Pulmonary Rehabilitation and Humidification in Tracheostomy Care
For patients who are self-ventilated through a tracheostomy tube, the body's natural humidification system is bypassed, which can seriously compromise pulmonary health1,2,3. Optimization strategies for humidification therapy have not been systematically defined limiting evidence‑based guidance for selecting and adjusting clinical protocols4.
On the contrary, failing to address humidification can lead to chronic complications for tracheostomy patients, such as:
- Recurrent respiratory infections1,2,3
- Increased in-hospital complications and cost5
- Reduced quality of life6
Impact of tracheostomy on respiratory function
The upper airways, particularly the nasal cavities, are essential for conditioning the air we breathe by warming, humidifying, and filtering it7.
For patients with a tracheostomy, this function is bypassed, so the air reaching the trachea is not conditioned or filtered by the upper airway2.
As a result, such patients may face negative effects on their lung health, including a higher risk of lower respiratory tract infections, increased coughing, and greater production of tracheobronchial mucus1,2,3.
Given these complications, inhaled air should be filtered, heated, and humidified; therefore, artificial humidification is recommended for patients with tracheostomy2.
Types of artificial Humidification
1. Active Humidification
Active humidifiers, or Conventional External Humidification Systems (CEHS), work by passing air through a water reservoir. CEHS include cold-water baths and heated humidifiers8.
With cold water baths, medical inspired gases pass through a water reservoir (at room temperature) before being delivered to the patient8.
In contrast with heated humidifiers (HH), gases pass across a heated water chamber8.
2: Passive Humidification
Passive humidifiers have a media which captures the heat and moisture from exhaled air, maintain humidity by capturing exhaled moisture and the heat and moisture is recycled as inhaled air passes through the media.
Types include protectors ("bibs"), Heat and Moisture Exchangers (HMEs), and HMEs with Electrostatic Filters (HMEFs), which attach directly to tracheostomy tubes 9.
During exhalation: the natural heat and moisture of the air are retained by the HME system.
During Inhalation: the HME releases stored heat and moisture, thereby warming and humidifying the inspired air.
HMEs and their clinical benefits
HMEs compensate for the loss of normal upper respiratory tract functions through three properties: heat and moisture exchange, resistance, and filtration10.
HMEs retain heat and moisture from exhaled air and return it to the respiratory tract during inhalation. They are suitable for both mechanically ventilated and self-ventilating patients and can be attached between various connectors and the breathing system or directly to a tracheostomy tube connector10, 11.
Regarding breathing resistance, an HME generates positive expiratory pressure, helps prevent alveolar collapse, and increases lung volume10.
For filtration of small particles, HMEFs should be used; these devices provide humidification and electrostatic filtration, achieving over 98% efficiency for bacteria and viruses. Electrostatic filters use charged fiber mats to trap small particles effectively13.
Our solutions for humidification
TrachPhone
TrachPhone is a heat and moisture exchanger equipped with a 15 mm ISO connector, designed for use by patients self-ventilating via a tracheostoma.
The TrachPhone HME is a versatile device that features hygroscopic foam to retain heat and moisture from exhaled air, a valve with a spring that can be occluded with a finger facilitating speech, an integrated suction port (that allows for tracheal suction without removing the HME), and a port for low-flow oxygen delivery.
During coughing episodes or obstructions, the suction port functions as a pressure relief valve, allowing for clearing of the tracheostomy tube when mucus accumulation occurs.
Lightweight in design, the device attaches securely to the distal end of a tracheostomy tube.
Freevent XtraCare and XtraCare Mini
Freevent XtraCare is a heat and moisture exchanger with an effective electrostatic filter (HMEF).
It contains a hygroscopic foam core which traps moisture and warmth from the patient’s exhaled breath and then releases this heat and moisture during inhalation.
Additionally, the filter provides protection against airborne particles, including viruses and bacteria, with a filtration efficiency of more than 98% 14.
It is intended for self-ventilating patients with a tracheostoma.
Freevent XtraCare and Freevent XtraCare Mini offer an optional O2 adaptor that can be positioned over the device, enabling oxygen delivery via the HMEF.
The use of Freevent XtraCare HME and XtraCare Mini has been recommended by several guidelines and protocols for safe tracheostomy care, especially during the COVID-19 pandemic15, 16.*
*Since pathogens can enter and leave the human body in other ways (such as the mouth, nose, and eyes), Freevent XtraCare and Freevent XtraCare Mini can never guarantee complete protection. Please read the instructions for use for guidance.
Freevent DualCare
The Freevent DualCare is a speaking valve that allows hands-free speech and includes an HME to humidify inhaled air. Users can switch between speaking and HME modes by twisting the lid. In speaking mode, a one-way membrane lets patients speak during exhalation. In HME mode, the membrane shifts to create a two-way valve for normal breathing through the device.
Freevent HME DigiTop and HME DigiTop O2 lets patients use the HME without the speaking valve attachment, however, they can still use manual occlusion for speech. The DigiTop O2 model also allows oxygen tubing attachment via its port for those needing extra oxygen.
Freevent DualCare has been evaluated in one in-vivo clinical study and one ex-vivo clinical study. They showed that Freevent DualCare speaking valve also offers humidification when used in HME mode 17, 18.
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12. Scheenstra RJ, Muller SH, Vincent A, Ackerstaff AH, Jacobi I, Hilgers FJ. Short-term endotracheal climate changes and clinical effects of a heat and moisture exchanger with an integrated electrostatic virus and bacterial filter developed for laryngectomized individuals. Acta Otolaryngol. 2010;130(6):739-46.
13. Raynor PC, Kim BG, Ramachandran G, Strommen MR, Horns JH, Streifel AJ. Collection of biological and non-biological particles by new and used filters made from glass and electrostatically charged synthetic fibers. Indoor Air. 2008;18(1):51-62.
14. Viral Filtration Efficiency and Bacterial Filtration Efficiency at an increased Challenge Level Test procedure adapted from ASTM F2101 at Nelson Laboratories (US) in accordance with USFDA (21 CFR Parts 58, 210, 211 and 820) regulations. Mean VFE and BFE was >99%. Data on file.
15. Kelley J, Gallagher F, Steele A. The Kelley Circuit: A solution for the management of in-hospital self-ventilating tracheostomy patients, providing humidification and filtration, with closed circuit suctioning. 2020. Available from: http://www.tracheostomy.org.uk/storage/files/The%20Kelley%20Circuit%20For%20Tracheostomy.pdf.pdf.
16. Fikkers B. NVIC tracheotomy protocol COVID-19. Radboud University Medical Center; 2020
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