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Arnott A, Hart R, McQueen S, Watson M, Sim M. Prospective randomised unblinded comparison of sputum viscosity for three methods of saline nebulisation in mechanically ventilated patients: A pilot study protocol. PLoS One 2023; 18:e0290033. [PMID: 37590203 PMCID: PMC10434882 DOI: 10.1371/journal.pone.0290033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023] Open
Abstract
INTRODUCTION Heat and moisture exchanger (HME) filters are commonly used as passive circuit humidifiers during mechanical ventilation, however, are only ~80% efficient. As a result, patients that undergo mechanical ventilation in critical care with HME filter circuits will be exposed to partial airway humidification. This is associated with detrimental effects including increased secretion load which has been shown to be an independent predictor of failed extubation. Nebulised normal saline is commonly utilised to supplement circuit humidification in ventilated patients with high secretion loads, although there are no randomised control trials evaluating its use. Novel vibrating mesh nebulisers generate a fine aerosol resulting in deeper lung penetration, potentially offering a more effective means of nebulisation in comparison to jet nebulisers. The primary aim of this study is to compare the viscosity of respiratory secretions after treatment with nebulised normal saline administered via vibrating mesh nebuliser or jet nebuliser. METHODS AND ANALYSIS This randomised controlled trial is enrolling 60 mechanically ventilated adult critical care patients breathing on HME filter circuits with high secretion loads. Recruited patients will be randomised to receive nebulised saline via 3 modalities: 1) Continuous vibrating mesh nebuliser; 2) Intermittent vibrating mesh nebuliser or 3) Intermittent jet nebuliser. Over the 72-hr study period, the patients' sputum viscosity (measured using a validated qualitative sputum assessment tool) and physiological parameters will be recorded by an unblinded assessor. A median reduction in secretion viscosity of ≥0.5 on the qualitative sputum assessment score will be deemed as a clinically significant improvement between treatment groups at analysis. DISCUSSION At the conclusion of this trial, we will provisionally determine if nebulised normal saline administered via vibrating mesh nebulisation is superior to traditional jet nebulisation in terms of reduced respiratory secretion viscosity in intubated patients. Results from this pilot study will provide information to power a definitive clinical study. TRIAL REGISTRATION ClinicalTrails.Gov Registry (NCT05635903).
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Affiliation(s)
- Andrew Arnott
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Robert Hart
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Scott McQueen
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Malcolm Watson
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Malcolm Sim
- Critical Care Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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Narang I, Carberry JC, Butler JE, Gandevia SC, Chiang AKI, Eckert DJ. Physiological Responses and Perceived Comfort to High Flow Nasal Cannula Therapy in Awake Adults: Effects of Flow Magnitude and Temperature. J Appl Physiol (1985) 2021; 131:1772-1782. [PMID: 34709070 DOI: 10.1152/japplphysiol.00085.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Clinical use of heated, high flow nasal cannula (HFNC) for non-invasive respiratory support is increasing and may have a therapeutic role in stabilizing the upper airway in obstructive sleep apnea (OSA). However, physiological mechanisms by which HFNC therapy may improve upper-airway function and effects of different temperature modes are unclear. Accordingly, this study aimed to determine effects of incremental flows and temperature modes (heated and non-heated) of HFNC on upper airway muscle activity (genioglossus), pharyngeal airway pressure, breathing parameters and perceived comfort. Six participants (2 females, aged 35±14 years) were studied during wakefulness in supine position and received HFNC at variable flows (0-60 L/min) during heated (37ºC) and non-heated (21ºC) modes. Breathing parameters via calibrated Respitrace inductance bands (chest and abdomen), upper-airway pressures via airway transducers, and genioglossus muscle activity via intra-muscular bipolar fine wire electrodes were measured. Comfort levels during HFNC were quantified using a visual analogue scale. Increasing HFNC flows did not increase genioglossus muscle activation despite increased negative epiglottic pressure swings (p=0.009). HFNC provided ~7cmH2O positive airway pressure at 60 L/min in non-heated and heated modes. In addition, increasing the magnitude of HFNC flow reduced breathing frequency (p=0.045), increased expiratory time (p=0.040), increased peak inspiratory flow (p=0.002), and increased discomfort (p=0.004). Greater discomfort occurred at higher flows in non-heated versus heated mode (p=0.034). These findings provide novel insight into key physiological changes that occur with HFNC for respiratory support and indicate the primary mechanism for improved upper-airway stability is positive airway pressure, not increased pharyngeal muscle activity.
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Affiliation(s)
- Indra Narang
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Neuroscience Research Australia (NeuRA), Randwick, Sydney, NSW, Australia
| | - Jayne C Carberry
- Neuroscience Research Australia (NeuRA), Randwick, Sydney, NSW, Australia.,School Of Medicine, University College Dublin, Dublin, Ireland
| | - Jane E Butler
- Neuroscience Research Australia (NeuRA), Randwick, Sydney, NSW, Australia.,School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Simon C Gandevia
- Neuroscience Research Australia (NeuRA), Randwick, Sydney, NSW, Australia.,School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Alan K I Chiang
- Neuroscience Research Australia (NeuRA), Randwick, Sydney, NSW, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Randwick, Sydney, NSW, Australia.,Flinders Health and Medical Research Institute Sleep Health/Adelaide Institute for Sleep Health, Flinders University, Bedford Park, SA, Australia.,School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
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Wellbeloved MA. Humidification and the HME filter. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s3.2564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The process of intubation and ventilation bypasses both the physiological humidification system and protective filtering processes. Various devices have been developed to aid in providing humidification of medical gasses and to serve as filters to reduce transmission of microbes. The following types of devices are available:
* Heat and moisture exchanger without filter (HME)
* Electrostatic filter with or without HME
* Pleated filter with or without HME
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Fullick J, Oliver M. “Water, water, everywhere”: a challenge to ventilators in the COVID-19 pandemic. Br J Anaesth 2020; 125:e188-e190. [PMID: 32389392 PMCID: PMC7252111 DOI: 10.1016/j.bja.2020.04.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 11/10/2022] Open
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Neilson DM, Viscasillas J, Alibhai HIK, Kenny PJ, Niessen SJM, Sanchis-Mora S. Anaesthetic management and complications during hypophysectomy in 37 cats with acromegaly. J Feline Med Surg 2019; 21:347-352. [PMID: 29848149 PMCID: PMC10814632 DOI: 10.1177/1098612x18778697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
OBJECTIVES The aim of this study was to describe the anaesthetic management and perianaesthetic complications encountered during hypophysectomy surgery in acromegalic cats. We explored relationships between animal demographic data, the anaesthetic protocol used and presence of perioperative complications. METHODS Cats having undergone hypophysectomy surgery for the treatment of feline acromegaly at a single veterinary referral hospital were identified from hospital records. The anaesthesia records and clinical notes of these animals were retrospectively reviewed. Descriptive statistics were produced and binary logistic regression run to assess for any relationship between patient factors, anaesthetic management and complications during the perioperative period. RESULTS Perianaesthetic complications identified included hypothermia, hypotension, bradycardia and airway obstruction. Mortality at 24 h post-anaesthesia was 8%. The use of alpha (α)2 agonists was associated with a lower incidence of hypotension. Fentanyl infusion was associated with a higher incidence of airway obstruction compared with remifentanil. Subjectively assessed anaesthetic recovery quality had an association with the number of days spent in the intensive care ward postoperatively. CONCLUSIONS AND RELEVANCE The anaesthetic management described seems effective for hypophysectomy surgery in cats. Intraoperative complications were common and, while not apparently associated with 24 h patient outcome, drugs and equipment to manage these complications should be available.
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Affiliation(s)
| | - Jaime Viscasillas
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, UK
| | - Hatim IK Alibhai
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, UK
| | - Patrick J Kenny
- Small Animal Specialist Hospital, North Ryde, NSW, Australia
| | - Stijn JM Niessen
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, UK
| | - Sandra Sanchis-Mora
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, UK
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A New Method for In Vivo Analysis of the Performances of a Heat and Moisture Exchanger (HME) in Mechanically Ventilated Patients. Pulm Med 2019; 2019:9270615. [PMID: 30937191 PMCID: PMC6413364 DOI: 10.1155/2019/9270615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/26/2019] [Accepted: 02/03/2019] [Indexed: 11/30/2022] Open
Abstract
Aim To evaluate the conditioning capabilities of the DAR™ Hygrobac™ S, a Heat and Moisture Exchanger (HME), using a new device to measure the temperature (T) and the absolute humidity (AH) of the ventilated gases in vivo during mechanical ventilation in Intensive Care Unit (ICU) patients. Materials and Methods In 49 mechanically ventilated ICU patients, we evaluated T and AH, indicating the HME efficacy, during the inspiratory phase upstream and downstream the HME and the ratio of inspired AH to expired AH and the difference between expired T and inspired T indicated the HME efficiency. Efficacy and efficiency were assessed at three time points: at baseline (t0, HME positioning time), at 12 hours (t1), and at 24 hours (t2) using a dedicated, ad hoc built wireless device. Differences over time were evaluated using one-way ANOVA for repeated measures, whereas differences between in vivo and laboratory values (declared by the manufacturer according to UNI® EN ISO 9360 international standard) were evaluated using one-sample Student t-test. Results 49 HMEs were analysed in vivo during mechanical ventilation. T and AH means (SD) of the inspired gas (the efficacy) were 31.5°C (1.54) and 32.3 mg/l (2.60) at t0, 31.1°C (1.34) and 31.7 mg/l (2.26) at t1, and 31°C (1.29) and 31.4 mg/l (2.27) at t2. Both efficiency parameters were constant over time (inspired AH/expired AH=89%, p=0.24; and expired T–inspired T = 2.2°C, p=0.81). Compared with laboratory values, in vivo T and AH indicating efficacy were significantly lower (p<0.01), whereas the efficiency was significantly higher (p<0.01). Conclusions HME performances can be accurately assessed for prolonged periods in vivo during routine mechanical ventilation in ICU patients. Temperature and absolute humidity of ventilated gases in vivo were maintained within the expected range and remained stable over time. HME efficacy and efficiency in vivo significantly differed from laboratory values.
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