Bedside Evaluation of Efficient Airway Humidification During Mechanical Ventilation of the Critically Ill

Jean-Damien Ricard, Philippe Markowicz, Kamel Djedaini, Laurence Mier, Franois Coste and Didier Dreyfuss Chest 1999;115;1646-1652 DOI 10.1378/chest.115.6.1646

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Bedside Evaluation of Efficient Airway Humidification During Mechanical Ventilation of the Critically Ill*
Jean-Damien Ricard, MD; Philippe Markowicz, MD; Kamel Djedaini, MD; Laurence Mier, MD; Franc ois Coste, MD; and Didier Dreyfuss, MD

Study objective: To determine the correlation between simple rating of condensation seen in the flex-tube connecting the heating and humidifying device used with the endotracheal tube and hygrometric parameters (absolute and relative humidity and tracheal temperature) measured by psychrometry. Design: Prospective randomized clinical trial. Setting: Medical ICU of Louis Mourier Hospital, Colombes, France, a university-affiliated teaching hospital. Patients: Forty-five consecutive mechanically ventilated critically ill patients. Interventions: Patients undergoing mechanical ventilation were randomly assigned to receive humidification with one of the four heat and moisture exchangers (HMEs) tested or with a conventional heated humidifier. Measurements: The hygrometric performances of four HMEs (BB2215, BB50, and BB100 from Pall Biomedical, Saint-Germaine-en-Laye, France; and Hygrobac-Dar from Mallinckrodt, Mirandola, Italy) and a heated humidifier (Fisher & Paykel; Auckland, New Zealand) were studied after 3 h and also after 48 h of use for the Hygrobac-Dar and correlated to a clinical visual inspection rating the amount of condensation in the flex-tube of the endotracheal tube. Results: A total of 95 measurements in 45 patients were performed. The best hygrometric parameters were obtained with the heated humidifier (p < 0.001). The Hygrobac-Dar yielded significantly higher values for both humidities and tracheal temperature than the other three HMEs (p < 0.001). The performance of Hygrobac-Dar was unchanged after 48 h of use. There was a significant correlation between the condensation seen in the flex-tube and the hygrometric parameters measured by psychrometry (absolute humidity, rho 0.7; relative humidity, rho 0.7; tracheal temperature, rho 0.5, p < 0.0001). Conclusion: In mechanically ventilated ICU patients, visual evaluation of the condensation in the flex-tube provides an estimation of the heating and humidifying efficacy of the heating and humidifying device used, thus allowing the clinician bedside monitoring of airway humidification. (CHEST 1999; 115:1646 1652)
Key words: acute respiratory failure; airway humidification; endotracheal tube; heat and moisture exchangers; mechanical ventilation; psychrometry Abbreviations: AH absolute humidity; HD Hygrobac-Dar; HH heated humidifier; HME heat and moisture exchanger; RH relative humidity; SAPS Simplified Acute Physiology Score

loss of moisture and heat that occurs when the T he upper respiratory tract is bypassed by the insertion of an endotracheal tube can lead to severe
*From the Service de Re animation Me dicale, Ho pital Louis Mourier (Assistance Publique-Ho pitaux de Paris), Colombes, and Unite de Recherches Inserm U82, Faculte de Me decine Xavier Bichat, Universite Paris VII, Paris, France. The authors did not receive any financial support from and do not have any commitment with any of the brands of the humidifying devices tested in this study. Manuscript received July 8, 1998; revision accepted December 1, 1998. Correspondence to: Didier Dreyfuss, MD, Service de Re animation Me dicale, Ho pital Louis Mourier, 178, rue des Renouillers, 92700 Colombes, France; e-mail: didier.dreyfuss@lmr.ap-hop-paris.fr
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airway damage during mechanical ventilation.1,2 Heated humidifiers (HHs), and more recently, heat and moisture exchangers (HME), have been used to prevent this. HMEs are now widely used in ICUs. Many types of HME are available, but not all of them are suitable for use during long-term ventilation. Indeed, some have been responsible for endotracheal tube occlusions in 12 h,3 and cases of death from endotracheal tube occlusion have been reported.4 Endotracheal tube occlusion seemed to be due to insufficient airway humidification with HMEs exhibiting hydrophobic properties only.37 In contrast, the capacity of HMEs with both hydrophoClinical Investigations in Critical Care

bic and hygroscopic properties to heat and humidify inspired gases has been validated in several studies.8 10 These HMEs are also safe and effective when used for 48 h. Indeed, changing these HMEs every 48 h did not affect their capacity to humidify inspired gases or the incidence of nosocomial pneumonia.11 The clinician wishing to use an HME must identify the ones that perform poorly without having to conduct hygrometric measurements. This may make him/her reluctant to use HMEs for all ICU patients. Recommendation for using or not using an HME lack evidence-based guidelines.12 Furthermore, indications for when to use an HME during mechanical ventilation (including the type of patients appropriate for HME use and the duration of ventilation with an HME) are still a matter of debate. Indeed, Branson and colleagues1315 tend to limit their use of HMEs to surgical patients and for a maximum of 5 days of mechanical ventilation, while others, ourselves included, use HMEs for all patients, surgical and medical, including patients with COPD, whatever the duration of mechanical ventilation.8 11,16 However, as pointed out in a recent editorial,17 a simple method for evaluating HMEs is needed to allow comparison of the various brands of HMEs available and selection of the appropriate one for mechanical ventilation. The lack of evidence-based guidelines is undoubtedly due to the few data available from independent laboratories on the performance of HMEs. Indeed, the characteristics of the HMEs indicated by the manufacturer have not necessarily been established by an independent laboratory. Objective measurements are time consuming and require equipment that is not routinely available. This study was therefore carried out to provide an objective assessment of the performance of HMEs and to determine whether a clinician can assess this performance at the bedside by observing simple visual parameters. We recently reported that visual inspection of the amount of moisture in the flex-tube correlated adequately with the performance of the HME given by manufacturers.18 However, we did not check our visual scale against objective hygrometric measurements performed at the bedside. This study compares the amounts of moisture seen in the flex-tube with the hygrometric parameters measured psychometrically, thus enabling the clinician to evaluate the efficacy of a given HME without hygrometric measurements. Materials and Methods
Patients All consecutive mechanically ventilated patients were eligible for inclusion in the study. Patients were randomly allocated to

ventilation using one of five humidification devices (see below) for a 3-h period, after which they were ventilated with the device normally used in our unit, the Hygrobac-Dar (HD) (Mallinckrodt Medical S.p.A.; Mirandola, Italy). Indications for mechanical ventilation according to Zwillich and coworkers19 were recorded along with the Simplified Acute Physiology Score (SAPS).20 Materials Four HMEs and one HH were tested. Two HMEs were purely hydrophobic (Pall Ultipor Filter BB2215 and BB50; Pall Biomedical; Saint-Germaine-en-Laye, France); the two others had both hygroscopic and hydrophobic properties (Pall Ultipor Filter BB100; Pall Biomedical; and HD). The conventional HH was the Fisher & Paykel MR 450; Auckland, New Zealand (FP450). The ventilators used were either a Servo 900D ventilator (SiemensElema; Solna, Sweden) or a Bird 8400 (Bird Products Corp; Palm Springs, CA). Hygrometric Measurements Hygrometric measurements (absolute humidity [AH], relative humidity [RH]) and tracheal temperature measurement were performed after 3 h of mechanical ventilation for all devices and also after 48 h for the HD, which is routinely used for this time in our unit.11 The number of times devices delivered AH below 24 mg H2O/L was recorded. AH and RH were obtained using the psychrometric method.2124 A device to separate inspiratory and expiratory gas flow by the means of two unidirectional valves was inserted between the endotracheal tube and the HME (or between the endotracheal tube and the Y-piece when the HH was used). Two thermal probesa dry one and a wet onewere placed in the inspiratory part of the device. The temperatures recorded by the two probes were measured and displayed on a chart recorder (Yokogawa; Tokyo, Japan). Tracheal temperature was measured with another thermal probe inserted in the endotracheal tube and also displayed on the chart recorder. Mean temperatures were recorded from both probes after a 30-min period allowing for optimal thermal equilibrium. The psychrometric method is based on comparing the temperatures obtained with the two probes placed on the inspiratory part of the separating device. The dry probe is placed upstream and measures the actual gas temperature. The downstream probe is coated with sterile cotton wetted with sterile water. Evaporation in the inspiratory part is proportional to the dryness of the gas. The temperature gradient between the two probes varies inversely as the humidity of the inspired gas. There is no thermal gradient when the inspired gas is fully saturated with water (100% RH). RH was calculated by reference to a psoriometric diagram taking into account the temperature difference between the two probes.25 AH at saturation point (100% of RH) (AHs) was calculated with the following formula: AHs 16.451563 0.731 T 0.03987 T2 (mg H2O/L), where T(C) is the dry probe temperature. AH was obtained with the following formula: AH (AHs RH)/100 (mg H2O/L). Room temperature was kept constant between 23.5 and 25C throughout the trials. Visual Evaluation The amount of moisture in the flex-tube connecting the HME (or the Y-piece when the HH was used) to the endotracheal tube was rated at the same time by an independent observer unaware
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Table 1Characteristics of Patients According to the Device Used*

BB2215 (n 20) Age, yr SAPS Minute ventilation, L/mn Tidal volume, mL Indication for mechanical ventilation Chronic airway obstruction Other pulmonary diseases Postoperative respiratory failure Neurologic emergency Miscellaneous *Values are mean SD or No. of patients. 46 21 12.2 5.1 10.0 2.0 490 94 5 7 0 8 0 BB50 (n 20) 56 21 12.1 4.1 10.7 3.0 504 90 2 7 2 7 2 BB100 (n 20) 54 23 14.9 7.3 10.3 2.4 491 97 3 4 1 9 3 HD (n 10) 61 5 14.8 2.4 10.8 2.2 468 63 5 3 0 2 0 FP450 (n 15) 51 22 14.2 5.3 11.1 2.3 516 69 2 7 1 4 1 p Value 0.3 0.3 0.8 0.6 0.6

of the hygrometric results as follows: dry, moisture only, moisture few water droplets, moisture several water droplets, moisture numerous water droplets, and dripping wet. These items were assigned values from 1 (dry) to 6 (dripping wet). The first three items of the scale were counted as dry and the last three as wet in some analyses to make comparisons between devices easier. This protocol was approved by the institutional review board for human studies of the French Intensive Care Society. Informed consent was not requested since all procedures were considered routine practice, and none was invasive. Statistical Analysis All results are means SD. Hygrometrics parameters were compared by analysis of variance. When analysis of variance indicated differences among groups, the groups were compared using protected least significant difference. Kruskal-Wallis analysis was used to compare the clinical rating scores of each humidifying device. Contingency table analysis was used to compare the number of times AH was 24 mg H2O/L. The correlation between the clinical rating of humidifying efficiency and the measured values was performed using Spearmans rank correlation coefficient. A p value 0.05 was considered significant. Statistical analysis was done with a commercial statistical package (Statview; Abacus Concepts Inc; Berkeley, CA).

patients. There were 20 measurements for each HME and 15 measurements for the HH. There were no differences between the patients allocated to each of the devices in terms of age, SAPS,20 minute ventilation, tidal volume, or indications for mechanical ventilation19 (Table 1). Hygrometric Measurements There were significant differences between the hygrometric parameters (AH, RH, and tracheal temperature) of the various HMEs and the HH (Table 2). The best results were obtained with the FP450 HH, which had significantly better AH and tracheal temperature than all the HMEs. The HD was the HME that gave the best values (Table 2). These performances were unchanged after 48 h of use. The poorest performances were obtained with the purely hydrophobic HMEs (BB2215 and BB50). The BB100 showed values that were intermediate between those of the poorest performing devices and those of HD. Table 3 shows the number of times each of the devices was found to deliver 24 mg H2O/L AH. This occurred significantly more frequently with the BB2215 and BB50 HMEs than with all the other devices.

Results A total of 87 clinical measurements and 95 psychrometric measurements were performed on 45

Table 2Hygrometric and Clinical Assessment of the Performances of the Devices*

BB2215 (n 20) Hygrometric assessment AH, mg H2O/L RH, % Tracheal temperature, C Clinical assessment 21.8 1.5 86.2 5.9 31.5 1.0 2.6 1.1 BB50 (n 20) 22.0 1.6 88.4 6.1 31.5 1.3 3.2 1.1 BB100 (n 20) 25.1 1.6 94.2 4.0 32.1 0.9 4.2 0.7 HD H3 (n 10) 30.5 1.0 99.1 1.0 33.1 0.7 4.3 0.8 HD H48 (n 10) 30.4 1.3 98.3 1.7 33.2 0.8 4.5 0.8 FP450 (n 15) 34.3 1.3 99.9 0.4 34.8 0.7 5.4 0.8

*Results are expressed as mean SD. Measurements are performed after 3 h of use for all devices, and also after 48 h for HD HME only. HD H3 denotes evaluation of HD HME after 3 h of use and HD H48 denotes evaluation of HD HME after 48 h of use. p 0.001 (difference with HD). p 0.05 (difference with BB100). p 0.01 (difference with HD). p 0.05 (difference with HD). 1648
Clinical Investigations in Critical Care

Table 3Number of Times Each Device Delivered < 24 mg H2O/L AH and Results of Visual Inspection
No. of Times AH 24 mg H2O/L BB2215 BB50 BB100 HD H3 HD H48 FP450 19/20* 19/20* 4/20 0/10 0/10 0/15 No. of Times Dry 15/20 16/20 3/20 2/10 0/10 0/7 No. of Times Wet With AH 24 mg H2O/L 4/20 3/20 4/20 0/10 0/10 0/7

than in the four other conditions where this event was rare. Miscategorization of HMEs (ie, flex-tube rated wet when in fact AH is 24 mg H2O/L) is shown in Table 3. Accuracy of the scale was 88%. Correlations Between Hygrometric Measurements and Visual Evaluation There was a significant correlation between the visual rating of the condensation in the flex-tube and the AH measured by psychrometry (rho 0.7, p 0.0001) (Fig 1). The correlation was also significant with the other two parameters (RH and tracheal temperature), though less powerful (rho 0.7, and rho 0.5, respectively, both with p 0.0001).

*Different from all the others with p 0.05. Different from all the others with p 0.001.

Visual Evaluation of Humidifying Performance Table 2 shows the results of visual ratings of humidifying efficacy. Statistical analysis revealed significant differences in these parameters, with the purely hydrophobic HMEs being the least effective. Table 3 shows the number of times each device was rated dry by visual inspection. The number of times the two purely hydrophobic devices were dry was significantly higher Discussion This study shows that simple visual inspection of the amount of moisture in the flex-tube connecting the HME to the endotracheal tube (or the Y-piece to the endotracheal tube when using a HH) provides an accurate estimation of the humidifying performances

Figure 1. Correlation between the visual scale rating the condensation in the flex-tube and the actual AH measured by psychrometry after 3 h of use for all the devices and after 48 h for the HD; 1 dry; 2 moisture only; 3 moisture few water droplets; 4 moisture several water droplets; 5 moisture numerous water droplets; 6 dripping wet.
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of the heating and humidifying device used (ie, HME or HH). These findings may be important since recommendations for the use of HMEs in the ICU lack evidence-based guidelines partly because of the few data available on assessment of HME performance at the bedside.12 Characteristics of HMEs given by the manufacturer may not have been established by an independent laboratory and the need for accurate bedside evaluation of the efficiency of HMEs has been emphasized recently.17 Thus, our results indicate that such evaluation is possible and may be useful for managing and monitoring HMEs in the ICU. The gas inspired during mechanical ventilation must be adequately heated and humidified. HMEs are increasingly employed because they are easy to use and cost-effective.8,9,11 Though the clinical importance of sufficient humidification has been often debated, there is no simple, visual method for evaluating the efficacy of HMEs during long-term mechanical ventilation. Indirect parameters such as the occurrence of nosocomial pneumonia, number of endotracheal tube occlusions, number of tracheal suctionings, and instillations required8,9,11 have been reported, but they do not always reflect accurately the hygrometric performance of a given HME.16 Indeed, in this previous report,16 the clinical evaluation of three different HMEs found no differences in humidifying properties, whereas hygrometric measurements revealed great differences between them. The only direct parameters suitable for evaluation are the hygrometric measurements. They may be expressed as an amount of water loss26 or expressed as humidity outputs obtained by psychrometric method. This method is the one most often used, but it requires a flow divider, three thermal probes, and 30 to 60 min to ensure thermal equilibrium.4 6 These measurements are not available in all ICUs and are not feasible in routine practice. This is why a suitable visual evaluation method is worthwhile. We found that the humidity in the flex-tube was correlated with values provided by the manufacturers for AH.18 We have now evaluated each heating and humidifying device using a visual rating and precise hygrometric measurements to determine whether there was a correlation between the two means of evaluation on the same patient. A group of four commonly used HMEs was tested to validate our visual rating of the condensation in the flex-tube. As the room temperature was constant in our unit, the condensation in the flex-tube reflected the humidity delivered by the HME, rather than thermal variations. The hygrometric parameters measured were consistent with those measured in other studies for each HME tested, and confirm the
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superiority of the HH FP450 and of the HD.2124 The humidifying properties of this hygroscopic and hygrophobic filter have been studied and it consistently gives better hygrometric parameters than many other HMEs. These data were also obtained after use of the HME for 24 h or 48 h.16 We selected HMEs having very different efficacies to emphasize the differences in the visual assessment. It would have been difficult to detect hygrometric differences with a visual scale if all the HMEs had produced similar humidities. Thus, the visual rating provides an accurate, satisfactory evaluation of both the effective HMEs (HD and BB100), and the less effective ones (BB2215 and BB50). The AH delivered by the HME to the patient via the inspired gas is a decisive determinant of the humidifying performance of an HME. The lower the AH, the higher total amount of water lost by the patient during mechanical ventilation. The ideal gas is 37C with 100% RH (44 mg H2O/L water vapor) because it does not remove water from the patient.27 This is clinically important since endotracheal tube occlusions occurred when the AH delivered was insufficient.3 6 These occlusions occurred after 12 h of use3 and some were lethal.4 Endotracheal tube occlusions occur after gradual reduction of the tubes diameter, and depend partly on the type of humidification device used, purely hydrophobic HMEs having a significantly greater reduction of their tracheal tube diameter.7 The precise AH an HME should deliver to avoid endotracheal tube occlusion is not clear, but some recommendations suggest that 24 mg H2O/L is the minimum an HME should deliver when used for long-term ventilation.28 However, International Standards Organization recommends that a minimum of 30 mg H2O/L should be provided by devices during mechanical ventilation. Interestingly, a number of studies evaluating different HMEs at the bedside report, however, much lower humidity output measured with commonly used HMEs. Indeed, measured values of absolute humidity are well below 30 mg H2O/L: 20.6 mg H2O/L for the Pall BB2215,22 22.9 mg H2O/L for the Intersurgical Filtatherm (Intersurgical; Wokingham, England),21 25.8 mg H2O/L for the Clear-Thermal (Intersurgical),16 26 mg H2O/L for the Pall BB50,23 and 28.8 mg H2O/L for the Hygrobac filter.22 It also appears that no endotracheal occlusion has been reported with AH 24 mg H2O/L. This is the reason why 24 mg H2O/L was set as the lowest acceptable inspired gas AH. In this setting, the scale described herein enables satisfactory rating of the poorly performing HMEs, since most of those delivering 24 mg H2O/L AH were rated dry. Similarly, most of those delivering 24 mg H2O/L AH were rated humid. Our findings are consistent with
Clinical Investigations in Critical Care

those of Miyao and colleagues27 who reported that the condensation in the breathing circuit is a good way of monitoring the humidity delivered by a humidifying device. They also speculated that the condensation helps to prevent the secretions inside the endotracheal tube from drying out. Both HMEs and HHs present several drawbacks. Placing an HME in the respiratory circuit generates gasflow resistance. This increase in the circuits resistance has been studied previously; it reaches approximately 2.5 cm H2O/Ls and is related to the water load of the HME.29,30 The clinical impact of this resistance has not been studied extensively. Conti and coworkers31 found that in COPD patients receiving volume-controlled mechanical ventilation, the presence of an HME in the circuit did not modify intrinsic positive end-expiratory pressure. Moreover, the additional resistance occasioned by the HME is not higher than the one caused by an HH.32 Additional dead space may also be caused by an HME, and increased Paco2 and minute ventilation during weaning from mechanical ventilation in comparison with HHs.33 However, a possible increase in total weaning time caused by HMEs has not been evaluated (to our knowledge) and the problem of increased dead space is easily overcome by increasing pressure support level.34 It has been shown clearly in the literature either by in vitro or in vivo studies that increase in tidal volume or minute ventilation affected the performances of some HMEs. However, only the purely hydrophobic HMEs (Pall BB2215 and BB50) suffered from this drop in performance. Indeed, Martin and coworkers22 have shown that the efficacy of the HD was not affected by minute ventilation 10 L/min. In our study, humidifying devices were used with minute ventilation 10 L/min. In fact, minute ventilation ranged from 7 to 15 L/min. Therefore, our scale can assess the performances of a humidifying device whatever the minute ventilation used. The use of purely hydrophobic HMEs cannot be recommended during mechanical ventilation with minute ventilation 10 L/min for which clinicians may use either hydrophobic and hygroscopic HMEs or HHs.22,23 Excessive humidification (which can be caused only by a HH) can lead to epithelial and mucociliary damage.35 However, insufficient humidification still remains the major problem that faces a clinician wishing to choose a humidifying device. Evaluation of the efficacy of this device whether it be an HH or an HME can be achieved with this simple inspection. This inspection must be performed several times during the use of the HME. A flex-tube that is always dry indicates a HME delivering insufficient humidity, and therefore at risk of endotracheal tube occlu-

sion. In such instances, we believe it is wise either to change the HME used for a high-performing HME or to switch the patient to an HH. In our unit, we use only high-performing HMEs and such instances have never occurred whatever the type of patient.9,11,16 However, a flex-tube that is constantly covered in water droplets indicates that the HME is appropriate for long-term mechanical ventilation without fear of endotracheal tube occlusion. Our observations indicate that clinicians can evaluate the performance of an HME at the bedside. This may result in considerable cost containment since mechanical ventilation with HMEs is much less expensive than with HH,8,9,11 and could lead to the widespread use of HMEs with further substantial savings as long as contraindications to the use of HMEs be carefully respected; these include profound hypothermia, bronchopleural fistulas, and breath-eliminated drug poisoning. It is thus possible to evaluate the efficacy of HMEs visually by rating the amount of moisture in the flex-tube connecting the HME to the endotracheal tube. References
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Bedside Evaluation of Efficient Airway Humidification During Mechanical Ventilation of the Critically Ill Jean-Damien Ricard, Philippe Markowicz, Kamel Djedaini, Laurence Mier, Franois Coste and Didier Dreyfuss Chest 1999;115;1646-1652 DOI 10.1378/chest.115.6.1646 This information is current as of June 26, 2008
Updated Information & Services References Updated information and services, including high-resolution figures, can be found at: http://chestjournal.org/cgi/content/full/115/6/1646 This article cites 33 articles, 15 of which you can access for free at: http://chestjournal.org/cgi/content/full/115/6/1646#BIBL This article has been cited by 2 HighWire-hosted articles: http://chestjournal.org/cgi/content/full/115/6/1646 Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://chestjournal.org/misc/reprints.shtml Information about ordering reprints can be found online: http://chestjournal.org/misc/reprints.shtml Receive free email alerts when new articles cite this article sign up in the box at the top right corner of the online article.

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