Ex vivo water exchange performance and short-term clinical feasibility assessment of newly developed heat and moisture exchangers for pulmonary rehabilitation after total laryngectomy.

Laryngectomized patients suffer from respiratory complaints due to insufficient warming and humidification of inspired air in the upper respiratory tract. Improvement of pulmonary humidification with significant reduction of pulmonary complaints is achieved by the application of a heat and moisture exchanger (HME) over the tracheostoma. The aim of this study was to determine whether the new Provox HMEs (XM-HME and XF-HME) have a better water exchange performance than their predecessors (R-HME and L-HME, respectively; Atos Medical, Hörby, Sweden). The other aim was to assess the short-term clinical feasibility of these HMEs. The XM-HME and XF-HME were weighed at the end of inspiration and at the end of expiration at different breathing volumes produced by a healthy volunteer. The associations between weight changes, breathing volume and absolute humidity were determined using both linear and non-linear mixed effects models. Study-specific questionnaires and tally sheets were used in the clinical feasibility study. The weight change of the XM-HME is 3.6 mg, this is significantly higher than that of the R-HME (2.0 mg). The weight change of the XF-HME (2.0 mg) was not significantly higher than that of the L-HME (1.8 mg). The absolute humidity values of both XM- and XF-HME were significantly higher than that of their predecessors. The clinical feasibility study did not reveal any practical problems over the course of 3 weeks. The XM-HME has a significantly better water exchange performance than its predecessor (R-HME). Both newly designed HMEs did succeed in the clinical feasibility study.

MRI in patients with a cerebral aneurysm clip; review of the literature and incident databases and recommendations for the Netherlands.

BACKGROUND: In the past ferromagnetic cerebral aneurysm clips that are contraindicated for Magnetic Resonance Imaging (MRI) have been implanted. However, the specific clip model is often unknown for older clips, which poses a problem for individual patient management in clinical care. METHODS: Literature and incident databases were searched, and a survey was performed in the Netherlands that identified time periods at which ferromagnetic and non-ferromagnetic clip models were implanted. Considering this information in combination with a national expert opinion, we describe an approach for risk assessment prior to MRI examinations in patients with aneurysm clips. The manuscript is limited to MRI at 1.5 T or 3 T whole body MRI systems with a horizontal closed bore superconducting magnet, covering the majority of clinical Magnetic Resonance (MR) systems. RESULTS: From the literature a list of ferromagnetic clip models was obtained. The risk of movement or rotation of the clip due to the main magnetic field in case of a ferromagnetic clip is the main concern. In the incident databases records of four serious incidents due to aneurysm clips in MRI were found. The survey in the Netherlands showed that from 2000 onwards, no ferromagnetic clips were implanted in Dutch hospitals. DISCUSSION: Recommendations are provided to help the MR safety expert assessing the risks when a patient with a cerebral aneurysm clip is referred for MRI, both for known and unknown clip models. This work was part of the development of a guideline by the Dutch Association of Medical Specialists.

Understanding and predicting the performance of passive heat and moisture exchangers using a numerical model.

BACKGROUND: To improve the understanding of the thermodynamics and performance of small passive hygroscopic Heat and Moisture Exchangers (HMEs), a computer model simulating HME function is required. METHODS: We developed a numerical HME model to calculate the HME's water and heat exchange. The model was tuned and verified with experimental data and validated by applying it to HME design variations. RESULTS: Verification of the model's results to the experimental data shows that the tuned model yields reliable results. The mass of the core, which determines the HME's total heat capacity, is the most important parameter influencing the performance of passive HMEs. CONCLUSIONS: Increasing the HME's diameter is an effective way to improve an HME, as it yields higher performance and lowers breathing resistance. HMEs intended for use in warm or dry climates should contain more and those for use in cold humid climates should contain less hygroscopic salt.

Cine MRI of swallowing in patients with advanced oral or oropharyngeal carcinoma: a feasibility study.

Treatment of oral and oropharyngeal cancer may cause dysphagia. Purpose is to examine whether cine magnetic resonance imaging (MRI) yields additional information compared to standard examination in the evaluation of posttreatment dysphagia and mobility of oral and oropharyngeal structures. Thirty-four cine MRIs were made in 23 patients with advanced oral and oropharyngeal cancer, consisting of an MR image every 800 ms during swallowing which is compared to videofluoroscopy and quality of life questionnaires. A scoring system was applied to assess mobility on cine MR and videofluoroscopy leading to a score ranging from 9 to 17. Cine MRI of the swallowing in a midsagittal plane visualized the tumor (if located in the same plane), important anatomic structures and surgical reconstructions. Posttreatment mobility on cine MRI and videofluoroscopy was significantly diminished compared to pretreatment, mean pretreatment cine MRI score was 10.8 and posttreatment 12.4 (p = 0.017). Impaired mobility on cine MRI was significantly correlated to more swallowing problems (Spearman's correlation coefficient 0.73, p = 0.04), on videofluoroscopy not. Cine MRI is a promising new technique as an adjunct to standard examinations for evaluation of swallowing in patients with oral and oropharyngeal cancer. Cine MRI directly visualizes the dynamics of swallowing and allows evaluation of pre- and posttreatment differences. Abnormal findings are significantly correlated with subjective swallowing complaints of patients.

Adjustable breathing resistance for laryngectomized patients: Proof of principle in a novel heat and moisture exchanger cassette.

BACKGROUND: Due to the heat and moisture exchanger's (HME) breathing resistance, laryngectomized patients cannot always use an (optimal) HME during physical exercise. We propose a novel HME cassette concept with adjustable "bypass," to provide adjustment between different breathing resistances within one device. METHODS: Under standardized conditions, the resistance and humidification performance of a high resistance/high humidification HME (XM) foam in a cassette with and without bypass were compared to a lower resistance/lesser humidification HME (XF) foam in a closed cassette. RESULTS: With a bypass in the cassette, the resistance and humidification performance of XM foam were similar to those of XF foam in the closed cassette. Compared to XM foam in the closed cassette, introducing the bypass resulted in a 40% resistance decrease, whereas humidification performance was maintained at 80% of the original value. CONCLUSIONS: This HME cassette prototype allows adjustment between substantially different resistances while maintaining appropriate humidification performances.

Optimizing the colloid particle concentration for improved preoperative and intraoperative image-guided detection of sentinel nodes in prostate cancer.

PURPOSE: Lymphatic mapping for prostate cancer can be used to determine therapeutic strategies. Sentinel node visualization requires sufficient nodal tracer uptake. We evaluated the effect of an increase in particle concentration on preoperative and intraoperative sentinel node depiction. METHODS: Enrolled in the study were 50 consecutive patients with prostate cancer. The first 25 patients (group A) received nanocolloid with standard labelling (0.4 ml (99m)Tc per 0.1 mg nanocolloid). The last 25 patients (group B) received nanocolloid with a reduced labelling dilution volume (0.4 ml (99m)Tc per 0.2 mg nanocolloid). The aimed injected volume and dosage were the same for both groups (225 MBq in 0.4 ml). Intratumoral tracer injection was followed by planar lymphoscintigraphy (15 min and 2 h), SPECT/CT and laparoscopic sentinel lymphadenectomy. Lymph node visualization was evaluated using a four-point scoring system (0 nonvisualization to 3 intense visualization) and count quantification on the 2-h anterior lymphoscintigram. In addition to the gamma ray detection probe, a portable gamma camera was used for intraoperative sentinel node visualization. RESULTS: Preoperative visualization in group A was 88% (mean 2.0 sentinel nodes per patient) versus 100% in group B (mean 2.6 sentinel nodes per patient). Visualization scores (p=0.008), total counts (p=0.001) and maximum counts per pixel (p=0.034) in the sentinel nodes were significantly better in group B. This also led to more efficient intraoperative detection of the sentinel nodes with the portable gamma camera (84% in group A versus 100% in group B). CONCLUSION: Enhancement of the particle concentration may lead to significant improvement in sentinel node visualization and intraoperative localization in patients with prostate cancer. Further research regarding optimization of radiotracer labelling by changing the particle concentration is warranted.

Breast tomosynthesis in clinical practice: initial results.

PURPOSE: The purpose of this study was to assess the potential value of tomosynthesis in women with an abnormal screening mammogram or with clinical symptoms. Mammography and tomosynthesis investigations of 513 woman with an abnormal screening mammogram or with clinical symptoms were prospectively classified according to the ACR BI-RADS criteria. Sensitivity and specificity of both techniques for the detection of cancer were calculated. In 112 newly detected cancers, tomosynthesis and mammography were each false-negative in 8 cases (7%). In the false-negative mammography cases, the tumor was detected with ultrasound (n = 4), MRI (n = 2), by recall after breast tomosynthesis interpretation (n = 1), and after prophylactic mastectomy (n = 1). Combining the results of mammography and tomosynthesis detected 109 cancers. Therefore in three patients, both mammography and tomosynthesis missed the carcinoma. The sensitivity of both techniques for the detection of breast cancer was 92.9%, and the specificity of mammography and tomosynthesis was 86.1 and 84.4%, respectively. Tomosynthesis can be used as an additional technique to mammography in patients referred with an abnormal screening mammogram or with clinical symptoms. Additional lesions detected by tomosynthesis, however, are also likely to be detected by other techniques used in the clinical work-up of these patients.

A self-assembled multimodal complex for combined pre- and intraoperative imaging of the sentinel lymph node.

Specific removal of the sentinel lymph node (SLN) during breast cancer surgery presents physicians with the opportunity to detect early metastatic disease. To increase the accuracy of intraoperative SLN detection, new methods with higher sensitivity and specificity are required. We have quantitatively compared conventional preoperative lymphoscintigraphy with albumin radiocolloids ((99m)Tc-NanoColl) with optical intraoperative guidance using the near infrared dye indocyanine green (ICG) in an orthotopic mouse model for metastatic breast cancer. Furthermore, we have applied a self-assembled multimodal complex, in which ICG is non-covalently bound to the albumin radiocolloid, to attain identical dynamics of the radioactive and optical components. The SLN specificity of the multimodal complex is similar to conventional lymphoscintigraphy, while the fluorescent signal-to-noise ratio is improved by 86% compared to ICG alone. In addition, the multimodal complex permits scintigraphic validation of the fluorescent findings. The multimodal ICG-(99m)Tc-NanoColl complex can be used both for lymphoscintigraphy by preoperative single photon emission computed tomography/computed tomography and for surgical navigation by intraoperative fluorescence imaging.

Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition.

BACKGROUND: The value of regular surveillance for breast cancer in women with a genetic or familial predisposition to breast cancer is currently unproven. We compared the efficacy of magnetic resonance imaging (MRI) with that of mammography for screening in this group of high-risk women. METHODS: Women who had a cumulative lifetime risk of breast cancer of 15 percent or more were screened every six months with a clinical breast examination and once a year by mammography and MRI, with independent readings. The characteristics of the cancers that were detected were compared with the characteristics of those in two different age-matched control groups. RESULTS: We screened 1909 eligible women, including 358 carriers of germ-line mutations. Within a median follow-up period of 2.9 years, 51 tumors (44 invasive cancers, 6 ductal carcinomas in situ, and 1 lymphoma) and 1 lobular carcinoma in situ were detected. The sensitivity of clinical breast examination, mammography, and MRI for detecting invasive breast cancer was 17.9 percent, 33.3 percent, and 79.5 percent, respectively, and the specificity was 98.1 percent, 95.0 percent, and 89.8 percent, respectively. The overall discriminating capacity of MRI was significantly better than that of mammography (P<0.05). The proportion of invasive tumors that were 10 mm or less in diameter was significantly greater in our surveillance group (43.2 percent) than in either control group (14.0 percent [P<0.001] and 12.5 percent [P=0.04], respectively). The combined incidence of positive axillary nodes and micrometastases in invasive cancers in our study was 21.4 percent, as compared with 52.4 percent (P<0.001) and 56.4 percent (P=0.001) in the two control groups. CONCLUSIONS: MRI appears to be more sensitive than mammography in detecting tumors in women with an inherited susceptibility to breast cancer.

Ex vivo humidifying capacity and patient acceptability of stoma cloths in laryngectomized individuals.

BACKGROUND: Heat and moisture exchangers (HMEs) improve respiratory function after laryngectomy, but there is virtually no information on the benefit of traditional stoma cloths or other covers. METHODS: Two sequential studies were performed: (1) an ex vivo test was used to compare the humidifying capacity of stoma cloths to other coverings; and (2) a 4-week randomized trial was then performed to assess patient acceptability of cloths both alone and with an HME (N = 18). RESULTS: The humidifying capacity of the coverings tested varied widely. For stoma cloths, a humidifying capacity of 13.7 mg/L was found to decrease to 8.5 mg/L if air-leaks around the cloth occurred. Patients who used HMEs disliked stoma cloths because they interfered with voicing, they became soiled more easily, and were less effective at reducing coughing and mucus production. CONCLUSION: Although less acceptable to patients who use an HME, stoma cloths do provide significant humidifying capacity and should be encouraged when HMEs are unavailable or inappropriate. © 2017 Wiley Periodicals, Inc. Head Neck 39: 921-931, 2017.

Additional breast lesions in patients eligible for breast-conserving therapy by MRI: impact on preoperative management and potential benefit of computerised analysis.

This study was conducted to assess the incidence and impact of additional findings from magnetic resonance imaging (MRI) on the workup of patients eligible for breast-conserving therapy (BCT) and to optimise the specificity of further workup by combining radiological reading with computerised analysis. One hundred and sixteen patients eligible for BCT underwent preoperative MRI where the gold standard was histology or follow-up (median 35 months, range 23-48). The incidence of additional findings and impact on treatment (wider excision/conversion to mastectomy) were assessed. The specificity of referral to further workup was also assessed without and with computerised analysis. Additional findings from MRI occurred in 41% of patients, requiring workup in 78%. In 22% the findings were malignant, causing change in treatment. Specificity was 33% (10/30) for radiological reading alone, and 97% (29/30) combined with computer analysis. Our findings show that additional findings preoperative MRI required workup in approximately one-third of patients and we suggest that combining radiological reading with computer analysis has the potential to accurately exclude benign lesions from further workup.

Pulmonary function following high-dose radiotherapy of non-small-cell lung cancer.

PURPOSE: To study changes of pulmonary function tests (PFTs) after radiotherapy (RT) of non-small-cell lung cancer (NSCLC) in relation to radiation dose, tumor regression, and changes in lung perfusion. METHODS AND MATERIALS: Eighty-two patients with inoperable NSCLC were evaluated with PFTs (forced expiratory volume in 1 s [FEV(1)] and diffusion capacity [T(L,COc)]), a computed tomography (CT) scan of the chest, and a single photon emission CT (SPECT) lung perfusion scan, before and 3-4 months after RT. The reductions of PFTs and tumor volume were calculated. The lung perfusion was measured from pre- and post-RT SPECT scans, and the difference was defined as the measured perfusion reduction (MPR). In addition, the perfusion post-RT was estimated from the dose distribution using a dose-effect relation for regional lung perfusion, and compared with the pre-RT lung perfusion to obtain the predicted perfusion reduction (PPR). The difference between the actually measured and the PPR was defined as reperfusion. The mean lung dose (MLD) was computed and weighted with the pre-RT perfusion, resulting in the mean perfusion-weighted lung dose (MpLD). Changes of PFTs were evaluated in relation to tumor dose, MLD, MpLD, tumor regression, and parameters related to perfusion changes. RESULTS: In a multivariate analysis, the total tumor dose and MLD were not associated with reductions of PFTs. Tumor regression resulted in a significant improvement of FEV(1) (p = 0.02), but was associated with a reduction of T(L,COc) (p = 0.05). The MpLD and the PPR showed a significant (p = 0.01 to 0.04) but low correlation (r = 0.24 to 0.31) with the reduction of both PFTs. The other parameters for perfusion changes, the MPR and reperfusion were not correlated with changes in PFTs. CONCLUSION: The perfusion-related dose variables, the MpLD or the PPR, are the best parameters to estimate PFTs after RT. Tumor regression is associated with an improvement of FEV(1) and a decline of T(L,COc). Reperfusion was not associated with an improvement of global pulmonary function.

Accuracy of internal mammary lymph node localization using lymphoscintigraphy, sonography and CT.

BACKGROUND AND PURPOSE: An accurate internal mammary (IM) lymph node localization technique is required for proper irradiation of the IM lymph nodes in breast cancer patients. In this study the measurement accuracy of three techniques for direct or indirect localization of the IM nodes was estimated. MATERIALS AND METHODS: In 40 patients the IM lymph node depth and lateral distance from the patient midline were measured with lymphoscintigraphy in intercostal spaces 2, 3 and 4. The corresponding position of an IM vessel was measured with sonography and CT in intercostal spaces 1-4. The sonography and CT vessel measurements in the four intercostal spaces were compared to determine the measurement accuracy of sonography. The node and vessel data in intercostal space 2 were inserted into a mathematical model to determine the measurement accuracy of lymphoscintigraphy and CT for node detection. RESULTS: Vessel depths measured by sonography were systematically too shallow and the lateral vessel position could not be accurately determined. The mathematical model showed that the node depth and lateralization in one intercostal space can be measured directly by lymphoscintigraphy within an accuracy (1 SD) of 5 mm in depth and 6 mm in the lateral direction. The accuracy of CT for indirect node detection was 6 mm in depth and 7 mm in the lateral direction. CONCLUSIONS: Sonography is not a suitable technique for measuring the IM vessel or node position. Lymphoscintigraphy and CT have measurement accuracies for node detection that are acceptable for radiotherapy.

Portal imaging to assess set-up errors, tumor motion and tumor shrinkage during conformal radiotherapy of non-small cell lung cancer.

PURPOSE: To investigate patient set-up, tumor movement and shrinkage during 3D conformal radiotherapy for non-small cell lung cancer. MATERIALS AND METHODS: In 97 patients, electronic portal images (EPIs) were acquired and corrected for set-up using an off-line correction protocol based on a shrinking action level. For 25 selected patients, the orthogonal EPIs (taken at random points in the breathing cycle) throughout the 6-7 week course of treatment were assessed to establish the tumor position in each image using both an overlay and a delineation technique. The range of movement in each direction was calculated. The position of the tumor in the digitally reconstructed radiograph (DRR) was compared to the average position of the lesion in the EPIs. In addition, tumor shrinkage was assessed. RESULTS: The mean overall set-up errors after correction were 0, 0.6 and 0.2 mm in the x (left-right), y (cranial-caudal) and z (anterior-posterior) directions, respectively. After correction, the standard deviations (SDs) of systematic errors were 1.4, 1.5 and 1.3 mm and the SDs of random errors were 2.9, 3.1 and 2.0 mm in the x-, y- and z-directions, respectively. Without correction, 41% of patients had a set-up error of more than 5 mm vector length, but with the set-up correction protocol this percentage was reduced to 1%. The mean amplitude of tumor motion was 7.3 (SD 2.7), 12.5 (SD 7.3) and 9.4 mm (SD 5.2) in the x-, y- and z-directions, respectively. Tumor motion was greatest in the y-direction and in particular for lower lobe tumors. In 40% of the patients, the projected area of the tumor regressed by more than 20% during treatment in at least one projection. In 16 patients it was possible to define the position of the center of the tumor in the DRR. There was a mean difference of 6 mm vector length between the tumor position in the DRR and the average position in the portal images. CONCLUSIONS: The application of the correction protocol resulted in a significant improvement in the set-up accuracy. There was wide variation in the observed tumor motion with more movement of lower lobe lesions. Tumor shrinkage was observed. The position of the tumor on the planning CT scan did not always coincide with the average position as measured during treatment.

Optimizing radiation treatment plans for lung cancer using lung perfusion information.

PURPOSE: To study the impact of incorporation of lung perfusion information in the optimization of radical radiotherapy (RT) treatment plans for patients with medically inoperable non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: The treatment plans for a virtual phantom and for five NSCLC patients with typical defects of pre-RT lung perfusion were optimized to minimize geometrically determined parameters as the mean lung dose (MLD), the lung volume receiving more than 20 Gy (V20), and the functional equivalent of the MLD, using perfusion-weighted dose-volume histograms. For the patients the (perfusion-weighted) optimized plans were compared to the clinically applied treatment plans. RESULTS: The feasibility of perfusion-weighted optimization was demonstrated in the phantom. Using perfusion information resulted in an increase of the weights of those beams that were directed through the hypo-perfused lung regions both for the phantom and for the studied patients. The automatically optimized dose distributions were improved with respect to lung toxicity compared with the clinical treatment plans. For patients with one hypo-perfused hemi-thorax, the estimated gain in post-RT lung perfusion was 6% of the prescribed dose compared to the geometrically optimized plan. For patients with smaller perfusion defects, perfusion-weighted optimization resulted in the same plan as the geometrically optimized plan. CONCLUSION: Perfusion-weighted optimization resulted in clinically well applicable treatment plans, which cause less radiation damage to functioning lung for patients with large perfusion defects.

Reproducibility of mammary gland structure during repeat setups in a supine position.

PURPOSE: In breast conserving therapy, complete excision of the tumor with an acceptable cosmetic outcome depends on accurate localization in terms of both the position of the lesion and its extent. We hypothesize that preoperative contrast-enhanced magnetic resonance (MR) imaging of the patient in a supine position may be used for accurate tumor localization and marking of its extent immediately prior to surgery. Our aims in this study are to assess the reproducibility of mammary gland structure during repeat setups in a supine position, to evaluate the effect of a breast immobilization device, and to derive reproducibility margins that take internal tissue shifts into account occurring between repeat setups. MATERIALS & METHODS: The reproducibility of mammary gland structure during repeat setups in a supine position is estimated by quantification of tissue shifts in the breasts of healthy volunteers between repeat MR setups. For each volunteer fiducials are identified and registered with their counter locations in corresponding MR volumes. The difference in position denotes the shift of breast tissue. The dependence on breast volume and the part of the breast, as well as the effect of a breast immobilization cast are studied. RESULTS: The tissue shifts are small with a mean standard deviation on the order of 1.5 mm, being slightly larger in large breasts (V> 1000 cm3), and in the posterior part (toward the pectoral muscle) of both small and large breasts. The application of a breast immobilization cast reduces the tissue shifts in large breasts. A reproducibility margin on the order of 5 mm will take the internal tissue shifts into account that occur between repeat setups. CONCLUSION: The results demonstrate a high reproducibility of mammary gland structure during repeat setups in a supine position.

Ex vivo assessment and validation of water exchange performance of 23 heat and moisture exchangers for laryngectomized patients.

BACKGROUND: Breathing through a tracheostoma results in insufficient warming and humidification of the inspired air. This loss of air conditioning, especially humidification, can be partially restored with the application of a heat and moisture exchanger (HME) over the tracheostoma. For medical professionals, it is not easy to judge differences in water exchange performance of various HMEs owing to the lack of universal outcome measures. This study has three aims: assessment of the water exchange performance of commercially available HMEs for laryngectomized patients, validation of these results with absolute humidity outcomes, and assessment of the role of hygroscopic salt present in some of the tested HMEs. METHODS: Measurements of weight and absolute humidity at end inspiration and end expiration at different breathing volumes of a healthy volunteer were performed using a microbalance and humidity sensor. Twenty-three HMEs from 6 different manufacturers were tested. Associations were determined between core weight, weight change, breathing volume, and absolute humidity, using both linear and nonlinear mixed effects models. RESULTS: Water exchange of the 23 HMEs at a breathing volume of 0.5 L varies between 0.5 and 3.6 mg. Both water exchange and wet core weight correlate strongly with the end-inspiratory absolute humidity values (r2 =0.89/0.87). Hygroscopic salt increases core weight. CONCLUSIONS: The 23 tested HMEs for laryngectomized patients show wide variation in water exchange performance. Water exchange correlates well with the end-inspiratory absolute humidity outcome, which validates the ex vivo weight change method. Wet core weight is a predictor of HME performance. Hygroscopic salt increases the weight of the core material. The results of this study can help medical professionals to obtain a more founded opinion about the performance of available HMEs for pulmonary rehabilitation in laryngectomized patients, and allow them to make an informed decision about which HME type to use.

Water Uptake Performance of Hygroscopic Heat and Moisture Exchangers after 24-Hour Tracheostoma Application.

OBJECTIVE: After total laryngectomy, patients suffer from pulmonary complaints due to the shortcut of the upper airways that results in decreased warming and humidification of inspired air. Laryngectomized patients are advised to use a heat and moisture exchanger (HME) to optimize the inspired air. According to manufacturers' guidelines, these medical devices should be replaced every 24 hours. The aim of this study is to determine whether HMEs still function after 24-hour tracheostoma application. STUDY DESIGN: Assessment of residual water uptake capacity of used HMEs by measuring the difference between wet and dry core weight. SETTING: Tertiary comprehensive cancer center. SUBJECTS AND METHODS: Three hygroscopic HME types were tested after use by laryngectomized patients in long-term follow-up. Water uptake of 41 used devices (including 10 prematurely replaced devices) was compared with that of control (unused) devices of the same type and with a control device with a relatively low performance. RESULTS: After 24 hours, the mean water uptake of the 3 device types had decreased compared with that of the control devices. For only one type was this difference significant. None of the used HMEs had a water uptake lower than that of the low-performing control device. CONCLUSION: The water uptake capacity of hygroscopic HEMs is clinically acceptable although no longer optimal after 24-hour tracheostoma application. From a functional point of view, the guideline for daily device replacement is therefore justified.

A novel, simplified ex vivo method for measuring water exchange performance of heat and moisture exchangers for tracheostomy application.

BACKGROUND: Breathing through a tracheostomy results in insufficient warming and humidification of inspired air. This loss of air-conditioning can be partially compensated for with the application of a heat and moisture exchanger (HME) over the tracheostomy. In vitro (International Organization for Standardization [ISO] standard 9360-2:2001) and in vivo measurements of the effects of an HME are complex and technically challenging. The aim of this study was to develop a simple method to measure the ex vivo HME performance comparable with previous in vitro and in vivo results. METHODS: HMEs were weighed at the end of inspiration and at the end of expiration at different breathing volumes. Four HMEs (Atos Medical, Hörby, Sweden) with known in vivo humidity and in vitro water loss values were tested. The associations between weight change, volume, and absolute humidity were determined using both linear and non-linear mixed effects models. RESULTS: The rating between the 4 HMEs by weighing correlated with previous intra-tracheal measurements (R(2) = 0.98), and the ISO standard (R(2) = 0.77). CONCLUSIONS: Assessment of the weight change between end of inhalation and end of exhalation is a valid and simple method of measuring the water exchange performance of an HME.