Sudden upper airway obstruction due to invisible rain-out in the heat and moisture exchange filter

Heat and moisture exchangers and breathing system filters: their use in anaesthesia and intensive care. Part 2 - practical use, including problems, and their use with paediatric patients

Heat and moisture exchangers and breathing system filters are intended to replace the normal warming, humidifying and filtering functions of the upper airways. The first part of this review considered the history, principles of operation and efficiency of these devices. The aim of this part of the review is to summarise recent guidelines on the use of these devices and outline the problems that can occur. In particular, the effect of these devices on gas analysis, dead space, resistance to gas flow and blockage of the breathing system is considered. In children, it is important to consider the addition of dead space and resistance to gas flow. A body weight of 2.5 kg is probably the lower weight limit for use with heat and moisture exchangers, and 3 kg for filters. The resistance to gas flow of a heat- and moisture-exchanging filter added to a Mapleson F breathing system can cause a delay in the induction of anaesthesia.

[Humidification assessment of four heat and moisture exchanger filters according to ISO 9360: 2000 standard]

OBJECTIVE

This work consisted of the assessment of humidification parameters and flow resistance for different heat and moisture exchanger filters (HMEF) used in intensive care unit. Four electrostatic HMEF were assessed: Hygrobac S (Tyco); Humidvent compact S (Teleflex); Hygrovent S/HME (Medisize-Dräger); Clear-Therm+HMEF (Intersurgical).

MATERIAL AND METHODS

Humidification parameters (loss of water weight, average absolute moisture [AAM], absolute variation of moisture) have been evaluated on a bench-test in conformity with the ISO 9360: 2000 standard, for 24h with the following ventilatory settings: tidal volume at 500 ml, respiratory rate at 15 c/min, and inspiration/expiration ratio at 1:1. The flow resistance of HMEFs assessed using the pressure drop method was measured before and after 24h of humidification for three increasing air flows of 30, 60, and 90 l/min.

RESULTS

All the HMEFs allowed satisfactory level of humidification exceeding 30 mgH(2)O/l. The less powerful remained the Clear-Therm. Concerning HMEFs flow resistance, results showed a pressure drop slightly more important for the Hygrobac S filter as compared with other filters.

CONCLUSION

This test showed differences between the HMEFs for both humidification and resistance parameters. When compared to the new version of the standards, HMEFs demonstrated their reliability. However, evolution of humidification and flow resistance characteristics over 24h showed a structural degradation of HMEFs, limiting their use over a longer period.

Performance of breathing filters under wet conditions: a laboratory evaluation

INTRODUCTION

Heat and moisture exchangers in combination with a bacterial and viral filter (HMEF) are widely used during general anaesthesia. Excess patient secretions occluding the HMEF have been responsible for previous case reports of airway obstruction. A previous study suggested that differences in HMEF design might contribute to filter obstruction under wet conditions.

METHODS

We tested 14 types of HMEF under wet conditions to establish which design features contributed to HMEF obstruction. Incremental amounts of saline were added to each filter. The pressure across the filter was measured with an air flow of 60 litre min(-1).

RESULTS

We observed that saline added to the filter was often not easily visible to the casual observer. This concealment volume varied between filters. Ceramic hydrophobic pleated-membrane filters did not absorb saline and their resistance did not change. The composite filter where the moisture exchange component was either polyurethane foam or cellulose absorbed saline and contributed to a rise in resistance of 70-480% with the higher value more typical of the cellulose-paper-based HMEF.

CONCLUSION

The ideal HMEF for use during general anaesthesia should prevent the passage of viral, bacterial and prion material, should provide this filtration performance even under wet conditions, should supplement humidification of the inspired air and anaesthetic gases and should not increase respiratory work. We have identified large variations in HMEF performance under wet conditions. Users should be aware of performance variation in HMEFs and use a filter suited to the intended application.