Breathing system filters

Antony R. Wilkes BSc MSc

Key points Both gas- and liquidborne routes of transmission of contamination are important, the latter particularly so in circle systems Pleated hydrophobic filters generally have better gas-borne filtration performance than electrostatic filters Pleated hydrophobic filters prevent liquid-borne transmission; the ability of electrostatic filters to prevent liquid-borne transmission depends on the volume of liquid, the filter area and the orientation of the filter material during use As performance depends on its size, a filter should be used with an internal volume appropriate to the patients tidal volume Filters increase resistance to gas flow and deadspace in breathing systems and may prevent adequate ventilation by becoming blocked

Intubation bypasses the normal warming, humidifying and filtering functions of the nasopharynx. Breathing system filters are intended to replace the filtering function of the nasopharynx and may also replace its warming and humidifying functions. Filters reduce the risk of the interior of breathing systems, equipment and the ambient air becoming contaminated by patients. The use of a breathing system filter sited at the Y-piece to provide both filtration and humidification was first described in 1984, although filters attached directly to ventilators had been described previously. There is now a wide variety of different filters on the market from a large number of manufacturers. The routine use of filters is recommended by a number of professional bodies especially when breathing systems are used for more than one patient.

Reducing the risk of cross-infection

The use of filters is only one measure that should be used to reduce the risk of cross-infection during anaesthesia and in intensive care. For example, the anaesthetists hands and gloves can be contaminated during invasive procedures. Unless the gloves are removed or the hands washed immediately following the procedure, any equipment (such as breathing systems) or surfaces touched will then become contaminated. If this contaminated equipment is not cleaned adequately after each use, and normal cleaning procedures may not remove all contamination, infective material may be transferred by further glove or hand contact to other patients. Microbial contamination of the interior of breathing systems may cause cross-infection and breathing system filters reduce this. Microbes exist in sputum and blood and contamination may result from either the gas- or liquid-borne route.

A.R.Wilkes BSc MSc Senior Research Fellow, Department of Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN Tel: 029 2074 3103 Fax: 029 2074 4706 E-mail: wilkes@cf.ac.uk

In the gas-borne route, an aerosol of sputum droplets containing microbes is expelled from a patient and remains suspended in the gas stream. Typical sizes of droplets which remained suspended and are important for alveolar deposition are 15 m. The gas-borne route is important for the spread of diseases such as tuberculosis and influenza. The liquid-borne route is where sputum flows from the patients respiratory tract into the breathing system. If trauma has occurred to the airways during intubation or if there is pre-existing injury causing blood-stained sputum, then sputum may contain blood-borne viruses such as hepatitis B and C and HIV. Prions in patients with vCJD are found primarily in nervous and lymphatic tissue. Therefore, they are unlikely to be found in sputum, even if blood is present. In both cases, coughing is the predominant cause of contamination in breathing systems. Very few droplets are expelled from the airways during normal, quiet breathing. During coughing, the size of the droplets produced depends on the force of the cough, so that a more forceful cough produces smaller droplets which can remain suspended in the gas-stream. Titres of microbes in sputum and blood are rarely greater than 107 ml1. A typical cough contains droplets with a total volume of about 2 107 ml. Therefore, at most, there are likely to be only a few infected droplets expelled during each cough. In contrast, 0.2 ml of sputum expelled by a patient into the breathing system has the potential to contain a million times more microbes than that in droplets expelled during a cough. Coughing occurs during intubation, extubation and inhalation of irritant anaesthetic agents. Smokers are more likely to cough than non-smokers. Techniques to reduce the incidence of coughing, and hence the potential contamination of breathing systems, should be used where possible.

DOI 10.1093/bjacepd/02.05.151

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The use of breathing system filters

Inspiratory and expiratory gases are separated in the breathing systems used in intensive care and open breathing systems used during anaesthesia, although there is a partial common pathway in the latter. In these cases, microbes expelled by one patient are unlikely to be inhaled by another if the breathing system is re-used, although preventing the release of microbes into the ambient air is obviously desirable. In contrast, in circle breathing systems, expired gas is returned to the patient when the carbon dioxide has been removed and microbes could be transferred between patients if this type of breathing system is re-used. Condensation occurs in circle breathing systems due to the release of water vapour from the reaction of the soda lime with carbon dioxide and from the water vapour exhaled by the patient. Condensation containing microbes may then enter the patients respiratory tract from the breathing system.

much larger than their physical cross-sectional area and can, therefore, be captured comparatively easily by the filter material. Particles in the most penetrating particle size range are too small to be captured easily by direct interception and are too large to undergo significant Brownian motion.

Reducing liquid-borne contamination

The transmission of liquid is prevented by using a hydrophobic layer on the filter to prevent the ingress of water-based liquid solutions into the filter material. The liquid entering the filter housing may have a large range of viscosity. The respiratory secretions of patients can become particularly viscous if they receive inadequate humidification during long-term ventilatory assistance and such secretions may adhere to the filter material and prevent adequate ventilation.

Reducing gas-borne contamination

Filter material can reduce the passage of gas-borne particles by 5 mechanisms (Table 1). The effectiveness of these mechanisms depends, amongst other parameters, on the size of the particle passing through the filter material. For all filter materials, there is a size of particle that passes through the filter material most easily: the diameter of this particle is known as the most penetrating particle size, normally 0.050.5 m. For particles with diameters close to the most penetrating particle size, the two most important filtration mechanisms are diffusion and interception (Fig. 1). Particles with diameters larger than the most penetrating particle size are directly intercepted by the fibres in the filter material. Particles < ~0.1 m undergo significant Brownian motion, so that they randomly traverse areas
Table 1 Filtration mechanisms
Mechanism Interception Effect

Types of breathing system filters

Pleated hydrophobic filters
The breathing system filter first described in 1984 contains a sheet of resin-bonded ceramic fibres. The fibres are packed densely and hence the sheet has a high resistance to gas flow per unit area. The resistance to gas flow is reduced by using a sheet with a large surface area. The sheet is pleated to fit within a housing of acceptable internal volume. This type of sheet is hydrophobic and, under normal conditions, does not absorb water.

Electrostatic filters
Breathing system filters containing electrostatic filter material became available in the late 1980s. One type of material is made from a sheet of polypropylene on which a permanent electrostatic charge is applied during manufacture. The sheet is subsequently split into fibres which are then pressed together to form a wad.
Combinedefficiency 100

A particle following a gas streamline around a fibre in the filter material comes within one particle radius of the surface of the fibre and strikes the fibre A particle, unable to follow a gas streamline around a fibre because of its inertia, strikes the fibre Small particles undergoing Brownian motion cross gas streamlines which increases the probability of them striking a fibre Large particles in slow moving air settle onto fibres due to gravity Charged particles are attracted to oppositely charged fibres by coulombic attraction. Neutral particles are attracted to a charged fibre as the electric field induces a dipole in the particle and charged particles are attracted to neutral fibres by inducing image forces on the fibres

90 80 70 60 50 40 30 20 10 0 0.01 Interception Diffusion

Inertial impaction Diffusion

Gravitational settling Electrostatic attraction

0.10 Particle diameter (m)

1.00

Fig. 1 Filtration efficiency (%).

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Such filter material is termed an Electret. Other types of electrostatic filter are also available. The fibre density is lower than in sheets of resin-bonded ceramic fibres and hence the resistance to gas flow is lower per unit area. The removal of particles by direct interception is also lower, although the electrostatic charge improves the efficiency of the deposition of particles on fibres (Table 1). Hence, this filter material does not need to be pleated and a flat layer is generally used in breathing system filters.

Table 2 Size of pathogenic microbes compared with the size of microbes used to challenge breathing system filters.Viruses rarely exist free from cell debris and other solids (e.g. nutrient solutions) thus increasing their effective diameter.The most penetrating particle size for filters is normally 0.050.5 m
Microbe Bacteria Bacillus subtilis var. niger (test microbe) Pseudomonas aeruginosa Tubercle bacilli Staphylococci Streptococcus pneumoniae Viruses MS-2 (test microbe) Hepatitis B Hepatitis C HIV Typical size (m) Width x length 0.6 x 1.1 0.6 x 2 0.4 x 3 1x1 0.5 x 1 Diameter (naked) 0.023 0.042 0.045 0.09

Combined filters and heat and moisture exchangers

Many filters also contain a heat and moisture exchanging layer to return some of the exhaled moisture and heat to the patient during the next inspiration. Humidification in general was dealt with in an earlier issue of CEPD Reviews (Br J Anaesth CEPD Rev 2001; 1: 403).

Filtration performance
Gas-borne
Filtration performance is expressed in terms of penetration (number of particles passing through the filter as a percentage of the number of particles in the challenge to the filter), or as efficiency, i.e. [100 penetration] (%). Filtration performance can be determined using challenges of aerosols of droplets containing bacteria, viruses or inorganic particles (e.g. sodium chloride). Much larger microbial challenges are used than would be encountered in normal clinical use, so that the same challenge can cover the whole range of likely filtration performance. Typical microbial challenges consist of an aerosol containing more than 107 microbes. The microbes used need to be robust (in order to withstand nebulisation) and act as particles enabling filtration performance to be determined by counting the number of microbes that pass through the filter. Bacteria tend to be larger than the most penetrating particle size and viruses tend to be smaller (Table 2), although the droplets containing viruses are also likely to be larger, as the viruses will be attached to cell debris rather than being naked.

However, sodium chloride particles can be generated such that their size is close to the most penetrating particle size for the filter. Therefore, filtration performance determined using sodium chloride particles gives the worst-case performance for the filter. This method has been adopted for the European Standard as the size and number of the particles can be generated accurately and precisely and the technique has been used to measure the filtration performance of other devices. Part 1 of the standard specifies a test method to measure filtration performance (but does not specify a level that the filter has to achieve). Part 2 specifies tests and requirements for other aspects of the filter (pressure drop, internal volume, connectors, labelling, etc.). In general, pleated hydrophobic filters reduce gas-borne transmission of bacteria, viruses and sodium chloride particles more effectively than electrostatic filters (Table 3). In particular, during in vitro tests, most pleated hydrophobic filters effectively prevent all bacteria passing through the filter material. Filtration efficiency is increased if the density of the fibres is increased and if the depth of the filter material is increased, although, in both these cases, the resistance to gas flow also increases. Filtration efficiency also depends on the face velocity,

Table 3 Typical penetration values through different types of breathing system filters with various challenges.The two types of electrostatic filters differ in the way they are manufactured.Tested using a flow of 30 litre min1
Challenge Pleated hydrophobic Type I Bacterial (Bacillus subtilis var. niger) Viral (MS-2) Sodium chloride particles of the most penetrating particle size < 0.000005 to 0.00009% 0.00014 to 0.0047% 0.015 to 0.68% 0.00012 to 0.0035% 0.0097 to 0.085% 0.28 to 2.85% Filter type Electrostatic Type II 0.053 to 0.17% 0.67 to 1.03% 4.5 to 11%

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Table 4 Differences in performance between a small and large pleated hydrophobic filters from the same manufacturer with the same filter material
Parameter Internal volume (ml) Filter area (cm2) Pressure drop (Pa) at 30 litre min1 Moisture output (g m3) at tidal volume of 0.5 litre Filtration performance (penetration [%]) Bacterial Viral Sodium chloride particles *Less than the limit of detection. Small filter 39 240 133 17 < 0.000007* 0.0047 0.056 Large filter 96 700 75 26 < 0.000007* 0.00092 0.022

Clinical use of breathing system filters

Intensive care
The prevention of respiratory infection in patients receiving ventilatory assistance in intensive care is of primary importance. However, it is generally accepted that the majority of cases of ventilator-associated pneumonia occurs from the patients own microbial flora. The use of breathing system filters is, therefore, unlikely to reduce the incidence of this problem. Gases delivered to patients from pipelines or cylinders via a ventilator should be free of microbes and should not require further filtration. However, filters could be used to reduce surface contamination near the exhaust ports of ventilators.

Anaesthesia
The routine use of breathing system filters theoretically reduces the risk of cross-infection when breathing systems are used for more than one patient. However, a reduction in the incidence of nosocomial infection when filters are used has yet to be demonstrated, although the use of filters has been shown to prevent bacterial contamination of the interior of breathing systems. Condensation may collect in a circle breathing system: this has the potential to be transferred into the next patients respiratory tract. The use of an appropriate filter would reduce the risk of this.

i.e. volume flow per unit area of filter material. Resistance to gas flow also depends on the filter area, so that a filter with a larger surface area can either have lower resistance to gas flow or a more efficient (denser or thicker) filter material with a similar resistance to a filter with a smaller surface area. Generally, therefore, a larger filter will have a greater filtration efficiency than a smaller filter (Table 4). However, it is important to note that the clinical relevance of the difference in filtration performance between different filters has yet to be established.

Hazards and complications of breathing filters

The use of filters is not free of risk. They increase total resistance to gas flow and work of breathing. They may affect the triggering of some ventilators. When sited at the Y-piece, the filter housing increases dead-space, so total ventilation must be increased to maintain adequate alveolar ventilation thus increasing peak alveolar pressure. Blockage due to water, secretions, inhalants and manufacturing faults have all been reported.

Liquid-borne
During in vitro tests, pleated hydrophobic filter material prevents the transmission of liquid, and hence liquid-borne microbes such as blood-borne viruses, under pressures normally encountered in clinical practice. A pressure difference of > 10 kPa is typically necessary to force liquid through a pleated hydrophobic filter. In contrast, liquid (and any microbes contained in the liquid) can be forced through electrostatic filter material if the liquid has formed a layer covering the filter material and there is a difference in pressure across the filter layer greater than about 1.6 kPa. The risk of transmission of liquid through electrostatic filters can be reduced by using a filter with a large surface area and by orientating the filter such that the filter layer is vertical. However, the surface area of the filter material that can be used is limited by the shape and internal volume of the filter housing. The internal volume should be a small fraction of the patients tidal volume to prevent unreasonable levels of re-breathing. These in vitro tests are generally of short duration. However, filters may be used for up to 24 h. Whether contamination present on one side of the filter material during the early part of its use may pass through to the other side by the end of this period of use has not been investigated.
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Key references
Hinds WC. Aerosol Technology. Properties, Behaviour, and Measurement of Airborne Particles, 2nd edn. New York:Wiley, 1999 Rathgeber J, Keitzmann D, Mergeryant H, Hub R, Zchner K, Kettler D. Prevention of patient bacterial contamination of anaesthesia-circlesystems. A clinical study of the contamination risk and performance of different heat and moisture exchangers with Electret filter (HMEF). Eur J Anaesthesiol 1997; 14: 36873 Wilkes AR, Benbough JE, Speight SE, Harmer M.The bacterial and viral filtration performance of breathing system filters. Anaesthesia 2000; 55: 45865 Wilkes AR. Measuring the filtration performance of breathing system filters using sodium chloride particles. Anaesthesia 2002; 57: 1628 Wilkes AR.The ability of breathing system filters to prevent liquid contamination of breathing systems a laboratory study. Anaesthesia 2002; 57: 339

See multiple choice questions 103 and 104.

British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 5 2002