National Patient Safety Alerts


Alerts relevant to anaesthesia

Risk of using different airway humidification devices simultaneously

15 December 2015
Alert Reference: NHS/PSA/W/2015/012

A joint patient safety alert has been issued by NHS England and the Medicines & Healthcare Products Regulatory Agency (MHRA) to raise awareness of the risk of having two different types of airway humidification devices simultaneously connected to a patient’s ventilation equipment.

There are two humidifiers in common use: heated [water] humidifiers (HHs), usually located between the ventilator and the breathing system; and heat and moisture exchangers (HMEs), placed at the patient’s end of the breathing system. The inadvertent use of both types of humidifier simultaneously can cause the HME to become saturated with water and could lead to the airway becoming obstructed.

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