A patient safety alert has been issued over the risk of using different airway humidification devices simultaneously.
The joint patient safety alert was issued last month by NHS England and the Medicines and Healthcare Products Regulatory Agency.
“In some cases nursing staff noticed that patients were deteriorating but they could not always identify the cause of the problem”
They said the move was designed to raise awareness of the risk of having two different types of airway humidification devices simultaneously connected to a patient’s ventilation equipment.
The alert warned that the inadvertent use of heated [water] humidifiers – usually located between the ventilator and the breathing system – and heat and moisture exchangers – placed at the patient’s end of the breathing system – could cause the latter to become saturated with water and obstruct the airway.
It said the risk was identified in a recent journal article and a subsequent search of the National Reporting and Learning System identified 76 incidents where a heat and moister exchangers had accidentally been left attached to a wet circuit.
In many cases the error was not recognised for several hours and caused respiratory distress, noted the alert. One incident resulted in severe cardiovascular instability and in another for the patient to lose consciousness.
In some instances nursing staff noticed that patients were deteriorating but they could not always identify the cause of the problem, said the alert.
Most cases were related to patients mechanically ventilated via an endotracheal tube, but there were also two relating to patients on non-invasive ventilation and one relating to a tracheostomy.
NHS providers have been asked to take local action to prevent the risk occurring, including performing routine safety checks, with a particular focus on patients recently transferred on ventilators, and adding the risk to the transport checklist.
“If using wet humidification, the heat and moisture exchanger must be removed as it can get saturated with water and block the airway,” stated the alert.
“Safety information about specific products is available in the manufacturer’s instructions and it is important that these are available and understood by staff,” it added.