Transudative pleural effusions: false reassurance against malignancy.

Four rounds of treatments/measurements were performed in three patients who were receiving nebulized treatments in our ICU; three of four cases were treated first with the catheter in the system during nebulization, followed by a second treatment with the catheter and connector removed from the system. One patient received two rounds of measurements (both with the catheter in the system for the first albuterol treatment). With the catheter in the system during treatments, airway resistance was 19.0 Ϯ 1.5 cm H 2 O/L/s before and 18.1 Ϯ 1.9 cm H 2 O/L/s (p ϭ 0.24) after 2.5 mg of nebulized albuterol. Airway resistance decreased significantly from 19.4 Ϯ 2.8 to 14.4 Ϯ 2.6 cm H 2 O/L/s (p ϭ 0.01) after 2.5 mg of albuterol administered with the suction catheter out of (removed from) the system. Because treatments were not randomized and because there were only eight observations, we drew no conclusions from these findings. Nonetheless, these data suggest that the closed in-line suction catheter used in our hospital prevented aerosolized medication from reaching the airways of these intubated patients receiving mechanical ventilation. We suspect that the 90°, three-way connec-tor between the ETT and the wye trapped aerosolized particles. Importantly, aerosolized bronchodilators were effective when administered with another brand of in-line closed suction device 3 (Rajiv Dhand, MD; personal communication; March 2000). Either bench trials or prospective, randomized clinical studies are required to answer this question for each device on the market. Physicians and respiratory therapists should be aware that some brands of closed in-line suction catheters, used by 93% of nurses caring for adult patients, 1 may impede delivery of therapeutic aerosols. When aerosolized bronchodilator treatments fail to reduce airway resistance, and elevated resistance increases risk to the patient (eg, significant dynamic hyperinflation and/or weaning failure), clinicians should consider removing the suction catheter during treatment to determine if removal leads to the desired effect (bronchodilation). To reduce the risk of infection to health-care workers and patients, closed-suction systems are now used in the majority of critically ill patients receiving mechanical ventilation. Not infrequently, new devices are introduced to the clinical arena with the best of intentions, but without thorough consideration of potential negative effects. We should have learned from the available data that, in aerosol delivery, " the devil is in the details. " Seemingly trivial changes in the patient-ventilator circuit can significantly reduce the effectiveness of these treatments. …