Chapter 11

Humidification Equipment
General Considerations
Terminology
Humi di ty i s a general term used to descri be the amount of wat er vapor i n a gas. I t
may be expressed several ways.
Absolute Humidity
Absol ute humidi t y is t he mass of water vapor present i n a volume of gas. It i s
commonl y expressed i n mi l l i grams of wat er per l i ter of gas.
Humi dity at Saturati on
The maximum amount of water vapor that a vol ume of gas can hold i s the humidi t y
at saturati on. This wi l l vary
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wi th t he temperature. The warmer the temperature, t he more wat er vapor can be
hel d i n a gas. Table 11.1 shows the absolut e humi di ty of saturated gas at vari ous
t emperat ures. At a body temperature of 37C, i t i s 44 mg H
2
O/ L.
TABLE 11.1 Water Vapor Pressure and Absolute Humidity in Moisture-saturated Gas
Temperature Cmg H
2
O/L mm Hg
0 4.84 4.58
1 5.19 4.93
2 5.56 5.29
3 5.95 5.69
4 6.36 6.10
5 6.80 6.54
6 7.26 7.01
7 7.75 7.51
8 8.27 8.05
9 8.81 8.61
10 9.40 9.21
11 10.01 9.84
12 10.66 10.52
13 11.33 11.23
14 12.07 11.99
15 12.82 12.79
16 13.62 13.63
17 14.47 14.53
18 15.35 15.48
19 16.30 16.48
20 17.28 17.54
21 18.33 18.65
22 19.41 19.83
23 20.57 21.07
24 21.76 22.38
25 23.04 23.76
26 24.35 25.21
27 25.75 26.74
28 27.19 28.35
29 28.74 30.04
30 30.32 31.82
31 32.01 33.70
32 33.79 35.66
33 35.59 37.73
34 37.54 39.90
35 39.57 42.18
36 41.53 44.56
37 43.85 47.07
38 46.16 49.69
39 48.58 52.44
40 51.03 55.32
41 53.66 58.34
42 56.40 61.50

Relative Humidity
Rel at ive humi di t y, or percent sat urati on, is the amount of water vapor at a
part icular temperature expressed as a percentage of t he amount that woul d be held
i f the gas were saturated.
Water Vapor Pressure
Humi di ty may also be expressed as the pressure exerted by water vapor i n a gas
mi xture. Tabl e 11. 1 shows t he vapor pressure of wat er i n saturated gas at vari ous
t emperat ures.
Inter-relationships
I f a gas sat urated wi t h wat er vapor i s heated, i ts capaci ty t o hol d moisture
i ncreases and i t becomes unsaturated (has <100% rel at ive humidi t y). Its absolute
humi di ty remai ns unchanged. Gas that is 100% sat urated at room t emperature and
warmed to body temperature wi thout addi t i onal humi di ty wi l l absorb wat er by
evaporat ion f rom the surf ace of t he respi rat ory tract mucosa unti l i t becomes
saturat ed.
I f gas saturat ed wi th wat er vapor i s cooled, i t wi l l condense (rai n out ) wat er. The
absol ute humidi t y wi l l f al l , but t he rel at ive humi di ty wi l l remai n at 100%.
I f inspi red gas is t o have a relati ve humi di ty of 100% at body temperature, i t must
be mai nt ai ned at body temperature af ter l eavi ng the humi dif i er or heated above
body temperature at the humi di f i er and all owed t o cool as i t f l ows t o t he pati ent .
Cooli ng wi l l resul t i n condensat ion (rai n out) i n the breathi ng system.
The speci f ic heat of gas is l ow. As a consequence, i t qui ckly assumes t he
t emperat ure of the surrounding envi ronment. I nhal ed gases qui ckl y approach body
t emperat ure, and gases i n corrugated tubes rapidl y approach room t emperature.
The heat of vapori zat ion of wat er i s rel at ivel y high. Evaporat ion of water, t heref ore,
requi res considerabl y more heat than warmi ng of gases. Li kewi se, condensati on of
wat er yi el ds more heat than cool ing of gases.
Considerations for Anesthesia
Water i s i nt ent i onal l y removed f rom medi cal gases so that gases del ivered f rom t he
anesthesi a machine are dry and at room temperature. As gases f l ow t o the alveol i ,
i nspi red gas i s brought t o body t emperature (ei t her by heati ng or cool i ng) and 100%
rel ative humi di ty (ei ther by evaporat ion or condensati on). I n t he unint ubated
pati ent , the upper respi rat ory tract (especi al l y t he nose) f unct i ons as t he pri ncipal
heat and moi st ure exchanger (HME). During normal nasal breathi ng, t he
t emperat ure i n the upper t rachea i s bet ween 30C and 33C, wi th a
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rel ative humi di ty of approxi matel y 98%, provi di ng a wat er content of 33 mg/L (1).
Tracheal tubes and supragl ot t ic ai rway devices bypass the upper ai rway, modi f yi ng
t he pat tern of heat and moisture exchange so t hat the t racheobronchi al mucosa
must assume a greater rol e in heati ng and humidif yi ng gases.
Effects of Inhaling Dry Gases
The i mportance of humidif i cat i on i n anesthesi a remains uncert ain. It i s of greatest
benef i t i n pediat ri c pat i ents, pati ents at i ncreased ri sk f or devel opi ng pul monary
compl i cati ons, and l ong procedures.
Damage to the Respiratory Tract
As the respi rat ory mucosa dri es and i ts temperat ure drops, secreti ons t hi cken,
ci l iary funct ion is reduced, surf actant act ivity is i mpai red, and t he mucosa becomes
more suscept ible to i nj ury (2,3). If secret ions are not cl eared, atelectasi s or ai rway
obstruct i on can resul t . Thi ckened pl ugs may provide l oci for i nf ecti on. Dry gases
can cause bronchoconst rict i on, f urther compromi si ng respi ratory funct ion.
Humi di f yi ng gases may decrease t he i nci dence of respi ratory compli cati ons
(coughing and breat h hol ding) associ at ed wi th an i nhal at i on induct i on (4, 5).
There i s no agreement about the mi ni mum humi di t y necessary t o prevent
pathological changes. Recommendati ons have ranged f rom 12 t o 44 mg H
2
O/L
absol ute humidi t y (2,3,6, 7,8,9). The durati on of exposure i s import ant . I t is unli kel y
t hat a brief exposure to dry gases wi l l damage the tracheobronchi al tree. As ti me
i ncreases, the li kel i hood that si gni fi cant tracheobronchi al damage wi l l become
great er.
Body Heat Loss
Body temperature is l owered as the ai rways bri ng t he inspi red gas int o thermal
equil i bri um and saturat e i t wi t h water. The use of a humi di f icati on device can
decrease the heat l oss that occurs duri ng anesthesi a and may provi de some heat
i nput (10,11,12,13,14,15,16,17). Cont rol l i ng i nspi red gas temperature and humi di ty
i s not an ef f icient met hod of mai nt ai ni ng body t emperat ure. Means to i ncrease body
t emperat ure are di scussed i n Chapt er 31.
Absorbent Desiccation
The eff ects of dry absorbent on t he composi ti on of i nspi red gases are discussed i n
Chapter 9. Whi le HMEs preserve pati ent heat and humi di ty, they al so may
contri but e to absorbent desi ccati on (18).
Tracheal Tube Obstruction
Thi ckened secreti ons i n a tracheal t ube i ncrease i ts resistance and can resul t in
compl ete obstructi on (19,20,21,22,23,24).
Consequences of Excessive Humidity
An i ncreased water l oad can cause ci l i ary degenerat ion and paral ysi s, pul monary
edema, al tered alveol ar-arteri al oxygen gradi ent, decreased vit al capaci t y and
compl i ance, and a decrease i n hemat ocri t and serum sodium (25).
Sources of Humidity
Carbon Dioxide Absorbent
The reacti on of absorbent wi t h carbon di oxide l i berates water (Chapter 9). Water is
al so contained i n the absorbent granules. Si nce t he react ion i s exothermi c, heat i s
produced. I f the absorbent granules desi ccate, they may react wi th cert ai n
anesthet ics and produce ext reme heat. Thi s i s di scussed i n detai l i n Chapter 9.
Exhaled Gases
There i s some rebreathing i n the t racheal tube, the supragl ott i c ai rway device, and
t he connecti ons to t he breathi ng system. Almost hal f of the humi di t y i n expi red gas
i s preserved i n thi s manner (26).
I n systems that al l ow rebreathi ng of exhal ed gases (Chapter 8), t he humi di ty and
t emperat ure of the i nspi red gases depend on the rel at ive proport i ons of f resh and
expi red gases. Thi s wi l l depend on the system and the f resh gas f l ow. As t he f resh
gas f l ow i s i ncreased, t he inspi red t emperature and humi di ty are reduced. Use of
t he system by a previ ous pati ent wi l l i ncrease t he humi di ty.
Moistening the Breathing Tubes and Reservoir Bag
Ri nsi ng the inside of the breathi ng tubes and reservoi r bag wi th water before use
i ncreases the i nspi red humi di ty (27).
Low Fresh Gas Flows
Usi ng l ow f resh gas f l ows wi th a ci rcl e breat hi ng system wi l l conserve moisture.
Thi s i s discussed i n more detai l i n Chapter 9.
Coaxial Breathing Circuits
Coaxi al ci rcl e syst ems, when combi ned wi t h l ow f l ows, wi l l i ncrease the humidi t y
more qui ckl y than a system wi t h two separat e l i mbs (2), but this i s not very ef f ici ent
i n terms of heat or humi di t y i mprovement (28).
The Bai n syst em (see Chapter 8) i s a coaxial versi on of t he Mapl eson D. It does not
meet opt imal
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humi di f icati on requi rements because of t he hi gh f resh gas f l ow requi red (26).
Heat and Moisture Exchangers
An HME conserves some exhal ed wat er and heat and returns them t o the pati ent i n
t he i nspi red gas. Many HMEs also perform bacteri al /vi ral f i l t rati on and prevent
i nhal at i on of smal l part icles. The HME i s also known as a condenser humidif ier,
Swedish nose, art i fi ci al nose, nose humi di f i er, passi ve humi di f i er, regenerat i ve
humi di f i er, moi sture exchanger, and vapor condenser. When combi ned wi th a f i l ter
f or bacteri a and vi ruses, i t i s cal l ed a heat and moi sture exchangi ng f i l t er (HMEF).
Two i nt ernati onal st andards on HMEs have been publ i shed (29, 30).
Description
HMEs are disposabl e devi ces wi t h t he exchangi ng medi um encl osed i n a pl ast ic
housi ng. They vary in si ze and shape. Typical ones are shown i n Figure 11.1. Each
has a 15-mm female connecti on port at t he pati ent end and a 15-mm mal e port at
t he other end. The pati ent port may al so have a concentri c 22-mm mal e f i tt ing
(Fi g.11.1C,D). There may be a port to at t ach t he gas sampl i ng l ine f or a respi ratory
gas moni t or (Fi g. 11.1B,D) or an oxygen l i ne. One type uti l i zes a ceramic heat i ng
el ement wi t h a water i nput port , a membrane, and an al umi num gri d that vapori zes
t he wat er (31).
The dead space of HMEs vari es. Pedi at ri c and neonat al HMEs wi th l ow dead space
are avai l abl e (32,33). Most modern HMEs are one of t wo types, as shown i n Tabl e
11.2.
Hydrophobic
Hydrophobi c HMEs have a hydrophobic membrane wi t h smal l pores. The membrane
i s pleated to i ncrease t he surf ace area. A pl eated hydrophobic membrane provi des
moderatel y good i nspi red humi di ty. The perf ormance of thi s type of HME may be
i mpai red by high ambient temperatures (1,21).
Hydrophobi c HMEs are eff icient bacteri al and vi ral f i l t ers (34, 35,36,37,38,39). A
pl eated hydrophobic f i l ter wi l l consi st ent l y prevent t he hepat i t i s C vi rus f rom
passi ng whi l e a hygroscopic f i l ter may be i nef fecti ve (40). They all ow the passage
of water vapor but not l iquid water at usual venti l atory pressures (34,36). They are
associ ated wi th smal l i ncreases i n resi stance even when wet (12,41,42).
Hygroscopic
Hygroscopi c HMEs contain a wool , f oam, or paperl ike materi al coated wi t h
moi st ure-ret aining chemi cal s. The medi um may be i mpregnated wi t h a bacteri ci de
(43). Composi t e hygroscopi c HMEs consi st of a hygroscopi c l ayer pl us a layer of
t hin, nonwoven f iber membrane that has been subj ected to an electri cal f i eld t o
i ncrease i ts pol ari t y. Thi s i mproves fi l trat ion eff iciency and hydrophobici t y.
Most studi es have shown t hat composi te hygroscopi c HMEs are more ef f i ci ent at
moi st ure and temperature conservat ion t han hydrophobic ones
(1,22,44,45,46,47, 48,49,50, 51,52,53). They wi l l l ose thei r ai rborne f i l t rati on
ef fi ci ency if they become wet , and mi croorganisms held by t he f i l ter medi um can be
washed through the devi ce. Thei r resi stance can increase great l y when they
become wet (42).
Indi cati ons
An HME can be used to i ncrease i nspi red heat and humi di t y during both short - and
l ong-term venti l ati on. HMEs may be especi al l y useful when t ransport i ng i ntubated
pati ents, because transport vent i l ators f requent ly have no means f or humidif yi ng
i nspi red gases.
An HME can be used to suppl y supplement al oxygen to an intubated pati ent or
pati ent wi t h a supragl ott i c ai rway by connecti ng oxygen t ubi ng t o the gas sampl i ng
port (54, 55,56).
Contrai ndications
Contrai ndi cat ions incl ude pat i ents wi t h thi ck, copious, or bloody secreti ons and
pati ents wi t h a leak that prevents exhal ed gas f rom traversing t he passi ve
humi di f i er (e. g. , bronchopl eural cutaneous f i stul a or l eaki ng or absent tracheal t ube
cuff ). HMEs shoul d be used wi t h caut i on when weaning a pati ent f rom respi ratory
support (57,58).
Factors Affecting Moisture Output
Heat and Moisture Exchanger Type
Composi te hygroscopic HMEs have bet ter heat and moi sture exchangi ng properti es
t han do hydrophobi c ones.
Initial Humidity
I ncreasi ng t he humi di ty i n the gas enteri ng t he HME f rom t he breathi ng system wi l l
i ncrease t he i nspi red humi di ty (59).
Inspiratory and Expiratory Flows
The f aster t hat gas passes t hrough the HME, the l ess ti me t here i s to evaporate or
deposi t moi sture, so a large t i dal volume may cause the humi di ty of the i nspi red
gas to fal l (45,48,59,60,61).
System Continuity
A leak around t he tracheal tube wi l l resul t in decreased i nspi red humi di ty (32, 62).
Use
The HME sel ected shoul d be of an appropriat e si ze for the pati ent' s ti dal vol ume. If
a smal l HME is used i n a l arge pat ient, the HME wi l l be i neff icient (63). Connecti ng
more than one HME i n seri es wi l l i mprove performance (64,65). Care must be taken
t hat the uni ts are pushed f i rml y together and t hat t he increase i n dead space i s not
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excessive for t hat parti cul ar pati ent. Added dead space i s especi al l y i mportant i n
smal l pati ents.

View Figure

Figure 11.1 Heat and moisture exchangers. A,E: Straight
variety. B: Right angle HME with port for aspiration of
respiratory gases on the breathing system side. C: The
flexible tube attached to the HME extends the distance
between the patient and the breathing system and allows the
angle between the breathing system and the patient to be
altered. Because this HME has significant dead space, it
should be used only with high tidal volumes and controlled
ventilation with monitoring of inspired and exhaled carbon
dioxide. D: Hydrophobic HME with respiratory gas
aspiration port. (Pictures C, D, and E courtesy of Gibeck
Respiration, Pall Biomedical Products Corp. and ARC
Medical Inc.)

An HME should be vi si bl e and accessible at al l ti mes i n order to detect
contaminati on or disconnection. The greatest inspi red rel ative humi di t y occurs wi th
t he HME posi ti oned next to the t racheal t ube, mask, or supraglot t ic ai rway devi ce.
Some gas moni tors (Chapt er 22) are part icul arl y sensi t i ve to water. I f the sampl ing
l i ne i s on the machi ne si de of the HME, the amount of moi sture to whi ch the
moni tor i s exposed wi l l be reduced.
An HME can be used wi t h any breat hi ng system. Wi th t he Mapleson systems, dead
space can be reduced by
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ut i l i zi ng the gas sampl i ng port as t he f resh gas inl et (66). Oxygen can be
admi ni stered through the gas sampl e port on the HME (55, 56). An HME may be
used for pat ients who have a tracheostomy (67).
TABLE 11.2 Comparison of Hygroscopic and Hydrophobic Heat and Moisture Exchangers
Type Hygroscopic Hydrophobic
Heat and moisture exchanging
efficiency
Excellent Good
Effect of increased tidal volume on
heat and moisture exchange
Slight decrease Significant
decrease
Filtration efficiency when dry Good Excellent
Filtration efficiency when wet Poor Excellent
Resistance when dry Low Low
Resistance when wet Significantly
increased
Slightly
increased
Effect of nebulized medications Greatly increased
resistance
Little effect

An HME may be used as the sole source of humi di ty or may be combi ned wi t h
another source such as an unheated humi di f ier (68) but shoul d not be used wi th a
heated humi dif i er.
I f a nebuli zer or metered-dose inhal er (Chapt er 7) is used to del i ver medi cati on, i t
shoul d be inserted between the HME and the pat i ent or t he HME removed f rom the
ci rcui t during aerosol t reatment .
An HME should be repl aced i f contami nated wi t h secreti ons.
Advantages
HMEs are inexpensive, easy t o use, smal l , l i ght wei ght , rel i abl e, si mpl e i n desi gn,
and si l ent in operati on. They have l ow resi st ance when dry. They do not requi re
wat er, an external source of energy, a temperature moni tor, or al arms. There i s no
danger of overhydrati on, hypert hermi a, ski n or respi ratory tract burns, or elect ri cal
shock. Thei r use may i ncrease the correl at ion between esophageal and core
t emperat ures (69). They act as a barri er to l arge parti cl es, and some are eff i ci ent
bacteri al and vi ral f i l ters, al though t hei r role i n reduci ng nosocomi al inf ecti ons
remai ns cont roversi al . They may reduce probl ems caused by humi di t y i n the
breat hi ng system such as obstruct ion of l ines and venti l ator mal -f unct i on (70).
Disadvantages
The mai n di sadvantage of HMEs is the li mi ted humi di t y that these devices can
del i ver. Thei r cont ri buti on to t emperature preservati on i s not si gnif icant .
Temperature management i s di scussed i n Chapter 31. Acti ve heati ng and
humi di f icati on are more ef f ective t han an HME i n retai ning body heat, al l eviati ng
t hick secreti ons, and preventi ng tracheal t ube bl ockage
(19,21,22, 23, 71,72,73, 74,75). The dif ference is more apparent af ter int ubati on
l ast ing f or several days.
Pl aci ng an HME bet ween t he breathi ng system and the pat ient i ncreases dead
space. Thi s may necessi tate an i ncrease i n ti dal vol ume and can lead to dangerous
rebreat hi ng (76). I t al so i ncreases the work of breathi ng duri ng both inspi rat i on and
exhal ati on (77).
Hazards
Excessive Resistance
The use of an HME increases resi st ance, al t hough usual l y i t i s not a major
component of the total work of breat hi ng (78). Resistance i ncreases wi t h use
(9,33,35,38,58,78, 79,80,81, 82,83,84, 85,86). Heavy vi scous secreti ons can greatl y
i ncrease resi st ance. An HME shoul d not be used wi t h a heated humi di f i er, as this
can cause a dangerous i ncrease in resi st ance. Nebul i zed medicati on i ncreases the
resi st ance of hygroscopi c HMEs (34,38).
Wi th a Mapl eson system, i ncreased resistance may cause di versi on of f resh gas
down t he expi rat ory l i mb (87, 88,89).
Hi gh resistance may resul t i n suf fi ci ent back pressure to prevent the l ow ai rway
pressure al arm f rom being acti vated i f t here i s a di sconnecti on bet ween t he pat i ent
and the HME (90,91).
I f increased resi stance i s suspected duri ng control led vent il ati on, the peak pressure
shoul d be measured wi th and wi t hout the HME i n place. Spont aneousl y breathing
pati ents shoul d be observed f or si gns of i ncreased work of breathi ng.
Airway Obstruction
An HME can become obstructed by f lui d, blood, secreti ons, a manuf acturi ng def ect ,
or nebul i zed drugs (18, 92,93,94, 95,96,97, 98,99,100,101,102). Parts may become
detached and bl ock the breathi ng system (103). The HME' s wei ght may cause the
t racheal tube t o ki nk.
I f an HME i s used for l ong-t erm venti l at ion, tracheal t ube occl usi on may occur
(20,21,22, 23, 24,73).
Inefficient Filtration
Li qui d can break t hrough a hygroscopic HME, resul t i ng in poor f i l trat ion (34,36).
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Foreign Particle Aspiration
Parts of the HME may become det ached (64,104,105,106,107). The parts may then
be i nhal ed by the pat i ent .
Rebreathing
The HME dead space may cause excessi ve rebreathi ng, especi al l y wi t h smal l ti dal
volumes. Speci al l ow-vol ume devices are avai l able f or pediatrics. Even these smal l
devices may be t oo large f or i nf ants under 15 kg (108). HMEs shoul d not be used
f or mask vent il ati on i n smal l i nf ants (109).
Leaks and Disconnections
Addi ng an HME to a breat hi ng system i ncreases the potent ial f or di sconnect i ons
and l eaks (18,92,110,111,112).
Hypothermia
Pat i ent warmi ng is di scussed in Chapter 31. HMEs are a means to conserve
t emperat ure, but t he amount of heat preserved by this met hod i s smal l
(15,113,114,115).
Dry Carbon Dioxide Absorbent
HMEs wi l l decrease t he amount of humi di t y avai l abl e to the absorbent . The extent
t o whi ch HMEs wi l l l ead to absorbent desiccat ion i s uncl ear. The eff ect of dry
carbon dioxi de absorbents on the producti on of Compound A and carbon monoxi de
i s discussed i n Chapt er 9. In addi t ion, dry absorbent wi l l absorb some vol ati l e
agents. Thi s can i mpede anestheti c i nduct i on wi t h these agents (18).
Humidifiers
A humi di f i er (vapori zer or vapori zi ng humi di f ier) passes a st ream of gas over wat er
(pass-over), across wi cks di pped i n wat er (blow-by), or through water (bubbl e or
cascade). Humi dif i ers may be heated or unheated.
Unheated
Most unheated humi dif i ers are di sposabl e, bubbl e-through devi ces that are used to
i ncrease t he humi di ty i n oxygen suppl ied t o pati ents via a f ace mask or nasal
cannul a. They cannot deli ver more than about 9 mg H
2
O/ L.
Heated
Heated humidi f i ers i ncorporate a devi ce to warm the water i n the humi dif i er. Some
al so heat the inspi ratory tube.
Description
Humidification Chamber
The humidif icat ion chamber contai ns the l i qui d wat er. It may be disposabl e or
reusable. A cl ear chamber makes i t easy t o check the water l evel . Some humi di fi ers
have an integral or remote reservoi r t hat suppl i es l i quid wat er t o the humidif i cat ion
chamber (Fi g. 11.2).
Heat Source
Heat may be suppl i ed by heat ed rods immersed i n the water or a plate at the
bot tom of the humidi f i cat ion chamber (Fi g. 11.3).
Inspiratory Tube
The i nspi ratory t ube conveys humi di f i ed gas f rom t he humi di f i er outl et t o the
pati ent . If i t i s not heated, the gas wi l l cool and l ose some of i ts moi sture as i t
t ravel s to the pati ent. This water wi l l col l ect i n t he inspi ratory tubing. A wat er trap
wi l l be necessary to coll ect the condensed water.
Heati ng or i nsul ati ng the i nspi rat ory t ube al l ows more precise cont rol of the
t emperat ure and humi di t y del i vered to the pat ient and avoi ds moi st ure rai nout
(116, 117). A heated wi re i nsi de t he inspi ratory tubi ng is most of ten used (Fi g.
11.3). I t shoul d extend as cl ose t o the pati ent connect ion as possi bl e. Di sposable
wi res i n preassembl ed di sposabl e breathing systems are avai l abl e. A reusabl e wi re
must be inserted manual l y i nto the i nspi rat ory t ube by using a draw wi re (118). If
t he gas t emperat ure del i vered to t he pati ent i s set above t he temperat ure of the
humi di f icati on chamber outl et , l ess than 100% relati ve humi di ty wi l l be del i vered
(119, 120,121,122).
Temperature Monitor(s)
Most heated humi di f i ers have a means to measure t he gas temperature at the
pati ent end of the breathing system. Usual ly, there are temperature sensors in t he
wat er reservoi r or i n contact wi th t he heater plate to activate al arms and shut of f
heater power when necessary.
Thermostat
Servo-controlled Units
A servo-control led uni t automat icall y regul at es power to t he heati ng el ement i n the
humi di f i er i n response to t he temperature sensed by a probe near t he pat ient
connecti on or t he humi di fi er outl et (123,124, 125). These devi ces are equi pped wi th
al arms t o warn of hi gh temperature. Of t en, there are t wo thermostats so t hat i f one
f ai l s, the other wi l l cut of f the power bef ore a dangerous temperature i s reached.
Nonservo-controlled Units
A nonservo-cont rol l ed uni t provides power to the heat ing el ement accordi ng to the
sett ing of a cont rol , i rrespecti ve of t he del i vered temperature. I t may i ncl ude a
servo-control l ed ci rcui t , but the servo-cont rol l ed uni t control s the heat er rather than
t he del ivered temperature (123,125).
Controls
Most humi di f i ers al l ow temperature sel ecti on at the end of the del i very t ube or at
t he humi di fi cat i on chamber out l et. Some al low l ess than 100% rel ati ve humidi t y to
be del ivered. Some model s generate saturat ed vapor onl y at a preset temperature
(8).
Alarms
Al arms may warn when the temperature at t he pati ent end of t he ci rcui t devi ates
f rom the set t emperature by a f ixed amount, when the t emperature probe is not in
pl ace, when the heater wi re i s not connect ed, when the water l evel i n the
humi di f icati on chamber i s l ow, or when the ai rway temperature probe does not
sense an i ncrease i n temperature wi thi n a certain t ime af ter the humidif i er is turned
ON. A l ow t emperature alarm wi l l hel p to det ect probl ems wi th t he heater el ement .
I t
P. 303

al so may be t he means of detect i ng lack of gas f l ow i n t he ci rcui t (126).

View Figure

Figure 11.2 Heated humidifier with separate water
reservoir. (Picture courtesy of Hudson RCI.)

Action
Some humidi f iers heat the gas to a temperat ure exceeding t he desi red pati ent
ai rway temperature (superheat i ng) so t hat the cool i ng t hat occurs as i t f lows t o the
pati ent wi l l resul t i n the desi red temperature at the pati ent connecti on. Cool i ng in
t he tube wi l l resul t i n water rai ni ng out in t he tube. I n other humi di f iers,
t emperat ure i ncreases as i t passes through the i nspi rat ory t ube so t hat gas wi th
l ess than 100% rel ati ve humidi t y i s del ivered.

View Figure

Figure 11.3 Heated humidifier. Heat is supplied from a
heated plate below the humidification chamber. The heating
wire at the left fits inside the delivery tube.

I f the del i very tube i s not heated, the temperature wi l l drop as i t f lows t o the
pati ent . The magni tude of the drop depends on many factors, incl udi ng ambi ent
t emperat ure; gas f low; and the l engt h, di amet er, and t hermal mass of the breathi ng
system. Cool i ng can be reduced by short eni ng or i nsul ati ng the del ivery t ube or by
using hi gher i nspi ratory f lows. I f the gas is saturat ed at t he humi di f i er outl et , t he
t emperat ure drop wi l l cause water vapor condensati on (rai nout) t o occur. A wat er
t rap wi l l be necessary t o col lect the condensed water.
Standard Requirements
An i nternati onal and a U. S. standard on humi di f iers have been publ i shed (127,128).
They contai n the f ol lowi ng provisions.
P. 304


Humi di f i ers must be capabl e of produci ng an output of at l east 10 mg H
2
O/ L.
Those intended f or use wi t h pati ents whose supragl ot tic ai rways have been
bypassed must be capable of produci ng an output of at least 33 mg H
2
O/L.
The average temperature at t he del i very tube out let shal l not f luctuate by
more than 2C f rom t he set temperature af ter a state of t hermal equi l i bri um
has been establ i shed f ol l owi ng a change i n gas f l ow or set t emperature. If
t he measured gas temperature di ff ers f rom t he set t emperat ure by more t han
t he range speci f i ed by the manuf acturer, an alarm must be acti vated.
The volume of l i qui d exi ti ng the humi di f ier shal l not exceed 1 mL/mi nute or
20 mL/ hour for humi dif i ers i ntended for use wi th neonat es or 5 mL/ minute or
20 mL/ hour for al l other humi di f i ers.
I f the humidif ier is heated, the gas t emperature at the del ivery tube outl et
shal l not exceed 41C or t he gas t emperature at the humi dif i er out l et shal l be
i ndi cated conti nuousl y and t he temperature-measuri ng device shal l acti vat e
an al arm when the t emperat ure exceeds 41C. The humi di f ier shal l i nterrupt
heati ng when the measured gas temperature exceeds 41C.
The accessi bl e surf ace t emperature of the del ivery t ube must not exceed
44C wi t hi n 25 cm of the pati ent connecti on port.
When t he humi di fi er i s ti l ted 20 f rom i ts normal operati ng posi t ion, there
shal l be no wat er spi l l ed i nto the breathi ng system.
Al l cal i brated cont rols and i ndicators shal l be accurat e to wi t hi n 5% of thei r
f ul l -scal e values, except for t emperature displ ays and cont rols. The
measured gas temperature shal l be accurate t o 2C.
The di rect ion of f l ow must be marked on humi di f i ers wi t h f l ow-di recti on
sensi ti ve components.
Use
I n t he ci rcle system, a heated humi dif ier i s pl aced i n the i nspi ratory li mb
downst ream of the uni di rect ional val ve by usi ng an accessory breathing tube. A
heated humi dif i er must not be pl aced in the expi ratory l imb (129, 130). I f a fi l ter is
used i n the breathing syst em, i t must be pl aced upst ream of t he humidi f i er to
prevent i t f rom becoming clogged.
I n Mapleson systems (Chapter 8), the humidif ier is usual l y pl aced i n the f resh gas
suppl y tube (131,132). Usi ng a l arge-di ameter t ubi ng and pl acing t he humi di f i er
near the end of the tube wi l l decrease condensati on. The del ivery t ube temperature
probe may be pl aced ei ther bet ween t he f resh gas suppl y tube and the T-pi ece or
bet ween t he T-pi ece and the pat i ent .
The humidif ier must be l ower than the pati ent t o avoid t he ri sk of water runni ng
down t he t ubi ng into the pat ient. The condensate must be drai ned peri odi cal l y or a
wat er t rap i nsert ed i n the most dependent part of t he tubi ng to prevent bl ockage or
aspi rat ion.
The heat er wi re i n t he del i very tube should not be bunched, but strung evenl y along
t he l engt h of the t ube. The del ivery tube shoul d not rest on ot her surf aces or be
covered wi t h sheets, bl ankets, or other materi al s. A boom arm or t ube t ree may be
used for support (133).
Advantages
Most heated humi di f i ers are capabl e of del iveri ng saturat ed gas at body
t emperat ure or above, even wi t h high f l ow rat es. A heated humi di f i er can produce
more eff ect i ve humi di f i cat i on than an HME (74,134). Some (but not al l ) can be used
f or spontaneousl y breathing and tracheot omi zed pat ients (67).
Disadvantages
Humi di f i ers are bulky and somewhat compl ex. These devi ces i nvol ve hi gh
mai ntenance costs, el ect ri cal hazards, and i ncreased work (temperature control ,
ref i l l i ng t he reservoi r, drai ni ng condensate, cl eaning, and steri l i zati on). Thei r use i s
associ ated wi th hi gher costs than HMEs.
Compared wi t h ci rcul at ing water and f orced-ai r warmi ng (Chapt er 31), t he heated
humi di f i er off ers rel at ivel y l i tt le protect i on agai nst heat l oss during anesthesia
(135).
Hazards
Infection
Bacteri al growt h can occur i n water st ored i n a reservoi r or t he condensate i n the
del i very tube. The use of a heated ci rcui t reduces the amount of condensate, whi ch
may reduce t he i nf ect ion risk.
Breathing System Problems
Report ed breathi ng system probl ems i ncl ude st i cki ng val ves, l eaks, di sconnecti ons,
i ncorrect connecti ons, obstructed f resh gas l i ne or i nspi ratory l i mb, noise, and
cl ogged f i l ters and HMEs (136,137,138,139,140,141).
The deli very tubi ng may mel t, resul t ing in an obstructi on or l eak
(118, 142,143,144, 145, 146,147, 148, 149,150). Fi res have been report ed
(123, 151,152). A charred breathi ng system may resul t i n fumes enteri ng t he
pati ent 's l ungs. Overheat ing of breathing ci rcui ts wi t h mel t i ng may be caused by
defects i n or damage to t he heated wi re; bunching of the heated-wi re coi l s wi t hi n
t he breathi ng system; el ectrical i ncompat ibi l i t y bet ween t he heated-wi re breathi ng
ci rcui t and the humi di fi er (153); operati ng the devi ce outsi de the speci fi ed range of
f lows or minute vol umes; or coveri ng the del ivery tube wi th sheets, bl ankets, or
ot her materi als (133,144,147). Probl ems may occur i f a ci rcui t t hat i s not f rom the
humi di f i er manuf acturer i s used. Electri cal connectors f or heated-wi re ci rcui ts that
are physical ly compati bl e may not be el ect ri cal l y int erchangeable (133). When
venti l ati on i s interrupted, as when cardi ac bypass i s begun, the humidif i er shoul d
be turned OFF. Wi thout a gas ai r f low, the temperature at the pat ient end wi l l drop
and the heati ng el ement may increase i ts output, causi ng the at tached breathi ng
ci rcui t to mel t .
P. 305


Addi ng a humidi f ier may change the breathi ng syst em vol ume and compl i ance
si gni f icant l y (154). Thi s can resul t i n l ess accurate smal l ti dal vol ume del ivery.
Venti lators that calcul ate t he system compl i ance and gas compressi on must
perf orm thei r checkout procedure wi th t he humi di f i er i n pl ace si nce t he humi di f i er
can aff ect vent il ator accuracy.
Water Aspiration
There i s danger of l iqui d water enteri ng the trachea and drowni ng the pat ient or
causi ng a burn i n the respi ratory t ract . These ri sks can be decreased by i nstal l i ng a
wat er t rap i n both the i nspi ratory and exhalati on si des i n the most dependent
port ion of the breathi ng tube, drai ni ng condensate f requentl y, and pl aci ng t he
humi di f i er and breathing tubes bel ow the pati ent.
Overhydration
A heated humi di f i er can produce a posi ti ve wat er balance and even overhydrati on.
Al though most anestheti cs are of suff i ci ent ly short durati on that thi s is not a
si gni f icant probl em, i t can be a problem wi t h i nf ants.
Thermal Injury
Del i veri ng overheated gases i nto the trachea can cause hyperthermi a or damage to
t he ti ssues l i ni ng the tracheobronchi al t ree. Ski n burns have been reported f rom
admi ni stering heated oxygen nasal l y and when cont i nuous posi t ive ai rway pressure
was del i vered (125, 155,156). Burns can al so occur when t i ssue i s i n contact wi t h
heated breathi ng ci rcui ts (157,158).
Overheati ng i nspi red gas may be caused by omi t ti ng, misplaci ng, disl odging, or not
f ul l y i nserti ng the ai rway t emperature probe or by t urning the humi di f i er ON wi th a
l ow gas f l ow (123, 155,156,159). A t emporary i ncrease i n inspi red gas temperature
may occur f ol l owi ng a peri od of i nterrupted f low or an increased f low rate (160).
Increased Work of Breathing
A heated humi di f i er increases resi st ance (26, 161,162). Most cannot be used wi t h
spontaneousl y breathing pat ients.
Monitoring Interference
A humi di f i er may add enough resistance to prevent a l ow ai r way pressure al arm
f rom bei ng acti vat ed i f the sensor i s upst ream of the humidi f i er (91). Some f l ow
sensors are aff ected by condensat ion, producing a f al se posi t i ve al arm (163).
Pressure and f l ow moni t oring are di scussed i n Chapter 23.
Hi gh humi di ty can cause problems wi t h sidest ream (aspi rat ing) respi rat ory gas
moni tors (Chapter 22).
Altered Anesthetic Agents
Hal othane may be al t ered if i t passes t hrough a humidi f i er whose heati ng element
i s i n di rect contact wi th t he gas at a t emperat ure of 68C or hi gher (164).
Equipment Damage or Malfunction
Venti lators are sensi t ive to rai nout caused by water condensati on. Signs incl ude
i ncreased resistance to exhal ati on, i naccurate pressure and vol ume measurements,
autocycl i ng, and vent il ator shut down (70,165). I n order to prevent these probl ems,
a wat er t rap shoul d be used i f wat er i s l i kely t o condense i n the breathi ng system.
These need to be inspected regularl y and empti ed as needed. The humi di f i er needs
t o be l ower than the pati ent and venti l ator.
Nebulizers
Description
A nebul i zer (aerosol generator, atomi zer, nebul i zing humidif i er) emi ts wat er in t he
f orm of an aerosol mi st (wat er vapor pl us part icul ate wat er) (166). The most
commonl y used are the pneumati cal l y dri ven (gas-driven, j et , hi gh pressure,
compressed gas) and ul t rasoni c nebul i zers. Both can be heated. In addi ti on to
provi di ng humi di f i cati on, nebul i zers may be used to del i ver drugs t o the breathi ng
system.
A pneumati c nebul i zer works by pushi ng a j et of hi gh-pressure gas i nto a l i qui d,
i nducing sheari ng f orces and breaki ng the water up i nto f ine part i cl es. An ul t rasoni c
nebul i zer produces a f i ne mist by subj ect ing t he l i quid to a high-f requency,
el ect rical l y driven ul t rasonic resonat or. The f requency of osci l l ati on determines the
si ze of t he dropl ets. There i s no need f or a driving gas. Ul t rasoni c nebul i zers creat e
a denser mi st t han pneumat ic ones (124).
Use
Because a hi gh f low of gas must be used wi th a pneumat ic nebul i zer, i t should be
pl aced i n the f resh gas l i ne. An ul t rasoni c nebuli zer can be used in the f resh gas
l i ne or the i nspi rat ory l i mb.
Hazards
Nebul i zed drugs may obst ruct an HME or f i l t er i n the breat hi ng system (95,96, 167).
Overhydat ion can occur. If t he dropl ets are not warmed, hypothermi a may resul t .
I nfecti on can be transmi t ted because microorganisms can be suspended i n t he
wat er dropl ets.
There are report ed cases where a nebul i zer was connected di rectl y to a t racheal
t ube wi thout provi si on f or exhal ati on (168). I n one case, this resul ted in a
pneumothorax.
Advantages
Nebul i zers can del iver gases sat urated wi t h water wi t hout heat and, if desi red, can
produce gases carryi ng more wat er.
Disadvantages
Nebul i zers are somewhat costl y. Pneumati c nebul i zers requi re hi gh gas f l ows.
Ul trasonic nebul i zers requi re a source of electri ci t y and may present el ectri cal
hazards. There may be consi derabl e wat er deposi ti on i n the tubi ngs, requi ring
f requent drai ni ng, water traps i n bot h the i nspi ratory and exhalat i on tubes, and
posing the dangers of wat er drai ni ng i nto the pat i ent or bl ocki ng the tubing.
P. 306


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P. 308


Questions
For the f ol lowing quest ions, sel ect t he correct answer.
1. Whi ch i s not an effect of inhal ing dry gases?
Dryi ng of the mucosa
Decreased compli ance
Devel opment of l oci f or i nf ecti on
I mpai rment of surf actant act ivi t y
Decreased al veol ar-art erial oxygen di ff erence
Vi ew Answer2. Where should a heated humi di fi er be l ocated in the circle
system?
Bet ween the exhal ati on tubi ng and the carbon di oxi de absorber
Bet ween the Y-pi ece and t racheal tube
Bet ween the i nspi ratory t ubi ng and t he Y-piece
Bet ween the absorber and t he i nspi ratory t ubi ng
Bet ween the Y-pi ece and the mask
Vi ew Answer3. If a bacterial fi lter i s used i n a ci rcle system that has a
heated humi di fi er, where shoul d the fi l ter be placed?
Bet ween the Y-pi ece and the tracheal t ube
Bet ween the Y-pi ece and the i nhal at ional tubi ng
Bet ween the i nhal at ional tubi ng and the humi di f ier
Bet ween the i nhal at ional unidi recti onal val ve and t he humi di f i er
Bet ween the Y-pi ece and the exhalati on tubi ng
Vi ew Answer4. Which i s the definition of absol ute humidi ty?
The pressure exerted by water vapor in a gas mi xt ure
The amount of wat er vapor at a part icul ar temperature as a percentage of the
amount that woul d be held i f the gas were sat urated
The maximum amount of water vapor that a vol ume of gas can hold
The mass of wat er vapor present i n a vol ume of gas.
The humidi t y of gases at body t emperature
Vi ew Answer5. What wil l cause water to rain out in the breathi ng hose?
Usi ng coaxi al tubes i n the breathing system
Heated humidi f i ed gas that cools i n the breathi ng tube
Warmi ng cool ed humi di f i ed gases in t he breat hi ng tube
Mai ntai ning t he t emperat ure of heated gas i n the breathi ng t ubes
Usi ng an extra-l ong breathing tube
Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
6. Whi ch of the fol l owing statements about humidi ty and ambient conditions
are true?
I f a gas sat urated wi t h wat er i s heat ed, i t can hol d more wat er
Gas t hat i s 100% saturated at room temperature and warmed to body temperature
wi l l be about 60% sat urated
I f a gas sat urated wi t h wat er i s heat ed, t he absol ute humidi t y remains t he same
I f a gas sat urated wi t h wat er i s heat ed, t he rel ative humi di t y i ncreases
Vi ew Answer7. A resul t of the low specifi c heat of gases i s
I nhal ed gas wi l l qui ckl y assume body temperature
Water wi l l condense i n the exhal at ion side of a ci rcl e system
Gas i n breathing t ubes wi l l quickly assume room temperature
Gas has a t endency t o change temperature sl owl y
Vi ew Answer8. Heat and moisture are normall y l ost duri ng anesthesia
because
Dry gases are suppl ied f rom the anesthesi a machi ne
Gases are heat ed by the body
Tracheal i ntubat i on bypasses normal humi di f i cati on mechani sms
The t racheal tube does not act to conserve heat or moi st ure
Vi ew Answer9. Sources of humi di ty in the breathi ng system include
Carbon di oxide absorbent
Exhal ed wat er f rom a previous pat ient
Rebreathi ng of previousl y exhal ed gases
Fresh gas
Vi ew Answer10. Advantages of a hydrophobic HME over a composi te
hygroscopi c HME i ncl ude
Bet t er fi l trat ion
Less resistance when wet
Nebul i zed drugs have l i t t le ef fect on resi stance
Bet t er humi di f i cati on
Vi ew Answer11. Usi ng a heated breathi ng tube with a heated humidi fi er
wi ll resul t i n
Rai nout i n the del i very tube
A hi gher t emperature at the Y-pi ece
Dryi ng of secreti ons
A del ivered rel at ive humi di t y of 100%
Vi ew Answer12. Hazards of heated humidifiers include
St icki ng val ves
Overhydrati on
Al terat i on of anesthet ic agents
Obstruct ion of si destream gas moni tors
Vi ew Answer13. Advantages of HMEs include
Fl uctuat i ng temperature and humidi t y
Decrease in dead space
Low compli ance
Decreased resi stance t o breathi ng
Vi ew Answer14. Contrai ndi cations to use of an HME include
Bl oody secret ions
Pat i ent temperat ure of less than 35C
Bronchopl eurocutaneous f i stul a
Uncuff ed t racheal tube
Vi ew Answer15. When usi ng an HME, the inspired humidity can be in-
creased by
Use of an uncuff ed tube
I ncreasi ng t he mi nute vol ume
Loweri ng t he humi di ty of gas ent ering t he HME
Use of a hygroscopi c rather t han a hydrophobic HME
Vi ew AnswerP. 309


16. Which pati ents or condi tions deri ve the greatest benefit from
humi di fi cation of i nspired gases?
Long anestheti cs
Pat i ents who are l ikel y to devel op pul monary compl i cat i ons
Pedi at ric pati ents
El derl y pati ents
Vi ew Answer17. Which of the foll owi ng are respi ratory compli cati ons of
dry respiratory mucosa?
Bronchoconst ri ct ion
Ai rway obst ructi on
I nfecti on
At el ect asi s
Vi ew Answer18. Consequences of excessive humi di ty incl ude which of
the fol lowing?
Pul monary edema
An i ncreased serum sodi um
Ci l i ary degenerati on
I ncreased pul monary compl i ance
Vi ew Answer19. Hazards associated with using a nebulizer include
Overhydrati on
Fi l ter obst ructi on
Bacteri a i nf ecti on
Hypothermi a
Vi ew Answer