The Humidity in a Dräger Primus Anesthesia Workstation

Using Low or High Fresh Gas Flow and With or Without a

Heat and Moisture Exchanger in Pediatric Patients
Gustavo P. Bicalho, MD,* Leandro G. Braz, MD, PhD,* Larissa S. B. de Jesus, MD,*
Cesar M. C. Pedigone,* Lídia R. de Carvalho, PhD,† Norma S. P. Módolo, MD, PhD,*
and José R. C. Braz, MD, PhD*

BACKGROUND: An inhaled gas absolute humidity of 20 mg H2O·L−1 is the value most con-
sidered as the threshold necessary for preventing the deleterious effects of dry gas on the
epithelium of the airways during anesthesia. Because children have small minute ventilation,
we hypothesized that the humidification of a circle breathing system is lower in children com-
pared with adults. The Primus anesthesia workstation (Dräger Medical, Lübeck, Germany) has
a built-in hotplate to heat the patient’s exhaled gases. A heat and moisture exchanger (HME) is
a device that can be used to further humidify and heat the inhaled gases during anesthesia. To
evaluate the humidifying properties of this circle breathing system during pediatric anesthesia,
we compared the temperature and humidity of inhaled gases under low or high fresh gas flow
(FGF) conditions and with or without an HME.
METHODS: Forty children were randomly allocated into 4 groups according to the ventilation
of their lungs by a circle breathing system in a Dräger Primus anesthesia workstation with low
(1 L·min−1) or high (3 L·min−1) FGF without an HME (1L and 3L groups) or with an HME (Pall
BB25FS, Pall Biomedical, East Hills, NY; HME1L and HME3L groups). The temperature and
absolute humidity of inhaled gases were measured at 10, 20, 40, 60, and 80 minutes after
connecting the patient to the breathing circuit.
RESULTS: The mean inhaled gas temperature was higher in HME groups (HME1L: 30.3°C ±
1.1°C; HME3L: 29.3°C ± 1.2°C) compared with no-HME groups (1L: 27.0°C ± 1.2°C; 3L: 27.1°C
± 1.5°C; P < 0.0001). The mean inhaled gas absolute humidity was higher in HME than no-HME
groups and higher in low-flow than high-flow groups ([HME1L: 25 ± 1 mg H2O·L−1] > [HME3L: 23
± 2 mg H2O·L−1] > [1L: 17 ± 1 mg H2O·L−1] > [3L: 14 ± 1 mg H2O·L−1]; P < 0.0001).
CONCLUSIONS: In a pediatric circle breathing system, the use of neither high nor low FGF pro-
vides the minimum humidity level of the inhaled gases thought to reduce the risk of dehydration
of airways. Insertion of an HME increases the humidity and temperature of the inhaled gases,
bringing them closer to physiological values. The use of a low FGF enhances the HME efficiency
and consequently increases the inhaled gas humidity values. Therefore, the association of an
HME with low FGF in the breathing circuit is the most efficient way to conserve the heat and the
moisture of the inhaled gas during pediatric anesthesia. (Anesth Analg 2014;119:926–31)

I
n normal breathing, inhaled air is warmed and humidi-
fied in the upper airways.1 During tracheal intubation and
mechanical ventilation, these mechanisms are partially
disrupted because the tracheal tube bypasses the upper air-
ways. In this situation, ventilation with dry and cold gases
leads to a considerable loss of water and heat from the respi-
ratory tract, unless appropriate means of humidification and
heating are used.2,3 Dehydration of the respiratory tract can
From the *Department of Anesthesiology, Botucatu Medical School, and
†Department of Biostatistics, Institute of Biosciences, UNESP—Universidade
Estadual Paulista, São Paulo State, Brazil.
Accepted for publication May 9, 2014.
Funding: Supported by grant 2011/13545-0, São Paulo Research Foundation
(FAPESP).
The authors declare no conflicts of interest.
This report was previously presented, in part, at the Annual Meeting,
American Society of Anesthesiologists, Washington, October 2012.
Reprints will not be available from the authors.
Address correspondence to Gustavo P. Bicalho, MD, Department of Anesthe-
siology, Botucatu Medical School, UNESP—Universidade Estadual Paulista,
­Distrito de Rubião Junior, P.O. Box 530, CEP: 18.618-970, São Paulo State,
­Brazil. Address e-mail to gpbicalho@gmail.com.
Copyright © 2014 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000000353
lead to cilia and mucous gland destruction, reduced muco-
ciliary transport, and thickening of secretions.3–5 Preventing
dehydration is especially important in children because of
the reduced caliber of the tracheal tube. Studies from animal
research3–5 and a recent review on the subject6 proposed that
during anesthesia, the minimum humidity level of inhaled
gases should be 20 mg H2O·L−1.
In anesthesia, the use of a circle breathing system with
low fresh gas flow (FGF) can help maintain the humidity of
the inhaled gases.4,7,8 This maintenance occurs because the
humidified exhaled gases are partially rebreathed, and water
is generated when the carbon dioxide (CO2) reacts with the
soda lime. In adults, it has been shown that the use of a circle
breathing system with low FGF can provide humidity lev-
els of the inhaled gases just above 20 mg H2O·L−1.8–10 Because
they have smaller minute ventilation, children generate less
CO2, water, and heat compared with adults. One may specu-
late that the humidification of a circle breathing system with
low FGF in children may be lower than that in adults. Circle
breathing systems are frequently used during pediatric anes-
thesia.11 Few studies have specifically examined the tempera-
ture and humidity of the inspired gases provided by a circle
breathing system during anesthesia in children.12,13

926   
www.anesthesia-analgesia.org October 2014 • Volume 119 • Number 4
 A heat and moisture exchanger (HME) is a device
designed to provide humidification and heating of inhaled
gases similar to that provided by the upper airways. It has
been shown that during anesthesia, the use of an HME can
increase the temperature and humidity of inhaled gases in
adults8–10 and children.14,15
The Primus anesthesia workstation (Dräger Medical,
Lübeck, Germany) has a built-in hotplate to heat the exhaled
gases and to prevent water condensation in the breathing
system. The temperature and humidity of the inhaled gases
coming from this anesthesia machine have not yet been
investigated in children. It may be expected that the hotplate
would warm the inhaled gases coming from this workstation.
The aim of this study was to compare the mean tempera-
ture and humidity of the inhaled gases using low or high
FGF with or without an HME in the circle breathing sys-
tem of the Primus anesthesia workstation during pediatric
anesthesia.
METHODS
This study was approved by the local Medical Ethics
Committee (CEP 3877-2011) and registered at ensaiosclini-
cos.gov.br (RBR-33bb7k). Written informed consent was
obtained from the parents of all children studied. Forty chil-
dren (10–30 kg), afebrile (T <37ºC) and with ASA physical
status I or II, who were scheduled for elective abdominal
or urological surgeries lasting 90 minutes or longer, were
enrolled in this study.
Patients were randomized into 4 groups (10 children
per group), according to the FGF used and the use of an
HME in the breathing circuit, as follows: 1L group, FGF of
1.0 L·min−1 without an HME; 3L group, FGF of 3 L·min−1
without an HME; HME1L group, FGF of 1.0 L·min−1 with
an HME; and HME3L group, FGF of 3 L·min−1 with an
HME. An anesthesiologist who was not involved in the
perioperative management of the patients printed 40 group
identification tags (10 for each group) and placed them in
40 envelopes (1 identification tag per envelope). Then the
same anesthesiologist sealed, mixed, and listed the enve-
lopes sequentially, i.e., numbered in ascending order. Just
before each anesthesia induction, 1 envelope was opened
following the sequential order.
Experimental Protocol
A Dräger Primus anesthesia workstation was used in all
cases. The anesthetic system was equipped with clean and
dry silicone pediatric corrugated tubes (1.5 m in length and
10 mm in internal diameter; Dräger Medical) for each case.
The CO2 canister (1.5 L) of the anesthesia machine was filled
with fresh soda lime (Drägersorb 800 Plus, Dräger, Lübeck,
Germany) before each case.
None of the selected patients was excluded from the
study. Patients received midazolam (0.3 mg·kg−1 by mouth)
60 minutes before their admission to the operating room
(OR). Upon arrival to the OR, the patients received standard
clinical monitoring with an electrocardiogram (DII and V5
leads), peripheral oxygen saturation (Spo2), and noninva-
sive arterial blood pressure measurements.
All patients received active conductive warming using a
pediatric circulating-water mattress from a warming device
(Medi-Therm III, Model MTA 6900, Gaymar Industries Inc.,
October 2014 • Volume 119 • Number 4
Orchard Park, NY) with the temperature initially set at 38oC.
The mattress was placed at the back of the patient from the
mid-thoracic region and below, and a single cotton sheet
separated the back of the patient from the water mattress.
Oxygen-sevoflurane mask induction with high FGF
(3 L·min−1) was performed in all patients. After the child
was unconscious, an IV line was inserted with a 22-G cath-
eter, and an infusion of lactated Ringer’s solution (4–6
mL·kg−1·h−1) at room temperature was initiated. An IV
bolus of fentanyl (5 µg·kg−1) and an IV bolus of cisatracu-
rium besylate (0.15 mg·kg−1) were given to facilitate tracheal
intubation with a cuffed tracheal tube. The cuff was inflated
to ensure the absence of any air leaks. A pediatric HME
(Pall BB25FS, Pall Biomedical, East Hills, NY) was placed
between the Y-piece of the breathing circuit and the tracheal
tube in the HME groups. The lungs were mechanically ven-
tilated using a pressure-controlled mode. An inspiratory
pressure was set to maintain a tidal volume of 8 mL·kg−1.
The respiratory rate was adjusted to maintain a Petco2 close
to 35 mm Hg. The inspiratory and expiratory sevoflurane
concentrations, oxygen concentration, end-tidal carbon
dioxide (Petco2), and ventilation variables were monitored
with the Primus built-in monitor.
After 5 minutes of high FGF (1.5 L·min−1 of O2 in 1.5
L·min−1 of air), with an inspiratory concentration of sevoflu-
rane at the minimum alveolar concentration (2%), the FGF
was reduced to 0.5 L·min−1 of O2 in 0.5 L·min−1 of air in the
patients randomly chosen to receive an FGF of 1 L·min−1
(1L and HME1L groups), but not in the groups selected to
receive an FGF of 3 L·min−1 (3L and HME3L groups). The
sevoflurane concentration was adjusted throughout the
anesthesia to maintain a systemic arterial blood pressure
and cardiac rate within ±20% of baseline. Anesthesia was
maintained with IV fentanyl (2 µg·kg−1) and cisatracurium
(0.02 mg·kg−1), if necessary.
The intraoperative esophageal (core) temperature was
measured after tracheal intubation using a thermocou-
ple sensor (90044 Mon-a-Therm®; Mallinckrodt Medical,
Veracruz, Mexico). The thermocouple sensors for the esoph-
agus and the OR temperature were attached to a 2-chan-
nel electronic thermometer (4070, Mallinckrodt Medical, St.
Louis, MO).
The temperature and relative humidity (RH) of the
gases were measured using a rapidly responding electronic
thermo-hygrometer (Kimo HD50, Marne La Vallée, France;
90% response in <1 seconds). The RH and temperature sen-
sor of the thermo-hygrometer was connected by a T-piece
between the Y-piece of the breathing circuit and the tracheal
tube in the no-HME groups and between the HME and the
tracheal tube in the HME groups; and it was connected to
the inspiratory limb outlet close to the anesthesia worksta-
tion in all the groups. The thermo-hygrometer operates on
a capacitative principle and has a stated accuracy of ±2.5%
for RH and ±0.3°C for temperature. The RH and tempera-
ture values fluctuated with the phases of the respiratory
cycles and were lower during the inspiratory phase. We
recorded the minimum values of the RH and temperature
over 10 respiratory cycles after 10, 20, 40, 60, and 80 min-
utes of connection between the patient and the breathing
circuit. The absolute humidity (AH) values were calculated
using the formula: AH = (3.939 + 0.5019T + 0.00004615T2 +
www.anesthesia-analgesia.org 927
Humidity of Inhaled Gases in Pediatric Anesthesia

0.0004188T)3 × RH/100, where AH is the absolute humidity (Windows Software, version 6.0; SPSS Inc., Chicago, IL).
(mg H2O·L−1), T is the temperature (oC), and RH is the rela- For all the analyses, P < 0.05 was considered statistically
tive humidity (%). significant.

Statistical Analysis RESULTS

The sample size of the groups was calculated based on pre- There were no statistically significant differences among the
vious studies regarding the humidification of gases during groups with regard to the patients’ characteristics (Table 1).
anesthesia, where the differences between groups who used There were no differences regarding hemodynamic vari-
an HME or not were >5.0 mg H2O·L−1.13,15,16 Thus, assum- ables (data not shown).
ing an AH difference of 5.0 mg H2O·L−1 among groups with There were no statistically significant differences among
an SD of ±3.0 mg H2O·L−1, a minimum of 10 patients in the groups with regard to the mean OR and core (esopha-
each group was necessary to detect this difference using a geal) temperatures (Table 2). The mean temperature of the
2-tailed test with the probability of a type I error (α) of 0.05 inhaled gas was higher in the HME groups compared with
and a type II error (β) of 0.05 (power of 95%). the no-HME groups (P < 0.0001; Table 3).
The normal distribution of the data was confirmed using The mean temperature in the inspiratory limb outlet of
the Lilliefors tests. Each of the 4 groups’ pooled data fol- the workstation was lower in the 1L group compared with
lowed a normal distribution (all Lilliefors P > 0.10). the HME groups (P = 0.003; Table 3). The mean RH and AH
The anthropometric variables were compared among values in the inspiratory limb outlet close to the anesthe-
groups by analysis of variance, and gender was compared sia workstation were higher in the groups using an FGF
among groups with the χ2 test. of 1 L·min−1 (1L and HME1L) compared with the groups
The AH, RH, and temperature values were compared who used an FGF of 3 L·min−1 (3L and HME3L; P < 0.0001;
among the 4 groups at different time points by a profile Table 4).
analysis. In this analysis, the hypotheses tested were the fol- The mean RH and AH values of the inhaled gases were
lowing: there was no interaction between groups and time significantly higher in the groups who used the HME
points, and there was no significant difference between (P < 0.0001). In the HME groups, the group with the low
mean groups over time. This analysis was followed by FGF (HME1L) had higher mean RH and AH values com-
Tukey test for pairwise comparisons. pared with the high FGF group (HME3L; P < 0.0001). In the
Pearson coefficient was used for the correlation analy- groups that did not use an HME, the group with the low
sis between the OR and inhaled gas temperatures in all the FGF (1L) had higher mean RH and AH values compared
groups. with the high FGF group (3L; P < 0.0001; Tables 5 and 6,
The data were expressed as the means ± SD and 95% respectively).
confidence interval. The statistical analysis was per- There was a significant and positive correlation between
formed using the Statistical Package for the Social Sciences the OR and inhaled gas temperatures in the no-HME groups
(1L: r2 = 0.52; P < 0.0001 and 3L: r2 = 0.31; P < 0.0001) but
not in the HME groups (HME1L: r2 = 0.0036; P = 0.66 and
Table 1.  Patient Characteristics Data (Means ± SD) HME3L: r2 = 0.014; P = 0.37).
in the Groups Studied None of the children had any surgical or clinical com-
Sexa plications, and all of the children were discharged from the
Groups N Age (y) Weight (kg) Height (cm) (M/F)
hospital, according to the guidelines and protocols estab-
1L 10 4.0 ± 2.4 18.4 ± 6.0 102.9 ± 18.6 8/2
lished for their particular surgical procedures.
3L 10 4.3 ± 2.6 19.3 ± 5.5 108.3 ± 18.6 10/0
HME1L 10 4.6 ± 1.9 19.5 ± 5.9 109.2 ± 18.0 9/1
HME3L 10 4.9 ± 2.5 19.4 ± 6.0 110.0 ± 13.0 10/0 DISCUSSION
P value 0.85 0.98 0.79 0.10 There are 3 main findings in the present study: (1) the
M = male; F = female. humidity of the inhaled gases in the Primus workstation
a
Data are frequency distributions. with a pediatric breathing circuit depends on the FGF and

Table 2.  Operating Room and Core Temperature Data (Means ± SD) in the Groups Studied
P value
Difference among Time × group
Temperature (ºC) Group Mean over time 95% CI groups interaction
Operating room 1L 22.6 ± 0.8 22.3–31.0 0.85 0.68
3L 22.8 ± 0.5 22.6–31.3
HME1L 22.8 ± 0.6 22.6–31.3
HME3L 22.7 ± 0.7 22.4–31.2

Core 1L 36.2 ± 0.5 36.0–49.9 0.18 0.04

3L 36.3 ± 0.4 36.1–50.0
HME1L 36.1 ± 0.4 36.1–49.8
HME3L 36.5 ± 0.5 36.3–50.3
Mean over time: mean of each parameter within each group from 10 to 80 min after connection of the patients to the breathing circuit. The SD listed is the SD
of the means among subjects.
CI = confidence interval.

928   
www.anesthesia-analgesia.org anesthesia & analgesia
Table 3.  Workstation Outlet Inspiratory Limb and Inhaled Gas Temperature Data (Means ± SD) in the
Groups Studied
P value
Difference among Time × group
Temperature (ºC) Group Mean over time 95% CI groups interaction
Workstation outlet 1L 30.2 ± 1.6b 29.5–41.4 0.003 0.54
inspiratory limb gas 3L 30.5 ± 1.3ab 30.0–41.9
HME1L 31.9 ± 1.0a 31.5–43.8
HME3L 31.8 ± 1.1a 31.4–43.7

Inhaled gas 1L 27.0 ± 1.2b 26.5–37.1 <0.0001 0.22

3L 27.1 ± 1.5b 26.6–37.2
HME1L 30.3 ± 1.1a 29.8–41.6
HME3L 29.3 ± 1.2a 28.8–40.3
Mean over time: mean of each parameter within each group from 10 to 80 min after connection of the patients to the breathing circuit. The SD listed is the SD
of the means among subjects. Means followed by different superscript letters are significantly different.
CI = confidence interval.

Table 4.  Relative and Absolute Humidity Data of the Gases in the Workstation Outlet Inspiratory Limb
(Means ± SD) in the Groups Studied
P value
Difference among Time × group
Group Mean over time 95% CI groups interaction
RH (%)
 Workstation outlet 1L 36 ± 5a 34–49 <0.0001 0.01
inspiratory limb gas 3L 15 ± 5c 13–19
HME1L 39 ± 3a 37–53
HME3L 20 ± 4b 18–27
AH (mg H2O·L−1)
 Workstation outlet 1L 11 ± 2b 10–15 <0.001 0.17
inspiratory limb gas 3L 5 ± 2d 4–6
HME1L 13 ± 1a 12–18
HME3L 7 ± 2c 6–9
Mean over time: mean of each parameter within each group from 10 to 80 min after connection of the patients to the breathing circuit. The SD listed is the SD
of the means among subjects. Means followed by different superscript letters are significantly different.
RH = relative humidity; AH = absolute humidity; CI = confidence interval.

Table 5.  Relative Humidity Data of the Inhaled Gases (Means ± SD) in the Groups Studied
Time (min)
Groups 10 20 40 60 80 Mean over time 95% CI P value
1L 65 ± 3 65 ± 4 65 ± 4 64 ± 4 65 ± 3 65 ± 4c 63–89 <0.0001
3L 56 ± 3 55 ± 5 55 ± 6 54 ± 3 54 ± 4 55 ± 4d 53–75
HME1L 80 ± 3 81 ± 2 81 ± 2 80 ± 1 81 ± 2 80 ± 2a 79–110
HME3L 77 ± 3 76 ± 4 76 ± 3 77 ± 3 76 ± 3 76 ± 3b 75–105
Mean over time: mean of each parameter within each group from 10 to 80 min after connection of the patients to the breathing circuit. In mean over time, the
SD listed is the SD of the means among subjects. There was no significant time × group interaction (P = 0.25). Means followed by different superscript letters
are significantly different.
CI = confidence interval.

Table 6.  Absolute Humidity Data of the Inhaled Gases (Means ± SD) in the Groups Studied
Time (min)
Groups 10 20 40 60 80 Mean over time 95% CI P value
1L 16 ± 1 17 ± 2 17 ± 1 17 ± 1 17 ± 1 17 ± 1c 16–23 <0.0001
3L 14 ± 1 15 ± 1 14 ± 1 14 ± 1 14 ± 1 14 ± 1d 14–19
HME1L 24 ± 2 25 ± 1 25 ± 2 25 ± 1 25 ± 1 25 ± 1a 24–34
HME3L 22 ± 2 22 ± 2 22 ± 2 22 ± 2 23 ± 2 22 ± 2b 22–31
Mean over time: mean of each parameter within each group from 10 to 80 min after connection of the patients to the breathing circuit. In mean over time, the
SD listed is the SD of the means among subjects. Means followed by different superscript letters are significantly different. There was significant time × group
interaction (P = 0.04).
CI = confidence interval.

is higher with a low FGF; (2) the minimum recommended HME increased the temperature and humidity of inhaled
inhaled gas humidity of 20 mg H2O·L−1 was not achieved gases, bringing them closer to physiological values, which
with either the high or low FGF; and (3) insertion of an were higher with the low FGF.

October 2014 • Volume 119 • Number 4 www.anesthesia-analgesia.org 929

Humidity of Inhaled Gases in Pediatric Anesthesia
There are 2 sources of humidity and heat in a circle
breathing system. One source is the rebreathing of exhaled
gas, which contains water and heat released by the patient,
and the other source is water vapor and heat released from
the CO2 absorbent in an exothermic reaction.17 The effi-
ciency of this humidity conservation depends on various
factors, including the FGF used, configuration of the breath-
ing system, and patient characteristics.
With a low FGF, the circle system permits a higher
rebreathing of exhaled gases and, consequently, a higher
humidity of the inhaled gases is expected. Our data con-
firmed this assumption, which is in accordance with another
study that showed the effect of a low FGF in increasing the
humidity of inhaled gases during pediatric anesthesia.12
In the breathing system of the Primus workstation, the
patient’s exhaled gases move through a hotplate and across
the soda lime once before mixing with the dry and cold FGF.
Then the mixed gases are pulled by the ventilator plunger
to fill the ventilator. When the inspiratory valve opens, the
ventilator’s plunger sends the gaseous mixture into the
inspiratory limb of the breathing circuit.10 Anesthetic work-
stations, such as the Cicero and Cato (Dräger), also have
built-in hotplates to heat the exhaled gases; however, unlike
the Primus, the exhaled gases mixed with a dry and cold
FGF pass through the CO2 absorber twice per breath.18 In
children, a study with a low FGF without an HME from
the Cicero workstation found higher inhaled gas humid-
ity (22 mg H2O·L−1) when compared with our data.12 The
difference in the humidity values is likely a result of the
different breathing circuit configurations of the anesthesia
workstations.
The hotplate in the circle system of the Primus work-
station kept the gases warm in the inspiratory limb close
to the inspiratory valve (approximately 30ºC–31ºC) in all
the groups. When an HME was not used, the inhaled gas
temperatures were lower (approximately 3ºC) than the gas
temperatures in the inspiratory limb close to the anesthesia
workstation. A study showed that the temperature is not
maintained in the inspiratory limb of the circle breathing
circuit during high- and low-flow anesthesia in infants.13
According to these authors, the speed and amount of the
heat loss are directly related to the heat transfer coefficient
of the material and the length of the inspiratory limb of the
breathing circuit. These findings are in accordance with our
data, i.e., a positive correlation between the OR and inhaled
gas temperatures in the no-HME groups. The use of corru-
gated tubes with thermal insulation materials could have
maintained the temperature of the gases in the inspiratory
limb of the breathing system.
In adults, a study using the Dräger Primus showed an
inhaled gas humidity of approximately 20 mg H2O·L−1 dur-
ing anesthesia with low FGF.10 In our study, children with
the low-flow breathing system of the Primus without an
HME (1L group) had lower mean inhaled gas humidity (17
mg H2O·L−1). Two factors may explain the difference in the
inhaled gas humidity. First, because children have lower
absolute minute volumes than adults, they provide less
CO2 to react with the soda lime, which results in the gen-
eration of less heat and water in the circle system.13 Second,
children produce a smaller exhaled gas volume relative to
930   
www.anesthesia-analgesia.org
the FGF than adults, thus allowing for proportionally less
rebreathing.
The optimal AH values in the airways, especially in
children, are not always clearly defined in the literature.
There is no minimum requirement for humidification per-
formance in children in HME standards.19 Nevertheless, the
mean AH of the inhaled gases in the groups with an HME,
regardless of the FGF used, were always >20 mg H2O·L−1,
which is the value most frequently cited as the threshold
necessary for preventing the deleterious effects of dry gas
on the epithelium of the airways during anesthesia.3,5,6 The
mean AH of the inhaled gases in the no-HME groups was
always <20 mg H2O·L−1.
Few studies evaluated the efficiency of an HME dur-
ing pediatric anesthesia. A study in young children using
an HME in the ventilatory system, with no rebreathing of
exhaled gas, showed an inhaled gas AH of 22 mg H2O·L−1.15
These results are in agreement with our data, because the
group with an HME and high FGF, which allowed for no
or minimal rebreathing, had a mean inspiratory AH of 23
mg H2O·L−1. Another study was performed in children
using an HME in the breathing system during 140 minutes
of ventilation.20 This study also did not allow rebreath-
ing. The authors showed a lower mean inhaled gas tem-
perature (28.4ºC ± 1.5ºC) and a higher mean AH (26.2 ± 1.7
mg H2O·L−1) compared with our data in the HME groups.
Differences between the HME used, the configuration of the
breathing systems, and the time of ventilation may explain
the different results between the studies. In addition, our
data showed that the FGF has a significant correlation with
the HME efficiency and that humidity values are increased
with low flow.
Two factors may explain the difference in the RH val-
ues between the gases in the inspiratory limb outlet (close
to the anesthesia workstation) and the inhaled gases in the
no-HME groups. First, the large difference between the OR
and inspiratory limb outlet temperatures (approximately
8ºC) caused water condensation in the inspiratory limb of
the breathing system. Second, a gas with a low RH has a
high thermal energy for absorbing the condensate water
along the inspiratory limb.21 In this way, the breathing sys-
tem itself worked as a moisture exchanger, although with
low efficiency, and it reached the humidity levels below
the threshold believed to preserve the ciliary function of
airways.
Children undergoing anesthesia are prone to develop-
ing hypothermia because of their large surface area to body
weight ratio.20 The mean esophageal temperature values
were similar and remained above 36ºC during the entire
procedure in all the groups. The use of an active warming
system associated with adequate covering of patients with
surgical drapes may have minimized the heat loss, thus
explaining the maintenance of normothermia during the
whole period studied. One study showed that the use of an
HME did not prevent intraoperative hypothermia in chil-
dren, but it did minimize it.14
There are some limitations to our study. First, the study
was not blinded. The gas humidity and temperature mea-
surements were made intermittently at predefined times.
Then it was necessary to place the thermo-hygrometer
anesthesia & analgesia
probe inside the T-piece for each measurement. In the
groups using an HME, the T-piece was connected between
the HME and the tracheal tube. Thus, due to the proximity,
it was not possible to conceal the presence of an HME in
the respiratory circuit during the measurements. Second,
the humidity values were recorded until 80 minutes after
the breathing circuit had been connected to the patients.
This recording period was compatible with typical pedi-
atric surgeries, which are often of short or medium dura-
tion. A study using the Primus machine in adults verified
an increase in the humidity of the inhaled gases after 90
minutes of ventilation with low FGF with and without an
HME.10 Increases in the humidity of inhaled gases could
have occurred after the time period studied. Because of the
short duration of most pediatric surgeries, a device that
properly humidifies and warms the inhaled gases should
be effective early in the procedure.15 The introduction of
an HME into the circuit produced an increase in humidity
and temperature of the inhaled gases beginning at the first
­measurement (10 minutes).
CONCLUSIONS
The use of neither high nor low FGF in the pediatric circle
breathing circuit of the Primus machine provided the mini-
mum humidity level of the inhaled gases thought to reduce
the risk of dehydration of airways. Insertion of an HME
increases the humidity and temperature of the inhaled gases,
bringing them close to physiological values. The FGF has a
significant correlation with HME efficiency and increases
humidity values when low flow is used. Therefore, the asso-
ciation of an HME with low FGF in the breathing circuit is
the most efficient way to conserve the heat and moisture of
the inhaled gas during pediatric anesthesia. E
DISCLOSURES
Name: Gustavo P. Bicalho, MD.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: Gustavo P. Bicalho has seen the original study data,
reviewed the analysis of the data, approved the final manu-
script, and is the author responsible for archiving the study files.
Name: Leandro G. Braz, MD, PhD.
Contribution: This author helped conduct the study.
Attestation: Leandro G. Braz has seen the original study data
and approved the final manuscript.
Name: Larissa S. B. de Jesus, MD.
Contribution: This author helped conduct the study.
Attestation: Larissa S. B. de Jesus has seen the original study
data and approved the final manuscript.
Name: Cesar M. C. Pedigone.
Contribution: This author helped conduct the study.
Attestation: Cesar M. C. Pedigone approved the final manuscript.
Name: Lídia R. de Carvalho, PhD.
Contribution: This author helped design the study and analyze
the data.
Attestation: Lídia R. de Carvalho has seen the original study
data, reviewed the analysis of the data, and approved the final
manuscript.
Name: Norma S. P. Módolo, MD, PhD.
Contribution: This author helped conduct the study.
Attestation: Norma S. P. Módolo has seen the original study
data and approved the final manuscript.
October 2014 • Volume 119 • Number 4
Name: José R. C. Braz, MD, PhD.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: José R. C. Braz has seen the original study data,
reviewed the analysis of the data, and approved the final
manuscript.
This manuscript was handled by: Peter J. Davis, MD.
REFERENCES
1. Irlbeck D. Normal mechanisms of heat and moisture exchange
in the respiratory tract. Respir Care Clin N Am 1998;4:189–98
2. Van Oostdam JC, Walker DC, Knudson K, Dirks P, Dahlby RW,
Hogg JC. Effect of breathing dry air on structure and function
of airways. J Appl Physiol (1985) 1986;61:312–7
3. Martins RH, Braz JR, Defaveri J, Curi PR. Study of humidifica-
tion and heating of inspired gases during mechanical ventila-
tion in dogs. Rev Bras Otorrinolaringol 1996;62:206–17.
4. Branson RD, Campbell RS, Davis K, Porembka DT. Anaesthesia
circuits, humidity output, and mucociliary structure and func-
tion. Anaesth Intensive Care 1998;26:178–83
5. Kleemann PP. Humidity of anaesthetic gases with respect to
low flow anaesthesia. Anaesth Intensive Care 1994;22:396–408
6. Wilkes AR. Heat and moisture exchangers and breathing sys-
tem filters: their use in anaesthesia and intensive care. Part
1—history, principles and efficiency. Anaesthesia 2011;66:31–9
7. Kleemann PP. The climatisation of anesthetic gases under
conditions of high flow to low flow. Acta Anaesthesiol Belg
1990;41:189–200
8. Henriksson BA, Sundling J, Hellman A. The effect of a heat and
moisture exchanger on humidity in a low-flow anaesthesia sys-
tem. Anaesthesia 1997;52:144–9
9. Yamashita K, Yokoyama T, Abe H, Nishiyama T, Manabe M.
Efficacy of a heat and moisture exchanger in inhalation anes-
thesia at two different flow rates. J Anesth 2007;21:55–8
10. Castro J Jr, Bolfi F, de Carvalho LR, Braz JR. The tempera-
ture and humidity in a low-flow anesthesia workstation with
and without a heat and moisture exchanger. Anesth Analg
2011;113:534–8
11. Meakin GH. Low-flow anaesthesia in infants and children. Br J
Anaesth 1999;83:50–7
12. Igarashi M, Watanabe H, Iwasaki H, Namiki A. Clinical evalua-
tion of low-flow sevoflurane anaesthesia for paediatric patients.
Acta Anaesthesiol Scand 1999;43:19–23
13. Hunter T, Lerman J, Bissonnette B. The temperature and humid-
ity of inspired gases in infants using a pediatric circle system:
effects of high and low-flow anesthesia. Paediatr Anaesth
2005;15:750–4
14. Bissonnette B, Sessler DI. Passive or active inspired gas humidi-
fication increases thermal steady-state temperatures in anesthe-
tized infants. Anesth Analg 1989;69:783–7
15. Monrigal JP, Granry JC. The benefit of using a heat and mois-
ture exchanger during short operations in young children.
Paediatr Anaesth 1997;7:295–300
16. Barra Bisinotto FM, Braz JR, Martins RH, Gregório EA, Abud
TM. Tracheobronchial consequences of the use of heat and
moisture exchangers in dogs. Can J Anaesth 1999;46:897–903
17. Foregger R. The regeneration of soda lime following absorption
of carbon dioxide. Anesthesiology 1948;9:15–20
18. Wada H, Higuchi H, Arimura S. Temperature and humid-
ity of the Dräger Cato anesthetic machine circuit. J Anesth
2003;17:166–70
19. International Standard Organization. Anaesthetic and
Respiratory Equipment - Heat and Moisture Exchangers
(HMEs) Humidifying Respired Gases in Humans—part
1: HMEs for Use Minimum Tidal Volumes of 250 ml. ISO
9360–1. Geneva, Switzerland: International Organization for
Standardization, 2000
20. Luchetti M, Pigna A, Gentili A, Marraro G. Evaluation of the
efficiency of heat and moisture exchangers during paediatric
anaesthesia. Paediatr Anaesth 1999;9:39–45
21. Miyao H, Hirokawa T, Miyasaka K, Kawazoe T. Relative humid-
ity, not absolute humidity, is of great importance when using a
humidifier with a heating wire. Crit Care Med 1992;20:674–9
www.anesthesia-analgesia.org 931