A critical incident is reported in which ribavirin administered from a smal
l particle aerosol generator (SPAG) into a ventilator circuit became deposi
ted around the humidifier temperature probe with the consequence that it be
came thermally insulated. This caused overheating of the humidifier and the
potential for thermal injury to the respiratory tract. The circuit for aer
osolized ribavirin administration is described and modifications suggested
to avoid crystal precipitation within the circuit.