1. The Science of HMEs May 2014

2. The Science of HMEs SteveKoontz ARCMedicalInc. skoontz@arcmedical.com May 2014 3. TheAr8cialNose: Howdoesitfunc8on The6typesofpassivehumidiers Design The3Cs Moisturemedia Importantfeatures Documenta8onofeec8veness Whattolookforwhenchoosingapassive humidier. May 2014 4. Ancientmandiscoveredmedicinalplantsby observa8onandexperience. Inhalingsmokefromplantswascommontoget pleasureandrelieffrombodytroubles. Nearlyallrespiratorytroublesweretreatedbyone formoranotherofinhala8on. May 2014 Inhalation Therapy 5. TreatmentforRespiratoryAilments WereCommonDuringtheLate1800s February2012 6. CompoundOxygen Scien'cadjustmenttooxygenandnitrogen Drs.StarkeyandPalen,1888 May 2014 7. May 2014 8. Compoundoxygenwasnot oxygenatall,butaverydilute "laughinggasmadebyhea8ng ammoniumnitrate. Theinhaledgaswasmixedwith ferriccarbonateorpotassium chlorate,togiveitcolorandhelp assurepa8entstheywere inhalingsomethingtangibleand useful. May 2014 9. Indica8onsforCompoundOxygen Asthma Bronchi8s Indiges8on Hayfever Headache Rheuma8sm Neuralgia Diarrheaandcurednone May 2014 10. May 2014 11. TheAmerican Associa8onof Inhala8on Therapy TheUniversityof ChicagoHospital establishesthe Inhala8onTherapy Associa8on in1946 May 2014 12. TheAmericanAssocia8onofInhala8onTherapy wasthersttoissuecer8ca8onclassesfor Inhala8onTherapists. Itwasanon-the-jobtrainingsystemfor so-called"oxygenjockeys. May 2014 13. AnEarlyOxygenTank May 2014 14. Humidica8onofinspiredgasduring mechanicalven8la8onismandatorywhenan endotrachealortracheostomytubeispresent. Thismaybeaccomplishedusingeithera heatedhumidieroraheatandmoisture exchanger. Thechosendeviceshouldprovideaminimum of30mgH2O/Lofdeliveredgasat30C. RespiratoryCare(RespirCare1992;37:887-890) AARCClinicalPrac8ceGuideline Humidica8onduringMechanicalVen8la8on May 2014 15. Whatis 30/30? February2012 16. 30/30 February2012 17. 17 Ac8ve?Passive?Both? Itisveryimportantforrespiratorytherapiststoevaluateeachpa8ent individuallyandchoosethecorrectdevice. May 2014 18. ClinicalPrac8ceGuidelines DuringMechanicalVen8la8on TheClinicalPrac8ceGuidelinesimplythatunless specicallycontraindicated,theHMEwillbe acceptable. ClinicalFounda8ons,APa8ent-focusededuca8onprogramforRespiratory CareProfessionals,Humidica8onDuringMechanicalVen8la8on: CurrentTrendsandControversies TimOptHolt,EdD,R.R.T.,AE-C,FAARC May 2014 19. HMEsshouldbeusedinallpa8entsinwhomthereis nocontraindica8on. RichardD.BransonMScRRTFAARC June2005 RespiratoryCareJournal November2011 20. AdvantagesofUsingAc'veHumidiers DuringMechanicalVen8la8on Havealarms Arecapableofregula8ngandmonitoring temperature Workwithallpa8ents,universal Seemtobereliable Heatedwirehelpstoreducecondensate. May 2014 21. AdvantagesofUsingAc'veHumidiers DuringMechanicalVen8la8on Oerswidevaria8onofop8onsintrea8ng pa8ents,versa8lity Preferredmethodofhumidica8onwithpre- exis8ngcondi8onssuchasCOPD. May 2014 22. DisadvantagesofUsingAc'veHumidiers DuringMechanicalVen8la8on Temperatureselngisnothumiditydelivered Costly,possibili8esofmalfunc8onanddown 8me UseproblemsasreportedinMAUDE ManufactureandUserFacilityDevice Experience May 2014 23. DisadvantagesofUsingAc'veHumidiers DuringMechanicalVen8la8on Maydevelopcondensa8onwithinthecircuit Possibleinfec8ouswaste(biologicalhazard) drainageintoheaterreservoir,theven8lator andmore Complextousewithoverorunderhydra8on possible Maynotproduceasmuchhumidityasthought. May 2014 24. BiologicalHazards Biologicalhazardsrefertobiological substancesthatposeathreattothehealthof livingorganisms,primarilythatofhumans. Thetermandassociatedsymbolaregenerally usedasawarning,sothatthosepoten8ally exposedtothesubstancewillknowtotake precau8ons. FromWikipedia,thefreeencyclopedia May 2014 25. Secre8ons=BiologicalHazard May 2014 26. HeatedHumidiers Puritan- Benneo Cascade Humidier May 2014 27. May 201427 28. May 2014 29. WhatisanAr8cialNose? CommonlycalledaHMEandorlter(although ltermediamaynotbepresent) Thesehumidica8ondevicesfunc8onwithout theaddi8onofawatersourceorelectricity Thesedevicescollectandconservethe pa8entsexpiredmoistureandheat. November2011 30. TheAr8cialNose Therstheatandmoistureexchanger,which wasmadewithcorrugatedaluminum,was presentedbyagroupofSwedishprofessorsin theearly1960s. Duetoitsweight,thedeviceneverbecame widelyused. November2011 31. TheAr8cialNose Thealuminumwasreplacedwithaspecialpaper inacorrugatedstructurewithalargecapacity forabsorbingandgivingomoisture. Overtheyearsthenoseshavebeengradually developedandthedesignhasbeenrened. Themarketbreakthroughforthear8cialnose didnotoccurun8lthebeginningofthe1970s. November2011 32. May 2014 33. Humidica8onDuringMechanicalVen8la8on Indica8ons: Humidica8onofinspiredgasduringmechanical ven8la8onismandatorywhenanendotrachealor tracheostomytubeispresent. Whenprovidingpassivehumidica8ontopa8ents undergoinginvasivemechanicalven8la8on,theHME shouldprovideaminimumof30mgH2O/L. RESPIRATORYCAREMAY2012VOL57NO5 May 2014 34. Humidica8onDuringMechanicalVen8la8on HMEContraindica8ons: UseofanHMEmaybecontraindicatedfor pa8entswithhighspontaneousminute volumes>10L/min. Thereareproductsonthemarketwhichdeliver 30mgofmoistureat20literminutevolumes. May 2014 35. Humidica8onDuringMechanicalVen8la8on HMEContraindica8ons: AnHMEmustberemovedfromthepa8ent circuitduringaerosoltreatmentswhenthe nebulizerisplacedinthepa8entcircuit. Withsomeproducts,placinganebulizerbetweenthePH andpa8entmaynotcreateaproblem. Pressuresshouldalwaysbemonitoredduringany treatment. May 2014 36. Humidica8onDuringMechanicalVen8la8on HMEContraindica8ons: UseofanHMEiscontraindicatedforpa8ents withbodytemperatureslessthan32C. Thesehypothermicpa8entsmaybebeoer managedusingaheatedhumidierbecauseit maybemoreecientatreducingfurtherheat loss. May 2014 37. Humidica8onDuringMechanicalVen8la8on HMEContraindica8ons: Pa8entswithpre-exis8ngpulmonarydisease characterizedbythick,copious,orbloody secre8onsshouldnotusePH. UseofanPHiscontraindicatedforpa8ents withanexpired8dalvolumelessthan70%of thedelivered8dalvolume-thosewithstulas orabsentendotrachealtubecu. May 2014 38. AdvantagesofUsingPassiveHumidiers DuringMechanicalVen8la8on Simpletouse,nomovingparts Producedry,coolcircuitswhichlowerstherisk ofcontamina8on Noneedforwaterorelectricity Nodown8me Lightweight,portable,easytouseandstore May 2014 39. AdvantagesofUsingPassiveHumidiers DuringMechanicalVen8la8on Impossibletooverhydratethepa8ent Impossibletooverheatorburnthepa8ent Helpstoeliminatecondensateintubing Lowerhumidica8oncosts Fasteranddrycircuitchanges-eliminatesthe possibleexposuretocondensatewhichis consideredinfec8ouswaste May 2014 40. DisadvantagesofUsingPassiveHumidiers DuringMechanicalVen8la8on Mayincreaseairwayresistance Increaseddeadspacemaycreateexcessive rebreathingespeciallywithsmall8dal volumes Poten8alforocclusion Notsuitableforallpa8ents. May 2014 41. DisadvantagesofUsingPassiveHumidiers DuringMechanicalVen8la8on Possiblepneumothorax Increaseinweightover8meETtube associatedproblems Themaximumamountofwatervaporwhich canbedeliveredtothepa8entinaspecic volumeofgaswillvarywithdierent temperatures May 2014 42. DisadvantagesofUsingPassiveHumidiers DuringMechanicalVen8la8on Again,Themaximumamountofwatervapor- whichcanbedeliveredtothepa8entina specicvolumeofgas- willvarywithdierenttemperaturesand dierentdevices May 2014 43. AdvantagesofUsingAc'veHMEHumidiers DuringMechanicalVen8la8on Universalapplica8on Helpstoeliminatecondensateintubing Helpstoproducedry,coolcircuitswithlowerwater consump8on Hasalarms Con8nuespassivehumidifyingifelectricityorwater fails May 2014 44. DisadvantagesofUsingAc'veHMEHumidiers DuringMechanicalVen8la8on Extradeadspace Poten8alforocclusions,highpressure,etc. Limitedtemperaturevaria8onstochoose Heaterclosetopa8ent Mustberemovedtodeliveraerosols Costsavingsonlywhencomparedtoac8ve systems,notHMEs May 2014 45. AllNosesAreNotAlike! May 2014 46. May 2014 47. heatandmoistureexchanger HME lterheatandmoistureexchanger FHME May 2014 48. hygroscopiccondensinghumidier HCH lterhygroscopiccondensing humidier FHCH May 2014 49. gasowmayberedirectedtoand aroundthemedia BypassHME heatandwateraddedtotheHME Ac'veHME May 2014 50. May 2014 Hygroscopic: Theabilityofasubstancetoaoractandhold watermoleculesfromthesurrounding environmentbyenhancingthenaturalphysical proper8es. Thisisachievedthrougheitherabsorp8onor adsorp8onwiththeabsorbingoradsorbing materialbecomingphysically"changed. 51. May 2014 Absorp'on:Incorpora'onofmoisture.Thismoisture becomesapartofthemedia Adsorp'on:Adhesionofmoisturetoasurface Adsorp'onisasurface-basedprocesswhileabsorp'on involvesthewholevolumeofthematerial 52. CoeePourTest 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 patients breath and becoming part of the product. Only a small portion of this moisture will be delivered back to the patient. May 2014 53. CoeePourTest May 2014 54. ExamplesofPassiveandAc8veHMEs May 2014 55. ExamplesofPassiveHumidierDesigns May 2014 56. ExamplesofPassiveHumidierDesigns May 2014 Manyextubeswill addabout2mgof moisture 57. ExamplesofTrachPassiveHumidierDesigns May 2014 58. ManyHMEProductsFailtoMeetthePa8ents NeedsResul8nginAdverseEvents Highpressurealarms Spontaneouspneumothorax Thickeningsecre8ons Endotrachealtubeocclusions Pluggedairways Andmore May 2014 59. ExamplesofHumidica8onMedia May 2014 60. CliniciansShouldRemember- ActualMoistureOutputVaries Asgasvolumesincreasemoistureoutputdecreases Whengasmovesthroughthemediaquickly,the abilityofthedevicetoremovemoisturefromexhaled gasandaddmoisturetoinspiredgas-diminishes Mostdonotbeginhumidifyingun8lsome8melater, maybeahourortwo. May 2014 61. ReplacedHME q24hours Bloodysecre8ons? Thicktenacioussputum? Lessthan70%? Coretempless320C? Evaluatesecre8on qualityandquan8ty Examinepa8ent Useheated humidica8on Examinepa8ents Hx/Px Morethan4HMEs usedin24hours? 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$entshumidityleveldropsover$me RRTreplacesHMEandperceiveseverythingtobeok 63. ' ! ! ! ! ! Pa$entshumidityleveldropsover$me 64. DontbeFooled,The3Cs Charging Coring Collec8ng May 2014 65. DontbeFooled,The3Cs Charging May 2014 66. Charging Func8onofMedia Thelongeryouusethehme,thebeoeritworks isacommonmisunderstanding Inreality,thelongerthesedevicesareused,the moremoistureisabsorbedfromthepa8ents breath Thepa8entmayhavelessmoisturea|erusing thesedevicesbecausemoistureisabsorbedinto themedia. May 2014 67. Charging Func8onofMedia May 2014 68. DontbeFooled,The3Cs Coring May 2014 69. Coring PossibleResultofDesign? Manyproductsareconstructedwithdiusors, walls,wings,etc.tohelpmovethegasow aroundinsidethehousing Rebreathingoccursinthecenterofthemedia Causingincreasedpressures Possibleabsorp8onofhumidityfromthepa8ents breath May 2014 70. Coring PossibleResultofDesign? May 2014 71. DontbeFooled,The3Cs Collec8ng May 2014 72. Collec8ng gas in May 2014 gas in gas out 73. Collec8ng May 2014 74. The3Cs Charging Coring Collec8ng May 2014 75. MostImportantFeaturesofPH Filter? Cost? Resistance? Moisture output? Dead space? Design? Respiratory Care; June 1999; Vol. 44 No. 6; Pg. 636 May 2014 76. TrendofHumidityDelivered HME lowest HMEF HCH HCHF highest May 2014 Respiratory Care; June 1999; Vol. 44 No. 6; Pg. 636 77. ShouldPHbeChosenBased UponMinuteVen8la8ons? May 2014 Humidiersshoulddeliver30/30forallminutevolumes 78. IsMyPa8entBeingHumidied? Regardlessofwhattypeofsystemis beingused,theclinicianshould ques8ontheeec8veness. Sincenosystemreportstheactual amountofhumiditybeingdelivered, othersignsmustbereliedupon. May 2014 79. Observeinsidethecircuitelbow,circuitwyeand HMEhousingforcondensa8on May 2014 80. Bedsidehygrometerswillgivefeedback however-onlyamomentin8me May 2014 81. SputumDescrip8ons WhatisaSpudic? Ittakes6SpudicstomakeoneSputum Ittakes10SputumstomakeonSpudi Ittakes10Spuditomakeonhonker! May 2014 82. AssessmentofSputumCharacteris8cs SuzukawasMethod: Thin-Suc8oncatheterisclearofsecre8onsfollowing suc8oning Moderate-A|ersuc8oning,thesuc8oncatheterhas secre8onsadheringtothesidesthatareeasilyremoved byaspira8ngwater Thick-A|ersuc8oning,thesuc8oncatheterhas secre8onsadheringtothesidesthatarenotremoved byaspira8ngwater May 2014 83. ResearchIndependentDocumenta8on ofEec8veness Thirdpartydocumenta8on Doestheinves8gatorhaveanancialinterest? Arethestudiesclinicalornon-clinicalselngs? Manybelieveinhousestudiesarelikebaseball catcherscallingtheirballsandstrikes! 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&UKMedicinesHealthcareProducts May 2014 86. RichardBransonsevalua8onof21HMEs,Table2. (RespirCare1996;41:736-743) May 2014 87. Documenta8onofPHEec8veness FDAMAUDE Database Manufacturerand UserFacilityDevice Experience May 2014 88. MAUDEAdverseEventReport Theaoendingstaremovedthepa8entfrom themechanicalven8latorandbeganmanual ven8la8on.Thepa8entwasresuscitated successfully. ThecircuitwasexaminedandtheHMEdevicewas determinedtobeblocked. Thedevicewasremovedandreplacedwithanew device.Mechanicalven8la8onwasresumed. May 2014 89. EarlyCoeeCups May 2014 90. TooLatetoCheckEec8veness May 2014 91. WhattoLookForWhenChoosingaPH ??? May 2014 92. WhattoLookForWhenChoosingaPH WillthePHdeliverthe30/30guidelinesforall pa8ents-for24hoursatallminutevolumes? Doesthemoistureoutputdataincludeminute volumes? Whatistheweightandresistanceattheendof 24hoursofuse,nota|erafewhours? May 2014 93. WhattoLookForWhenChoosingaPH Whatisthedeadspace? Whatisthe8dalvolumerange? IsthePHdesignedforICUuseoracross-over productbeingorderedforbothanesthesiaand respiratoryuse? Isacircularhousingusedtohelpprevent possiblebruising? May 2014 94. WhattoLookForWhenChoosingaPH Ishydrophobichumidica8onmedia incorporatedtopreventabsorp8on? Isachangeondatelabelneeded? Doesitbeginhumidifyinga|ertherstbreath? Willtherebeanincreaseinweightduetothe absorp8onofmoisture? May 2014 95. WhattoLookForWhenChoosingaPH Isthehousingclearsosecre8onsand condensa8oncanbeobserved? ThePHselectedshouldbeappropriatetothe pa8ent'sdeadspaceand8dalvolume. Isalterneeded? Ifitisalterproduct,doesithavenon- absorbingltermedia? May 2014 96. Ourndingssuggestthattheini8alapplica8onof anextended-usehygroscopiccondenserhumidieris asafeandmorecost-eec8vemethodofproviding humidica8ontopa8entsrequiringmechanical ven8la8oncomparedwithheated-water humidica8on. Chest.1998Mar;113(3):759-67. Arandomizedclinicaltrialcomparinganextended-usehygroscopiccondenserhumidier withheated-waterhumidica'oninmechanicallyven'latedpa'ents. KollefMH,ShapiroSD,BoydV,SilverP,VonHarzB,TrovillionE,PrenPceD. 96 May 2014 97. Questions? May 201497