I recently submitted a “Letter to the Editor” of the BJA in response to the clever study by Zhong and colleagues demonstrating that the use of high fresh gas flows (FGF) during TIVA produces a cost-saving with, importantly, no adverse environmental consequences. My letter was responding to their conclusion regarding the impact of high FGFs on humidification of inhaled gases, and specifically the issue of heat and moisture exchangers (HMEs).
The letter was edited and shortened significantly during the review process, so much so that I felt some important discussion around a commonly misunderstood device was missing. The published letter is now available here, but I felt it might be helpful to make the full text of the original letter (with some minor corrections) publicly available, so I have presented it below.
You can also find a Twitter thread I did on it here:
And a previous blog post I wrote on filters here.
To the Editor,
The paper by Zhong and colleagues involving an economic and environmental cost-analysis of differing fresh gas-flow (FGF) settings during TIVA raises an interesting and important point regarding the relationship between the FGF and the degree of circuit humidification. The concern is that the higher FGFs recommended in their study could result in patients being delivered gas with inadequate humidification. However, they address this by stating that “modern [humidity moisture exchanger] HME filters are highly efficient at maintaining the inspired humidity well above the acceptable limit across a wide range of FGFs”, citing a systematic review and two of its included studies .
At this point, it is helpful to clarify some potentially confusing aspects relating to HMEs and breathing system filters (BSFs). As Wilkes describes, HMEs are “intended to conserve a portion of the patient’s exhaled heat and moisture, and condition inspired gas by warming and humidifying it.” On the other hand, BSFs “are intended to reduce the transmission of microbes and other particulate matter in breathing systems ”. He then goes on to list the five different types of devices:
- HME with no filter
- Electrostatic filter only
- Pleated mechanical filter only
- Electrostatic filter with HME (HMEF)
- Pleated mechanical filter with HME (HMEF)
To further complicate what seems like a simple piece of equipment, the filter medium, in both electrostatic and pleated filters, has some degree of intrinsic HME function. However the level of intrinsic humidification is quite variable between devices , and it will be significantly less than that provided by a dedicated HME or a combined HMEF.
Unfortunately, despite this multiplicity of devices, with significantly different filtration and humidification capacities, the term “HMEF” is often used a catchall term for whatever device is placed between the patient’s airway device and the breathing circuit during general anaesthesia. This was the way I used the term for many years, and it seems Zhong and colleagues have done likewise.
Despite being referred to as an “HME filter”, the “Thermovent HEPA” used in their study is a “pleated mechanical filter only” according to the classifications above. As expected, this BSF does indeed have some intrinsic HME function, but direct comparison between devices is difficult for a number of reasons. For starters, the humidification performance of any given device is influenced by a number of factors, including the temperature and humidity of gases delivered to the device, ambient temperature, patient temperature, tidal volume and duration of use. These can all be controlled for with standardised laboratory testing, but it may be difficult to extrapolate these results to the clinical environment. They should at least provide a mechanism for comparison between devices, but even here, difficulties arise.
Testing an HME as per the current international standard, ISO 9360-1:2000, quantifies the moisture lost through the device when placed in a standardised test rig. The lower the “moisture loss”, the better the humidification performance. However, the standard that preceded it, ISO 9360:1992, used a different testing method and instead provides a value for the “moisture output” of an HME, with the higher the moisture output, the better its performance. This means there are inconsistencies in reporting humidification performance in both the published literature and manufacturer documentation. Further, because the standardised testing involves testing at different tidal volumes, this can also differ when humidification performance is reported.
Despite these difficulties, an attempt can still be made to compare the performance of the “Thermovent HEPA” BSF used in the Zhong study, with the HME devices used in the studies cited by them. I did this by reviewing both manufacturer documentation, and an assessment of BSFs performed by the Medicines Healthcare Products Regulatory Agency (MHRA) in 2004.
The moisture output of the “Thermavent HEPA” BSF was measured as 18 g.m-3 at a tidal volume of 0.5 L . In comparison, the moisture output of the HMEs used in some of the referenced studies were:
- 28 g.m-3 at a tidal volume of 0.6 L (“Humid Vent 2”, Gibeck, HME only, used in three studies )
- 27 g.m-3 at a tidal volume of 0.5 L (“BB 100”, Pall, pleated filter with HME, used in one study )
- 31 g.m-3 at a tidal volume of 0.2 L (“Humid Vent 1 Port”, Gibeck, HME only, used in one study )
Despite differences in tidal volumes between the test conditions, with a lower tidal volume generally improving humidification performance, the BSF used in the Zhong study has a significantly lower moisture output than that of the HMEs used in the studies cited by them to justify their comments regarding adequate circuit humidity levels. This means that if they are using FGFs of 6 L.min-1 in conjunction with the “Thermavent HEPA” filter, they may not be reaching the suggested minimum humidification level of 20 g.m-3.
As you can see, the issue of humidification of inspired gases in anaesthesia is complicated. In order to be confident we are providing appropriate humidification, we will need to consider not only the FGF and BSF or HME used, but also other patient, surgical, and anaesthetic factors such as the duration and site of surgery, patient co-morbidities and risk factors, as well as ventilatory parameters such as tidal volume. Further studies, both laboratory and clinically based, would help us make more informed decisions on this front, especially as new products come on to the market, and anaesthetic techniques evolve over time.
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1.
Rae, A., Provan, D., Aboelssaad, H. & Alexander, R. A manifesto for Reality-based Safety Science. Safety Science 126, 104654 (2020).
1.
Salmon, P. M. et al. The big picture on accident causation: A review, synthesis and meta-analysis of AcciMap studies. Safety Science 126, 104650 (2020).
1.
Zippel, C., Börgers, A., Weitzel, A. & Bohnet-Joschko, S. Many critical incidents could be avoided by preanaesthesia equipment checks: Lessons for high reliability organisations. European Journal of Anaesthesiology 31, 289–291 (2014).
1.
Zippel, C., Borgers, A., Weitzel, A. & Bohnet-Joschko, S. Many critical incidents could be avoided by preanaesthesia equipment checks: Lessons for high reliability organisations. [Letter]. Journal of Anaesthesiology 31, 289–291 (2014).
1.
Wilkes, A. R., Pandit, J. J. & O’Sullivan, E. The history of anaesthetic equipment evaluation in the United Kingdom: lessons for developing future strategy. Anaesthesia 66, 34–39 (2011).
1.
Cook, T. M. et al. Multicentre clinical simulation evaluation of the ISO 80369-6 neuraxial non-Luer connector. Anaesthesia 74, 619–629 (2019).
1.
Cassidy, C. J., Smith, A. & Arnot‐Smith, J. Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006–2008*. Anaesthesia 66, 879–888 (2011).
1.
Checklist for anaesthetic equipment. 2.
1.
Association of Anaesthetists of Great Britain and, Ireland et al. Checking Anaesthetic Equipment 2012: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 67, 660–668 (2012).
1.
Bourgain, J. L., Coisel, Y., Kern, D., Nouette-Gaulain, K. & Panczer, M. What are the main “machine dysfunctions” to know? Annales Françaises d’Anesthésie et de Réanimation 33, 466–471 (2014).
1.
Orihara, M. Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study. 10.
1.
Xie, A. & Carayon, P. A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety. Ergonomics 58, 33–49 (2015).
1.
Wilkes, A. R. Measuring the filtration performance of breathing system filters using sodium chloride particles. 7 (2002).
1.
Merry, A. F., Shipp, D. H. & Lowinger, J. S. The contribution of labelling to safe medication administration in anaesthetic practice. Best Practice & Research Clinical Anaesthesiology 25, 145–159 (2011).
1.
Shultz, J. et al. Standardizing anesthesia medication drawers using human factors and quality assurance methods. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 57, 490–499 (2010).
1.
Holloway, C. M. & Johnson, C. W. Reducing our ignorance: finding answers to certain epistemic questions for software systems. in
6th IET International Conference on System Safety 2011 D12–D12 (IET, 2011).
http://doi.org/10.1049/cp.2011.0269.
1.
Arthmar, R. VILFREDO PARETO. Manual of Political Economy. A critical and variorum edition. Edited by Aldo Montesano, Alberto Zanni, Luigino Bruni, John Chipman and Michael McLure. Oxford: Oxford University Press, 2014, 664 p. Estudos Econômicos (São Paulo) 45, 459–470 (2015).
1.
Donzelli, F. Pareto’s Mechanical Dream. 47.
1.
Muschara, T. Critical Steps: How to Identify and Manage the Most Important Human Performance Risks in Operations. Performance Improvement 53, 11–21 (2014).
1.
Keijzer, C., Perez, R. S. G. M. & de Lange, J. J. Compound A and carbon monoxide production from sevoflurane and seven different types of carbon dioxide absorbent in a patient model. Acta Anaesthesiologica Scandinavica 51, 31–37 (2007).
1.
Saito, M. Brown Adipose Tissue as a Regulator of Energy Expenditure and Body Fat in Humans. Diabetes & Metabolism Journal 37, 22 (2013).
1.
Razzouk, R. & Shute, V. What Is Design Thinking and Why Is It Important? Review of Educational Research 82, 330–348 (2012).
1.
Lally, P., Potts, H. W. W. & Wardle, J. Research article How are habits formed: Modelling habit formation in the real worldy. Eur. J. Soc. Psychol. 13 (2009).
1.
Catchpole, K., Bell, M. D. D. & Johnson, S. Safety in anaesthesia: a study of 12 606 reported incidents from the UK National Reporting and Learning System. Anaesthesia 63, 340–346 (2008).
1.
Nedergaard, J., Bengtsson, T. & Cannon, B. Unexpected evidence for active brown adipose tissue in adult humans. American Journal of Physiology-Endocrinology and Metabolism 293, E444–E452 (2007).
1.
Kothari, D. & Agrawal, J. Colour-coded syringe labels: a modification to enhance patient safety. British Journal of Anaesthesia 110, 1056–1058 (2013).
1.
Furniss, D., Dean Franklin, B. & Blandford, A. The devil is in the detail: How a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety.
Health Informatics Journal 146045821983957 (2019)
http://doi.org/10.1177/1460458219839574.
1.
Langer, T. et al. Intravenous balanced solutions: from physiology to clinical evidence. Anestezjologia Intensywna Terapia 47, 78–88 (2015).
1.
Berkes, Z. et al. MODE-SWITCHING IN AIR TRAFFIC CONTROL. 88.
1.
Standards Association of Australia & Standards New Zealand. User-applied labels for use on syringes containing drugs used during anaesthesia. (Standards Australia ; Standards New Zealand, 1996).
1.
Dellamonica, J., Boisseau, N., Goubaux, B. & Raucoules-Aimé, M. Comparison of manufacturers’ specifications for 44 types of heat and moisture exchanging filters. British Journal of Anaesthesia 93, 532–539 (2004).
1.
Frankenfield, D. C. On heat, respiration, and calorimetry. Nutrition 26, 939–950 (2010).
1.
Wears, R. L. & Hettinger, A. Z. The Tragedy of Adaptability. Annals of Emergency Medicine 63, 338–339 (2014).
1.
Webster, C. S., Merry, A. F., Larsson, L., McGrath, K. A. & Weller, J. The Frequency and Nature of Drug Administration Error during Anaesthesia. Anaesthesia and Intensive Care 29, 494–500 (2001).
1.
Ogawa, Y., Abe, K., Sakoda, A., Onizuka, H. & Sakai, S. FDG-PET and CT findings of activated brown adipose tissue in a patient with paraganglioma. European Journal of Radiology Open 5, 126–130 (2018).
1.
Boon, M. R. & van Marken Lichtenbelt, W. D. Brown Adipose Tissue: A Human Perspective. Handb Exp Pharmacol 233, 301–319 (2016).
1.
Frankenfield, D. C. On heat, respiration, and calorimetry. Nutrition 26, 939–950 (2010).
1.
Kaiyala, K. J. What does indirect calorimetry really tell us? Molecular Metabolism 3, 340–341 (2014).
1.
Shultz, J. et al. Standardizing anesthesia medication drawers using human factors and quality assurance methods. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 57, 490–499 (2010).
1.
Mostert, L. & R Coetzee, A. Central oxygen pipeline failure. Southern African Journal of Anaesthesia and Analgesia 20, 214–217 (2014).
1.
Schumacher, S. D., Brockwell, R. C., Andrews, J. J. & Ogles, D. Bulk Liquid Oxygen Supply Failure. Anesthes 100, 186–189 (2004).
1.
Wilkes, A. R. Measuring the filtration performance of breathing system filters using sodium chloride particles. 7 (2002).
1.
Merry, A. F. & Webster, C. S. Medication error in New Zealand—time to act. 121, 5 (2008).
1.
Asai, T., Matsumoto, S. & Shingu, K. Incidence of blood-borne infectious micro-organisms: would you still not wear gloves? Anaesthesia 55, 591–592 (2000).
1.
Marshall, S. D. & Chrimes, N. Medication handling: towards a practical, human-centred approach. Anaesthesia 74, 280–284 (2019).
1.
Orser, B. A., Chen, R. J. B. & Yee, D. A. Medication errors in anesthetic practice: a survey of 687 practitioners. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 48, 139–146 (2001).
1.
Lally, P., van Jaarsveld, C. H. M., Potts, H. W. W. & Wardle, J. How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology 40, 998–1009 (2010).
1.
Gardner, B. & Rebar, A. L. Habit Formation and Behavior Change. in Oxford Research Encyclopedia of Psychology (Oxford University Press, 2016). doi:10.1093/acrefore/9780190236557.013.129.