NHS FORTH VALLEY HUMIDIFICATION OF INSPIRED GASES IN THE NEONATAL UNIT

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1 NHS FORTH VALLEY HUMIDIFICATION OF INSPIRED GASES IN THE NEONATAL UNIT Approved 01/11/2009 Version 1.2 Date of First Issue 01/11/2009 Review Date 25/11/2014 Date of Issue 25/11/2012 EQIA Yes 25/11/2012 Author / Contact Sister Stephanie Cahill Group / Committee Final Approval W&C CG committee Version th November 2012 page 1 of 10

2 NHS Forth Valley Consultation and Change Record Contributing Authors: NNU SRI Paediatric Consultants Annette Frager Staff Grade paediatrics Consultation Process: NNU staff Paediatricians Distribution: NNU Intranet Change Record Date Author Change Version 10/10/2012 SC Addition on bottom of page 6 regarding Vapotherm 10/10/2012 SC Changes made to Humidifier top-ups in line with current practice Addition of Appendix 1 Change made to Humidifier settings as MR700 no longer in use. Insertion of information on changing circuits. References updated. Version th November 2012 page 2 of 10

3 NHS FORTH VALLEY HUMIDIFICATION OF INSPIRED GASES IN THE NEONATAL UNIT Contents Contents...3 Terminology...3 Principles...3 Physiology...4 Potential consequences of dry or cool air...4 Potential consequences of excess humidity...4 How is optimal humidity achieved?...5 Humidifier top-ups...6 Problems with rain-out...6 Humidifier settings...6 Acknowledgement...7 References...7 Terminology Humidity is the presence of water vapour in a gas. Absolute humidity is the amount of water vapour per litre of gas, expressed in mg/l. Relative humidity is a measure of how much water vapour is in a gas compared to its capacity to hold water vapour. It is measured as a percentage. Principles When dry gas passes over a moist surface evaporation occurs and the gas becomes more humid. When moist gas cools, water droplets condense and the gas becomes less humid. The warmer a gas, the more moisture (absolute humidity) it can carry. If a gas already has 100% humidity no more moisture will evaporate into it unless it is heated further. Version th November 2012 page 3 of 10

4 Physiology When we breathe in, cool air is warmed to body temperature as it passes through the upper airways and water vapour is add to it by evaporation from the mucosa. By the time gas reaches the lung it is at 37 centigrade and 100% relative humidity (i.e. completely saturated with water vapour). When we exhale, the gas cools as it passes back out, giving back a significant proportion of the moisture and warmth to the lining of the upper airways. This helps to minimise the amount of insensible water and heat loss from the body during breathing. The nasal passages are best able to warm and humidify inspired gas so even mouth breathing is less effective. If the upper airway is bypassed by an endotracheal tube or tracheostomy, this process cannot take place and dry cool gases can arrive in the distal airways. Water and heat are then lost from the mucosa as the gas warms and humidifies and these are lost from the body as the upper airway is bypassed on exhalation. If the inspiratory gases are cooler than body temperature, moisture will evaporate into them as they warm. If the inspiratory gases are less then 100% relative humidity, moisture will evaporate into them until 100% is reached. Ideally ventilator and CPAP gases should be as close to 37 centigrade and 100% humidity as possible at the point that they enter the patient. This corresponds to a water content of 44mg/l. Potential consequences of dry or cool air Increased heat loss Increased insensible water loss Drying and thickening of nasal and bronchial secretions Cilial dysfunction resulting in poor clearance of secretions and increased risk of infection. Inflammatory reaction of the lining cells of the respiratory tract. Increased tendency to airway/et tube plugging. Bronchospasm Possible increased risk of pneumothorax Discomfort for the baby. Potential consequences of excess humidity If the ventilator gases are fully humidified and warmer than body temperature, condensation could occur within the lungs. Condensation occurring in the tubing can trickle back in to the airway or block the tubing causing false ventilator or CPAP pressure measurements. Version th November 2012 page 4 of 10

5 How is optimal humidity achieved? See the figure below. The inspiratory limb of the ventilator (1) passes into the humidifier chamber (2). The humidifier heats the gas to 37C and 100% relative humidity. The gas then passes into tubing that is heated by wire to 40C preventing any cooling or loss of humidity (3). The last short piece of tubing beyond the temperature sensor (4) is unheated, allowing the gas to cool back to 37C by the time it reaches the patient. This corresponds to humidity settings of 40C minus 3 (temperature control and chamber control). Gas at 37C and 100% relative humidity is delivered to the patient manifold (5). The expiratory limb is unheated in the RT227 circuits (6). The gas cools rapidly on this side of the circuit and water condenses and should be collected in the trap (7) before reaching the expiratory block of the ventilator. The expiratory limb should pass down-hill from the patient manifold to prevent water trickling back into the patient. The trap should be emptied regularly. The expiratory limb of the RT268 circuit is heated plus water vapour diffuses through the tubing wall reducing condensation and the need for a water trap. N.B. when setting up the circuit, make sure the temperature sensors are fully inserted into the connectors. Version th November 2012 page 5 of 10

6 Humidifier top-ups If the humidifier chamber dries out, dry gases are delivered to the patient with risk of serious complications. This problem is particularly likely to occur when the Infant Flow Driver is used as this device uses high flows. When delivering ventilation using the RT227 and RT268 circuits with MR290 Dual Float Chamber, the system will automatically top-up the chamber. When the hourly nursing observations are performed the chamber should have just enough water to cover the heating plate. When delivering SiPAP/CPAP using The Infant Flow System and the MR225 humidity chamber with Water Feed Set with self closing clamp, manual filling of the humidity chamber is required. See Appendix 1 for instruction for use. When the hourly nursing observations are performed refill the humidity chamber to the line every time. This should be recorded on the nursing observation chart. Problems with rain-out This is due to ambient air outside the tubing being cool, causing the water vapour inside the tubing to cool down and condense. Check the temperature probe is inserted firmly into the circuit. Check for circuits leaks/loose connections (sometimes the ventilator won t detect small leaks). Minimise draughts within the nursery. Avoid the use of fans near the ventilator circuit. Position tubing to minimise the risk of rain out running into the airway. Humidifier settings All our ventilators, SiPAP and CPAP flow drivers are attached to Fisher&Paykel humidifiers MR850 MR850 Humidifier should be set to Invasive Mode. This is pre-set to 40C minus 3 delivering an airway temperature of 37C; this is displayed in the LED window and should be documented on the ITU observation chart. Ventilator and SiPAP/CPAP circuits should be changed every 7 days or when visibly soiled or mechanically malfunctioning. For Vapotherm see Humidified High Flow Nasal Cannulae Guideline. Please refer to Operators Manual for all Medical Devices. Version th November 2012 page 6 of 10

7 Acknowledgement These guidelines are from the Royal Infirmary of Edinburgh, Neonatal Unit and have been adapted as clinical guidelines for Stirling Royal Infirmary, Neonatal by Stephanie Cahill, Neonatal Sister. References Frey B, Shann F. Oxygen administration in infants. Diseases in Childhood Fetal & Neonatal edition 2003: 88: F84-F88. Davis M, Dunster K, Cartwright D. Inspired gas temperature in ventilated neonates. Pediatric Pulmonology 2004; 38(1): Merenstien G B, Gardner S L. Handbook of Neonatal Intensive Care 2006; Todd D A, Boyd J, Lloyd J, John E. Inspired gas humidity during mechanical ventilation: Effects of humidification chamber, airway temperature probe position and environmental conditions. Journal Paediatrics Child Health 2001; 37: Ho T, Mok J. Condensate clearance from CPAP circuit: An examination of two methods of draining condensate from the inspiratory tubing. Journal of Neonatal Nursing 2003; 9(4): Fisher and Paykel Healthcare 2011 Nurturing Life The F&P Infant Respiratory Care Continuum. Auckland: Fisher and Paykel Healthcare Fisher and Paykel Healthcare 2006 Inspired Care MR850 Humidification system. Auckland: Fisher and Paykel healthcare. Fisher and Paykel Healthcare 2005 Respiratory humidification - neonates. Auckland: fisher and Paykel Healthcare Fisher and Paykel Healthcare 2003 Why humidification is vital for neonates. Auckland: Fisher and Paykel Healthcare. Williams R., Rankin N., Smith T., Galler D., Seakins P., Relationship between the humidity and temperature of inspired gas and the function of airway mucosa. Critical Care medicine 1996; 24(11): Version th November 2012 page 7 of 10

8 Appendix 1 Water Feed Set with self closing clamp Instructions for use BEFORE FITTING CPAP TO BABY Use aseptic technique. Remove ring pin from self closing clamp and DISCARD pin. After removing the protective cover from the bag spike, insert the spike into the bag of sterile water for inhalation. Connect luer adaptor to humidity chamber. Suspend the bag of sterile water for inhalation. Squeeze the self closing clamp to allow the water to enter the humidity chamber. Fill to the maximum level as indicated on the humidity chamber. DO NOT OVERFILL Release the clamp to the closed position. ENSURE WATER FLOW HAS STOPPED After filling the humidity chamber, place the bag of water for inhalation below the humidity chamber. HUMIDIFIER TOP UP WHEN CPAP IS IN USE Suspend the bag of sterile water for inhalation. Squeeze the bag of water while at the same time squeezing the self closing clamp to allow the water to enter the humidity chamber. SQUEEZING THE BAG WILL PREVENT THE GASES ENTERING THE BAG Release the self closing clamp then release the bag. NOTE: IT MAY BE NECESSARY TO TEMPORARELY REDUCE THE CPAP GAS FLOW TO FACILITATE FILLING OF THE HUMIDITY CHAMBER, IN THIS CASE BE AWARE THAT CPAP PRESSURES TO THE BABY WILL BE TEMPORARELY REDUCED UNTIL FLOW IS RESET Fill to the maximum level as indicated on the humidity chamber. Version th November 2012 page 8 of 10

9 DO NOT OVERFILL Release the clamp to the closed position. ENSURE WATER FLOW HAS STOPPED After filling the humidity chamber, place the bag of water for inhalation below the humidity chamber. ENSURE THAT DESIRED CPAP PRESSURE IS BEING DELIVERED Version th November 2012 page 9 of 10

10 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - Version th November 2012 page 10 of 10

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