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The Science of HMEs

The Science of HMEs. Steve Koontz ARC Medical Inc. skoontz@arcmedical.com. The Science of HMEs. Commercial support provided by ARC Medical will not influence the objectives and content of the activity. The Science of HMEs. W e will discuss…. The birth of respiratory care

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The Science of HMEs

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

  2. The Science of HMEs Commercial support provided by ARC Medical will not influence the objectives and content of the activity. May 2014

  3. The Science of HMEs May 2014

  4. We will discuss… • The birth of respiratory care • The AARC Clinical Practical Guidelines • The artificial nose May 2014

  5. The Artificial Nose: • How does it function • The 6 types of passive humidifiers • Design • The 3 Cs • Moisture media • Important features • Documentation of effectiveness • What to look for when choosing a passive humidifier May 2014

  6. Inhalation Therapy Ancient man discovered medicinal plants by observation 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 inhalation. May 2014

  7. Compound Oxygen“Scientific adjustment to oxygen and nitrogen”Drs. Starkey and Palen, 1888 May 2014

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

  10. “Humidification of inspired gas during mechanical ventilation 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 Practice Guideline Humidification during Mechanical Ventilation May 2014

  11. Active? Passive? Both? It is very important for respiratory therapists to evaluate each patient individually and choose the correct device. May 2014

  12. Clinical Practice GuidelinesDuring Mechanical Ventilation The Clinical Practice Guidelines imply that unless specifically contraindicated, the HME will be acceptable. Clinical Foundations, A Patient-focused education programfor Respiratory Care Professionals, Humidification During Mechanical Ventilation: Current Trends and Controversies Tim Op’t Holt, EdD, R.R.T., AE-C, FAARC May 2014

  13. Heated Humidifiers Puritan-Bennett Cascade Humidifier May 2014

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  16. What is an Artificial Nose? • Commonly called a HME and or filter (although filter media may not be present) • These humidification devices function without the addition of a water source or electricity • These devices collect and conserve the patient’s expired moisture and heat. May 2014

  17. Humidification During Mechanical Ventilation Indications: • Humidification of inspired gas during mechanical ventilation is mandatory when an endotracheal or tracheostomy tube is present. • When providing passive humidification to patients undergoing invasive mechanical ventilation, the HME should provide a minimum of 30mg H2O/L. RESPIRATORY CARE • MAY 2012 VOL 57 NO 5 May 2014

  18. Humidification During Mechanical Ventilation Contraindications: • Use of an HME may be contraindicated for patients with high spontaneous minute volumes > 10L/min. • There are products on the market which deliver 30mg of moisture to 20 liter minute volumes. May 2014

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

  20. Humidification During Mechanical Ventilation Contraindications: • Use of an HME is contraindicated for patients with body temperatures less than 32° C . • These hypothermic patients may be better managed using a heated humidifier because it may be more efficient at reducing further heat loss. May 2014

  21. Humidification During Mechanical Ventilation Contraindications: • Patients with pre-existing pulmonary disease characterized by thick, copious, or bloody secretions should not use PH. • Use of an PH is contraindicated for patients with an expired tidal volume less than 70% of the delivered tidal volume - those with fistulas or absent endotracheal tube cuff. May 2014

  22. Advantages of Using Passive HumidifiersDuring Mechanical Ventilation • Simple to use, no moving parts • Produce dry, cool circuits which lowers the risk of contamination • No need for water or electricity • No down time • Lightweight, portable, easy to use and store • Helps to eliminate condensate in tubing • Lower humidification costs May 2014

  23. Disadvantages of Using Passive Humidifiers During Mechanical Ventilation • May increase airway resistance • Increased dead space may create excessive rebreathing – especially with small tidal volumes • Potential for occlusion • Not suitable for all patients. May 2014

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

  25. Advantages of Using Active HCHHumidifiersDuring Mechanical Ventilation • Universal application • Helps to eliminate condensate in tubing • Helps to produce dry, cool circuits with lower water consumption • Has alarms • Continues passive humidifying if electricity water fails May 2014

  26. Disadvantages of Using Active HME HumidifiersDuring Mechanical Ventilation • Extra dead space • Potential for occlusions, high pressure, etc. • Limited temperature variations to choose • Heater close to patient • Must be removed to deliver aerosols • Cost savings only when compared to active systems, not HMEs May 2014

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

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  31. Examples of Passive and Active HMEs May 2014

  32. Examples of Passive Humidifier Designs May 2014

  33. Examples of Humidification Media May 2014

  34. Many HME Products Fail to Meet the Patient’s Needs Resulting in Adverse Events • High pressure alarms • Spontaneous pneumothorax • Thickening secretions • Endotracheal tube occlusions • Plugged airways • And more… May 2014

  35. Clinicians Should Remember- Actual Moisture Output Varies • As Minute and Tidal volumes increase, the 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 until some time later, maybe a hour or two. May 2014

  36. Examine patient’s Hx/Px • Humidification for Patients with Artificial Airways • RESPIRATORY CARE; JUNE 1999; VOLUME: 44 NO 6; page 638 Bloody secretions? Thick tenacious sputum? Less than 70%? Core temp less 320 C? YES Use heated humidification NO Replaced HME q 24 hrs? Evaluate secretion quality and quantity Examine patient More than 4 HMEs used in 24 hours? NO YES May 2014

  37. RRT replaces HME and perceives everything to be ok Patient’s humidity level drops over time

  38. Don’t be Fooled, The 3Cs Charging Coring Collecting May 2014

  39. “Charging”is a function of humidification media • “The longer you use the hme, the better it works” is a common misunderstanding • In reality, the longer these devices are used, the more moisture is absorbed from the patient’s breath • The patient may have less moisture after using these devices because moisture is absorbed into the media. May 2014

  40. “Coring” is the Possible Result of Design • Many products are constructed with diffusors and wings to move the gas flow around inside the housing • Rebreathing occurs in the center of the media • Causing increased pressures • Possible absorption of humidity from the patient’s breath May 2014

  41. “Collecting”is the result of sputum and moisture droplets being captured • The gas flow is delivered unobstructed during inhalation but the exhalation gas flow may have difficulty passing through the media due to the collection of sputum or excess moisture. May 2014

  42. Collecting gas in gas in gas out May 2014

  43. Coffee Pour Test • Looking for: • Humidification media absorbing • Humidification 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

  44. Most Important Features of PH Respiratory Care; June 1999; Vol. 44 No. 6; Pg. 636 May 2014

  45. Trend of Humidity Delivered • Respiratory Care; June 1999; Vol. 44 No. 6; Pg. 636 May 2014

  46. Should PH be Chosen BasedUpon Minute Ventilations? Humidifiers should deliver 30/30 for all Minute Volumes May 2014

  47. Is My Patient Being Humidified? Regardless of what type of system is being used, the clinician should question the effectiveness. • Since no system reports the actual amount of humidity being delivered, other signs must be relied upon. May 2014

  48. Is My Patient Being Humidified? Other signs must be used: • Observe inside the circuit elbow, circuit wye and HME housing for condensation • Bedside hygrometers will give feedback however- but only a moment in time • Sputum trends should always be monitored May 2014

  49. Assessment of Sputum Characteristics Suzukawa’s Method: Thin‐ Suction catheter is clear of secretions following suctioning Moderate‐ After suctioning, the suction catheter has secretions adhering to the sides that are easily removed by aspirating water Thick‐ After suctioning, the suction catheter has secretions adhering to the sides that are not removed by aspirating water May 2014

  50. Secretions Trend May 2014

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