HUMIDIFICATION
Humidification is a method to artificially condition
the gas used in respiration of a patient as a
therapeutically modality.
Active method is by adding heat or water or both
to the device or passive which is recycling heat
and humidity which is exhaled by the patient.
INDICATIONS
Primary Secondary
Overcoming humidity To manage
deficit (upper airway hypothermia
bypass) To treat bronchospasm
To humidify dry (due to cold air)
medical gasses
Clinical signs and symptoms of
inadequate humidification
Dry and non-productive cough
Atelectasis
Increased airway resistance
Increased work of breathing
Increased incidence of infection
Thick and dehydrated secretions
Complaints of substernal pain
and airway dryness
Physiology
Heat and moisture exchange is a primary function of
the upper respiratory tract, mainly the nose.
The nasal mucosal lining is kept moist by secretions
from mucous glands, goblet cells, transudation of fluid
through cell walls, and condensation of exhaled
humidity.
As the inspired air enters the nose, it warms
(convection) and picks up water vapor from the moist
mucosal lining (evaporation), cooling the mucosal
surface.
Physiology cont
Condensation occurs on the mucosal surfaces during
exhalation, and water is reabsorbed by the mucus
(rehydration).
The mouth is less effective at heat and moisture exchange
than the nose because of the low ratio of gas volume to moist
and warm surface area and the less vascular squamous
epithelium lining the oropharynx and hypopharynx.
Principles of humidifier function
Temperature – As the temperature of a gas increases, its
ability to hold water vapour (capacity) increases and vice
versa.
Surface area – There is more opportunity for evaporation to
occur with greater surface area of contact between water and
gas.
Time of contact – There is greater opportunity for evaporation
to occur, the longer a gas remains in contact with water.
Thermal mass – The higher the mass of water or core element
of a humidifier, the higher its capacity to transfer or hold heat.
Method of humidification
Methods
Systemic hydration
Heated water bath humidifier
Heat & moisture exchange
Large volume jet nebulizers
Ultrasonic humidifier
Bubble through humidification
Passover humidifier
Heat and moisture exchange (HME)
Known as ‘Swedish nose’
Light weight disposal device
Used with mechanical ventilator or
breathing spontaneously
Similar to nasopharynx
It function without the additon of a
water source or electricity.
It collects and conserves the patient’s
expired moisture and heat.
Considered to be passive humidifier
Traps heat and humidity in expired gas
Has been used to provide humidity for
spontaneously and mechanically ventilated
patients
With a filter for bacteria and viruses it become
Heat and Moisture Exchanging Filter (HMEF)
Types of HMEs:
simple condenser humidifiers
Hydrophobic
hygroscopic
Simple condenser Hygroscopic heat Active Heat Moisture
humidifier exchanger Exchangers
Contains condenser Uses condenser Add heat or humidity
element to trap heat and element made of (or both) to inspired
humidity of expired gas paper, wool, or foam gas
Retains about 50% of Material includes a salt External heat and
expired heat and Maximum absolute moisture is introduced
humidity humidity is 22 to 34 into inspired gas
Maximum absolute Capable of providing
mg/L
humidity is 18 to 28 100% relative
mg/L humidity.
Hydrophobic Hygroscopic
Hydrophobic membrane with Contain a wool/foam/paper like
material coated with moisture-retaining
small pores chemicals
Membrane is pleated to increase Medium may be impregnated with a
the surface area bactericide
provides moderately good Composite hygroscopic HMEs – a
inspired humidity hygroscopic layer plus a layer of thin,
nonwoven fiber membrane that has
May be impaired by high
been subjected to an electrical field to
ambient temperatures increase its polarity -- improves
Efficient bacterial and viral filtration efficiency and
filters hydrophobicity.
Composite hygroscopic HMEs are
Prevent the HCV from passing
more efficient than hydrophobic ones
Allow the passage of water Lose their airborne filtration efficiency
vapor but not liquid water at if they become wet; microorganisms
usual ventilatory pressure held by the filter medium can be
Associated with small increases washed through the device
Their resistance can increase greatly
in resistance even when wet
when wet
Type Hygroscopic Hydrophobic
Heat and moisture exchanging Excellent Good
efficiency
Effect of increased tidal volume on Slight decrease Significant decrease
heat and moisture exchange
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 Little effect
resistance
Bubble through humidification
Gas passes through
tube to bottom of
water reservoir
Gas bubbles through
reservoir
Unheated bubbles
through humidifier
Provides humidity for
oxygen therapy
Passover humidifier
Direct gas over liquid or over surface
saturated by liquid
Types:
Simple reservoir model
Wick units
Membrane devices
Simple reservoir
Gas flows over surface of volume of water
Usually used as heated system to provide
humidity to mechanically ventilated
patients
Systemic hydration
Increase the amount of fluid intake orally or
intravenous
To keep our body from dehydrated
To avoid air way secretion become more tenacious
Hazards
Inhalation of cold mist or water may cause
bronchoconstriction in patients with hyper reactive
airways.
Water reservoirs – good culture medium for
bacteria – increase risk of infection – regular
disposal, disinfection or sterilization of all
equipment is must.
NEBULIZATION
Nebulization is means of administering drugs by
inhalation.
Liquid Nebulisation is a common method of medical
aerosol generation.
A nebuliser is a device that converts liquid into aerosol
droplets (fine mist) suitable for inhalation.
Nebulisers use oxygen, compressed air or ultrasonic
power to break up medication solutions and deliver a
therapeutic dose of Aerosol particles directly to the
lungs.
Indications
Delivery of bronchodilator drugs : On acute
attack of asthma Nebulization is the most common
means of delivery.
Administration of antibiotics and anti antifungal
agents: In some cases of resistant chest infections
for eg.cystic fibrosis antibiotics may be prescribed
to be inhaled directly into the lung.
To aid expectoration : Inhalation of hypertonic
saline has been found to increase clearance of
bronchial secretions.
Local analgesia: To relieve dyspnea in patients
such as those suffering from alveolar carcinoma.
Contraindications
Insome cases, nebulization is restricted or avoided
due to possible untoward results or rather
decreased effectiveness such as:
Patients with unstable and increased blood pressure
Individuals with cardiac irritability (may result to
dysrhythmias)
Persons with increased pulses
Unconscious patients (inhalation may be done via
mask but the therapeutic effect may be significantly
low)
Ideal Nebulizer
A minimum residual volume(< 0.5 ml)
Aerosol delivered only during inhalation.
No waste aerosol released to the environment.
Small and portable.
Aerosol delivered with a droplet size distribution
suitable for pulmonary deposition.
Rapid treatment time, quite and unobtrusive in use.
Finally,perhaps also a means to monitor patient
compliance.
Particle size
Massmedian aerodynamic
diameter
≤ 1μm : Reach up to the
alveoli,
0.5-5μm: Beyond the 10th
generation of bronchi
(respirable particles),
≥ 5 μm : oropharynx
Nebulizers
Solution or suspensions can be nebulized by ultrasonics
or an air jet and administered via a mouthpiece,
ventilation mask or tracheostomy.
Types of nebulizers :
Jet nebulizer
Ultrasonic wave nebulizer
Vibrating mesh Nebulizers
Air jet Nebulizer
In air jet nebulizer compessed air is
forced through an orifice, an area of
low pressure is formed where the air jet
exists.
A liquid may be withdrawn from a
perpendicular nozzle (the Bernoulli
effect) to mix with the air jet to form
droplets.
A baffle within the nebulizer is often
used to facilitate the formation of the
aerosol cloud.
Carrier gas (oxygen) can be used to
generate the “air jet”.
Jet nebulizers are the most commonly prescribed because they are
easy to use and inexpensive.
Disadvantages:
Less portable than inhalers
Delivery may take 5 to 10 mins or longer.
Require power sources, maintanance, cleaning.
Traditional jet nebulizers are often bulky and require an electrical
source, which can be a problem intraveling.
Noisy
Breath-Enhanced Jet Nebulizers
Continuous gas flow to neb chamber combined
with patients inspired air.
Exhaled air does not mix with aerosol, amount of
solution wasted is minimized.
ADVANTAGES DISADVANTAGES
High output ,short Cannot be used in
treatments. ventilator circuits.
Higher dose than T-Neb Not cost effective for
or MDI is possible. short term use.
Multiple one –way Not readily adaptable
valve reduce waste. to tracheostomy masks.
Dishwasher safe, may
be boiled or autoclaved
Cost effective for long -
term
Ultrasonic Nebulizer
Ultrasound waves are formed in an ultrasonic nebulizer chamber by
a ceramic piezoelectric crystal that vibrate when electrically excited.
These set up high-energy waves in the solution, within the device
chamber ,of a precise frequency that generates an aerosol cloud at
the solution surface.
Ultrasonic nebulisers (i.e. aerosonic nebulisers) are
characterised by fast nebulisation of medicine particles
into extra small size for enhanced absorption in the very
depth of the respiratory system, helping to increase the
effects of medication.
Ultrasonic nebulisers are fast and discreet with reduced
noise levels.
They can be used at home and during travel as many
modern ultrasonic nebulisers are not only mains powered,
but also battery powered for convenience.
Car adaptors are also used for nebulisation on the move or
for recharging batteries.
The only drawback is medication restrictions because heat
is transferred to the medication
Vibrating Mesh Nebulizer
In this technology a mesh/membrane
with 1000-7000 laser drilled holes
vibrates at the top of the liquid
reservoir, and thereby pressures out a
mist of very fine droplets through the
holes.
This technology is more efficient
than having a vibrating piezoelectric
element at the bottom of the liquid
reservoir, and thereby shorter
treatment times are also achieved.
The high nebulization capacity (>0.25 ml/min) device
offers short inhalation time.
The old problems found with the ultrasonic wave
nebulizer, having too much liquid waste and undesired
heating of the medical liquid, have also been solved by
the new Vibrating Mesh nebulizers.
New Generation Nebulizer
AERx
Advantages of the AERx System
Small hand-held devices
Very short administration
time(typically 1-2 breaths)
Highly efficient, precise aerosol
delivery
Breath control to ensure reliable
drug delivery to lung
Simple to use.
Nebulizer Solution Formulations
Nebulizers are designed primarily for use with aqueous
solution or suspension.
Drug suspension use primary particles in the range of
2-5 microns.
Nebulizer solutions are usually formulated in water,
although other cosolvent for eg. Glycerin, propylene
glycol,and ethanol may be used.
Nebulizer solution pH be greater than 5.0 to show that
bronchoconstriction is a function of hydrogen ion
concentration.
Method of Administration
Nebulized aerosol is introduced to the patient by
compressed air from a device known as positive pressure
ventilator.
A mouthpiece may be inserted in the mouth may be
attached tightly to the face.
A face tent fits more loosely around the patients
mouth,allowing speech.
A tracheostomy mask may be fitted to the patients
tracheostomy tube directly and require T shaped adapter.
Face masks should be avoided or sealed very tightly
when anticholinergic drugs are administered to patients
with glaucoma.
Face masks should ideally also be avoided for delivery
of nebulized corticosteroids, to prevent contact with the
surrounding facial skin and eyes.
Practical Issues
Cleaning :
Nebulizers should be cleaned daily in regular usage and
after each use in intermittent use.
The mask, mouthpiece and chamber should be disconnected,
disassembled and washed in a warm detergent and water
solution. The components should be left to dry overnight.
Before reuse, the nebuliser should be run for a few seconds
before adding medications.
Maintenance :
Disposable components such as the mouthpiece, mask,
tubing and nebulizer chamber should be changed every three
to four months.
Compressors require annual servicing by manufacturer or
local service provider.
