the potential impact that their design might have on treatment adherence and clinical outcomes. The rationale on the choice of the right interface among the wide variety of devices that are currently available is discussed here.

EXPERT OPINION

The paradigm "The right mask for the right patient" seems to be difficult to achieve in real life. Ranging from acute to chronic settings, the gold standard should include the tailoring of NIV interfaces to patients' needs and preferences. However, such customization may be hampered by issues of economic nature. High production costs and the increasing demand represent consistent burdens and have to be considered when dealing with patient-tailored NIV interfaces. New research focusing on developing advanced and tailored NIV masks should be prioritized; indeed, interfaces should be designed according to the specific patient and clinical setting where they need to be used.

Development of Personalized Non-Invasive Ventilation Interfaces for Neonatal and Pediatric Application Using Additive Manufacturing

The objective of this study was to present a methodology and manufacturing workflow for non-invasive ventilation interfaces (NIV) for neonates and small infants. It aimed to procure a fast and feasible solution for personalized NIV produced in-house with the aim of improving fit and comfort for the patient. Three-dimensional scans were obtained by means of an intraoral (Trios 3) and a facial scanner (3dMd Flex System). Fusion 360 3D-modelling software was employed to automatize the design of the masks and their respective casting molds. These molds were additively manufactured by stereolithography (SLA) and fused filament fabrication (FFF) technologies. Silicone was poured into the molds to produce the medical device. In this way, patient individualized oronasal and nasal masks were produced. An automated design workflow and use of additive manufacturing enabled a fast and feasible procedure. Despite the cost for individualization likely being higher than for standard masks, a user-friendly workflow for in-house manufacturing of these medical appliances proved to have potential for improving NIV in neonates and infants, as well as increasing comfort.

Reduced Air Leakage During Non-Invasive Ventilation Using a Simple Anesthetic Mask With 3D-Printed Adaptor in an Anthropometric Based Pediatric Head-Lung Model

Non-invasive ventilation (NIV) is increasingly used in the support of acute respiratory failure in critically ill children admitted to the pediatric intensive care unit (PICU). One of the major challenges in pediatric NIV is finding an optimal fitting mask that limits air leakage, in particular for young children and those with specific facial features. Here, we describe the development of a pediatric head-lung model, based on 3D anthropometric data, to simulate pediatric NIV in a 1-year-old child, which can serve as a tool to investigate the effectiveness of NIV masks. Using this model, the primary aim of this study was to determine the extent of air leakage during NIV with our recently described simple anesthetic mask with a 3D-printed quick-release adaptor, as compared with a commercially available pediatric NIV mask. The simple anesthetic mask provided a better seal resulting in lower air leakage at various positive pressure levels as compared with the commercial mask. These data further support the use of the simple anesthetic mask as a reasonable alternative during pediatric NIV in the acute setting. Moreover, the pediatric head-lung model provides a promising tool to study the applicability and effectiveness of customized pediatric NIV masks in the future.

Medical Device Development for Children and Young People-Reviewing the Challenges and Opportunities

Development of specific medical devices (MDs) is required to meet the healthcare needs of children and young people (CYP). In this context, MD development should address changes in growth and psychosocial maturation, physiology, and pathophysiology, and avoid inappropriate repurposing of adult technologies. Underpinning the development of MD for CYP is the need to ensure MD safety and effectiveness through pediatric MD-specific regulations. Contrary to current perceptions of limited market potential, the global pediatric healthcare market is expected to generate around USD 15,984 million by 2025. There are 1.8 billion young people in the world today; 40% of the global population is under 24, creating significant future healthcare market opportunities. This review highlights a number of technology areas that have led to successful pediatric MD, including 3D printing, advanced materials, drug delivery, and diagnostic imaging. To ensure the targeted development of MD for CYP, collaboration across multiple professional disciplines is required, facilitated by a platform to foster collaboration and drive innovation. The European Pediatric Translational Research Infrastructure (EPTRI) will be established as the European platform to support collaboration, including the life sciences industrial sector, to identify unmet needs in child health and support the development, adoption, and commercialization of pediatric MDs.

Custom-made 3D printed masks for children using non-invasive ventilation: a comparison of 3D scanning technologies and specifications for future clinical service use, guided by patient and professional experience

Non-invasive ventilation (NIV) is assisted mechanical ventilation delivered via a facemask for people with chronic conditions that affect breathing. Mass-produced masks are available for both the adult and paediatric markets but masks that fit well are difficult to find for children who are small or have asymmetrical facial features. A good fit between the mask and the patient's face to minimise unintentional air leakage is essential to deliver the treatment effectively. We present an innovative use of 3D assessment and manufacturing technologies to deliver novel custom-made facemasks for children for whom a well-fitting standard mask is not available. This paper aims to describe the processes undertaken to investigate and compare currently available technologies for 3D scanning children and to explore the design of a system for creating custom-made paediatric NIV masks within the NHS. The paper therefore considers not only the quality and accuracy of the data, but also other factors such as the time and ease of process. Searches for all currently available scanning technologies were made. Photogrammetry image stitch using a smartphone and a digital camera, and two structured light scanners were selected and compared in the laboratory, in discussion with user groups, and in adult volunteers. Using the processes described, it became apparent that the optimal 3D scanning system for this purpose was the handheld structured light scanner. This option offered both superior accuracy and convenience and was more cost effective.

Non-invasive Ventilation for Pediatric Hypoxic Acute Respiratory Failure Using a Simple Anesthetic Mask With 3D Printed Adaptor: A Case Report

Non-invasive ventilation (NIV) is increasingly used in the supportive treatment of acute respiratory failure in children in the pediatric intensive care unit (PICU). However, finding an optimal fitting commercial available NIV face mask is one of the major challenges in daily practice, in particular for young children and those with specific facial features. Large air leaks and pressure-related skin injury due to suboptimal fit are important complications associated with NIV failure. Here, we describe a case of a 4-year old boy with cardiofaciocutaneous syndrome and rhinovirus-associated hypoxic acute respiratory failure who was successfully supported with NIV delivered by a simple anesthetic mask connected to a headgear by an in-house developed and 3D printed adaptor. This case is an example of the clinical challenge related to pediatric NIV masks in the PICU, but also shows the potential of alternative NIV interfaces e.g., by using a widely available and relatively cheap simple anesthetic mask. Further personalized strategies (e.g., by using 3D scanning and printing techniques) that optimize NIV mask fitting in children are warranted.

Interfaces, Circuits and Humidifiers

Long-term non-invasive ventilation (LTNIV) has been increasingly used in children to manage chronic respiratory failure and airway obstruction. Interfaces are of paramount importance for non-invasive ventilation (NIV) effectiveness and patient compliance. However, historically, the choice of pediatric mask has been limited by the scarce availability of commercial interfaces. In recent years, an increasing number of different masks have been commercialized for children, allowing to increase the number of patients who could benefit from LTNIV. Factors such as the age of the child, disease, craniofacial conformation, type of ventilator and mode of ventilation, and children's and family's preferences should be taken into account when selecting the appropriate mask. Adverse events such as skin lesions, facial growth impairment, and leaks must be prevented and promptly corrected. Humidification is a controversial issue on NIV, but it may be useful in certain circumstances. Regular cleaning and disinfection of interfaces and equipment must be addressed. During follow-up, educational programs, close supervision, and continuous support to children and families are crucial to the success of LTNIV therapy.