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Constantine A. Manthous, MD, FCCP
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From the Bridgeport Hospital and Yale University School of Medicine.

Correspondence to: Constantine A. Manthous, MD, FCCP, Bridgeport Hospital and Yale University School of Medicine, 267 Grant St, Bridgeport, CT 06610; e-mail: Pcmant@bpthosp.org


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(5):1364. doi:10.1378/chest.11-3118
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To the Editor:

Although I hate to “rain on the parade” of Khorfan and colleagues,1 it is possible, if not likely, that methodologic nuances of aerosol delivery undermine the validity of their conclusions in their article in CHEST (December 2011), which states that “nebulized albuterol does not cause significant tachycardia or tachyarrhythmias.”1 In delivery of therapeutic aerosols, the devil is in the details, and the “Materials and Methods” section in the article does not provide any information regarding the aerosol delivery techniques used for study patients.1 This is especially true in patients who are mechanically ventilated, who composed >50% of the sample, in which we proved that veritably none of 100 puffs of albuterol was delivered to patients’ airways.2 Multiple variables, including circuit design, humidification, flow rates, and tidal volumes, impact aerosol delivery to critically ill patients.3 Poor techniques can lead to the illusion of treatment (ie, doses administered but not delivered to the airways because they rain out in the circuit). Accordingly, this study should be interpreted cautiously, because no evidence (eg, of reduced airway resistance) is provided to support that any of the administered doses were delivered.

Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients. Chest. 2011;1406:1466-1472. [CrossRef] [PubMed]
 
Manthous CA, Hall JB, Schmidt GA, Wood LD. Metered-dose inhaler versus nebulized albuterol in mechanically ventilated patients. Am Rev Respir Dis. 1993;1486 pt 1:1567-1570. [CrossRef] [PubMed]
 
Manthous CA, Hall JB. Administration of therapeutic aerosols to mechanically ventilated patients. Chest. 1994;1062:560-571. [CrossRef] [PubMed]
 

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Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients. Chest. 2011;1406:1466-1472. [CrossRef] [PubMed]
 
Manthous CA, Hall JB, Schmidt GA, Wood LD. Metered-dose inhaler versus nebulized albuterol in mechanically ventilated patients. Am Rev Respir Dis. 1993;1486 pt 1:1567-1570. [CrossRef] [PubMed]
 
Manthous CA, Hall JB. Administration of therapeutic aerosols to mechanically ventilated patients. Chest. 1994;1062:560-571. [CrossRef] [PubMed]
 
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