Anaesthesiu ~ 0 1 2 4no 4 October 1969

Humidification requirements and techniques

Including a review of the performance of equipment in current use

Anne R. Chamney

The importance of using warm and humid inspiratory gases for patients
who are ventilating, spontaneously or not, through a tracheostomy, an
endotracheal tube or a nasotracheal tube has been increasingly appreciated
in recent years. The complications which can arise when this heating and
humidification are neglected are the direct consequence of drying the
tracheal mucosa and are manifested clinically as the formation of tena-
cious, inspissated mucus and encrustation of the trachea 1- 3. Adequate
humidification of the inspired gases has been recommended spec.fically for
the treatment of tracheobronchitis4,5, severe chest injuries617, head
injuries8t9, poliomyelitis 1, pulmonary insufficiency of the new-born 10,
pulmonary burns’ 1, for the treatment of infants and children 1 2 - 1 4 and
to reduce the risk of tracheo-bronchial infections after tracheostomy 1 5
and fibrinous tracheitis with membrane formation and ulceration 1 6 1 7.
There are at present many types of humidifier available and the detailed
studies of performance which have been published refer to specific units.
The aim of this paper is to review the requirements of the patient whose
upper respiratory tract has been bypassed, to produce a specification for
heater-humidifiers which is based on the probable physiological needs of
these patients and to assess existing equipment by comparing its perform-
ance with that laid down in the specification.
Utiits
The comparative assessment of the results reported by different workers is
often complicated by the use of the term ‘relative humidity’. This term
means the amount of water vapour present in a gas at any temperature
expressed as a percentage of the amount of water vapour which the gas
would hold if it were fully saturated at that temperature. On the other hand,
the ‘absolute humidity’ is a measure of the actual quantity of water vapour
present in a unit volume of dry gas at a standard temperature and pressure.
To facilitate comparison, all the results quoted in this paper have been
converted into absolute humidity in milligrams of water per litre (which is
the same as grams per cubic metre) of dry gas at standard temperature and
Anne R . Cfiarnney,MSc, C.Etig, MlMech E, sometime James Clayton Fellow iti Medical
Engineering. Now ut Departnient of Mechanical Engineering, Uiiiversirv of Satford,
Salford 5 , Lancs.

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 Anaesthesia vol24 no 4 October 1969

80
90
98.4
26.7
32.2
36.9
I 25.3
34.2
43.7

PHYSIOLOGICAL REQUIREMENTS

Temperature
(a) In humans, the normal range of inspired gas temperature in the trachea
is 32-36°C even when breathing cold air through the nose 18-20.
(b)The comfort range for patients whose inspired gases are introduced
directly into the trachea is probably 30-35OC219 22.
(c) Tracheal inspired gas temperatures above 40°C appear to increase the
work of breathing and the incidence of laryngeal spasm and sweating23and
can cause hyperthermia24, while temperatures below 30°C depress ciliary
activity 22 2 5.
9

( d ) Inspiration of very cold air through the nose or mouth can increase
airway resistance in some asthmatics26.27.
(e) The comfort range for adult patients in a controlled environment
(such as a room) is around 21-24°C if the atmosphere is supersaturated28.
This, of course, is for the whole patient and does not apply to intratracheal
conditions. It also does not apply to the new-born.

Humidity
(a)The humidity of gas saturated with water vapour at 37°C is 44mg/litre.
(b) In humans, the normal range of humidity of inspired gases in the
trachea is about 34-35mg/litre even when breathing cold air through the
nose 18-20.
(c) At very high inspired humidities, a patient may gain water through
his respiratory tract with the consequent danger of water-intoxication,
especially in infants29.
( d ) The use of heated (30°C) and humidified (3lmg/litre) anaesthetic
gases can cause a striking reduction in the incidence of unwanted hypo-
thermia in infants and young children30.
(e) Inspiration of dry gas over a period leads to squamous metaplasia of
the trachea3 1.
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(f) Humidities of less than 8mg/litre are undesirable even for humans
breathing through the nose in a normal (indoor) ambient atmosphere if
they are exposed continuously32.
(g) Oxygen acts as a specific anti-expectorant3393J. It also causes drying
and dessication of the respiratory mucosa if it is not humidified29.
(h) In a controlled environment, humidities above 3lmg/litre are
dangerous35. As in clause (e)for temperature, this value refers to the whole
adult.
Results of animal experiments. ( i ) Tracheal gas humidities below 13mg/
litre depress ciliary activity after short periods36-38 and dry gases appear
to increase the work of breathing39. Dehydration of the respiratory
epithelium leads to squamous metaplasia in both chickens and dogs40.
( i i ) Very wet gases (i.e. supersaturated with water droplets) lead to
changes consistent with broncho-pneumonia in normal puppies41 and can
cause a significant decrease in arterial oxygen tension and a significant
increase in the alveolar-arterial oxygen gradient in intubated adult dogs
after only three hours' exposure".
(iii)In sheep, the instillation of lml of water per kg body weight into the
trachea causes hypoxaemia, gross drop in lung compliance and increases
in both the pulmonary vascular resistance and the pulmonary artery pres-
sure. These occur almost immediately and persist for considerable periods
of time although the fluid is absorbed from the lungs in 2-3 minutes43p44.
Adult dogs who aspirated 1lml/kg body weight showed an immediate drop
in their arterial oxygen tensions from 90-100mm Hg to 35-45mm Hg and
the tension was still low after 72 hours. Acidosis and hypercarbia, however,
were transient and disappeared within four hours of aspiration45. Thirty
ml of fresh water/kg body weight or 12.lml of physiological saline/kg may
be sufficient to drown healthy adult dogs46.
From the above, it would appear that the temperature range for the
inspired gases for patients whose upper respiratory tract has been bypassed
should be about 30-36°C. The optimum conditions for humidity are much
less clear-cut but a safe range would probably be 30-40mg/litre. For those
more accustomed to working in relative humidity, this is equivalent to a
range of 97-129% at 30°C or 72-95% at 36°C. It should be remembered
that all the work on the effects of exposure to very high humidity levels has
been undertaken on apparently healthy animals. Patients who already
have impaired ventilaiory function may well be less tolerant of non-
physiological conditions.

SPECIFICATION
The basic requirements will be examined under seven headings :
( I ) Inspired atmosphere
At the entry to the patient's trachea, the temperature and humidity of the
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gas should be within the ranges 30-36°C and 30-4Omg/litre. If the air-
conditioner is not connected to a ventilator, it should be able to deliver air
or oxygen+nriched air to the patient and the percentage oxygen which the
patient inspires should be predictable for a known oxygen supply rate,
i.e. a machine must not allow oxygen to leak out through the air inlet and
a controlled environment must be accurately controlled.

( 2 ) Sinip/icity in use
The apparatus must be simple to use and it must be so designed that in-
advertent or unskilled interference with the controls will not endanger
either the patient or his attendants. It should need little and infrequent
attention for servicing and it must be obvious when this is necessary.
(3) Adaptability
The apparatus should preferably be capable of operating with or without
an artificial ventilator and it must, as far as possible, be self-contained. If it
is to be moved to the patient, it must also be portable and compact.
Devices in the form of machines placed near the patient’s bed should be
capable of operating in any convenient position close to the patient, prefer-
ably at eye-level where they are probably most readily supervised. If they
are to be used with patients who are breathing spontaneously, the devices
should be capable of operating whether the source of gas is room air, com-
pressed oxygen or a combination of these.

( 4 ) Reliability
The apparatus must be robust. Failure to deliver the gas to the patient must
be immediately obvious and an adequate alarm system should be fitted to
ensure this. If the humidifier is fitted to a ventilator, the actuator can be
anywhere in the circuit and not necessarily between the humidifier and the
patient.

( 5 ) Patient comfort
Ideally, the patient should not suffer any additional distress due to the
presence of the humidifier. If a motor is used, it should be silent and
mechanical vibrations should not be transmitted to the patient. If the
device is fixed in a patient’s breathing circuit, it must not increase the work
of breathing by mechanical obstruction or by increased dead-space. If the
patient is treated by modifying his environment, the new ambient condi-
tions must be readily tolerable and the patient must be protected, as far as
possible, from a sense of isolation. This is particularly important for
intubated patients who cannot call for help.

(6) Safety
(a) Electrical and mechanical. If any form of heater is used, there must be a
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reliable over-riding cut-out in case the normal control system fails. If the
device is connected to the patient, there must be some pressure-release
system between the machine and the patient on the inspiratory side and
provision must be made for an adequate airway at all times so that the
patient will not be asphyxiated if he coughs up lumps of mucus. This
means that the tubing must be of adequate bore and that valves must be so
positioned that they do not become obstructed. If any machinery is used,
it must be as safe as possible with oxygen present and extra care is neces-
sary if both water and electricity are used in the same apparatus. All
apparatus should, as far as possible, be proof against uninformed inter-
ference, for example it should not be possible to gain access to the setting
of any safety system without the use of at least one tool such as a screw-
driver.
(b) Bacteriological. The apparatus must be bacteriologically safe and it
must be easy to clean and to sterilise.
(7) Access to thepatietit
The apparatus must not impede the medical and nursing staff attending
the patient.

EXISTING EQUIPMENT

Classif cat ion

There are two basic techniques applicable to the humidification of inspira-
tory gases for patients who are breathing spontaneously but only one of
these is suitable for patients who are being ventilated artificially.
(I) It is possible to modify the patient’s environment by using devices
such as fog rooms, steam tents or incubators. Since the limiting factors for
these units are imposed by the patient’s ability to tolerate the altered
environment, all these units will be treated as one group regardless of the
method used to heat and humidify the atmosphere.
(2) It is possible to modify the patient’s inspired gases without altering
his environment. Apparatus for this purpose is connected to his tracheal
tube either directly or by means of a delivery tube. The temperature and
humidity of the gases supplied depend largely on the system used. The four
main categories are :
(a) Heat-and-moisture exchangers (‘artificial noses’)
(6) Instillation or infusion
(c) Nebulizers (i) Gas driven
(ii) Mechanically actuated
(d) Water-bath humidifiers.
The delivery tube will be treated as part of the system where one is required,
i.e. groups (c) and (d), since the conditions which matter are those at the
entrance to the patient’s trachea and not those in the machine.
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Type I. Controlled environmerit

This section is taken to include all systems where the machine is connected
to the enclosure in which the patient is nursed and not to the patient him-
self. The devices which have been described include fog rooms*O~47~4*,
which are maintained at temperatures of 2425°C with humidities up to
27mg/litres, adult oxygen tents9 with temperatures of 20-22°C and humidi-
ties of 16-l7mg/litre and paediatric cold steam tents31.49~50 with oper-
ating ranges of 17-22°C and 15-22mg/litre. Incubators for use with new-
born babies also come into this category but they will not be considered as
these patients form a special group with different basic requirements.
It should be noted that most manufacturers of this type of apparatus claim
that it may obviate the need for a tracheostomy but not that it is necessarily
suitable for the patient whose upper respiratory tract has already been by-
passed. Its main use for these latter patients would appear to be in the
treatment of small children when it is often very difficult to use any other
technique successfully. It is, of course, only suitable for patients who are
ventilating spontaneously.

Tvpe 2. Controlled inspired atmosphere

(a) Heat-and-moisture exchangers. These devices are connected directly to
the patient’s tracheostomy or endotracheal tube and work automatically
during respiration, whether this is spontaneous or not. During expiration,
the warm, wet gases pass through a metal mesh or gauze which condenses
out some of the water vapour and also retains some of the heat. During the
next inspiration this heat and moisture are transferred to the cold, dry
incoming gases. Several versions have been described in the literaturesl-54.
It has been shown by Mapleson et al.54 that their efficiency depends
on the ambient atmospheric conditions and that they may return to the
patient between 40% and 90% of the moisture he would otherwise lose.
Tests have shown that these units give inspired gas conditions of 28-30°C
and 22-24mg/litres for normal ambient conditions31.51-53.55. Marshall,
Jones & Crichton56 found that the effectiveness of the units was reduced if
dry oxygen was added in appreciable quantities while Norris & Camp-
bell5 7 say that condenser-humidifiers are only efficient if they are reason-
ably dry: to achieve this the gauze should be changed about every three
hours. It has also been found58 that if the gauze is changed as frequently
as this it is possible to obtain a reasonable control of Pseudomonas pyo-
cyanea in units used on infected patients. The resistance of the units to gas
flow has been found to vary considerably and, in a comparative study of
three types59, the range quoted for a steady flow of dry air varied from
22mm of water at 28 litres/min for rolled wire gauze to only 5mm of water
at 60 litres/min for a multi-layer gauze model.
These units would appear to be best suited to the patient with few
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secretions who is being weaned from a humidifier, for whom they are
probably nearly ideal.
(b)Infusion. A very simple technique for humidifying a patient’s inspired
gas is to instil a suitable fluid, usually physiological saline or a mucolytic
agent, at a constant rate into the inspiratory tube close to the tracheostomy.
A number of different ways of doing it have been described including
adapting drip sets60.61 and using a micro-pump62. The rate of flow of
fluid is 2&30ml/hour. Sara31 calculated that with a minute volume of 8
litres/min and a flow rate of 4 drops/min (i6ml/hr) the theoretical humidity
of the inspired gas would be 3lmg/Iitre. Bryant61 recommended that no
more than 9Oml of fluid be placed in the infusion bottle at any one time
because of the danger of drowning the patient should the drip control fail.
As a system, this technique is far from ideal since the control is entirely in
the hands of persons who have frequently had little opportunity for
learning the theory of what is required or how to put it into practice, but
its great merits are its simplicity and the ease with which it can be set up
in any hospital ward. Intermittent infusion (injection of fluid into the
trachea at intervals) may be useful for loosening plugs of mucus prior to
suctioning and is perhaps better than nothing as a form of humidification
but alternate dehydration and flooding of the tracheal mucosa is unlikely
to be an acceptable physiological substitute for normal conditions and it
may have serious consequences if the fluid is absorbed through the lungs.
( c ) Nebulizers (i) Gas driven. These units work by expanding compressed
gas through a narrow orifice so placed that the jet of gas entrains water
from a reservoir. The larger water particles are baffled out before the gas
enters the delivery tube to the patient but even so the gas still contains both
water vapour and small droplets. Many nebulizers of this type are available,
some of which are heated. Tests by various workers 1983 1,639 6 4 have shown
that humidities of up to 29mg/litres can be achieved at the patient’s end of
the delivery tube with unheated models or up to 50mg/litres with heated
ones. Urbanowicz et a165 describe a unit which they claim gives an aerosol
‘65 % more concentrated’ than that obtained from other units but they give
no detailed performance data.
There are several serious disadvantages encountered with this type of
unit. One of these is the heavy condensation in the delivery tube66 which
is so severe with heated models that a narrow-bore tube is impracticable679
68 and an automatic bailing device to be fitted into the delivery tube has
been described6Y. A major problem which has received a considerable
amount of attention recently is the difficulty of cleaning and sterilising
these units adequately, especially as bacteria are readily transmitted in
small water particles such as those obtained from nebulizers70-75.
Other snags are that the jets readily become blocked19~50~76,77 and
that continuous nebulization may impede an artificial ventilator 5 5,769 78.
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On balance, it would appear that this is not a satisfactory method of

humidification though it is probably better than those described above.
(c) (ii) Mechanically actuated nebulizers. These nebulize water by
dripping it onto a disc rotating at high speed79 or onto a crystal vibrating
at very high frequenciesgo. The volume of water nebulized is usually
independent of the gas flow. In some machines it is fixed at about 0.72mg
(about 12 drops) per minute78*80while in others it is variable up to 6g per
minute41942 and the gas can leave the machine carrying 500mg/litresl. A
machine has also been described 8 2 for use with artificial ventilators where
the output ranged from 30mg/litre at a minute volume of 30 litres a n d a
respiratory rate of 40, to over 200mg/litre at 5 litre/min and a respiratory
rate of 12. The machine described by Herzog et aP0 gives a humidity of
72mg/litre for a gas flow of 10 litre/min and these workers showed experi-
mentally that the water gain by the patient was 8.8g/hour. They also
calculated that a normally-respiring infant may gain 200ml of water in 24
hours from the humidified gas since the humidity of the gas increases as the
minute volume decreases and may be twice as high for infants as for
adults78. Harris & Riley29 have pointed out the danger of water-intoxica-
tion under these conditions since the average new-born infant weighs 3kg,
has a total vascular volume of 225m1 and a glomerular filtration rate only
20-30% that of an adult. When treating small infants Smith83 recommends
reducing the fog output if systematic weighing indicates fluid retention,
while Pratt 8 4 suggests using an ultrasonic nebulizer for 15 minutes four
times a day.
The direct transmission of infection from the humidifier to the patient’s
lungs is an even greater hazard with this type of machine than it is with
gas-driven nebulizers. Water particles 1-5 microns in diameter are particu-
larly dangerous as they can reach the distal air spaces where pulmonary
clearance mechanisms may not be efficient and they can carry significant
numbers of viable bacteria70. For an ultrasonic nebulizer, 97% of the
particles may be in this size range against 55 % for gas-driven machines74.
A different facet of the same problem has been demonstrated by Corn &
Flynn 8 5 who passed the output from an ultrasonic nebulizer into an oxygen
tent, which was covering only the upper part of the bed, during the treat-
ment of a bedridden patient. Paiticles of a tracer introduced into the water
in the nebulizer were subsequently recovered from the corridor outside the
room and these workers suggest that infectious agents could be equally
easily dispersed.
It has been reported that the use of distilled water in these machines is
irritating and cough-provoking40~8038 1 and the use of either physiological
saline or half-strength physiological saline has been recommended. Un-
fortunately, animal experiments have indicated that these solutions are
potentially dangerous under these conditions, leading to broncho-
pneumonia in puppies41 and to arterial desaturation in tracheotomised
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adult dogs32. The changes in animals exposed to distilled water were much
less severe.
In general, it would appear that the considerable potential dangers of
these machines more than outweigh the advantages of their high perform-
ance. This is particularly serious since the symptoms of over-humidifica-
tion in a patient may be indistinguishable from those of his basic illness
and may therefore be misinterpreted. Where such machines are used, they
should be very carefully supervised and the patient must be closely
watched.
((1) Water-bath huniidij7ers. In these machines the gas is blown over, or
bubbled through, water which is in most cases heated. The size of the
water-gas interface is such that the gas is fully saturated at the tempera-
ture of the water-bath when i t leaves the unit and the gas then passes up a
delivery tube to the patient. A heated water-bath is regulated so that the
gas arrives at the patient’s end of the delivery tube at the temperature at
which he requires it. Heavy condensation occurs in the delivery tube since
the temperature drop may be 20‘C or more21 but the gas is fully saturated
at all times after leaving the water-bath and the fluid carried by the gas is
in the vapour phase. A large number of variants have been describedss-90
and others have also been produced both in the laboratory and
commercially. The performance of the unheated models can never be
satisfactory since they cannot do more than saturate the gas at a tempera-
ture slightly below ambient, giving humidities ranging from 2&22mg/litre
for some types to only 7-12mg/litre for others63~67~80. These latter
machines have frequently been described as totally inadequate61991-93.
Heated models may give up to 42mg/litre at 35°c39T63*87J94 or less
depending on the design and the heating element used88990. Temperature
control of the gasdelivered to the patient is a problem with some machines24
and has in some cases been controlled by adjusting the water-bath thermo-
stat for each patient95 or varying the length ofthe delivery tube22. Attempts
to reduce or overcome condensation problems have included the use of
lagging38>87*96and electrically-heated tape97. In some cases the diffi-
culties caused by the condensation have been such that the humidifier has
been removed from the circuit98.
Another point which does not seem to have been noticed by other
workers is the effect of the resistance of the delivery tube on the gas flow
from the blow-over type machines. Two models of different makes were
examined personally and the flow estimated by gas dilution techniques. In
each case, the gas delivered into the patient’s tracheostomy ‘box’was less
than one-third of that delivered by the machine when no tubing was
present. The delivery system used was a standard length of wide-bore
corrugated anaesthetic tubing, laid flat and straight on a laboratory
bench, with a standard tracheostomy ‘box’attached. The minimum bore at
the connection was %in(0.9cm). When the minimum bore was reduced still
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further to that of a Luer connector from a drip set, one of the machines
could just burst a soap bubble on the end while the other could not.
Transmission of bacteria poses few problems with this type of humidi-
fier, several workers having found that the output from these machines is
no more highly contaminated than the ambient air7**74,75199though
Phillips & Spencer 100 reported heavy contamination of their ventilators,
especially the humidifiers and inspiratory tubing, with Pseudonionas
aeruginosa.
This technique of humidification is probably potentially both the safest
and the most reliable but most of the present models are far from satis-
factory.

DISCUSSION

Existing equipment
This will be examined in relation to its performance relative to the speci-
fication.
( I ) Inspired atmosphere. A controlled environment cannot fulfil any of
the conditions laid down, nor can heat-and-moisture exchangers. Instilla-
tion, unheated gas nebulizers, mechanical nebulizers and unheated water-
baths cannot fulfil the temperature requirements. No nebulizer fulfils the
humidification requirement since none has any adequate control of the
upper end of the range. It is difficult or impossible to control the inspired
oxygen percentage reliably with controlled environments, heat-and-
moisture exchangers, gas-driven nebulizers or those water-bath humidi-
fiers where the gas is blown over and not bubbled through the water. Thus
the only system which is even potentially satisfactory is the bubble-through
water-bath humidifier.
(2) Simplicity in use. Apart from controlled environments, most of the
apparatus is basically reasonably simple to use. However, almost all the
models which are at present available have controls which are readily
accessible to all and, frequently, not clearly labelled. The obvious exception
is the heat-and-moisture exchanger but this should be serviced every three
hours and it is not readily apparent when this is necessary. Many of the
other devices also need attention more than once a day and few, if any,
have adequate warning systems.
(3) Adaptability. With the exception of fog rooms, all the equipment is
reasonably portable and compact. However, nebulizers and water-bath
humidifiers must be kept lower than the patient due to condensation in the
delivery tube and gas-driven nebulizers require a source of compressed gas.
( 4 ) Reliability. While much of the apparatus is sufficiently robust for
normal use, in no case is it immediately obvious to the staff if the patient is
not receiving gas from the device, nor are proper alarm systems fitted.
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These are particularly important in the case of nebulizers and water-bath

humidifiers where the delivery tube may easily be blocked with condensed
water.
( 5 ) Patient comfort. In general. all forms of humidifier appear to be
satisfactory in this respect.
(6) Safety. ( a ) Electrical and mechanical. Apart from fog rooms, none
of the heated systems has an over-riding temperature control and there is
rarely any provision in a circuit for a pressure-release valve. The use of
non-return valves near the patient can be dangerous since they readily
become obstructed both with condensate and with mucus 101. Heat-and-
moisture exchangers may be obstructed if the patient coughs up lumps of
mucus. Most of the equipment appears to be electrically safe with the
exception of the use of heating wire round the delivery tube79. Since few of
the devices have any safety systems, the only occasions when access to the
controls is too easy is in the thermostat setting of heated units.
(b)Bacteriological. All forms of nebulizer are bacteriologically dangerous
and they are very difficult to clean or to sterilise. Heat-and-moisture
exchangers need to be changed every three hours or so, and some models
are not easy to clean. Other equipment appears to give little trouble in this
respect.
(7) Access to the patient. Small controlled environments such as cold
steam tents can seriously impede the nursing staff, while heat-and-
moisture exchangers can be a definite nuisance on patients who need
frequent sucking out. Other equipment seems reasonably satisfactory in
this respect.

FUTURE DEVELOPMENTS

It would appear from the above that the only means of humidification at
present available which can fulfil the minimum requirements are heated
nebulizers and water-baths. The nebulizers have three outstanding dis-
advantages (i) in the present models it is impossible to control the upper
level of humidity reliably and automatically, ( i i ) much of the water is
condensed out in the delivery tube, leading to obstruction and the need for
frequent attention (iii) the machines are extremely difficult to clean and to
sterilise adequately and much of their output is in the form of droplets
small enough to penetrate into the deepest parts of the lungs. This last
point is clearly much the most serious since it cannot be overcome by
redesign as the others can. It was brought out by Peters102 when he said
‘respirators which deliver a visible mist are not delivering air saturated
with water vapour (water vapour is invisible) but rather a ventilatory
mixture contaminated with a bacteria-laden smog’. In another paper 1 0 3
he suggests that the recent upsurge of severe tracheobronchial infections in
patients on respirators may be largely due to this and similar opinions have
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been expressed by others72. Bacterial filters are unlikely to be of much help

in this situation since, if they are placed between the nebulizer and the
patient, the water droplets will be trapped in them. This will not only
reduce the water content of the gas the patient receives but also lead to
obstruction of the filter. Thus, until some reliable technique has been
devised to clean and to sterilise these machines and to ensure their contin-
ued freedom from contamination for reasonable periods of time, it would
appear to be unprofitable to continue with their development.
Water-bath humidifiers have two main disadvantages ( i ) it is difficult to
control the temperature of the gas at the patient’s end of the delivery tube
and, (ii) a large percentage of the water vapour is condensed out in the
delivery tube, leading to obstruction and the need for frequent attention.
These two points are by no means insuperable in a properly-designed
machine. Heironimus 10 4 pointed out that the ideal humidification system
should vaporise only the amount of water required by the patient. If this
amount of water is less than the amount needed to saturate the gas at the
temperature at which it is delivered to the patient then the problems due to
condensation can be eliminated. The problem of the control of the gas
temperature at the patient’s end of the delivery tube is also the responsi-
bility of the designer, as are the safety systems, but such a piece of appara-
tus will inevitably cost more than the simple devices at present in use.
It should, however, cost considerably less than, say, an ultrasonic
nebulizer.

CONCLUSIONS

(1)Patients whose upper respiratory tracts have been bypassed should have
their inspired gases heated to between 30 and 36°C and humidified so that
they contain between 30 and 40mg of water per litre of dry gas.
(2) The only types of equipment at present available which can fulfil the
minimum conditions are heated nebulizers and heated water-baths. There
is no means of preventing over-humidification on any of the nebulizers.
(3) All nebulizers readily become infected with bacteria and they are all
difficult to clean and to sterilise. The output from these machines is mainly
in droplets of a size which can penetrate into the smallest air passages and
these droplets form a vehicle for the transmission of bacteria to the patient.
Bacterial filters do not provide the answer to this problem.
( 4 ) The output from water-bath humidifiers is in the form of vapour
which does not carry bacteria. These devices could be re-designed so that
they complied with all the requirements of the specification.
Acknowledgements
I should like to thank Dr S. R. Montgomery, Dr P. J. D. Heaf, Dr M. K. Sykes and
Dr D. J. Wayne for much helpful criticism and advice in the preparation o f this paper,
also the Institution of Mechanical Engineers for awarding me the James Claytoti
Fellowship in Medico/ Engineering during the tenure of which this work was undertaken.
613
 Anaesthesia 101 24 no 4 October 1969

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