Efficiency and Safety of Mechanical Ventilation

with a Heat and Moisture Exchanger Changed

Only Once a Week
JEAN-DAMIEN RICARD, ERIC LE MIÈRE, PHILIPPE MARKOWICZ, SERGE LASRY, GEORGES SAUMON,
KAMEL DJEDAÏNI, FRANÇOIS COSTE, and DIDIER DREYFUSS
Service de Réanimation Médicale et de Bactériologie, Hôpital Louis Mourier (Assistance Publique-Hôpitaux de Paris), Colombes, France;
and Institut National de la Santé et de la Recherche Médicale, Unité 82, Faculté de Médecine Xavier Bichat, Paris, France

The cost of mechanical ventilation (MV) is high. Efforts to reduce this cost, as long as they are not
detrimental for the patients, are needed. MV with heat and moisture exchangers (HME) changed ev-
ery 48 h is safe, efficient, and cost-effective. Preliminary reports suggest that the life span of these fil-
ters may be prolonged. We determined prospectively whether a hygroscopic and hydrophobic HME
(Hygrobac-Dar; Mallinckrodt) provided safe and efficient heating and humidification of the inspired
gases when changed only once a week. Patients who were considered to require mechanical ventila-
tion for more than 48 h were included in the study. HMEs were initially set for 7 d. Efficient airway
heating and humidification were assessed by clinical parameters (number of tracheal suctionings and
instillations required, peak airway pressures) and hygrometric measurements performed by psy-
chrometry. Resistance was measured from Day 0 to Day 7. Bacterial colonization of circuits and HMEs
was studied. A total of 377 days of mechanical ventilation with 60 HMEs was studied. Clinical param-
eters and hygrometric measurements did not change between Day 0 and Day 7. Mean absolute hu-
midity was 30.3 6 1.3 mg H2O/L on Day 0 and 30.8 6 1.5 mg H2O/L on Day 7 (p 5 0.7). Endotracheal
tube occlusion never occurred. Three HMEs were replaced prematurely because of insufficient ab-
solute humidity. This rare event occurred only in patients with COPD and after the third day of
use. In addition, the absolute humidity delivered by the HMEs was significantly lower in patients with
COPD than in the rest of the population. Resistance did not change from Day 0 to Day 7 (2.4 6 0.3
versus 2.7 6 0.3 cm H2O/L/s; p 5 0.4). Bacterial samples of both circuits and ventilator sides of HMEs
were sterile in most cases. We conclude that mechanical ventilation can be safely conducted in non-
COPD patients using an HME changed only once a week, leading to substantial cost savings (about
$110,000 per year if these findings were applied to the university-affiliated hospitals in Paris). Ricard
J-D, Le Mière E, Markowicz P, Lasry S, Saumon G, Djedaïni K, Coste F, Dreyfuss D. Efficiency
and safety of mechanical ventilation with a heat and moisture exchanger changed only once
a week. AM J RESPIR CRIT CARE MED 2000;161:104–109.

Reducing costs is a major issue when treating critically ill pa-
tients. Mechanical ventilation of these patients requires ade-
quate airway heating and humidification to counterbalance
the bypassing of the upper respiratory tract. Without such
conditioning, the dry inspired gases may severely damage the
respiratory epithelium (1, 2). Heated humidifiers have been
used for many years. While the hot water system used pro-
vides adequate heat and humidity to the inspired gases, there
are undesired side effects, such as excessive condensation in
(Received in original form in February 16, 1999 and in revised form June 10, 1999)
Disclosure of potential conflict of interest: We received no financial support from
and do not have any commitment to the brand of the device tested in this study.
Presented in part at the ATS meeting, April 24–29, 1998.
Correspondence and requests for reprints should be addressed to Didier Drey-
fuss, Service de Réanimation Médicale, Hôpital Louis Mourier, 178, rue des Re-
nouillers, 92700 Colombes, France. E-mail: didier.dreyfuss@lmr.ap-hop-paris.fr
Am J Respir Crit Care Med Vol 161. pp 104–109, 2000
Internet address: www.atsjournals.org
the circuit, circuit contamination, high cost, and increased
work load (3–6). Disposable devices called heat and moisture
exchangers (HMEs) have been developed. Their clinical effi-
cacy is comparable to that of the heated humidifier (6–8), de-
spite their slightly lower humidity outputs. The types of HMEs
include (1) purely hydrophobic HMEs, which possess high an-
timicrobial properties, but perform poorly in terms of humid-
ity output and have been responsible for endotracheal tube
occlusions (9–12), (2) hygroscopic HMEs, which have better
humidifying qualities than the hydrophobic HMEs, but do not
possess antimicrobial filtration properties, and (3) hydropho-
bic and hygroscopic HMEs, which have both satisfactory hu-
midity outputs and antimicrobial properties. The manufactur-
ers recommend that these disposable HMEs be changed every
24 h, although this is not supported by objective data. It has
been previously shown that a hydrophobic and hygroscopic
HME (Hygrobac-Dar; Mallinckrodt Medical, Mirandola, It-
aly) could be changed only every 48 h without any adverse ef-
fects for the patients (13). The rates of nosocomial pneumonia
were identical whether the HME were replaced every 24 h or
Ricard, Le Mière, Markowicz, et al.: Heat and Moisture Exchangers Changed Weekly
every 48 h. Finally, extending the use period to 48 h provided
measurable savings per year (13). But clinical evaluation of
the humidifying and heating performances of HMEs with pa-
rameters such as the number of tracheal suctionings and instil-
lations required daily, and the peak airway pressure, is insuffi-
cient because it does not always detect less effective HMEs.
A preliminary study showed that the clinical parameter of
adequate airway humidification of a moderately performing
HME was not different from that of efficient HMEs, whereas
hygrometric measurements revealed much lower values for
both absolute humidity and relative humidity than those ex-
hibited by the efficient HMEs (14). These data clearly indicate
the need for an objective in vivo evaluation of the heating and
humidifying performances of HMEs before extending the du-
ration of their use. The remarkable stability of the values for
absolute humidity and relative humidity obtained with the Hy-
grobac-Dar after 48 h of use indicates that this hygroscopic
and hydrophobic HME may be appropriate for even longer
periods of mechanical ventilation without being changed. Al-
though the economic impact of further extending the use of
HMEs may be important in an era of diminished resources,
studies addressing this issue must certainly not, for obvious
ethical reasons, place the patients at risk. Extending the use of
HMEs on clinical grounds only is insufficient. We therefore
assessed the safety and efficacy of mechanical ventilation with
a hygroscopic and hydrophobic HME changed only once a
week, using both hygrometric measurements and bacterial col-
onization surveillance.
METHODS
Study Design
All of the patients hospitalized over a 9-mo period in the Service de
Réanimation Médicale of the Louis-Mourier University Hospital (a
12-bed intensive care unit) who were considered likely to require con-
tinuous mechanical ventilation for more than 48 h were included. Ex-
clusion criteria included profound hypothermia (temperature , 338 C),
a bronchopleural fistula, or poisoning with breath-eliminated drugs
(hydrocarbons). The HME used was the hygroscopic and hydropho-
bic Hygrobac-Dar (Mallinckrodt Medical). The ventilators used were
Siemens Servo 900 D (Siemens-Elema, Solna, Sweden), Bird 8400 Sp
(Bird Products, Palm Springs, CA), and César respirators (CFPO,
Paris, France). Each HME was initially installed for a period of 7 d
after which it was replaced. Premature replacement could occur un-
der certain circumstances (see below). Patients ventilated for more
than 7 d therefore provided several 7-d study periods.
Positioning of the HMEs
HMEs were placed between the endotracheal tube and the Y-piece of
the circuit. Particular care and attention were given to positioning
each HME in relation to the endotracheal tube. The HME had to be
placed vertically above the tracheal tube (by means of a flex tube) in
order to reduce the risk of partial obstruction of the HME due to re-
fluxed secretions from the tracheal tube. Nurses and doctors repeatedly
checked the position of each HME.
Clinical Evaluation of HME Safety and Efficacy
The same simple parameters as those used in our previous studies (7,
13) were recorded. The number of tracheal suctionings and tracheal
instillations was recorded daily (in our unit, tracheal aspirations are
performed every 4 h and whenever breathing sounds are heard, and
instillations are performed by the nurse only when the secretions are
considered thick and difficult to suction). Peak airway pressures were
recorded every 6 h and averaged (they are subsequently referred to as
mean peak airway pressures). These measurements were done after
patient suctioning. Tracheal tube occlusion was prospectively defined
as an unexplained rise in the peak airway pressure without evidence
of filter obstruction and an inability to insert a suction catheter
through the previously patent tube, leading to its replacement. Epi-
105
sodes of HME obstruction were identified by unexplained rises in air-
way pressure and confirmed by visual inspection of the removed filter
and the immediate normalization of airway pressures after replace-
ment of the HME.
Hygrometric Measurements
Absolute humidity, relative humidity, and tracheal temperature were
measured within the first 48 h and then daily from Day 3 until Day 7.
Absolute humidity is the amount of water vapor contained in air (mg
H2O/L). Absolute humidity at saturation (AHs) is the maximum
amount of water vapor that air can contain at a given temperature.
Relative humidity is the ratio of absolute humidity to absolute humid-
ity at saturation, and is expressed as a percentage. These parameters
may be measured by psychrometry, a technique widely used in clinical
studies that evaluate HME performance (14–18). Briefly, inspiratory
and expiratory gas flows were separated by a device containing two
one-way valves inserted between the endotracheal tube and the HME.
Two thermal probes—a dry one and a wet one—were placed in the in-
spiratory 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 to allow for optimal thermal equilibrium.
The psychrometric method compares the temperatures obtained with
the two probes in the inspiratory part of the separating device. The
dry probe is placed upstream and measures the actual gas tempera-
ture. The downstream probe is coated with sterile cotton wetted with
sterile water. Evaporation around the wet probe in the inspiratory
part is proportional to the dryness of the gas. The temperature gradi-
ent between the two probes increases as the inspired gas humidity de-
creases. There is no thermal gradient when the inspired gas is fully
saturated with water (100% relative humidity).
Relative humidity (RH) was calculated by reference to a nomo-
gram, taking into account the difference between temperatures mea-
sured by the two probes. Absolute humidity at saturation (100% RH;
AHs) was calculated with the following formula: AHs 5 16.451563 2
0.731T 1 0.03987T2 mg H2O/L, where T (8C) is the dry probe temper-
ature. Absolute humidity (AH) was obtained from the formula AH 5
(AHs 3 RH)/100 (in mg H2O/L). Room temperature was constant at
23.5–258 C.
HMEs were replaced before the seventh day of use when the abso-
lute humidity was , 26 mg H2O/L or when there was partial obstruc-
tion of the HME by tracheal secretion.
Resistance of the HMEs to Air Flow
HME resistance to air flow was measured daily in one of every three
patients, from Day 0 until Day 7, according to the International Stan-
dards Organization ISO 9360 (19). Briefly, resistance was calculated
from the pressure drop from either side of the HME when a constant
60-L/min flow was applied through the HME (Flowmeter; Fischer &
Porter, Warminster, PA). Pressure was measured with pressure sen-
sors (SCX 0.0045 DV, AST, Vanves, France) and the signal was ana-
lyzed and displayed on a two-track recorder (Windograf; Gould, Cleve-
land, OH).
TABLE 1
NUMBER OF HMEs STUDIED ACCORDING
TO THE NUMBER OF DAYS ON MECHANICAL
VENTILATION AND THE REASON FOR VENTILATION
Number of Days on
Mechanical Ventilation
Reason for Ventilation 3 4 5 6 7
Chronic airway obstruction (n 5 10)* 2 2 4 3 15
Other pulmonary disease (n 5 13) 0 1 3 1 16
Other† (n 5 10) 0 1 2 1 9
Total HMEs studied 2 4 9 5 40
* Numbers in parentheses represent the number of patients studied.
†
Postoperative mechanical ventilation, neurologic emergency, miscellaneous.
106 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 161 2000

TABLE 2
VENTILATORY PARAMETERS AND PATIENT BODY TEMPERATURE:
COMPARISONS BETWEEN PATIENTS WITH AND WITHOUT COPD

COPD Others
(n 5 10) (n 5 23) p Value

Tidal volume, ml 484 6 73 495 6 95 NS

Respiratory rate, breaths per minute 18.6 6 2.4 20.6 6 2.8 NS
FIO2, % 55 6 10.2 49 6 13.7 NS
Time spent under pressure support ventilation (percentage
of total time under mechanical ventilation) 23.4 6 25.9 33.7 6 34.5 NS
Temperature, °C 37.4 6 0.2 37.3 6 0.6 NS

Colonization of HMEs and Circuits
The bacteria-filtering properties of the HME were assessed by open-
ing them aspetically after their seventh day of use (day of replace-
ment), and placing the ventilator side of the HME on CLED agar.
Circuit bacterial colonization was assessed by plating a 1-cm2 swab-
bing of the Y-piece on CLED agar and incubating the plates for 48 h.
Colonies were counted and identified. Bacterial counts are expressed
as colony-forming units (CFU) per HME or per square centimeter of
the Y-piece.
Data Collection and Definitions
The parameters recorded for each patient included age, sex, indica-
tion for ventilatory support according to the classification of Zwillich
and colleagues (20), simplified acute physiology score on admission
(21), mean tidal volume, respiratory rate, FIO2 (fraction of inspired ox-
ygen), body temperature over time, and the percentage of time spent
on inspiratory pressure ventilation (defined as the ratio of time spent
on inspiratory pressure ventilation to total duration of mechanical
ventilation).
This protocol was approved of by the Institutional Review Board
for human studies of the French Intensive Care Society. Informed
consent was not requested since all procedures were considered to be
routine practice, and none was invasive.
Statistical Analysis
The parameters for the HMEs are given as means 6 SD, or as the
number of patients affected. Continuous data for the groups were as-
sessed by analysis of variance (ANOVA). When ANOVA indicated
differences between groups, they were compared using the protected
least significant difference. Hygrometric values over time were com-
pared according to the indication for mechanical ventilation, using a t
test with Bonferroni’s correction. Categorical data were analyzed by
contingency table analysis. A p value , 0.05 was considered significant.
RESULTS
Study Population
Thirty-three patients were included in the study. The sex ratio
(M/F) was 18/15. The mean age was 67.3 6 13.1 yr (range, 23–
86 yr). The marker of acute illness used was the Simplified
Acute Physiologic Score 2 (21), with a mean of 49.2 6 15.7
(range, 21–87). Reasons for mechanical ventilation were the
following: there were 10 patients with chronic airway obstruc-
tion, 13 patients with other pulmonary diseases, and 10 pa-
tients with nonrespiratory diseases (4 postoperative mechani-
cal ventilation, 1 neurologic emergency, and 5 miscellaneous).
Of the 60 HMEs studied, 40 were studied for 7 d. The 33 pa-
tients enrolled provided a total of 377 d of mechanical ventila-
tion. Of these, 12 patients (6 chronic airway obstruction, 4
other pulmonary diseases, 1 neurologic emergency, 1 miscella-
neous) provided several 7-d study periods: 7 periods in 1 pa-
tient, 4 periods in 2 patients, 3 periods in 2 patients, and 2 peri-
ods in 7 patients; 5 patients provided one 7-d period. The
remaining patients (16) provided 20 periods of less than 7 d
because of mechanical ventilation cessation or premature
HME replacement (see below). Table 1 shows the number of
HMEs studied according to the number of days of mechanical
ventilation and the reasons for it.
Only two modes of mechanical ventilation were used: as-
sist-control ventilation and inspiratory pressure support venti-
lation. The conditions of mechanical ventilation and body
temperature were identical in patients with COPD and in the
rest of the patient population (Table 2).
Clinical Evaluation of Humidifying Efficacy
The parameters used to evaluate the safety and efficacy of the
HMEs are shown in Table 3. No endotracheal tube occlusion
occurred. There were no differences between Days 0 and 7 in
terms of the number of tracheal suctionings, tracheal instilla-
tions, or the mean peak airway pressures. There were also no
differences when these comparisons were performed from one
day to another (data not shown).
Only 6 of the 60 HMEs used were changed prematurely (be-
fore Day 7) because of partial obstruction of the HME by tra-
cheal secretions, thus amounting to 0.015 HME changed per
day of mechanical ventilation. This rare event was not corre-
lated with the duration of HME use (data not shown), was not
related to the performance of the HMEs, but was encountered
in productive patients and had no adverse effect on the patient.
Hygrometric Measurements
The hygrometric parameters of the Hygrobac-Dar, measured
within the first 48 h of mechanical ventilation (referred to as
Day 0–2) and then daily (Day 3 to Day 7), were remarkably
constant throughout the 7-d study period (Table 4). The val-
ues for absolute humidity, relative humidity, and thracheal
temperature measured on Day 7 were identical to those mea-
sured on Day 0–2 (Table 4).
During the whole study period, only three HMEs were re-
placed prematurely because of insufficient absolute humidity.
This represented 3 HMEs/377 d, or 0.7 time per 100 d of me-
chanical ventilation. All three HMEs replaced concerned pa-
tients with chronic obstructive pulmonary disease (COPD).
One HME delivered less than 26 mg H2O/L of absolute hu-
midity on Day 5, and the other two HMEs were replaced, de-
TABLE 3
CLINICAL ASSESSMENT OF HUMIDIFYING EFFICIENCY
Day 0 Day 7 p Value
Tidal volume, ml 482 6 109 488 6 146 0.9
Respiratory rate, breaths per minute 19.6 6 3.5 21.1 6 3.9 0.3
Mean peak airway pressure,* cm H2O 29.3 6 6.7 33.8 6 6.5 0.2
No. of tracheal suctionings, per day 9.3 6 2.4 9.2 6 1.9 0.7
No. of tracheal instillations, per day 0.16 6 0.6 0.25 6 0.8 0.1
* Peak airway pressures were recorded every 6 h and averaged.
Ricard, Le Mière, Markowicz, et al.: Heat and Moisture Exchangers Changed Weekly 107

TABLE 4
HYGROMETRIC PARAMETERS

Day

0–2 3 4 5 6 7 p Value

Absolute humidity,
mg H2O/L 30.3 6 1.3 30.5 6 1.5 30.4 6 1.4 30.3 6 1.6 31.0 6 1.8 30.8 6 1.5 0.7
Relative humidity, % 99.3 6 0.8 99.3 6 0.8 98.3 6 1.1 99.0 6 1.1 99.3 6 0.8 99.3 6 0.8 0.5
Tracheal temperature, 8C 33.1 6 0.8 33.2 6 0.8 33.3 6 0.7 33.0 6 0.9 33.4 6 0.9 33.2 6 0.8 0.9

spite study protocol, on Day 3 and Day 4. Although their ab-
solute humidity values were not less than 26 mg H2O/L, they
were constantly declining and were close to the set threshold
(Table 5). Importantly, the gradual decrease in absolute hu-
midity before HME replacement observed in these three in-
stances led to no adverse effect on the patients. As this rare
event occurred solely in patients with COPD, we analyzed the
results of this category of patients separately from those of the
remaining population. Table 6 shows the values for absolute
humidity in patients with COPD (including those in whom the
HME was replaced prematurely) and the values for absolute
humidity measured in the other patients. The HMEs used by
the patients with COPD had significantly lower values of ab-
solute humidity than did those of the other patients after 72 h
of use. This difference did not reach significance on Day 6 and
Day 7 because of the smaller number of HMEs left for analysis.
Resistance of HMEs to Air Flow
The resistance of the HME to air flow was measured daily in
10 patients; the results of these measurements are shown in
Table 7, and indicate that the resistance did not change from
Day 0 to Day 7.
Bacteriological Study
Thirty-three Y-pieces and ventilator sides of HMEs were sam-
pled. HMEs (ventilator side) were sterile in 20 cases, whereas
13 grew negligible amounts of microorganisms (fewer than 10
CFU/side of coagulase-negative staphylococci in 11 cases, 1
CFU/side of Candida albicans or of a Bacillus sp. in one in-
stance each). The results were comparable for the Y-piece: no
growth in 30 instances, and fewer than 10 CFU/cm2 of coagu-
lase-negative staphylococci in 2 cases and an Enterococcus sp.
in one case.
DISCUSSION
This prospective clinical study clearly shows that a hygro-
scopic and hydrophobic HME (Hygrobac-Dar) can be used
safely for seven continuous days of mechanical ventilation in
all ICU patients except patients with COPD. These important
findings are based on both clinical and hygrometric assess-
ment, and confirm that the duration of use of this particular
TABLE 5
ABSOLUTE HUMIDITY* DELIVERED BY THE THREE REPLACED HMEs
Day
Patient 0–2 3 4
1 30.5 28.3 28.3
2 28.5 27.9 26.5†
3 28.8 26.6†
* ln mg H2O/L.
†
The HME was replaced after this measurement.
HME can be extended (13). These findings may have impor-
tant medical and economical consequences.
We believe that this study is the first to evaluate an HME for
such a long period with daily hygrometric measurements. Indeed,
more than 350 d of mechanical ventilation were monitored.
Clinical parameters, such as the number of tracheal suc-
tionings and instillations required per day, and peak airway
pressures, may help to assess adequate airway humidification,
but daily survey of these parameters is not sensitive enough to
detect a gradual fall in the humidity delivered by a humidify-
ing device. We have previously measured wide differences in
the absolute humidity delivered by different HMEs, whereas
the clinical parameters used to assess airway humidification
indicated no such differences (14). We therefore consider it
important to perform hygrometric measurements when inves-
tigating HMEs, and most importantly, when exploring the ex-
tended duration of use of an HME. Hygrometric parameters
were measured once a day after Day 2 in the present study, to
detect over time any fall in humidity performance that could
have been detrimental to the patient. Absolute humidity re-
mained remarkably stable over time in the non-COPD pa-
tients. This constant humidity output reflects the integrity of
the epithelial and mucociliary function. The HMEs act as pas-
sive heating and humidifying devices: they store heat and
moisture from the expired gas and return them to the patient
via the inspired gas. As the capacity to heat and humidify fresh
gas coming into the respiratory tract depends on the integrity
of the epithelial and mucociliary function, a constant absolute
humidity output over 7 d of mechanical ventilation indicates
indirectly that the heating and humidifying functions of the
respiratory tract have been preserved during this time. How-
ever, this was not true in all patients. Three HMEs were re-
placed prematurely. In one case, the absolute humidity was
below the safety threshold (26 mg H2O/L), and it was con-
stantly decreasing in the other two cases, being significantly
below the mean absolute humidity in the other patients on the
same day. The protocol was violated in these two patients be-
cause the particularly low absolute humidity could have con-
tinued to decrease and place the patient at risk of endotra-
PATIENT 6
ABSOLUTE HUMIDITY VALUES FOR PATIENTS
WITH COPD AND FOR ALL OTHER PATIENTS
Patients with
Day COPD Other Patients p Value
0–2 29.9 6 1 (25)* 30.6 6 1.5 (30) 0.3
5
3 29.7 6 1.3 (26) 31.1 6 1.3 (33) 0.001
24.9† 4 29.6 6 1.2 (24) 31.0 6 1.4 (34) 0.002
5 29.6 6 1.6 (20) 30.9 6 1.4 (28) 0.04
6 30.0 6 1.1 (13) 31.5 6 1.9 (20) 0.07
7 30.3 6 0.9 (15) 31.0 6 1.7 (25) 0.7
* Numbers in parentheses indicate the number of HMEs.
108 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
HME RESISTANCE TO AIR FLOW*
0 1 2 3
2.4 6 0.3 2.6 6 0.5 2.7 6 0.5
* Resistance units, cm H2O/L/s; ANOVA for repeated measurements revealed a p value of 0.4 for the changes in resistance from Day 0
to Day 7.
cheal tube occlusion. This rare decrease in HME objective
performance occurred only in patients with COPD. The val-
ues for absolute humidity were significantly lower in the
COPD patient group than in the rest of the study population.
This difference remained even when the three HMEs replaced
prematurely were excluded from the analysis. These surpris-
ingly low values for absolute humidity in patients with COPD
had not been encountered in our previous study, in which 371
measurements were performed, one-third on patients with
COPD (14). The HMEs were changed every 2 d in this previ-
ous study. Thus, it is possible that this is the longest period
that some patients with COPD can be on an HME before its
replacement; however, this remains to be confirmed. The rea-
sons for this decline in absolute humidity are not clear. As
mentioned above, an HME acts passively and cannot restitute
during the inspiratory phase more humidity than it has re-
ceived during the previous expiratory phase (22). The anatom-
ical and functional alterations in the bronchial epithelium of
patients with COPD may have contributed to the gradual de-
crease in absolute humidity in these three particular patients.
Thus, a decrease in HME performance after 48 h of use may
result in a marked decrease in humidity in those patients with
an altered respiratory epithelium. However, all patients with
COPD did not behave in the same way. Indeed, one patient
with COPD was ventilated for 47 d and two for 21 d with their
HME changed every week without any problem.
Insufficient humidification may lead to respiratory tract
desiccation and damage, and to life-threatening endotracheal
tube occlusion (9–12, 23). Tracheal tube occlusion never oc-
curred during the 377 d of mechanical ventilation we have
studied. Furthermore, HMEs have been changed every week
in our unit (except for patients with COPD) since this study
was completed (1 yr ago), and no tracheal tube occlusion has
occurred in 246 ventilated patients, 176 of whom were venti-
lated for more than 3 d outside the research setting.
Placing an HME in the breathing circuit generates resis-
tance to gas flow. Thus a fear of a major increase in this resis-
tance over time is a legitimate concern. This is why we mea-
sured the resistance of 10 HMEs every day from Day 0 to Day
7. Resistance did not change significantly over the 7-d use of
the HME. The additional resistance due to an HME is no
greater than that of a heated humidifier (24). Additional dead
space may be a potential drawback to the use of HMEs. The
use of HMEs leads to greater PaCO2 and minute ventilation
than with heated humidifiers, during weaning from mechani-
cal ventilation (25). Pelosi and coworkers showed that the use
of HMEs increased the work of breathing, although this in-
crease can be easily overcome by increasing pressure support
(26). The clinical impact of these observations on the course,
duration, and outcome of weaning remains unknown. In our
daily practice, patients are kept on HMEs during weaning
from mechanical ventilation.
Several studies have shown that the bacteria-filtering prop-
erties of the HME used in this study (Hygrobac-Dar) remain
stable after 48 h of use (13, 14). Our present findings are con-
VOL 161 2000
TABLE 7
Day
4 5 6 7
2.7 6 0.5 2.7 6 0.5 2.4 6 0.3 2.5 6 0.3 2.7 6 0.3
sistent with these results. The bacterial colonization of the
Y-piece and the ventilator side of the HME was low after 7 d
of use. In one of these previous studies addressing the issue of
nosocomial pneumonia (13), we showed that changing the Hy-
grobac-Dar every 48 h did not affect the rate of nosocomial
pneumonia.
There is now considerable evidence that HMEs may be
used for longer than the 24 h recommended by the manufac-
turers (13, 14, 27, 28). However, and most importantly, this is
not true of all HMEs. Our previous study of three different
hydrophobic and hygroscopic HMEs found that one of them
was clearly not suited for use beyond 24 h (14). These results
were based on daily measurements of humidity outputs. Such
measurements are essential since the clinical parameters used
to evaluate the humidification performances did not detect
the lower performances of this particular HME, and obviously
not all available HMEs are appropriate for extended use (14).
We therefore believe that hygrometric performance must be
assessed in any clinical study investigating the extended use of
HMEs. Tracheal tube occlusion is the most dangerous risk of
insufficient humidification. Although it appears to be rare, fa-
tal cases have been reported (11). Reducing the cost of me-
chanical ventilation is a laudable goal but it must certainly not
be done at the expense of a patient’s life.
This study demonstrates that a particular HME (Hygrobac-
Dar) can be safely used in non-COPD patients for 1 wk. Given
the fact that most patients are ventilated for shorter periods
(29), this implies that this HME can be used with total security
in patients for more than 2 d, without change. This is the first
objective demonstration of this possibility. One study (27)
compared the use of a hygroscopic HME (without bacteria-fil-
tering properties) over 7 d with a classic heated humidifier.
The authors concluded that this hygroscopic HME may be used
during the first 7 d of mechanical ventilation, reducing staff la-
bor and the cost of mechanical ventilation. But the study had
some drawbacks: first, the HMEs were systematically replaced
by heated humidifiers at the end of the first week of mechani-
cal ventilation, which precluded assessment of longer periods
of use; second, several HMEs were replaced by a heated hu-
midifier before the seventh day of use because of abundant se-
cretions. Tracheal tube occlusion might have occurred if the
HME had been continued in these patients, and hygrometric
measurements (which were not performed) might have de-
tected insufficient humidification in these patients; third, pre-
maturely replaced HMEs were excluded from the analysis;
last and most important, the mean duration of mechanical
ventilation was 4.2 6 5.1 d, thus only 21 of 147 HMEs were
used for at least 7 d. Our study included 40 HMEs used for
more than 7 d.
It is important to note that the economic savings obtained
by prolonging the use of HMEs may be considerably reduced
if they are replaced prematurely owing to partial obstruction
by secretions. For instance, in the study by Kollef and co-
workers (27), the number of prematurely replaced HMEs was
0.036 per day of mechanical ventilation (27 HMEs/750 d of
Ricard, Le Mière, Markowicz, et al.: Heat and Moisture Exchangers Changed Weekly
mechanical ventilation) whereas this number is 0.015 (6 HMEs/
377 d of mechanical ventilation) in our study. This difference
is probably due to the attention paid by the nurses and doctors
in our unit to keeping the HMEs above the endotracheal tube:
they are kept vertically above the endotracheal tube by means
of a flex-tube in order to limit refluxes of secretion.
The balance between cost savings and quality improvement
in clinical research in the ICU is a major issue. In the present
study, most of the patients with COPD were ventilated with-
out any problem when their HME was changed only once a
week. If hygrometric measurements had not been performed,
the conclusion of this study (based on the results of the clinical
parameters only) would probably have been that mechanical
ventilation with an HME changed only once a week was safe
and efficient in all patients, COPD included. However, because
measurements were performed, three patients with COPD in
whom HMEs delivered an absolute humidity significantly
lower than the values measured in all of the other patients
were detected. This event occurred only 0.7 time per 100 d of
mechanical ventilation. However, we prefer to stay on the safe
side, and recommend a 48-h change of HMEs in patients with
COPD. We decided to adopt a conservative approach in order
that patient safety issues not be sacrificed for economic rea-
sons. In addition, less frequent HME changes reduce the num-
ber of septic procedures, thus improving quality of care.
In conclusion, our study shows that mechanical ventilation
with an HME changed every week is safe, efficient, and cost-
effective for non-COPD patients. Patients with COPD should
have their HMEs changed every 48 h (13). Expanding the life
span of this HME may result in considerable cost savings—
more than $110,000 if these findings are extended to the 800
intensive care beds (medical and surgical ICUs) of the 20
acute-care teaching hospitals of the Administration Générale
de l’Assistance Publique de Paris (to which the Hôpital Louis
Mourier belongs). Nevertheless, focusing only on cost reduc-
tion, on the assumption that all available HMEs are safe and
suitable for prolonged use, may lead to unacceptable adverse
effects (30).
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