Humidification in the Intensive Care Unit: The Essentials

Description:

The 2^nd edition of this book aims to underline how inadequate humidification of inspired gases can be the cause of a variety of serious problems and, thus, it brings new results and trends in humidification, updates about technological analyses in equipment’s ventilator modes and again the impact of humidification in complementary therapies such airway secretions in mechanical ventilated patients.

These aspects are analysed in critically ill patients requiring various options of ventilatory approach (i.e. invasive, noninvasive, nasal high flow oxygen). The book starts with an exhaustive description of the pathophysiology of humidification in critically ill, and continues analyzing the impact of mechanical ventilation modalities (high-flow oxygen therapy, noninvasive mechanical ventilation, invasive mechanical ventilation, etc.), monitoring prevention of complications related to inadequate humidification. Important chapters are devoted to analyze determinants – ventilator associated pneumonia-humidification; humidification strategies in tracheostomized critical care patients; humidification and impact in airway clearance managements and the key aspects about humidification in the healthcare organization.

This book is intended for all healthcare professionals working in Intensive Care Units (intensivists, anaesthesiologists, pulmonologist, neonatologist, nurses and respiratory therapist).

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Preface

The significant number of patients with acute respiratory failure requiring various forms of treatment with oxygen therapy, nasal high flow, non-invasive ventilation and invasive mechanical ventilation due to various epidemiological causes and high hospital demand, especially in intensive care units in the last decade, and the significant development of new equipment and technologies are a constant in daily medical practice, and widely contrasted by various medical specialties that care for these patients with severe respiratory failure.

However, despite this important clinical and technological advance, the practice and knowledge of humidification in critically ill patients continues to be the subject of research and technological innovation. This continuous interest in the knowledge of humidification is based on some essential clinical questions, which we still do not know, such as (a) the evaluation of a correct indication, monitoring and definition of standard evaluation of results and complications regarding adequate humidification, (b) how our humidification practice can impact on our daily clinical objectives and, finally, what are the terms and role of adequate or inadequate humidification? This situation is a more complex one, if these questions are translated to the complexity of the critically ill patient admitted to intensive care units for respiratory failure with a complex humidification pathophysiology.

Despite these and other questions about excellence in humification in critically ill patients, we believe that this second edition in its sections and chapters continues to provide the healthcare professional with an updated vision, basic concepts and new lines of research in the future.

It is necessary to propose new models of clinical and technological analysis on the practice and technique of humification, especially in critical ill patients, that incorporate an adequate number of variables or factors, and that can be included in a single universal model of “excellence” of perfect humidification in critical patients.

To this end, we hope that this second edition will serve as a bridge to the goal of adequate training and clinical practice of humidification in critically ill patients.

As Editor of this second edition of Humidification in the Intensive Care Unit: The Essentials, I would like to thank all the authors for their collaboration.

Murcia, Spain Antonio M. Esquinas

Table of contents :
Preface
Contents
Part I: Humidification and Devices
1: Heated Humidification Devices
1.1 Introduction
1.2 Active Heated Humidifiers
1.3 Passive Humidifiers
1.4 Active Heat and Moisture Exchangers
1.5 Hot Water Humidifiers
References
2: Heat and Moisture Exchangers (HMEs)
2.1 Active Heat and Moisture Exchangers
2.2 Clinical Use
2.3 Efficacy
2.4 Ensuring Adequate Humidification
References
3: Main Techniques for Evaluating the Performances of Humidification Devices Used for Mechanical Ventilation
3.1 Visual Evaluation of Condensation
3.1.1 Condensation in the Flex Tube
3.1.2 Condensation on the Humidification Chamber’s Inner Wall
3.2 Techniques to Measure the Hygrometry of Gases During Mechanical Ventilation
3.2.1 What Is Hygrometry?
3.2.2 Psychrometry
3.2.2.1 Working Principles of Psychrometry
3.2.3 Comparison of Psychrometry with Other Techniques
3.2.3.1 Studies Using the Psychrometry
3.2.3.2 Studies Using the Gravimetry
3.2.3.3 Studies Using Capacitance Hygrometer
3.2.4 Limitations of the Psychrometric Method
3.2.5 Limitations of the Gravimetric Method (and ISO 9360)
3.3 Benches for Measurements of Hygrometry (for HME, “Active” HME, and Heated Humidifiers)
3.4 Use of the Heated Humidifier Heater Plate Temperature
References
Part II: Humidification and High-Flow Oxygen Therapy
4: Humidification During Conventional Oxygen Therapy: Physiology
4.1 Conventional Oxygen Therapy
4.2 Airway Humidification and Heating System
4.3 The Need for Warming and Humidification in Oxygen Therapy
4.4 Humidification Effect
4.5 Recommended Humidification Level
References
5: Humidification and High-Flow Oxygen Therapy in Critically Ill Patients: Devices and Humidification Technology and Clinical Implications
5.1 Introduction
5.2 Devices and Humidification Technology
5.3 Humidification Devices
5.4 Flow Generator
5.5 Inspiratory Limb
5.6 Interface
5.7 Clinical Implications
5.7.1 Nasopharyngeal Dead Space Washout
5.7.2 Mucociliary Clearance
5.7.3 Reduction of Nasopharyngeal Resistance
5.7.4 Positive Expiratory Pressure (PEEP Effect)
5.8 Conclusion
References
Part III: Humidification and Noninvasive Ventilation
6: Humidification and Noninvasive Ventilation
6.1 Introduction
6.2 Effects of Insufficient Gas Conditioning During the NIV Procedure
6.3 Factors Contributing to Insufficient Gas Conditioning During NIV
6.4 Types of Humidifiers
6.5 Humidifier Settings During Noninvasive Ventilation
6.6 Conclusion
References
Part IV: Humidification and Invasive Mechanical Ventilation
7: Humidification in Mechanically Ventilated Patients and Selection of Devices
7.1 Introduction
7.2 Effects of Inadequate Humidification
7.3 Passive Humidification
7.4 Hydrophobic HMEs
7.5 Hygroscopic HMEs
7.6 Pleated or Electrostatic Filters
7.7 Active Humidification
7.8 Bubble Humidifiers
7.9 Pass-Over Humidifiers
7.10 Counter-Flow Humidifiers
7.11 Monitoring on Humidification Systems
7.12 Selecting the Appropriate Humidifier
7.13 Conclusion
References
8: Impact of Humidification Strategy During Lung (and Heart)-Protective Ventilation
8.1 Lung-Protective Ventilation Is Not Only Tidal Volume Reduction
8.2 From Lung-Protective Ventilation to Lung- and Heart-Protective Ventilation
8.3 How to Set the Initial Respiratory Rate in Critically Ill Patients with Low or Very Low Tidal Volumes?
8.4 What Is the Dead Space During Invasive Mechanical Ventilation?
8.5 Impact of the Instrumental Dead Space on VD/VT and Alveolar Ventilation During Lung-Protective Ventilation
8.6 Impact of Dead Space Reduction on Respiratory Parameters with Constant Alveolar Ventilation
References
9: Effect of Airway Humidification Devices in Lung Mechanics (Volume/Airflow)
9.1 Introduction
9.2 Humidification Techniques [4–12] 9.3 Active Humidification
9.4 Passive Humidification [16–19] 9.5 Humidifier Filters and Respiratory Mechanics [23–26] 9.6 Dead Space [27, 28] 9.7 Resistance and Flow [30–35] 9.8 Conclusions
References
10: Humidification During Invasive Mechanical Ventilation
10.1 Introduction
10.2 Hygrometric Performances of the Main Humidification Systems
10.2.1 What Is the Optimal Level of Humidification During Invasive Mechanical Ventilation?
10.2.2 Effects of Under-Humidification of Delivered Gases
10.2.3 Risk Scale for Endotracheal Tube Occlusion
10.2.4 Heated Humidifiers’ Humidification Performances
10.2.5 Heat and Moisture Exchangers’ Humidification Performances
10.2.5.1 Comparison with the Literature on the Risk of Tracheal Occlusion (Fig. 10.3)
10.2.5.2 Impact of External Conditions on HME’s Hygrometric Performances
10.2.5.3 Other Parameters to Evaluate Airway Humidification Impact
10.2.5.4 Active HME
10.3 Mechanical Proprieties of Humidification Systems (Resistances and Dead Space)
10.4 Comparison of Humidification Devices’ Cost
10.5 Conclusion (Table 10.4 and Fig. 10.5)
References
11: Postoperative Mechanical Ventilation-Humidification
11.1 Introduction
11.2 The Need for Humidification
11.3 Humidification at an Optimal Level
11.4 Type of Humidifiers, Advantages, and Disadvantages for Postoperative Invasive Mechanical Ventilation
11.5 The Latest Type of Humidifiers (See Detail in Sect. 11.2)
11.6 Recommendations About the Type of Humidification in International Guideline Based on Invasive Mechanical Ventilation
11.7 Conclusions
References
12: Humidification in Laparoscopy
12.1 Brief Discussion
12.2 Conclusion
References
13: Humidification in Intensive Care Medicine: Humidification and Complications in Invasive Mechanical Ventilation
13.1 Introduction
13.2 Humidification Device Selection Considerations
13.3 Risk of Infection with Each Device
13.4 Conclusion
References
14: Humidification in Postextubation Respiratory Failure
14.1 Introduction
14.2 Need for Humidification During Postextubation Respiratory Failure
14.3 Indication of Humidification in Postextubation
14.4 High-Flow Nasal Cannula Therapy as a Prevention of Postextubation Hypoxemic Respiratory Failure
14.5 High-Flow Nasal Cannula Therapy as a Prevention of Postextubation Hypercapnic Respiratory Failure
14.6 Conclusion
References
Part V: Humidification and Ventilator Associated Pneumonia
15: Humidification During Invasive Mechanical Ventilation: Selection of Device and Replacement
15.1 Which Device for which Patients
15.2 Humidification During Invasive Mechanical Ventilation
15.2.1 Frequency of HME Replacement
15.2.2 Bedside Adjustment
15.3 Assessing HMEs and Heated Humidifiers at the Bedside
15.4 Assessing Adequacy of Inspired Gas Conditioning
References
Part VI: Humidification Tracheostomized
16: Humidification Tracheostomy: Physiology and Device
16.1 Introduction
16.2 Humidification for Tracheostomy
16.3 Passive Heat and Moisture Exchangers (HME)
16.4 Active Humidifiers (HH)
16.5 Bubble Humidifier
16.6 Passover
16.7 Counterflow
16.8 Inline Vaporizer
16.9 High Flow Humidifiers
16.10 Advantages and Disadvantages of Passive and Active Humidifiers
16.11 Aerosol Therapy Humidifiers
16.12 Conclusion
References
17: Ineffective Complications in Tracheostomized Patients
References
18: Humidification Tracheostomized Patients
18.1 Introduction
18.2 Active Humidifiers
18.3 Passive Humidifiers
18.4 Clinical Comparison of Active and Passive Humidifiers
18.5 Combination of the Active and Passive Humidification
18.6 Use of the Humidifier in the in Tracheostomized Patients
References
Part VII: Humidification in Critically Ill Neonates
19: Humidification in Critically Ill Neonates
19.1 Unconditioned Gases and Pulmonary Damage
19.2 Resuscitation Gases in the Delivery Room
19.3 Humidification and Thermoregulation
19.4 Over-humidification
19.5 Summary
References
20: Humidification During Non-invasive Respiratory Support of the Newborn
20.1 Bubble Continuous Positive Airway Pressure (BCPAP)
20.2 Heated Humidified High-Flow Nasal Cannula (HHHFNC)
20.3 Summary
References
21: Humidification in Neonatal-Pediatric Critical Care: Invasive Ventilation
21.1 High-Frequency Ventilation
21.2 High-Frequency Oscillatory Ventilation
21.3 High-Frequency Jet Ventilation
References
22: Technology, Complications, and Prevention
22.1 Cold Passover, Bubble-Through, and Heated Water Humidifier
22.2 Heated Humidifier with Heated Wire Tubing Circuitry
22.3 Heat and Moisture Exchangers (“Artificial Noses”)
22.4 Summary
References
Part VIII: Humidification and Airways Clearance Secretions
23: Airway Clearance in Chronic Respiratory Disorders: Obstructive CF, COPD, and Asthma
23.1 Introduction
23.2 Role of Airway Clearance in MODs
23.3 Airway Clearance in Acute Exacerbation of Bronchial Asthma
23.4 Airway Clearance in Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)
23.5 Airway Clearance in Acute Exacerbation of Obstructive Cystic Fibrosis Bronchiectasis
23.6 Conclusions
References
24: Airway Clearance Neuromuscular Disorders: Chronic and Acute Conditions
24.1 Introduction
24.2 Respiratory Measurements for Patients with NMD
24.3 Management of Airway Clearance
24.4 Postural Drainage (PD)
24.5 Chest Wall Strapping (CWS)
24.6 Airway Clearance Techniques in NMD
24.7 Proximal Airway Clearance Techniques: Cough Augmentation Techniques
24.8 Assisted Inspiration in Patients Without Bulbar Dysfunction
24.9 External Assisted Inspiratory Support
24.10 Manually Assisted Cough (MAC)
24.11 High-Frequency Chest Wall Oscillations (HFCWO)/High-Frequency Chest Wall Compression (HFCWC)
24.12 Percussive Intrapulmonary Ventilation (IPV)
24.13 Vacuum Technique
24.14 Conclusions
References
25: Weaning from Mechanical Ventilation, Extubation, and Airway Sections and Humidification Evaluation
References
26: Airway Clearance Disorders (Hypoxemic): ARDS, Pneumonia, and Cardiac Pulmonary Edema
26.1 Introduction
26.2 Changes in Mucociliary Clearance and Intensive Care Unit
26.3 Airway Clearance Hipomexic Disorders
26.3.1 Acute Respiratory Distress Syndrome (ARDS)
26.3.2 Pneumonia
26.3.3 Cardiac Pulmonary Edema
26.4 Conclusion
References
27: Airway Clearance in Conditions of High-Risk Infections: COVID-19 and Other Conditions
27.1 Introduction
27.2 Infection Consideration
27.3 Role of Mucosal Hydration
27.4 Clearing the Airways
27.5 Oral/Pharyngeal Hygiene
27.6 Tracheal Aspiration
27.7 Therapy Kinetics
27.8 Chest Physiotherapy
27.9 Thoracic Physiotherapy Techniques
27.10 Mucus Control Agents
27.11 Bronchoscopy for Atelectasis
27.12 Discussion and Conclusion
References
28: Humidification, Airway Secretion Management, and Aerosol Therapy
28.1 Introduction
28.1.1 Concept Humidity and Physiology and Role of the Upper Airway
28.2 Humidification Devices
28.3 Active Humidifiers
28.3.1 Assembly
28.3.2 Precautions and Monitoring for Active Humidifiers
28.4 Passive Humidifiers
28.4.1 Dead Space
28.4.2 Resistance
28.4.3 Active or Passive Humidification?
28.4.4 Background of Aerosol Therapy
28.4.5 Fundamentals of Aerosol Therapy
28.4.6 Device Effects
28.4.7 The Heliox Effect
28.4.8 Type of Aerosol Generator in the Circuit
28.4.9 Features of Breath
28.4.10 Dose Effect and the Time
28.5 High-Flow Nasal Cannula Effect
28.5.1 Contemporary Applications of Aerosol Therapy in Critical Care: Focus on Antibiotics
28.5.2 Limits of Aerosol Therapy in Intensive Care
28.6 Conclusion
References
29: Airway Clearance in Neonatology-Pediatric Critical Care
29.1 Physiology
29.2 Pharmacology
29.3 Techniques
References
Part IX: Technology and Methodology Airway Clearance Techniques, Cough Assisted and Oscillation
30: Non-assisted Airway Clearance Techniques
30.1 Introduction
30.2 Non-assisted Airway Clearance Techniques
30.2.1 Manual-Assisted Techniques
30.2.2 Active Breathing Cycle
30.2.3 PEP Mask
30.2.4 Instrumental Therapy: Acapella® and Flutter®
30.3 Conclusion
References
31: Airway Clearance: Cough-Assisted Devices
31.1 Introduction
31.2 The Importance of the Cough Reflex in the Critically Ill Patient
31.3 Proximal Techniques
31.3.1 Expiratory Assistance
31.3.1.1 Mechanical Devices
31.3.2 Inspiratory Assistance
31.3.2.1 Single Breath
31.3.2.2 Stacked Breath
31.3.3 Combined Assistance: Inspiratory + Expiratory
31.3.3.1 Mechanical Insufflation-Exsufflation Devices
Indications, Contraindications, and Complications
Necessary Material
Technical Optimization
Variables and Its Thresholds
How to Program the Device and Apply the Treatment?
31.4 Outcomes
31.5 Main Obstacles
31.6 Conclusion
References
32: High-Frequency Chest Wall Oscillations and Compressions
References
33: Humidification Recommendations in High-Frequency Percussive Ventilation
33.1 Introduction
33.2 Physiological Airway Control of Heat and Humidity
33.3 Types of Humidifiers
33.3.1 Active Humidifiers: Heated Humidifiers
33.3.1.1 Bubble Humidifiers
33.3.1.2 Pass-over Humidifiers
33.3.1.3 Counter-Flow Humidifier
33.3.1.4 Inline Vaporizer
33.3.2 Passive Humidifiers
33.3.2.1 Heat and Moisture Exchangers (HMEs)
33.3.2.2 Hygroscopic Condenser Humidifiers (HCHs) or Hygroscopic Heat and Moisture Exchangers (HHMEs)
33.3.2.3 Heat and Moisture Exchangers with Filter
33.3.2.4 Combined Heat and Moisture Exchangers
33.3.3 Special Humidifiers
33.3.3.1 Humidifiers for Aerosol Therapy
33.3.3.2 Heat and Moisture Exchanger Booster
33.3.3.3 Active Hygroscopic Heat and Moisture Exchangers
33.4 Principles of HFPV
33.5 Humidification During HFPV
References
34: Biphasic Cuirass Ventilation for Airway Secretions
34.1 The Secretion Clearance Spectrum: Modification > Mobilization > Expectoration
References
35: Aerosol Therapy and Humidification
35.1 Humidification in the Intensive Care Unit
35.2 Aerosol Therapy Combined with Humidification
35.3 Effect of Humidification on Aerosol Drug Delivery
35.4 Effect on Aerosol Droplet Diameters
35.5 Spontaneous Breathing: Mouthpiece
35.6 Spontaneous Breathing: HFNO
35.7 Mechanical Ventilation
References
36: Airway Clearance in Critically Ill Patients
36.1 Introduction
36.2 Mucoactive Therapies
36.2.1 N-acetylcysteine (NAC)
36.2.2 Dornase Alfa
36.2.3 Hypertonic Saline
36.3 Cough Augmentation Strategies
36.3.1 Mechanical Insufflation-Exsufflation (MI-E)
36.3.2 Manually Assisted Cough
36.3.3 Lung Volume Recruitment (LVR)
36.3.4 High-Frequency Chest Wall Oscillation (HFCWO)
36.3.5 Oscillatory Positive Expiratory Pressure
36.3.6 Manual Percussion
36.4 Postural Drainage
36.5 Endotracheal Suction
36.6 Other Therapies
36.7 Conclusion
References
37: Airway Clearance in Tracheostomized Patients
37.1 Introduction
37.2 Discussion and Analysis Main Topic
37.2.1 Conventional Chest Physiotherapy
37.2.1.1 Postural Drainage
37.2.1.2 Continuous Rotational Therapy
37.2.1.3 Percussion and Vibration
37.2.1.4 Manual and Ventilator Hyperinflation
37.2.2 Alternative Techniques
37.2.2.1 PEP
37.2.2.2 Flutter Valve
37.2.2.3 Intrapulmonary Percussive Ventilation and High-Frequency Chest Wall Oscillation
37.2.3 Assisted Mucus-Clearing Techniques
37.2.3.1 Insufflation-Exsufflation
37.2.3.2 Free Aspire
37.3 Conclusions
References
Index