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1 May 2014. 2 3 4 The birth of respiratory care The AARC Clinical Practical Guidelines The...
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Transcript of 1 May 2014. 2 3 4 The birth of respiratory care The AARC Clinical Practical Guidelines The...
The Science of HMEs
Commercial support provided byARC Medical will not influence the
objectives and content of the activity.
2 May 2014
The Science of HMEs
3 May 2014
We will discuss…
4
The birth of respiratory care The AARC Clinical Practical Guidelines The artificial nose
May 2014
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
5 May 2014
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.
6 May 2014
Inhalation Therapy
Compound Oxygen“Scientific adjustment to oxygen and nitrogen”
Drs. Starkey and Palen, 1888
7 May 2014
8 May 2014
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
“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
10 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
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 program for Respiratory Care Professionals, Humidification During Mechanical Ventilation:
Current Trends and ControversiesTim Op’t Holt, EdD, R.R.T., AE-C, FAARC
12 May 2014
Heated Humidifiers
13
Puritan-Bennett
Cascade Humidifier
May 2014
14 May 2014
15 May 2014
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.
16 May 2014
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
17 May 2014
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.
18 May 2014
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.
19 May 2014
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.
20 May 2014
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.
21 May 2014
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
22 May 2014
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.
23 May 2014
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
24 May 2014
Advantages of Using Active HCH HumidifiersDuring 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
25 May 2014
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
26 May 2014
All “Noses” Are Not Alike!
27 May 2014
28
• heat and moisture exchanger
HME
• filter heat and moisture exchanger
FHME
May 2014
29
• hygroscopic condensing humidifier
HCH
• filter hygroscopic condensing humidifier
FHCH
May 2014
30
• gas flow may be redirected to and around the media
Bypass HME
• heat and water added to the HME
Acti ve HME
May 2014
Examples of Passive and Active HMEs
31 May 2014
Examples of Passive Humidifier Designs
32 May 2014
Examples of Humidification Media
33 May 2014
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…
34 May 2014
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.
35 May 2014
Replaced HME q 24 hrs?
Bloody secretions? Thick tenacious sputum?
Less than 70%? Core temp less 320 C?
Evaluate secretion quality and quantity
Examine patient
Use heated humidification
Examine patient’sHx/Px
More than 4 HMEs used in 24 hours?
NO
YES
YES
NO
May 201436
Humidification for Patients with Artificial Airways RESPIRATORY CARE; JUNE 1999; VOLUME: 44 NO 6; page 638
Patient’s humidity level drops over time
RRT replaces HME and perceives everything to be ok
Don’t be Fooled, The 3Cs
Charging Coring Collecting
38 May 2014
“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.
39 May 2014
“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
40 May 2014
“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.
41 May 2014
Collecting
42
gas in
May 2014
gas in
gas out
Coffee Pour Test
43
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
Most Important Features of PH
44
Filter?
Cost?
Resistance?
Moisture output?
Dead space?
Design?
Respiratory Care; June 1999; Vol. 44 No. 6; Pg. 636
May 2014
Trend of Humidity Delivered
HME lowest
HMEF HCH HCHF highest
45 May 2014
Respiratory Care; June 1999; Vol. 44 No. 6; Pg. 636
Should PH be Chosen BasedUpon Minute Ventilations?
5L VE
10L VE
15L VE
20L VE
46 May 2014
Humidifiers should deliver 30/30 for all Minute Volumes
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.
47 May 2014
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
48 May 2014
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
49 May 2014
Secretions Trend
50
Clear White Yellow Green Cream Brown
May 2014
Research Independent Documentationof Effectiveness
Third party documentation Does the investigator have a financial interest? Are the studies clinical or non-clinical settings?
Many believe in house studies are like baseball catchers calling their balls and strikes!
51 May 2014
52
This patient was featured on The Learning Channel.
2nd and 3rd degree burns over 60% of the bodyand 3 months LOS (tracheal not comprised)
Only this product was used to humidify the patient.Used with permission
May 2014
•
MHRA - Medicines and Healthcare Products Regulatory Agency & UK Medicines Healthcare Products
53 May 2014
54
Richard Branson’s evaluation of 21 HMEs, Table 2. (Respir Care 1996; 41:736-743)
May 2014
Documentation of PH Effectiveness
FDA – MAUDE Database
Manufacturer and User Facility Device
Experience
55 May 2014
An Example - MAUDE Adverse Event Report
The attending staff removed the patient from the mechanical ventilator and began manual ventilation. The patient 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 ventilation was resumed.
56 May 2014
Too Late to Check Effectiveness
57 May 2014
Early Sputum Collection Cups
58 May 2014
Early Coffee Cups
59 May 2014
What to Look For When Choosing a PH
60
???
May 2014
What to Look For When Choosing a PH
Will the PH deliver the 30/30 guidelines for all patients - 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 for a few hours?
61 May 2014
What to Look For When Choosing a PH
What is the dead space? What is the tidal 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?
62 May 2014
What to Look For When Choosing a PH
Is hydrophobic humidification media incorporated to prevent absorption?
Is a “change on date” label needed? Does it begin humidifying after the first breath? Will there be an increase in weight due to the
absorption of moisture?
63 May 2014
What to Look For When Choosing a PH
Is the housing clear so secretions and condensation can be observed?
The PH selected should be appropriate to the patient's dead space and tidal volume.
Is a filter needed? If it is a filter product, does it have non-absorbing
filter media?
64 May 2014
“Our findings suggest that the initial application of an extended-use hygroscopic condenser humidifier is a safe
and more cost-effective method of providing humidification to patients requiring mechanical ventilation compared with
heated-water humidification.”
Chest. 1998 Mar; 113(3): 759-67.A randomized clinical trial comparing an extended-use hygroscopic condenser humidifier
with heated-water humidification in mechanically ventilated patients.Kollef MH, Shapiro SD, Boyd V, Silver P, Von Harz B, Trovillion E, Prentice D.
65 May 2014
Questions?
May 201466
