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Communications to the Editor |

In-line Suction Catheters May Impede Aerosol Delivery to Patients Receiving Mechanical Ventilation FREE TO VIEW

Constantine A. Manthous, MD, FCCP; Mohammad Khamiees, MD
Author and Funding Information

Bridgeport Hospital Bridgeport, CT

Correspondence to: Constantine A. Manthous, MD, FCCP, Bridgeport Hospital, West Tower 6, 267 Grant St, Bridgeport, CT 06610; e-mail: pcmant@bpthosp.org



Chest. 2000;118(3):884-885. doi:10.1378/chest.118.3.884-a
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Published online

To the Editor:

A recent article suggests that closed in-line suction catheters are used frequently in patients receiving intubation and/or mechanical ventilation.1We have been concerned that some of these devices trap aerosolized medications, preventing them from reaching the airways of our patients. Some in-line suction catheters include a potentially turbulence-creating 90° adapter that becomes moist during use. Theoretically, these attributes could impede the delivery of therapeutic aerosols to patients’ airways.2

We informally examined the effectiveness of a nebulized bronchodilator when administered with an in-line suction catheter left in place, vs having it removed from the patient-ventilator circuit. The Steri-Cath (SIMS Portex; Keene, NH) is a closed-suction system used for all patients receiving intubation and/or mechanical ventilation in our hospital. This system consists of a 57-cm, 14F (4.7-mm outer diameter) catheter wrapped in plastic foil, connected in a straight line with the endotracheal tube (ETT) via a three-way connector. The inner diameter of the orifice connecting to the ETT is 15 mm. The ventilator wye-piece connects at 90° to the ETT-suction catheter axis via the third aperture (inner diameter, 12 mm) of the three-way connector.

Two sequential nebulized albuterol treatments of 2.5 mg in 3 mL were given to three patients at intervals of 20 to 30 min, one with the suction catheter in the circuit, and one with the suction catheter and three-way connector out (wye connected directly to the ETT). Airway pressures (peak and plateau) were measured with constant inspiratory flow rates of 60 L/min, before and 20 min following treatments. The suction catheter was in-line during measurements, but the catheter was withdrawn into its plastic sheath (outside the three-way connector). No endotracheal suctioning occurred between sets of treatments/measurements. Airway resistance was computed as the difference between peak and plateau airway pressure. 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 ± 1.5 cm H2O/L/s before and 18.1 ± 1.9 cm H2O/L/s (p = 0.24) after 2.5 mg of nebulized albuterol. Airway resistance decreased significantly from 19.4 ± 2.8 to 14.4 ± 2.6 cm H2O/L/s (p = 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 connector between the ETT and the wye trapped aerosolized particles. Importantly, aerosolized bronchodilators were effective when administered with another brand of in-line closed suction device3 (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.,4

References

Paul-Allen, J, Ostrow, CL (2000) Survey of nursing practices with closed-system suctioning.Am J Crit Care9,9-17
 
Dhand, R, Tobin, MJ Inhaled bronchodilator therapy in mechanically ventilated patients.Am J Respir Crit Care Med1997;156,3-10
 
Dhand, R, Jubran, A, Tobin, MJ Bronchodilator delivery by metered-dose inhaler in ventilator-supported patients.Am J Respir Crit Care Med1995;151,1827-1833
 
Newhouse, MT, Fuller, HD Rose is a rose is a rose? Aerosol therapy in ventilated patients: nebulizers versus metered dose inhalers; a continuing controversy.Am Rev Respir Dis1993;148,1444-1446
 

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References

Paul-Allen, J, Ostrow, CL (2000) Survey of nursing practices with closed-system suctioning.Am J Crit Care9,9-17
 
Dhand, R, Tobin, MJ Inhaled bronchodilator therapy in mechanically ventilated patients.Am J Respir Crit Care Med1997;156,3-10
 
Dhand, R, Jubran, A, Tobin, MJ Bronchodilator delivery by metered-dose inhaler in ventilator-supported patients.Am J Respir Crit Care Med1995;151,1827-1833
 
Newhouse, MT, Fuller, HD Rose is a rose is a rose? Aerosol therapy in ventilated patients: nebulizers versus metered dose inhalers; a continuing controversy.Am Rev Respir Dis1993;148,1444-1446
 
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