The document discusses the history of inhalation therapy and humidification during mechanical ventilation. It traces the early use of inhaling medicinal plant smoke and various inhalation therapies in the late 1800s. The development of professional organizations for inhalation therapists is covered, along with guidelines for humidification and heat moisture exchangers. Key aspects of humidification such as maintaining minimum moisture levels are emphasized.

1. April 1 2015 1

2. The FirstArtificial Nose
2 April 1 2015

3. Let’s begin…
The Science of HMEs
April 1 2015

4.
Ancient
man
discovered
medicinal
plants
by
observa3on
and
experience.
Inhaling
smoke
from
plants
was
common
to
get
pleasure
and
relief
from
body
troubles.
Nearly
all
respiratory
troubles
were
treated
by
one
form
or
another
of
inhala3on.
Inhalation Therapy
April 1 2015

5.
Treatment
for
Respiratory
Ailments
Were
Common
During
the
Late
1800s
April 1 2015

6.
Compound
Oxygen
“Scien'fic
adjustment
to
oxygen
and
nitrogen”
Drs.
Starkey
and
Palen,
1888
April 1 2015

7. April 1 2015

8. The
inhaled
gas
was
mixed
with
various
chemicals
to
give
it
color
and
to
assure
pa3ents
they
were
inhaling
something
tangible
and
useful.
Compound
oxygen
was
not
oxygen,
but
a
very
dilute
laughing
gas”
made
by
hea3ng
ammonium
nitrate.
April 1 2015

9.
Indica3ons
for
Compound
Oxygen
ü Asthma
ü Bronchi3s
ü Indiges3on
ü Hay
fever
ü Headache
ü Rheuma3sm
ü Neuralgia
ü Diarrhea
…and
cured
none
April 1 2015

10.
April 1 2015

11.
The
American
Associa3on
of
Inhala3on
Therapy
The
University
of
Chicago
Hospital
establishes
the
Inhala3on
Therapy
Associa3on
in
1947
April 1 2015

12.
The
American
Associa3on
of
Inhala3on
Therapy
was
the
first
to
issue
cer3fica3on
classes
for
Inhala3on
Therapists.
The
ITA
is
formally
chartered
as
a
not-­‐for-­‐profit
en3ty
in
the
state
of
Illinois.
The
new
Associa3on
had
59
charter
members,
17
of
whom
were
from
various
religious
orders.
It
was
an
on-­‐the-­‐job
training
system
for
so-­‐called
oxygen
jockeys.”
April 1 2015

13. An
Early
Oxygen
Tank
April 1 2015

14.
AARC
Clinical
Prac3ce
Guideline
Humidifica*on
During
Invasive
and
Noninvasive
Mechanical
Ven*la*on
RESPIRATORY
CARE
·∙
MAY
2012
VOL
57
NO
5
Ruben
D
Restrepo
MD
RRT
FAARC
Brian
K
Walsh
RRT-­‐NPS
FAARC
April 1 2015

15.
“Humidifica3on
of
inspired
gas
during
mechanical
ven3la3on
is
mandatory
when
an
endotracheal
or
tracheostomy
tube
is
present.”
April 1 2015

16. “This
may
be
accomplished
using
either
a
heated
humidifier
or
a
heat
and
moisture
exchanger.”
April 1 2015

17.
When
providing
passive
humidifica3on
to
pa3ents
undergoing
invasive
mechanical
ven3la3on,
it
is
suggested
that
the
HME
provide
a
minimum
of
30
mg
H2O/L.
April 1 2015

18. Humidity
and
the
pa3ent,
simply
put…
The
Rule
of
Five
April 1 2015

19.
1.
A
desired
outcome
is
the
single
most
important
goal
when
humidifying
ven3lator
pa3ents.
2.
Undesirable
outcomes
should
be
addressed
and
fixed.
April 1 2015

20.
3.
All
passive
humidifiers
must
deliver
30mg
of
water
with
the
first
breath
and
the
last
breath,
at
any
minute
volume,
while
using
the
device.
April 1 2015

21.
4.
AARC
and
other
standards
must
be
met
in
order
to
maintain
The
Standard
of
Care
Prac3ces.
Bad
things
happen
when
uses
policies
are
outside
of
The
Standard
of
Care
Prac3ces.
April 1 2015

22.
5.
No
study
has
shown
that
disconnec3on
of
a
dry
HME
circuit
increases
the
rate
of
VAP.
April 1 2015

23.
Clinical
Prac3ce
Guidelines
During
Mechanical
Ven3la3on
The
Clinical
Prac3ce
Guidelines
imply
that
unless
specifically
contraindicated,
the
HME
will
be
acceptable.
Clinical
Founda3ons,
A
Pa3ent-­‐focused
educa3on
program
for
Respiratory
Care
Professionals,
Humidifica3on
During
Mechanical
Ven3la3on:
Current
Trends
and
Controversies
Tim
Op’t
Holt,
EdD,
R.R.T.,
AE-­‐C,
FAARC
April 1 2015

24. “HMEs
should
be
used
in
all
pa3ents
in
whom
there
is
no
contraindica3on.”
Richard
D.
Branson
MSc
RRT
FAARC
June
2005
Respiratory
Care
Journal
April 1 2015

25. 25 April 1 2015

26. 26 April 1 2015

27.
U.S.
Department
of
Health
and
Human
Services
MAUDE
-­‐
Manufacturer
and
User
Facility
Device
Experience
Type
-­‐
BZE
Year
Reports
Ac3ve
Heated
Water
2013
382
Ac3ve
Heated
Water
2012
586
Ac3ve
Heated
Water
2011
668
Ac3ve
Heated
Water
2010
560
Ac3ve
Heated
Water
2009
557
Ac3ve
Heated
Water
2008
457
April 1 2015

28.
Advantages
of
Using
Ac've
Humidifiers
During
Mechanical
Ven3la3on
ü
Have
alarms
ü
Are
capable
of
regula3ng
and
monitoring
temperatures
ü
Work
with
all
pa3ents,
universal
ü
Seem
to
be
reliable
ü
Heated
wire
helps
to
reduce
condensate.
April 1 2015

29.
Advantages
of
Using
Ac've
Humidifiers
During
Mechanical
Ven3la3on
ü
Offers
wide
varia3on
of
op3ons
in
trea3ng
pa3ents,
versa3lity
ü
Preferred
method
of
humidifica3on
with
pre-­‐exis3ng
condi3ons
such
as
COPD…
April 1 2015

30.
Disadvantages
of
Using
Ac've
Humidifiers
During
Mechanical
Ven3la3on
ü
Temperature
sejng
is
not
humidity
delivered
ü
Costly,
possibili3es
of
malfunc3on
and
down
3me
ü
User
problems
as
reported
in
MAUDE
–
FDA
-­‐
Manufacture
and
User
Facility
Device
Experience
April 1 2015

31.
Disadvantages
of
Using
Ac've
Humidifiers
During
Mechanical
Ven3la3on
ü
May
develop
condensa3on
within
the
circuit
ü
Possible
infec3ous
waste
(biological
hazard)
drainage
into
heater
reservoir,
the
ven3lator,
onto
prac3oner’s
face
and
more
ü
Complex
to
use
with
over
or
under
hydra3on
possible
ü
May
not
produce
as
much
humidity
as
thought.
April 1 2015

32. Secre3ons
=
Biological
Hazard
April 1 2015

33. Secre3ons
=
Biological
Hazard
Even
from
the
circuit
April 1 2015

34. Heated
Humidifiers
Puritan-­‐
Bennep
Cascade
Humidifier
April 1 2015

35. 35 April 1 2015

36. 36 April 1 2015

37. April 1 2015

38.
What
is
an
Ar3ficial
Nose?
ü
Commonly
called
a
HME
and
or
filter
(although
filter
media
may
not
be
present)
ü
These
humidifica3on
devices
func3on
without
the
addi3on
of
a
water
source
or
electricity.
ü
These
devices
collect
and
conserve
the
pa3ent’s
expired
moisture
and
heat.
April 1 2015

39. The
Ar3ficial
Nose
The
first
heat
and
moisture
exchanger,
which
was
made
with
corrugated
aluminum,
was
presented
by
a
group
of
Swedish
professors
in
the
early
1960’s.
Due
to
its
weight,
the
device
never
became
widely
used.
April 1 2015

40. April 1 2015

41. The
Ar3ficial
Nose
The
aluminum
was
replaced
with
a
special
paper
in
a
corrugated
structure
with
a
large
capacity
for
absorbing
and
giving
off
moisture.
Over
the
years
the
“noses”
have
been
gradually
developed
and
the
design
has
been
refined.
The
market
breakthrough
for
the
ar3ficial
nose
did
not
occur
un3l
the
beginning
of
the
1970’s.
April 1 2015

42.
Humidifica3on
During
Mechanical
Ven3la3on
Indica3ons:
ü
Humidifica3on
of
inspired
gas
during
mechanical
ven3la3on
is
mandatory
when
an
endotracheal
or
tracheostomy
tube
is
present.
ü
When
providing
passive
humidifica3on
to
pa3ents
undergoing
invasive
mechanical
ven3la3on,
the
HME
should
provide
a
minimum
of
30mg
H2O/L.
RESPIRATORY
CARE
•
MAY
2012
VOL
57
NO
5
April 1 2015

43.
Humidifica3on
During
Mechanical
Ven3la3on
HME
Contraindica3ons:
ü
Use
of
an
HME
may
be
contraindicated
for
pa3ents
with
high
spontaneous
minute
volumes
10L/min.
ü
There
are
products
on
the
market
which
deliver
30mg
of
moisture
at
20
liter
minute
volumes.
April 1 2015

44.
Humidifica3on
During
Mechanical
Ven3la3on
HME
Contraindica3ons:
ü
An
HME
must
be
removed
from
the
pa3ent
circuit
during
aerosol
treatments
when
the
nebulizer
is
placed
in
the
pa3ent
circuit.
ü With
some
products,
placing
a
nebulizer
between
the
PH
and
pa3ent
may
not
create
a
problem.
ü Pressures
should
always
be
monitored
during
any
treatment.
April 1 2015

45.
Humidifica3on
During
Mechanical
Ven3la3on
HME
Contraindica3ons:
ü
Use
of
an
HME
is
contraindicated
for
pa3ents
with
body
temperatures
less
than
32°
C
.
ü
These
hypothermic
pa3ents
may
be
beper
managed
using
a
heated
humidifier
because
it
may
be
more
efficient
at
reducing
further
heat
loss.
April 1 2015

46.
Humidifica3on
During
Mechanical
Ven3la3on
HME
Contraindica3ons:
ü
Pa3ents
with
pre-­‐exis3ng
pulmonary
disease
characterized
by
thick,
copious,
or
bloody
secre3ons
should
not
use
PH.
ü
Use
of
an
PH
is
contraindicated
for
pa3ents
with
an
expired
3dal
volume
less
than
70%
of
the
delivered
3dal
volume
-­‐
those
with
fistulas
or
absent
endotracheal
tube
cuff.
April 1 2015

47.
Humidifica3on
During
Mechanical
Ven3la3on
HME
Contraindica3ons:
Lung-­‐protec3ve
ven3la3on
strategies:
ü
When
providing
humidifica3on
to
pa3ents
with
low
3dal
volumes
HMEs
are
not
recommended
because
they
contribute
addi3onal
dead
space...
April 1 2015

48.
Advantages
of
Using
Passive
Humidifiers
ü
Simple
to
use,
no
moving
parts
ü
Produce
dry,
cool
circuits
which
lowers
the
risk
of
contamina3on
ü
No
need
for
water
or
electricity
ü
No
down
3me
ü
Lightweight,
portable,
easy
to
use
and
store.
April 1 2015

49.
Advantages
of
Using
Passive
Humidifiers
ü
Impossible
to
over
hydrate
the
pa3ent
ü
Impossible
to
over
heat
or
burn
the
pa3ent
ü
Helps
to
eliminate
condensate
in
tubing
ü
Lower
humidifica3on
costs
ü
Faster
and
dry
circuit
changes
-­‐
eliminates
the
possible
exposure
to
condensate...
April 1 2015

50.
Disadvantages
of
Using
Passive
Humidifiers
ü
May
increase
airway
resistance
ü
Increased
dead
space
may
create
excessive
rebreathing
–
especially
with
small
3dal
volumes
ü
Poten3al
for
occlusion
ü
Not
suitable
for
all
pa3ents.
April 1 2015

51.
Disadvantages
of
Using
Passive
Humidifiers
ü
Possible
pneumothorax
ü
Increase
in
weight
over
3me
ü
ET
tube
associated
problems
ü
The
maximum
amount
of
water
vapor
which
can
be
delivered
to
the
pa3ent
in
a
specific
volume
of
gas
will
vary
with
different
temperatures…
April 1 2015

52.
Advantages
of
Using
Ac've
HME
Humidifiers
ü
Universal
applica3on
ü
Helps
to
eliminate
condensate
in
tubing
ü
Helps
to
produce
dry,
cool
circuits
with
lower
water
consump3on
ü
Have
alarms
ü
Con3nues
passive
humidifying
if
electricity
or
water
fails.
April 1 2015

53.
Disadvantages
of
Using
Ac've
HME
Humidifiers
ü
Extra
dead
space
ü
Poten3al
for
occlusions,
high
pressure,
etc.
ü
Limited
temperature
varia3ons
to
choose
ü
Heater
close
to
pa3ent
ü
Must
be
removed
to
deliver
aerosols
ü
Cost
savings
only
when
compared
to
ac3ve
systems,
not
HMEs…
April 1 2015

54. All
“Noses”
Are
Not
Alike!
April 1 2015

55.
U.S.
Department
of
Health
and
Human
Services
MAUDE
-­‐
Manufacturer
and
User
Facility
Device
Experience
Type
-­‐
CAH
Year
Reports
Passive
Humidifier
2013
47
Passive
Humidifier
2012
16
Passive
Humidifier
2011
9
Passive
Humidifier
2010
39
Passive
Humidifier
2009
18
Passive
Humidifier
2008
27
April 1 2015

56.
What
is
30/30?
April 1 2015

57. 30/30
April 1 2015

58.
Does
2
mg
H2O/L
returned
between
devices
make
a
difference?
ü
If
every
Liter
of
air
delivered
to
the
pa3ent
has
2
extra
mg
H2O
ü
If
a
minute
ven3la3on
of
7
L
–
The
pa3ent
receives
an
extra
14
mg
of
H2O
every
minute.
ü
840
mg
H2O
extra
per
hour
ü
20,160
mg
H2O
extra
per
day
A
real
benefit
for
the
pa3ent
and
most
likely
beper
outcomes
April 1 2015

59. April 1 2015

60. • heat
and
moisture
exchanger
HME
• filter
heat
and
moisture
exchanger
FHME
April 1 2015

61. • hygroscopic
condensing
humidifier
HCH
• filter
hygroscopic
condensing
humidifier
FHCH
April 1 2015

62. • gas
flow
may
be
redirected
to
and
around
the
media
Bypass
HME
• heat
and
water
added
to
the
HME
Ac've
HME
April 1 2015

63.
Hygroscopic:
The ability of a substance to attract and hold water
molecules from the surrounding environment by
enhancing the natural physical properties.
This is achieved through either:
ü absorption or adsorption
with the material becoming physically changed.”
April 1 2015

64. Absorp'on:
Incorpora'on
of
moisture.
This
moisture
becomes
a
part
of
the
media
(gray
arrows)
Adsorp'on:
Adhesion
of
moisture
to
a
surface
(blue
arrows)
April 1 2015

65. Coffee
Pour
Test
Looking for:
ü Media absorbing
ü Media non-absorbing
Pour coffee (so you can see) into the
PH media to see if the media absorbs
the coffee.
Absorption of coffee represents the
media taking moisture from the patient’s
breath and becoming part of the
product.
April 1 2015

66. Coffee
Pour
Test
April 1 2015

67. Examples
of
Passive
By-­‐Pass
Ac3ve
HMEs
April 1 2015

68. Examples
of
Passive
Humidifier
Designs
April 1 2015

69. Examples
of
Passive
Humidifier
Designs
Many
flex
tubes
will
add
about
2
mg
of
moisture
April 1 2015

70. Examples
of
Trach
Passive
Humidifier
Designs
April 1 2015

71. Examples
of
Humidifica3on
Media
April 1 2015

72.
Many
HME
Products
Fail
to
Meet
the
Pa3ent’s
Needs
-­‐-­‐
Resul3ng
in
Adverse
Events
ü
High
pressure
alarms
ü
Spontaneous
pneumothorax
ü
Thickening
secre3ons
ü
Endotracheal
tube
occlusions
ü
Plugged
airways
ü
And
more…
April 1 2015

73.
Clinicians
Should
Remember…
Actual
Moisture
Output
Varies
ü
As
gas
volumes
increase
moisture
output
decreases
-­‐-­‐
Tidal
volumes
ü
When
gas
moves
through
the
media
quickly,
the
ability
of
the
device
to
remove
moisture
from
exhaled
gas
and
add
moisture
to
inspired
gas
–
diminishes
-­‐-­‐
Respiratory
rates
April 1 2015

74. Replaced
HME
q
24
hours
Bloody
secre3ons?
Thick
tenacious
sputum?
Less
than
70%?
Core
temp
less
320
C?
Evaluate
secre3on
quality
and
quan3ty
Examine
pa3ent
Use
heated
humidifica3on
Examine
pa3ent’s
Hx/Px
More
than
4
HMEs
used
in
24
hours?
NO
YES
YES
NO
74
Humidification for Patients with Artificial Airways
RESPIRATORY CARE; JUNE 1999; VOLUME: 44 NO 6; page 638
April 1 2015

75. Inconsistent)Therapy?)
Passive'humidifiers'and'inaccurate'active'humidification'
settings'may'lead'to'undesirable'sputum'outcomes,'
endotracheal'tube'occlusions'and/or'pneumothorax.'
'
!
!
! !
!
Pa$ent’s
humidity
level
drops
over
$me
RRT
replaces
HME
and
perceives
everything
to
be
ok

76. Don’t
be
Fooled,
The
3Cs
①
Charging
②
Coring
③
Collec3ng
April 1 2015

77.
“Charging” -­‐-­‐
Func3on
of
Media
ü
“The
longer
you
use
the
hme,
the
beper
it
works”
is
a
common
misunderstanding
ü
In
reality,
the
longer
these
devices
are
used,
more
moisture
is
absorbed
from
the
pa3ent’s
breath
ü
The
pa3ent
may
have
less
moisture
a}er
using
these
devices
because
moisture
is
absorbed
into
the
media.
April 1 2015

78. Don’t
be
Fooled,
The
3Cs
①
Charging
April 1 2015

79.
“Charging”
-­‐-­‐
Func3on
of
Media
Secre*ons
cover
the
material
April 1 2015

80.
“Charging” -­‐-­‐
Func3on
of
Media
April 1 2015
Absorp$on

81.
“Coring” -­‐-­‐
Possible
Result
of
Design?
ü
Many
products
are
constructed
with
diffusors,
walls,
wings,
etc.
to
help
move
the
gas
flow
around
inside
the
housing
ü
Rebreathing
occurs
in
the
center
of
the
media
ü
Causing
increased
pressures
ü
Possible
absorp3on
of
humidity
from
the
pa3ent’s
breath
April 1 2015

82. Don’t
be
Fooled,
The
3Cs
②
Coring
April 1 2015

83.
Too
Late
to
Check
Effec3veness
April 1 2015

84. Don’t
be
Fooled,
The
3Cs
③
Collec3ng
April 1 2015

85.
Collec3ng…
gas in gas in
gas out
April 1 2015

86.
①
Charging
?
②
Coring
?
③
Collec3ng
?
April 1 2015

87. Should
PH
be
Chosen
Based
Upon
Minute
Ven3la3ons
Moisture
Delivered?
Humidifiers
should
deliver
30/30
for
all
minute
volumes
April 1 2015

88. How
Do
I
Know
My
Pa3ent
Is
Being
Humidified?
Regardless
of
what
type
of
system
is
being
used,
the
clinician
should
ques3on
the
effec3veness.
Since
no
system
reports
the
actual
amount
of
humidity
being
delivered,
other
signs
must
be
relied
upon.
April 1 2015

89. Observe
inside
the
circuit
elbow,
circuit
wye
and
HME
housing
for
condensa3on
April 1 2015

90. Bedside
hygrometers
will
give
feedback
however
-­‐
only
a
moment
in
3me
April 1 2015

91. Assessment
of
Sputum
Characteris3cs
Suzukawa’s
Method:
Thin
-­‐
Suc3on
catheter
is
clear
of
secre3ons
following
suc3oning
Moderate
-­‐
A}er
suc3oning,
the
suc3on
catheter
has
secre3ons
adhering
to
the
sides
that
are
easily
removed
by
aspira3ng
water
Thick
-­‐
A}er
suc3oning,
the
suc3on
catheter
has
secre3ons
adhering
to
the
sides
that
are
not
removed
by
aspira3ng
water
April 1 2015

92.
Research
Independent
Documenta3on
of
Effec3veness
ü
Third
party
documenta3on
ü
Does
the
inves3gator
have
a
financial
interest?
ü
Are
the
studies
clinical
or
non-­‐clinical
sejngs?
Many
believe
in
house
studies
are
like
baseball
catchers
calling
their
balls
and
strikes!
April 1 2015

93.
This patient was featured on The Learning Channel.
2nd and 3rd degree burns over 60% of the body
and 3 months LOS (tracheal not comprised)
Only this HCHF was used to humidify the patient.
Used with permission
April 1 2015

94.
MHRA
UK
Medicines
Healthcare
Products
April 1 2015

95. Richard
Branson’s
evalua3on
of
21
HMEs,
Table
2.
(Respir
Care
1996;
41:736-­‐743)
April 1 2015

96. Documenta3on
of
PH
Effec3veness
FDA
–
MAUDE
Database
Manufacturer
and
User
Facility
Device
Experience
April 1 2015

97. MAUDE
Adverse
Event
Report
The
apending
staff
removed
the
pa3ent
from
the
mechanical
ven3lator
and
began
manual
ven3la3on.
The
pa3ent
was
resuscitated
successfully.
The
circuit
was
examined
and
the
HME
device
was
determined
to
be
blocked.
The
device
was
removed
and
replaced
with
a
new
device.
Mechanical
ven3la3on
was
resumed.
April 1 2015

98.
Early
Coffee
Cups
April 1 2015

99. What
to
Look
For
When
Choosing
a
PH
???
April 1 2015

100. Most
Important
Features
of
PH
Filter
Cost
Resistance
Moisture
output
Dead
space
Design
Respiratory Care; June
1999; Vol. 44 No. 6; Pg. 636
April 1 2015

101.
“Our
findings
suggest
that
the
ini3al
applica3on
of
an
extended-­‐use
hygroscopic
condenser
humidifier
(HCH)
is
a
safe
and
more
cost-­‐effec3ve
method
of
providing
humidifica3on
to
pa3ents
requiring
mechanical
ven3la3on
compared
with
heated-­‐
water
humidifica3on.”
Chest.
1998
Mar;
113(3):
759-­‐67.
A
randomized
clinical
trial
comparing
an
extended-­‐use
hygroscopic
condenser
humidifier
with
heated-­‐water
humidifica'on
in
mechanically
ven'lated
pa'ents.
Kollef
MH,
Shapiro
SD,
Boyd
V,
Silver
P,
Von
Harz
B,
Trovillion
E,
Pren*ce
D.
101 April 1 2015