Intensive Medicine REVISIONS
2013 - 30 Nº 1
Key words
■ Bacterial/viral filters
■ Filtration
■ artificial airway and
mechanical ventilation
■ Interfaces
The Use of bacterial/viral
filters during artificial
airway and invasive
mechanical ventilation
Sebastián Fredes, Emiliano Gogniat, Gustavo Plotnikow, Roger
Rodrigues-La Moglie
Chapter of Kinesiology in Critical Patient, Intensive Care Argentine
Society
Correspondence:
Lic. Gustavo Plotnikow
gplotnikow@gmail.com
Conflicts of Interests: None.
Abstract
Medical gases that go towards the patient in mechanical ventilation, and
those which exit to the environment should always be filtered. The particle
removal by filtration can be achieved by different mechanisms of action,
either with mechanical or electrostatic filters.
The use of bacterial/viral filters should apply to all patients who required
artificial airway and mechanical ventilation in intensive care units.

INTRODUCTION
Medical gases that go towards the patient by artificial
airway and mechanical ventilation and those which exit to
the environment should always be filtered. The particle
removal by filtration can be achieved by different
mechanisms of action, either with mechanical or
electrostatic filters. The objective of this summary is to
describe the main technical features in bacterial filters
used in the Intensive Care Unit, both their indications and
contraindications of use and their limitations.
Materials and Methods
The Chapter of Kinesiology of Intensive Care
Argentine Society developed a bibliographic
search so as to make this summary. The
search was made in LILACS, MEDLINE
Cochrane Library and SciELO data base with
the following key words: viral-bacterial
filters, filtration, mechanical ventilation,
interfaces. The most relevant articles were
selected from the search according to authors’
criteria.
Development
The term “Filtration” is defined as the act of or process
of filtering or, more specifically, as the process of passing
liquids or gases through a filter in order to remove solid
particles.1 Filters are employed to prevent the entry of
undesirable particles into the patient through inspired
gases and, potentially, remove particles from the exhaled
gases. The gas exhaled by infected critical patients might
contain viral or bacterial pathogens which can be
transmitted to other patients, healthcare workers or
visitors.
Multiple bacteria (both inhaling and exhaling ones)
have been isolated from ventilator circuits as well in
humidifiers) Some of the isolated bacteria are
Pseudomonas maltophilia, Pseudomonas aeruginosa,
Klebsiella pneumoniae, Proteus mirabi-lis, Enterobacter
cloacae, Enterobacter agglomerans, Citrobacter diversus,
Candida albicans, Flavobacte-rium meningosepticun,
different kinds of Proteus y Streptococcus. The respiratory
tract is the commonest entry route inside human body. The
shedding of viral particles into the lungs depends on
Physical principles such as Sedimentation, Impaction and
Diffusion. All particles less than 10 micrometers diameter
(µm) diameter (1 µm = 0,001 millimeters) are potentially
active biologically speaking in susceptible patients
INTENSIVE MEDICINE - 2013 - 30 Nº 1
from the toxicologically point of view. Most of the
particles less than 8 µm diameter could impact above
larynx without reaching the lungs. Particles from 1 to 8
µm diameter could be deposited into the upper airways
and lower airways as well into the alveolus . The particle
between 1 and 2 µm diameter is the particle which reaches
the major alveolus deposit level.
Mechanical ventilation circuits used in the Intensive Care
Unit are open and they liberate the exhaled air to the
Intensive Care Unit’s atmosphere. That creates a potential
way of hospital-acquired infections among patients.
Visitors and health workers are at risk of exhaled particles
of exposure.
A filter is a device commonly composed of an external
rigid structure which has a laminar made of fibers.
Particles are captured by the fibers material when the gas
flows thorough the sinuous path created by the hollow
interconnected spaces inside the filter structure. That is to
say, as gas moves through the filter, particles are being
deposited over the material. .
Filtration mechanisms
Particles removal by filtration can be achieved by 6
different mechanisms of action:2
Interception takes place when a particle which is
following a gas streamline comes within one particle
radius of a filter fiber. The particle touches the fiber and is
captured, thus being removed from the gas. This
mechanism occurs with medium rank particles, that is to
say, from 0.1 to 1 millimeter or bigger which are big
enough so as to have a significant inertia but too small so
as to diffuse into gas flow.
Inertial Impaction: The particles subjected to inertial
impaction are usually greater between 0.3 a 1 mm.
 Gravitational settling: Large particles in slow-moving
air do not follow gas streamline is more than one particle
radius from the fiber. As a result, these particles will be
adhered to the fiber This principle affects to bigger
particles, usually bigger than 10 mm.
Diffusional impaction: Particles’ Kinetic activity plays
an important role in filtration. All particles are in
continuous random movement colliding each other. This
mechanism affects smaller particles, especially those
lesser tan 0.1 millimeters. The smaller the particle is the
slower the gas flow is and there is a greater chance that the
particle may be adhered to the filter.
Electrostatic attraction: Some filter material is
electrostatically charged during manufacture in order to
enhance its ability to capture particles. There aret
mechanisms of capture: charged particles in the gas stream
are attracted to a charged fiber as the electric field on the
fiber induces a dipole in the particles (positive and
negative charges on opposite sides of the particles) and
charged particles are attracted to neutral fibers by inducing
image forces on the fibers.
Sieving: Sieving is produced when particles are
physical unable to pass through openings in the filter
structure and are captured due to their greater size. That is
to say, the air stream carries a particle between two fibers,
but the particle is larger than the gap, so it becomes
ensnared.
Figure 1. Mechanical filter
Types of filters:
There are two types of filters for bacteria/viruses
available to filter inspired gases. Mechanical filters stop
physically particles, due to their small pores which are the
result of filter’s design; electrostatic filters are
electrostatically charged so they attract and capture
charged particles. 3
Mechanical filters: They consist in a sheet of resin
bonded glass fibers- (Figure 1).4 The fibers are packed
densely and the sheet has a high-resistance to gas flow
because of the high density of their fibers. A sheet with a
large surface area is used to reduce the resistance to the
gas flow to an acceptable level. The glass fiber sheet is
then pleated to minimize the required volume and hence
dead space for the housing.
Glass fiber laminar is hydrophobic and under normal
clinical conditions does not absorb water. (Figure 2).
Electrostatic filters: Unlike glass fiber filters,
Electrostatic filters use a flat layer of fiber material as a
barrier (Figures 3 y 4).4 Fiber density of electrostatic
filters is lower than in glass fiber filters; therefore,
electrostatic filters provide a lower resistance to gas flow
per unit area. Filtration performance is enhanced by
applying an electrostatically charged material which
attracts and binds any particle which passes through
the filter material. Filter material does not need to be
pleated to increase surface area because of its lesser
resistance to gas flow and electrostatic particles attraction.
For that reason, these filters offer a less dead space. 2
There are two kinds of electrostatic filters:
a. Tribocharged filters: an electrostatic charge can be
induce don two dissimilar fibers by rubbing them
together during the manufacturing process, so that one
type becomes positively charged and the other type
negatively charged (tribocharging) One such filter
material is made from fibers of polypropylene and
modacrylic which can be converted into a non woven
felt

Figure 2. Mechanical filter pleated sheet
Figure 3. Electrostatic filter.
Figure 4. Flat layer of fiber material.
b. Fibrillated coronal- charged filters: An electrostatic
charge can be applied to a sheet of polypropylene by
using a point electrode emitting ions (corona
charging). An opposite charge can be induced on the
rear of the sheet. This type of material is often called
an electret. If the sheet of polypropylenes now
stretched, the strength of the molecular bonds is
enhanced in the direction of the stretching but reduced
in a direction perpendicular to it. The sheet can then be
split into fibers- a process called fibrillation and made
into a non-woven filter wad.
Efficiency, technical
specifications and clinical
relevance
Efficiency: The filtration efficiency of a filter is
determined by measuring the number of particles through
Intensive Medine - 2013 - 30 Nº 1
the filter as a percentage of the number of particles in an
aerosol challenge to the filter. The percentage is the
penetration value for the filter. Although challenges of
microbes can be used, the standard for breathing system
filters specifies that the challenge should consist of a
particular quantity of an aerosol containing sodium
chloride particles having diameters close to the most
penetrating particles size. The filter is challenged at a flow
of 15 or 30 L. min for filters intended for use with
pediatric or adult patients, respectively.
Another method to determine filter’s efficiency is
High Efficiency Particulate Air (HEPA) which is
considered the most rigorous test. HEPA filters are
classified into True HEPA and HEPA-type, with a
subgroup of HEPA, called Ultra Low Penetration Air
(ULPA). ULPA filters offer an enhanced resistance but
because of their resistance level is too high so as to
employ them with medical devices. HEPA filers are
HEPA filters have a pleated fiberglass which is used to
increase their surface contact and minimize the required
volume and dead space.5 Larger particles (larger than 0.3
µm) are captured through inertial (and sieving)
mechanisms, while smaller particles are retained by
diffusion. 0.3 µm particles are the most difficult ones to be
captured by filtration.
There are two mechanisms accepted by HEPA
certification: British method BS3928 Sodium Flame and
USA Hot DOP (di-ocytyl-phthalate). BS 3928 is the
British standard that specfies the sodium flame test
method for Hepa filters. In this test, the particle size is
smaller than the particle used in USA Hot DOP. BS 3928
uses a particle with 0.07 µm. In contrast, USA test
employs a 0,3 µm5 particle diameter. HEPA filters are
classified according to the percentage of particles of an
specific size which are not filtered. (See Table).
As it was already mentioned, 0.3 µm particle is the most
difficult particle size to capture by filtration. A filter
should capture particles smaller than de 0.3 µm in
order to be classified as HEPA FILTER. However, it is
important to take into account that HEPA is a scale with
different filtration percentages. For instance, H10 HEPA
filters could capture 85% of all particles and H14 HEPA
filters could capture 99.995% of all particles. Table below
shows HEPA Filters performance.
TABLE
HEPA FILTERS PERFORMANCE
TYPE Class
HEPA H 10
HEPA H 11
HEPA H 12
HEPA H 13
HEPA H 14
Volume flow Range: Each manufacturer states that the
product can be used safely according to the volume flow
range. The filter use in patients with flow volumes outside
the range could reduce their efficiency and affect
resistance to air flow.
Pressure drop: If there is a huge difference of pressure
in both sides of the filter because of its resistance to the air
flow, this will make difficult for patients with mechanical
ventilation to breath. Differential pressure through a filter
is measured according to a 15 l/min flow for pediatric
filters or 30 l/min for adult filters. This is stated in pascals
(100 Pa = 1.02 cmH2O).
Weight: A too heavy filter could create traction over
ventilator circuit or the artificial airway. Filter weight
stated by each manufacturer must be obtained when the
filter is under dry conditions and with no use. Any
condensation inside the filter when it was used could
increase filter’s weight.
Dimensions: The large of a filter is the distance between
distal ends’ connectors. Width is the maximum distance
through filter housing horizontally and height is the
maximum distance through its structure vertically.
Diameter must be considered for those rounded filters.
Efficiency Penetration
85% 15%
95% 5%
99.5% 0.5%
99.95% 0.05%
99.995% 0.005%
 Internal volume: Filter Internal volume must be
considered inside dead space if the distal is used as a “Y”
piece. (placed between patient’s artificial airway and “Y”
piece circuit)
Connectors: Filters have two connectors: one with 15
mm and another with 22 mm.
7. Mostofi R, Wang B, Haghighat F, et al. Performance of me-
chanical filters and respirators for capturing nanoparticles-
limitations and future direction. Ind Health 2010; 48: 296-304.
Lawes EG. Hidden hazards and dangers associated with the use
of HME/filters in breathing circuits. Br J Anaesth 2003; 91: 249-
8. 264.

Macroscopic Monitoring

It is advisable to perform a macroscopic monitoring

filter in search of elements which could affect the device
normal functioning (impaction with secretions,
excessive condensation, visible particles, etc.)

The inclusión of a new device inside ventilator circuit

could affect any of the mechanical ventilation patient’s
parameters and measurements obtained in respiratory
revision undertaken. It is important that you can monitor
peak pressure, plateau pressure and medium pressure
parameters, that is to say, to monitor inhaling and exhaling
resistance. The increase of resistance created by a filter
could trigger the presence of intrinsic PEEP and the
consequent rise of peak pressure, plateau pressure and
medium pressure (Intrinsic PEEP occurs when the
expiratory time is shorter than the time needed to fully
deflate the lungs, preventing the lung and chest wall from
reaching an elastic equilibrium point)

Characterístics of a perfect filter

A perfect filter should have the following

characteristics:
• Small internal volume
• Low resistance (electrostatic)
• Transparent
• Lightweight
• Cheap
• High percentage efficiency
• Hydrophobic

Bibliography
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http://lema.rae.es/drae/?val=filtracion
2. Davey AJ. Ward’s Anesthetic Equipment, 5a ed. Philadelphia,
PA: Elsevier Saunders; 2005: 133-153.
3. Lee MG, Ford JL, Hunt PB, et al. Bacterial retention prop-erties
of heat and moisture exchange filters. Br J Anaesth. 1992; 69:
522-525.
4. Wilkes A. Assessing breathing-system filters. Medical De-vices
Tech 2004; 15(5): 12-14.

5. Wilkes AR. The effect of gas flow on the filtration perfor-mance

of breathing system filters. Anaesthesia 2004; 59: 278-282.

6. Trust Science Innovation. Health and safety. Mechanisms of

Filtration for High Efficiency Fibrous Filters. Application notes
ITI-041. 2008.