Breathing system filters
Antony R. Wilkes BSc MSc
Key points
Both gas- and liquid-
borne routes of trans-
mission of contamination
are important, the latter
particularly so in circle
systems
Pleated hydrophobic fil-
ters generally have better
gas-borne filtration per-
formance than electro-
static filters
Pleated hydrophobic fil-
ters prevent liquid-borne
transmission; the ability
of electrostatic filters to
prevent liquid-borne
transmission depends on
the volume of liquid, the
filter area and the orien-
tation of the filter mater-
ial during use
As performance depends
on its size, a filter should
be used with an internal
volume appropriate to
the patient’s tidal volume
Filters increase resistance
to gas flow and dead-
space in breathing sys-
tems and may prevent
adequate ventilation by
becoming blocked
A.R.Wilkes BSc MSc
Senior Research Fellow, Department
of Anaesthetics and Intensive Care
Medicine, University of Wales
College of Medicine, Heath Park,
Cardiff CF14 4XN
Tel: 029 2074 3103
Fax: 029 2074 4706
E-mail: wilkes@cf.ac.uk
DOI 10.1093/bjacepd/02.05.151
© The Board of Management and Trustees of the British Journal of Anaesthesia 2002
Intubation bypasses the normal warming, humid-
ifying and filtering functions of the nasopharynx.
Breathing system filters are intended to replace
the filtering function of the nasopharynx and may
also replace its warming and humidifying func-
tions. Filters reduce the risk of the interior of
breathing systems, equipment and the ambient air
becoming contaminated by patients.
The use of a breathing system filter sited at the
Y-piece to provide both filtration and humidifica-
tion was first described in 1984, although filters
attached directly to ventilators had been described
previously. There is now a wide variety of differ-
ent filters on the market from a large number of
manufacturers. The routine use of filters is rec-
ommended by a number of professional bodies
especially when breathing systems are used for
more than one patient.
Reducing the risk of
cross-infection
The use of filters is only one measure that should
be used to reduce the risk of cross-infection dur-
ing anaesthesia and in intensive care. For exam-
ple, the anaesthetist’s hands and gloves can be
contaminated during invasive procedures. Unless
the gloves are removed or the hands washed
immediately following the procedure, any equip-
ment (such as breathing systems) or surfaces
touched will then become contaminated. If this
contaminated equipment is not cleaned adequate-
ly after each use, and normal cleaning procedures
may not remove all contamination, infective
material may be transferred by further glove or
hand contact to other patients.
Microbial contamination of the interior of
breathing systems may cause cross-infection and
breathing system filters reduce this. Microbes
exist in sputum and blood and contamination may
result from either the gas- or liquid-borne route.
British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 5 2002
In the gas-borne route, an aerosol of sputum
droplets containing microbes is expelled from a
patient and remains suspended in the gas stream.
Typical sizes of droplets which remained sus-
pended and are important for alveolar deposition
are 1–5 µm. The gas-borne route is important for
the spread of diseases such as tuberculosis and
influenza. The liquid-borne route is where sputum
flows from the patient’s respiratory tract into the
breathing system. If trauma has occurred to the
airways during intubation or if there is pre-existing
injury causing blood-stained sputum, then sputum
may contain blood-borne viruses such as hepatitis
B and C and HIV. Prions in patients with vCJD are
found primarily in nervous and lymphatic tissue.
Therefore, they are unlikely to be found in spu-
tum, even if blood is present.
In both cases, coughing is the predominant
cause of contamination in breathing systems.
Very few droplets are expelled from the airways
during normal, quiet breathing. During coughing,
the size of the droplets produced depends on the
force of the cough, so that a more forceful cough
produces smaller droplets which can remain sus-
pended in the gas-stream. Titres of microbes in
sputum and blood are rarely greater than 107 ml–1.
A typical cough contains droplets with a total vol-
ume of about 2 × 10–7 ml. Therefore, at most,
there are likely to be only a few infected droplets
expelled during each cough. In contrast, 0.2 ml of
sputum expelled by a patient into the breathing
system has the potential to contain a million times
more microbes than that in droplets expelled dur-
ing a cough.
Coughing occurs during intubation, extubation
and inhalation of irritant anaesthetic agents.
Smokers are more likely to cough than non-smok-
ers. Techniques to reduce the incidence of cough-
ing, and hence the potential contamination of
breathing systems, should be used where possible.
151
Breathing system filters
The use of breathing system filters
Inspiratory and expiratory gases are separated in the breathing sys-
tems used in intensive care and ‘open’ breathing systems used dur-
ing anaesthesia, although there is a partial common pathway in the
latter. In these cases, microbes expelled by one patient are unlikely
to be inhaled by another if the breathing system is re-used, although
preventing the release of microbes into the ambient air is obviously
desirable. In contrast, in circle breathing systems, expired gas is
returned to the patient when the carbon dioxide has been removed
and microbes could be transferred between patients if this type of
breathing system is re-used. Condensation occurs in circle breath-
ing systems due to the release of water vapour from the reaction of
the soda lime with carbon dioxide and from the water vapour
exhaled by the patient. Condensation containing microbes may then
enter the patient’s respiratory tract from the breathing system.
Reducing gas-borne contamination
Filter material can reduce the passage of gas-borne particles
by 5 mechanisms (Table 1). The effectiveness of these mech-
anisms depends, amongst other parameters, on the size of the
particle passing through the filter material. For all filter mate-
rials, there is a size of particle that passes through the filter
material most easily: the diameter of this particle is known as
the ‘most penetrating particle size’, normally 0.05–0.5 µm.
For particles with diameters close to the most penetrating parti-
cle size, the two most important filtration mechanisms are diffu-
sion and interception (Fig. 1). Particles with diameters larger than
the most penetrating particle size are directly intercepted by the
fibres in the filter material. Particles < ~0.1 µm undergo signif-
icant Brownian motion, so that they randomly traverse areas
Table 1 Filtration mechanisms
Mechanism Effect
Interception A particle following a gas streamline around a fibre
in the filter material comes within one particle
radius of the surface of the fibre and strikes the fibre
Inertial A particle, unable to follow a gas streamline around a
impaction fibre because of its inertia, strikes the fibre
Diffusion Small particles undergoing Brownian motion cross gas
streamlines which increases the probability of them
striking a fibre
Gravitational Large particles in slow moving air settle onto fibres due
settling to gravity
Electrostatic Charged particles are attracted to oppositely charged
attraction fibres by coulombic attraction. Neutral particles are
attracted to a charged fibre as the electric field induces a
dipole in the particle and charged particles are attracted
to neutral fibres by inducing image forces on the fibres
152 British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 5 2002
much larger than their physical cross-sectional area and can,
therefore, be captured comparatively easily by the filter materi-
al. Particles in the most penetrating particle size range are too
small to be captured easily by direct interception and are too
large to undergo significant Brownian motion.
Reducing liquid-borne contamination
The transmission of liquid is prevented by using a hydropho-
bic layer on the filter to prevent the ingress of water-based liq-
uid solutions into the filter material. The liquid entering the
filter housing may have a large range of viscosity. The respi-
ratory secretions of patients can become particularly viscous
if they receive inadequate humidification during long-term
ventilatory assistance and such secretions may adhere to the
filter material and prevent adequate ventilation.
Types of breathing system filters
Pleated hydrophobic filters
The breathing system filter first described in 1984 contains a
sheet of resin-bonded ceramic fibres. The fibres are packed
densely and hence the sheet has a high resistance to gas flow per
unit area. The resistance to gas flow is reduced by using a sheet
with a large surface area. The sheet is pleated to fit within a hous-
ing of acceptable internal volume. This type of sheet is hydropho-
bic and, under normal conditions, does not absorb water.
Electrostatic filters
Breathing system filters containing electrostatic filter material
became available in the late 1980s. One type of material is made
from a sheet of polypropylene on which a permanent electrostatic
charge is applied during manufacture. The sheet is subsequently
split into fibres which are then pressed together to form a wad.
Combinedefficiency
100
90
80
70
60
50
40
Diffusion
30 Interception
20
10
0
0.01 0.10 1.00
Particle diameter (µm)
Fig. 1 Filtration efficiency (%).
 Breathing system filters

Such filter material is termed an Electret. Other types of elec- Table 2 Size of pathogenic microbes compared with the size of
trostatic filter are also available. The fibre density is lower microbes used to challenge breathing system filters.Viruses rarely
exist free from cell debris and other solids (e.g. nutrient solutions)
than in sheets of resin-bonded ceramic fibres and hence the thus increasing their effective diameter.The most penetrating parti-
resistance to gas flow is lower per unit area. The removal of cle size for filters is normally 0.05–0.5 µm
particles by direct interception is also lower, although the
Microbe Typical size (µm)
electrostatic charge improves the efficiency of the deposition
Bacteria Width x length
of particles on fibres (Table 1). Hence, this filter material does Bacillus subtilis var. niger (test microbe) 0.6 x 1.1
not need to be pleated and a flat layer is generally used in Pseudomonas aeruginosa 0.6 x 2
Tubercle bacilli 0.4 x 3
breathing system filters. Staphylococci 1x1
Streptococcus pneumoniae 0.5 x 1
Combined filters and heat and moisture exchangers
Viruses Diameter (naked)
Many filters also contain a heat and moisture exchanging MS-2 (test microbe) 0.023
layer to return some of the exhaled moisture and heat to the Hepatitis B 0.042
Hepatitis C 0.045
patient during the next inspiration. Humidification in general HIV 0.09
was dealt with in an earlier issue of CEPD Reviews (Br J
Anaesth CEPD Rev 2001; 1: 40–3).
However, sodium chloride particles can be generated such that
Filtration performance their size is close to the most penetrating particle size for the filter.
Gas-borne Therefore, filtration performance determined using sodium chlo-
Filtration performance is expressed in terms of penetration (num- ride particles gives the worst-case performance for the filter. This
ber of particles passing through the filter as a percentage of the method has been adopted for the European Standard as the size and
number of particles in the challenge to the filter), or as efficiency, number of the particles can be generated accurately and precisely
i.e. [100 – penetration] (%). and the technique has been used to measure the filtration perfor-
Filtration performance can be determined using challenges of mance of other devices. Part 1 of the standard specifies a test
aerosols of droplets containing bacteria, viruses or inorganic par- method to measure filtration performance (but does not specify a
ticles (e.g. sodium chloride). Much larger microbial challenges level that the filter has to achieve). Part 2 specifies tests and require-
are used than would be encountered in normal clinical use, so that ments for other aspects of the filter (pressure drop, internal volume,
the same challenge can cover the whole range of likely filtration connectors, labelling, etc.).
performance. Typical microbial challenges consist of an aerosol In general, pleated hydrophobic filters reduce gas-borne trans-
containing more than 107 microbes. The microbes used need to mission of bacteria, viruses and sodium chloride particles more
be robust (in order to withstand nebulisation) and act as particles effectively than electrostatic filters (Table 3). In particular, during
enabling filtration performance to be determined by counting the in vitro tests, most pleated hydrophobic filters effectively prevent
number of microbes that pass through the filter. Bacteria tend to all bacteria passing through the filter material.
be larger than the most penetrating particle size and viruses tend Filtration efficiency is increased if the density of the fibres is
to be smaller (Table 2), although the droplets containing viruses increased and if the depth of the filter material is increased,
are also likely to be larger, as the viruses will be attached to cell although, in both these cases, the resistance to gas flow also
debris rather than being naked. increases. Filtration efficiency also depends on the face velocity,
Table 3 Typical penetration values through different types of breathing system filters with various challenges.The two types of electro-
static filters differ in the way they are manufactured.Tested using a flow of 30 litre min–1
Challenge Filter type
Pleated hydrophobic Electrostatic
Type I Type II
Bacterial (Bacillus subtilis var. niger) < 0.000005 to 0.00009% 0.00012 to 0.0035% 0.053 to 0.17%
Viral (MS-2) 0.00014 to 0.0047% 0.0097 to 0.085% 0.67 to 1.03%
Sodium chloride particles of the most penetrating particle size 0.015 to 0.68% 0.28 to 2.85% 4.5 to 11%

British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 5 2002 153

Breathing system filters

Table 4 Differences in performance between a small and large Clinical use of breathing system filters
pleated hydrophobic filters from the same manufacturer with the
same filter material Intensive care
Parameter Small Large The prevention of respiratory infection in patients receiving ventila-
filter filter tory assistance in intensive care is of primary importance. However,
Internal volume (ml) 39 96 it is generally accepted that the majority of cases of ventilator-asso-
Filter area (cm2) 240 700
Pressure drop (Pa) at 30 litre min–1 133 75 ciated pneumonia occurs from the patient’s own microbial flora.
Moisture output (g m–3) at tidal The use of breathing system filters is, therefore, unlikely to reduce
volume of 0.5 litre 17 26
the incidence of this problem. Gases delivered to patients from pipe-
Filtration performance (penetration [%])
Bacterial < 0.000007* < 0.000007* lines or cylinders via a ventilator should be free of microbes and
Viral 0.0047 0.00092 should not require further filtration. However, filters could be used to
Sodium chloride particles 0.056 0.022
reduce surface contamination near the exhaust ports of ventilators.
*Less than the limit of detection.
Anaesthesia
The routine use of breathing system filters theoretically reduces the
i.e. volume flow per unit area of filter material. Resistance to gas risk of cross-infection when breathing systems are used for more
flow also depends on the filter area, so that a filter with a larger sur- than one patient. However, a reduction in the incidence of nosoco-
face area can either have lower resistance to gas flow or a more mial infection when filters are used has yet to be demonstrated,
efficient (denser or thicker) filter material with a similar resistance although the use of filters has been shown to prevent bacterial con-
to a filter with a smaller surface area. Generally, therefore, a larger tamination of the interior of breathing systems. Condensation may
filter will have a greater filtration efficiency than a smaller filter collect in a circle breathing system: this has the potential to be
(Table 4). However, it is important to note that the clinical rele- transferred into the next patient’s respiratory tract. The use of an
vance of the difference in filtration performance between different appropriate filter would reduce the risk of this.
filters has yet to be established.
Hazards and complications of breathing filters
Liquid-borne The use of filters is not free of risk. They increase total resistance
During in vitro tests, pleated hydrophobic filter material prevents to gas flow and work of breathing. They may affect the triggering
the transmission of liquid, and hence liquid-borne microbes such as of some ventilators. When sited at the Y-piece, the filter housing
blood-borne viruses, under pressures normally encountered in clin- increases dead-space, so total ventilation must be increased to
ical practice. A pressure difference of > 10 kPa is typically neces- maintain adequate alveolar ventilation thus increasing peak alveo-
sary to force liquid through a pleated hydrophobic filter. In con- lar pressure. Blockage due to water, secretions, inhalants and man-
trast, liquid (and any microbes contained in the liquid) can be ufacturing faults have all been reported.
forced through electrostatic filter material if the liquid has formed
a layer covering the filter material and there is a difference in pres-
Key references
Hinds WC. Aerosol Technology. Properties, Behaviour, and Measurement of
sure across the filter layer greater than about 1.6 kPa. The risk of
Airborne Particles, 2nd edn. New York:Wiley, 1999
transmission of liquid through electrostatic filters can be reduced
Rathgeber J, Keitzmann D, Mergeryant H, Hub R, Züchner K, Kettler D.
by using a filter with a large surface area and by orientating the fil- Prevention of patient bacterial contamination of anaesthesia-circle-
ter such that the filter layer is vertical. However, the surface area of systems. A clinical study of the contamination risk and performance
of different heat and moisture exchangers with Electret filter
the filter material that can be used is limited by the shape and inter-
(HMEF). Eur J Anaesthesiol 1997; 14: 368–73
nal volume of the filter housing. The internal volume should be a Wilkes AR, Benbough JE, Speight SE, Harmer M.The bacterial and viral fil-
small fraction of the patient’s tidal volume to prevent unreason- tration performance of breathing system filters. Anaesthesia 2000; 55:
able levels of re-breathing. 458–65
These in vitro tests are generally of short duration. However, Wilkes AR. Measuring the filtration performance of breathing system fil-
ters using sodium chloride particles. Anaesthesia 2002; 57: 162–8
filters may be used for up to 24 h. Whether contamination present
Wilkes AR.The ability of breathing system filters to prevent liquid cont-
on one side of the filter material during the early part of its use amination of breathing systems – a laboratory study. Anaesthesia
may pass through to the other side by the end of this period of use 2002; 57: 33–9
has not been investigated. See multiple choice questions 103 and 104.

154 British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 5 2002