This is the presentation, The Science of HMEs which was given at the Spring 2014 FOCUS Conference in Orlando Florida.

1. The Science of HMEs
May 2014

2. The Science of HMEs
Steve
Koontz
ARC
Medical
Inc.
skoontz@arcmedical.com
May 2014

3.
The
Ar8ficial
Nose:
• How
does
it
func8on
• The
6
types
of
passive
humidifiers
• Design
• The
3
Cs
• Moisture
media
• Important
features
• Documenta8on
of
effec8veness
• What
to
look
for
when
choosing
a
passive
humidifier.
May 2014

4.
Ancient
man
discovered
medicinal
plants
by
observa8on
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
inhala8on.
May 2014
Inhalation Therapy

5.
Treatment
for
Respiratory
Ailments
Were
Common
During
the
Late
1800s
February
2012

6.
Compound
Oxygen
“Scien'fic
adjustment
to
oxygen
and
nitrogen”
Drs.
Starkey
and
Palen,
1888
May 2014

7. May 2014

8.
Compound
oxygen
was
not
oxygen
at
all,
but
a
very
dilute
"laughing
gas”
made
by
hea8ng
ammonium
nitrate.
The
inhaled
gas
was
mixed
with
ferric
carbonate
or
potassium
chlorate,
to
give
it
color
and
help
assure
pa8ents
they
were
inhaling
something
tangible
and
useful.
May 2014

9.
Indica8ons
for
Compound
Oxygen
• Asthma
• Bronchi8s
• Indiges8on
• Hay
fever
• Headache
• Rheuma8sm
• Neuralgia
• Diarrhea
…and
cured
none
May 2014

10.
May 2014

11.
The
American
Associa8on
of
Inhala8on
Therapy
The
University
of
Chicago
Hospital
establishes
the
Inhala8on
Therapy
Associa8on
in
1946
May 2014

12.
The
American
Associa8on
of
Inhala8on
Therapy
was
the
first
to
issue
cer8fica8on
classes
for
Inhala8on
Therapists.
It
was
an
on-­‐the-­‐job
training
system
for
so-­‐called
"oxygen
jockeys.”
May 2014

13. An
Early
Oxygen
Tank
May 2014

14.
•
“Humidifica8on
of
inspired
gas
during
mechanical
ven8la8on
is
mandatory
when
an
endotracheal
or
tracheostomy
tube
is
present.
•
This
may
be
accomplished
using
either
a
heated
humidifier
or
a
heat
and
moisture
exchanger.
•
The
chosen
device
should
provide
a
minimum
of
30
mg
H2O/L
of
delivered
gas
at
30°
C”.
Respiratory
Care
(Respir
Care
1992;37:887-­‐890)
AARC
Clinical
Prac8ce
Guideline
Humidifica8on
during
Mechanical
Ven8la8on
May 2014

15.
What
is
30/30?
February
2012

16. 30/30
February
2012

17. 17
Ac8ve?
Passive?
Both?
It
is
very
important
for
respiratory
therapists
to
evaluate
each
pa8ent
individually
and
choose
the
correct
device.
May 2014

18.
Clinical
Prac8ce
Guidelines
During
Mechanical
Ven8la8on
The
Clinical
Prac8ce
Guidelines
imply
that
unless
specifically
contraindicated,
the
HME
will
be
acceptable.
Clinical
Founda8ons,
A
Pa8ent-­‐focused
educa8on
program
for
Respiratory
Care
Professionals,
Humidifica8on
During
Mechanical
Ven8la8on:
Current
Trends
and
Controversies
Tim
Op’t
Holt,
EdD,
R.R.T.,
AE-­‐C,
FAARC
May 2014

19. “HMEs
should
be
used
in
all
pa8ents
in
whom
there
is
no
contraindica8on.”
Richard
D.
Branson
MSc
RRT
FAARC
June
2005
Respiratory
Care
Journal
November
2011

20.
Advantages
of
Using
Ac've
Humidifiers
During
Mechanical
Ven8la8on
• Have
alarms
• Are
capable
of
regula8ng
and
monitoring
temperature
• Work
with
all
pa8ents,
universal
• Seem
to
be
reliable
• Heated
wire
helps
to
reduce
condensate.
May 2014

21.
Advantages
of
Using
Ac've
Humidifiers
During
Mechanical
Ven8la8on
• Offers
wide
varia8on
of
op8ons
in
trea8ng
pa8ents,
versa8lity
• Preferred
method
of
humidifica8on
with
pre-­‐
exis8ng
condi8ons
such
as
COPD.
May 2014

22.
Disadvantages
of
Using
Ac've
Humidifiers
During
Mechanical
Ven8la8on
• Temperature
selng
is
not
humidity
delivered
• Costly,
possibili8es
of
malfunc8on
and
down
8me
• Use
problems
as
reported
in
MAUDE
–
Manufacture
and
User
Facility
Device
Experience
May 2014

23.
Disadvantages
of
Using
Ac've
Humidifiers
During
Mechanical
Ven8la8on
• May
develop
condensa8on
within
the
circuit
• Possible
infec8ous
waste
(biological
hazard)
drainage
into
heater
reservoir,
the
ven8lator
and
more
• Complex
to
use
with
over
or
under
hydra8on
possible
• May
not
produce
as
much
humidity
as
thought.
May 2014

24.
Biological
Hazards
• Biological
hazards
refer
to
biological
substances
that
pose
a
threat
to
the
health
of
living
organisms,
primarily
that
of
humans.
• The
term
and
associated
symbol
are
generally
used
as
a
warning,
so
that
those
poten8ally
exposed
to
the
substance
will
know
to
take
precau8ons.
From
Wikipedia,
the
free
encyclopedia
May 2014

25. Secre8ons
=
Biological
Hazard
May 2014

26. Heated
Humidifiers
Puritan-­‐
Benneo
Cascade
Humidifier
May 2014

27. May 201427

28. May 2014

29.
What
is
an
Ar8ficial
Nose?
• Commonly
called
a
HME
and
or
filter
(although
filter
media
may
not
be
present)
•
These
humidifica8on
devices
func8on
without
the
addi8on
of
a
water
source
or
electricity
•
These
devices
collect
and
conserve
the
pa8ent’s
expired
moisture
and
heat.
November
2011

30. The
Ar8ficial
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.
November
2011

31. The
Ar8ficial
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
ar8ficial
nose
did
not
occur
un8l
the
beginning
of
the
1970’s.
November
2011

32. May 2014

33.
Humidifica8on
During
Mechanical
Ven8la8on
Indica8ons:
•
Humidifica8on
of
inspired
gas
during
mechanical
ven8la8on
is
mandatory
when
an
endotracheal
or
tracheostomy
tube
is
present.
•
When
providing
passive
humidifica8on
to
pa8ents
undergoing
invasive
mechanical
ven8la8on,
the
HME
should
provide
a
minimum
of
30mg
H2O/L.
RESPIRATORY
CARE
•
MAY
2012
VOL
57
NO
5
May 2014

34.
Humidifica8on
During
Mechanical
Ven8la8on
HME
Contraindica8ons:
•
Use
of
an
HME
may
be
contraindicated
for
pa8ents
with
high
spontaneous
minute
volumes
>
10L/min.
• There
are
products
on
the
market
which
deliver
30mg
of
moisture
at
20
liter
minute
volumes.
May 2014

35.
Humidifica8on
During
Mechanical
Ven8la8on
HME
Contraindica8ons:
•
An
HME
must
be
removed
from
the
pa8ent
circuit
during
aerosol
treatments
when
the
nebulizer
is
placed
in
the
pa8ent
circuit.
• With
some
products,
placing
a
nebulizer
between
the
PH
and
pa8ent
may
not
create
a
problem.
• Pressures
should
always
be
monitored
during
any
treatment.
May 2014

36.
Humidifica8on
During
Mechanical
Ven8la8on
HME
Contraindica8ons:
•
Use
of
an
HME
is
contraindicated
for
pa8ents
with
body
temperatures
less
than
32°
C
.
•
These
hypothermic
pa8ents
may
be
beoer
managed
using
a
heated
humidifier
because
it
may
be
more
efficient
at
reducing
further
heat
loss.
May 2014

37.
Humidifica8on
During
Mechanical
Ven8la8on
HME
Contraindica8ons:
•
Pa8ents
with
pre-­‐exis8ng
pulmonary
disease
characterized
by
thick,
copious,
or
bloody
secre8ons
should
not
use
PH.
•
Use
of
an
PH
is
contraindicated
for
pa8ents
with
an
expired
8dal
volume
less
than
70%
of
the
delivered
8dal
volume
-­‐
those
with
fistulas
or
absent
endotracheal
tube
cuff.
May 2014

38.
Advantages
of
Using
Passive
Humidifiers
During
Mechanical
Ven8la8on
• Simple
to
use,
no
moving
parts
• Produce
dry,
cool
circuits
which
lowers
the
risk
of
contamina8on
• No
need
for
water
or
electricity
• No
down
8me
• Lightweight,
portable,
easy
to
use
and
store
May 2014

39.
Advantages
of
Using
Passive
Humidifiers
During
Mechanical
Ven8la8on
• Impossible
to
over
hydrate
the
pa8ent
• Impossible
to
over
heat
or
burn
the
pa8ent
• Helps
to
eliminate
condensate
in
tubing
•
Lower
humidifica8on
costs
• Faster
and
dry
circuit
changes
-­‐
eliminates
the
possible
exposure
to
condensate
which
is
considered
infec8ous
waste
May 2014

40.
Disadvantages
of
Using
Passive
Humidifiers
During
Mechanical
Ven8la8on
• May
increase
airway
resistance
• Increased
dead
space
may
create
excessive
rebreathing
–
especially
with
small
8dal
volumes
• Poten8al
for
occlusion
• Not
suitable
for
all
pa8ents.
May 2014

41.
Disadvantages
of
Using
Passive
Humidifiers
During
Mechanical
Ven8la8on
•
Possible
pneumothorax
•
Increase
in
weight
over
8me
–
ET
tube
associated
problems
•
The
maximum
amount
of
water
vapor
which
can
be
delivered
to
the
pa8ent
in
a
specific
volume
of
gas
will
vary
with
different
temperatures
May 2014

42.
Disadvantages
of
Using
Passive
Humidifiers
During
Mechanical
Ven8la8on
Again,
The
maximum
amount
of
water
vapor-­‐
which
can
be
delivered
to
the
pa8ent
in
a
specific
volume
of
gas-­‐
will
vary
with
different
temperatures
and
different
devices
May 2014

43.
Advantages
of
Using
Ac've
HME
Humidifiers
During
Mechanical
Ven8la8on
•
Universal
applica8on
•
Helps
to
eliminate
condensate
in
tubing
•
Helps
to
produce
dry,
cool
circuits
with
lower
water
consump8on
•
Has
alarms
•
Con8nues
passive
humidifying
if
electricity
or
water
fails
May 2014

44.
Disadvantages
of
Using
Ac've
HME
Humidifiers
During
Mechanical
Ven8la8on
•
Extra
dead
space
•
Poten8al
for
occlusions,
high
pressure,
etc.
•
Limited
temperature
varia8ons
to
choose
•
Heater
close
to
pa8ent
•
Must
be
removed
to
deliver
aerosols
•
Cost
savings
only
when
compared
to
ac8ve
systems,
not
HMEs
May 2014

45. All
“Noses”
Are
Not
Alike!
May 2014

46. May 2014

47. • heat
and
moisture
exchanger
HME
• filter
heat
and
moisture
exchanger
FHME
May 2014

48. • hygroscopic
condensing
humidifier
HCH
• filter
hygroscopic
condensing
humidifier
FHCH
May 2014

49. • gas
flow
may
be
redirected
to
and
around
the
media
Bypass
HME
• heat
and
water
added
to
the
HME
Ac've
HME
May 2014

50. May 2014
Hygroscopic:
The
ability
of
a
substance
to
aoract
and
hold
water
molecules
from
the
surrounding
environment
by
enhancing
the
natural
physical
proper8es.
This
is
achieved
through
either
absorp8on
or
adsorp8on
with
the
absorbing
or
adsorbing
material
becoming
physically
"changed.”

51. May 2014
Absorp'on:
Incorpora'on
of
moisture.
This
moisture
becomes
a
part
of
the
media
Adsorp'on:
Adhesion
of
moisture
to
a
surface
Adsorp'on
is
a
surface-­‐based
process
while
absorp'on
involves
the
whole
volume
of
the
material

52. Coffee
Pour
Test
Looking for:
• Media absorbing
• 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.
Only a small portion of this moisture will
be delivered back to the patient.
May 2014

53. Coffee
Pour
Test
May 2014

54. Examples
of
Passive
and
Ac8ve
HMEs
May 2014

55. Examples
of
Passive
Humidifier
Designs
May 2014

56. Examples
of
Passive
Humidifier
Designs
May 2014
Many
flex
tubes
will
add
about
2
mg
of
moisture

57. Examples
of
Trach
Passive
Humidifier
Designs
May 2014

58.
Many
HME
Products
Fail
to
Meet
the
Pa8ent’s
Needs
Resul8ng
in
Adverse
Events
•
High
pressure
alarms
•
Spontaneous
pneumothorax
•
Thickening
secre8ons
•
Endotracheal
tube
occlusions
•
Plugged
airways
•
And
more…
May 2014

59. Examples
of
Humidifica8on
Media
May 2014

60.
Clinicians
Should
Remember-­‐
Actual
Moisture
Output
Varies
• As
gas
volumes
increase
moisture
output
decreases
• 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
•
Most
do
not
begin
humidifying
un8l
some
8me
later,
maybe
a
hour
or
two.
May 2014

61. Replaced
HME
q
24
hours
Bloody
secre8ons?
Thick
tenacious
sputum?
Less
than
70%?
Core
temp
less
320
C?
Evaluate
secre8on
quality
and
quan8ty
Examine
pa8ent
Use
heated
humidifica8on
Examine
pa8ent’s
Hx/Px
More
than
4
HMEs
used
in
24
hours?
NO
YES
YES
NO
May 201461
Humidification for Patients with Artificial Airways
RESPIRATORY CARE; JUNE 1999; VOLUME: 44 NO 6; page 638

62. 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

63. '
!
!
! !
!
Pa$ent’s
humidity
level
drops
over
$me

64. Don’t
be
Fooled,
The
3Cs
①
Charging
②
Coring
③
Collec8ng
May 2014

65. Don’t
be
Fooled,
The
3Cs
①
Charging
May 2014

66.
“Charging” Func8on
of
Media
•
“The
longer
you
use
the
hme,
the
beoer
it
works”
is
a
common
misunderstanding
•
In
reality,
the
longer
these
devices
are
used,
the
more
moisture
is
absorbed
from
the
pa8ent’s
breath
•
The
pa8ent
may
have
less
moisture
a|er
using
these
devices
because
moisture
is
absorbed
into
the
media.
May 2014

67.
“Charging” Func8on
of
Media
May 2014

68. Don’t
be
Fooled,
The
3Cs
②
Coring
May 2014

69.
“Coring” Possible
Result
of
Design?
• Many
products
are
constructed
with
diffusors,
walls,
wings,
etc.
to
help
move
the
gas
flow
around
inside
the
housing
• Rebreathing
occurs
in
the
center
of
the
media
•
Causing
increased
pressures
•
Possible
absorp8on
of
humidity
from
the
pa8ent’s
breath
May 2014

70.
“Coring” Possible
Result
of
Design?
May 2014

71. Don’t
be
Fooled,
The
3Cs
③
Collec8ng
May 2014

72.
Collec8ng…
gas in
May 2014
gas in
gas out

73.
Collec8ng…
May 2014

74. The
3Cs
①
Charging
②
Coring
③
Collec8ng
May 2014

75. Most
Important
Features
of
PH
Filter?
Cost?
Resistance?
Moisture
output?
Dead
space?
Design?
Respiratory Care; June
1999; Vol. 44 No. 6; Pg. 636
May 2014

76. Trend
of
Humidity
Delivered
HME
lowest
HMEF
HCH
HCHF
highest
May 2014
Respiratory Care; June 1999; Vol. 44 No. 6; Pg. 636

77. Should
PH
be
Chosen
Based
Upon
Minute
Ven8la8ons?
May 2014
Humidifiers
should
deliver
30/30
for
all
minute
volumes

78. Is
My
Pa8ent
Being
Humidified?
Regardless
of
what
type
of
system
is
being
used,
the
clinician
should
ques8on
the
effec8veness.
Since
no
system
reports
the
actual
amount
of
humidity
being
delivered,
other
signs
must
be
relied
upon.
May 2014

79. Observe
inside
the
circuit
elbow,
circuit
wye
and
HME
housing
for
condensa8on
May 2014

80. Bedside
hygrometers
will
give
feedback
however
-­‐
only
a
moment
in
8me
May 2014

81. Sputum
Descrip8ons
•
What
is
a
Spudic?
• It
takes
6
Spudics
to
make
one
Sputum
• It
takes
10
Sputums
to
make
on
Spudi
• It
takes
10
Spudi
to
make
on
honker!
May 2014

82. Assessment
of
Sputum
Characteris8cs
Suzukawa’s
Method:
Thin
-­‐
Suc8on
catheter
is
clear
of
secre8ons
following
suc8oning
Moderate
-­‐
A|er
suc8oning,
the
suc8on
catheter
has
secre8ons
adhering
to
the
sides
that
are
easily
removed
by
aspira8ng
water
Thick
-­‐
A|er
suc8oning,
the
suc8on
catheter
has
secre8ons
adhering
to
the
sides
that
are
not
removed
by
aspira8ng
water
May 2014

83.
Research
Independent
Documenta8on
of
Effec8veness
•
Third
party
documenta8on
•
Does
the
inves8gator
have
a
financial
interest?
•
Are
the
studies
clinical
or
non-­‐clinical
selngs?
Many
believe
in
house
studies
are
like
baseball
catchers
calling
their
balls
and
strikes!
May 2014

84.
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 product was used to humidify the patient.
Used with permission
May 2014

85.
MHRA
&
UK
Medicines
Healthcare
Products
May 2014

86. Richard
Branson’s
evalua8on
of
21
HMEs,
Table
2.
(Respir
Care
1996;
41:736-­‐743)
May 2014

87. Documenta8on
of
PH
Effec8veness
FDA
–
MAUDE
Database
Manufacturer
and
User
Facility
Device
Experience
May 2014

88. MAUDE
Adverse
Event
Report
The
aoending
staff
removed
the
pa8ent
from
the
mechanical
ven8lator
and
began
manual
ven8la8on.
The
pa8ent
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
ven8la8on
was
resumed.
May 2014

89.
Early
Coffee
Cups
May 2014

90.
Too
Late
to
Check
Effec8veness
May 2014

91. What
to
Look
For
When
Choosing
a
PH
???
May 2014

92. What
to
Look
For
When
Choosing
a
PH
•
Will
the
PH
deliver
the
30/30
guidelines
for
all
pa8ents
-­‐
for
24
hours
at
all
minute
volumes?
•
Does
the
moisture
output
data
include
minute
volumes?
•
What
is
the
weight
and
resistance
at
the
end
of
24
hours
of
use,
not
a|er
a
few
hours?
May 2014

93. What
to
Look
For
When
Choosing
a
PH
•
What
is
the
dead
space?
•
What
is
the
8dal
volume
range?
•
Is
the
PH
designed
for
ICU
use
or
a
cross-­‐over
product
being
ordered
for
both
anesthesia
and
respiratory
use?
•
Is
a
circular
housing
used
to
help
prevent
possible
bruising?
May 2014

94. What
to
Look
For
When
Choosing
a
PH
•
Is
hydrophobic
humidifica8on
media
incorporated
to
prevent
absorp8on?
• Is
a
“change
on
date”
label
needed?
• Does
it
begin
humidifying
a|er
the
first
breath?
•
Will
there
be
an
increase
in
weight
due
to
the
absorp8on
of
moisture?
May 2014

95. What
to
Look
For
When
Choosing
a
PH
•
Is
the
housing
clear
so
secre8ons
and
condensa8on
can
be
observed?
•
The
PH
selected
should
be
appropriate
to
the
pa8ent's
dead
space
and
8dal
volume.
•
Is
a
filter
needed?
•
If
it
is
a
filter
product,
does
it
have
non-­‐
absorbing
filter
media?
May 2014

96. “Our
findings
suggest
that
the
ini8al
applica8on
of
an
extended-­‐use
hygroscopic
condenser
humidifier
is
a
safe
and
more
cost-­‐effec8ve
method
of
providing
humidifica8on
to
pa8ents
requiring
mechanical
ven8la8on
compared
with
heated-­‐water
humidifica8on.”
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,
PrenPce
D.
96 May 2014

97. Questions?
May 201497