ARC Medical, Inc. ThermoFlo™ In-service Presentation

1. ARC Medical, Inc.ThermoFlo™ In-service Presentation Presented by ARC Medical, Inc. 800.950.2720 www.arcmedical.com

2. EXCEEDING THE STANDARD FOR NEARLY 25 YEARS. ARC was formed in 1990 to address the needs of providing in line humidification. Our goal is to replace the need for heated water bath humidifiers.

3. NOT ALL HMEs ARE CREATED EQUAL ThermoFlo™ System was the first to exceed AARC’s recommended standard of 30+mg H20/L air @ 20L VE. (As evidenced in independent studies.) Original HME devices were designed for short term use in ICU, Recovery, Anesthesia, etc. Most still do not provide adequate moisture for long term patient use.

4. PAPER, FOAM, SPONGEWhat happens when they get wet? They Absorb!

5. WHY IS THIS IMPORTANT? The termhygroscopicrefers to the ability of a material to absorb humidity from the air. (Hygroscope indicates changes in humidity.) Hydrophilicrefers to substances that absorb water. Hydrophobicmaterials hate water and repel it. Which term(s) do you think applies to ThermoFlo™? This is why we are different from the competition!

6. Zero!When used from Intubation to Extubation NEVER a reported endotracheal tube occlusion, or pneumothorax with ThermoFlo™.

7. CONSTRUCTION HME media Filter with hydrophobic membrane Unitized Construction

8. Exceeds Standards @ 20L VE Conventional “Passive Humidifiers” ThermoFlo™ Mg H20 / L Air @ 20L VE @ 10L VE @ 10L VE @ 20L VE Data on file

9. THERE IS SAFETY IN OUR NUMBERS No others match our performance record

11. KK Stout, Poster Presentation, American College of Chest Physicians Nov. 1994

12. COMPARISON OF LONG TERM USE OF A HYGROSCOPIC CONDENSING HUMIDIFIER VERSUS HEATED WIRE CIRCUIT • Duke University Medical Center, Durham, NC Sharon Day, RRT, Robert McConnell, RRT, Heather Fredericksen, RRT, Neil R. Maclntyre, MD BACKGROUND: A hygroscopic condensing humidifier (HCH) is a passive humidification device that collects heat and humidity from expired gas of a patient on a mechanical ventilator and conditions inspired gas as it passes back through the device. A heated wire circuit (HWC) actively adds heat and humidification to the inspiratory limb of a warmed circuit after passing through a heated water canister. METHODS: All patients requiring mechanical ventilation between 2/22/96 and 4/24/96 were eligible for the study. Patients were randomly assigned to receive either a hygroscopic condensing humidifier (ThermoFlo™ ARC Medical, Inc) or a heated wire circuit (Bear 5 circuit by Marquest). Sputum was categorized on each day of the mechanical ventilation as: watery (sputum that can be suctioned like water, after suction is terminated no secretions remain attached to the inner surface of the suction catheter), moderate (sputum of moderate viscosity, after suction is terminated, some secretions remain attached to the inner surface of the suction catheter) or tenacious (thick sputum, after suction is terminated, most secretions are still attached to the inner surface of the Catheter, and they cannot be easily removed by suctioning water through the catheter). If during different suctioning episodes on the same day, sputum was judged differently, both categories were used. Chi square analysis was used to compare sputum categories in each group with P < .05 taken as significant. RESULTS: Fifty-eight patients were recruited and 286 patient-days of sputum categorization were performed (125 in the HWC group, 161 in the HCH group). Sputum categories in each group (percentage of patient-days): WateryModerateTenacious HCH 12.4% 79.5% 11.2% HWC 11.2% 88% 13.6% There was no significant difference is sputum categories between the two groups. CONCLUSION:Sputum consistency was similar using either HCH or HWC humidification systems. OF-96-111 Presented at the AARC, November, 1996

13. RELATIVE CLINICAL PRACTICE GUIDELINES Humidification is recommended on every patient receiving invasive mechanical ventilation. When providing passive humidification to patients undergoing invasive mechanical ventilation, it is suggested the HME provide a minimum of 30 mg H20/L. Passive humidification is not recommended for noninvasive mechanical ventilation. Condensation from the patient circuit should be considered infectious waste and disposed of according to hospital policy, using strict universal precautions. AARC Clinical Practice Guideline Humidification During Invasive and Noninvasive Mechanical Ventilation: 2012 Ruben D. Restrepo, MD, RRT, FAARC & Brian K. Walsh, RRT-NPS FAARC

14. Why connect your ET tube to red bag waste… ...when you can use ThermoFlo™ and have a clean, dry circuit? “Condensation from the patient circuit should be considered infectious waste and disposed of according to hospital policy, using strict universal precautions.” AARC Clinical Practice Guideline 2012 Ruben D. Restrepo, MD, RRT, FAARC & Brian K. Walsh, RRT-NPS FAARC

15. ThermoFlo™ ENDS WATER PROBLEMS by providingA CLEAN, DRY CIRCUIT. NO more water on the bed, floor, or your shoes, when the circuit is disconnected! NO more water traps to drain! NO more Peep Spray!

16. ELIMINATES ADDITIONAL COSTS Eliminates the need for water columns. Eliminates water traps in line. Eliminates infectious peep spray while disconnecting the circuit. Eliminates the need to purchase costly water.

17. RECOMMENDATIONS

18. TAKE CARE NOT TO GET LAVAGING SOLUTION INTO THE ThermoFlo™ SYSTEM. If the drugs are introduced via MDI, or nebulizer into the circuit between the patient and the device, be aware of potential increased resistance. If there is an increase in resistance deemed clinically significant, replace the device.

19. CLOSED SUCTION WITH AN MDI ADAPTER Lavage the patient, being careful to keep the solution away from the ThermoFlo™ device. Hold unit at a 45o angle, and advance the catheter 4”- 6” into the endotracheal tube; a very nice guide into the ET tube is created. Administer lavage, hold suction, and complete procedure. It is acceptable to use an MDI adapter on the patient side of the ThermoFlo™. If you are using the MDI into the circuit, remove the ThermoFlo™ and replace after treatment.

20. CLOSED SUCTION SYSTEM NEBULIZATION An HME must be removed from the patient circuit during aerosol treatments when the nebulizer is placed in the patient circuit. When the HME is removed from the circuit during aerosol treatment, place the device so that the patient connection is facing up, reducing the chances of contaminating patient connection.

21. Relative CONTRAINDICATIONS Copious amounts of bloody secretions Body temperature less than 30° C Respiratory volume 25% less than inspiratory volume (possible fistula) Pulmonary edema Hypohydration (dehydration)

23. RELY ON THE SIGNS Regardless of what type of system is being used, the clinician should question the effectiveness. Since no system reports the actual amount of humidity being delivered, other signs must be relied upon.

24. YOU WILL SEE MOISTURE Moisture is a good thing!

25. Any visible moisture may be removed, should you choose. • In this demo, any liquid poured into our device may be poured out. Any sputum in the device will not be absorbed by the media. • Position the device horizontal or above the patient. • No visible moisture will be transferred back to the patient unless the device is turned completely upside down. (As shown in the photo on the bottom left.) Visible moisture will not be absorbed into the filter media potentially causing resistance.

26. ThermoFlo™ PROTOCOL AND SPUTUM EVALUATION

27. IDENTIFYING SPUTUM CHARACTERISTICS Watery: Sputum that can be suctioned like water. After suctioning, no secretions remain attached to the inner surface of the suction catheter. Moderate: Sputum of moderate viscosity. After suctioning, some secretions remain attached to the inner surface of the suction catheter, but they can be easily washed out by suctioning water through the catheter. Tenacious: Thick sputum. After suctioning, most secretions are still attached to the inner surface of the suction catheter. Suzukawa, et. al., Respiratory Care November 1989

28. MANUFACTURER RECOMMENDATION TO AVOID BACTERIAL COLONIZATION CHANGE EVERY 24 HOURS Our exclusive “change on” label makes it easy.

29. DISPOSALNo need to touch the device. SAFE DISPOSAL After disconnecting, place the device in your one hand, and remove your glove from the other while wrapping it around the used device. Dispose according to hospital policy .

30. The End