The upper airway plays a critical role in warming, humidifying, and filtering inspired air, which supports normal mucus production and effective mucociliary clearance. When a tracheostomy is performed, the upper airway is bypassed, resulting in exposure of the lower airway to cool, dry air. This loss of natural humidification can negatively impact pulmonary health and secretion management. As a result, artificial humidification is essential for patients with a tracheostomy. Humidification can be provided using two approaches: active humidification and passive humidification.
Active humidification delivers warmed, humidified air from an external source. Air passes through a heated water reservoir and is delivered via tubing to a tracheostomy collar, providing humidified airflow around the tracheostomy tube. Passive humidification, achieved with Heat and Moisture Exchangers (HMEs), utilizes the patient’s own exhaled heat and moisture to condition inspired air. A HME attaches directly to the tracheostomy tube and provides consistent heat and moisture exchange with each breath.
While active humidification has traditionally been considered the standard of care in tracheostomy management, HMEs offer several advantages for both patients and caregivers, including portability, ease of use, and support for long term airway health. Despite these benefits, misconceptions about HMEs remain common and warrant clarification.
Myth or fact: Both laryngectomy patients and tracheostomy patients need HMEs
FACT! Both laryngectomy and tracheostomy bypass the upper airway during inhalation and therefore lose the natural functions of warming, humidifying, and filtering inspired air. Reestablishing heat and moisture is essential for all patients with a surgical airway. While HMEs designed for laryngectomy and tracheostomy patients differ in size, attachment, and features, they function in the same way—by capturing heat and moisture from exhaled air and returning it during inhalation. Use of HMEs in both patient populations have been shown to be well tolerated and provide effective heat and humidification.
Myth or fact: Patients are at a greater risk of having mucus plugs when using an HME
MYTH! Studies show that use of an HME is associated with a lower risk of mucus plugging compared with no humidification (Foreman et al., 2016). When airway cilia are continuously exposed to cool, dry air, ciliary activity slows or stops, impairing mucus clearance and allowing secretions to accumulate. Reintroduction of warm, humidified air restores ciliary function, enabling effective mucus transport. When humidification is first initiated, patients may experience a temporary increase in secretions over the first few days as accumulated mucus is mobilized and cleared. Once this backlog is removed, ongoing humidification supports continuous mucus clearance, which can reduce secretion buildup and the risk of mucus plugs. In the laryngectomy population, studies have shown HMEs to be superior to active humidification in preventing mucus plugs (Ebersole et al., 2020). Comparable studies in the tracheostomy population are not yet available.
Myth or fact: If a patient uses a speaking valve, they don’t need to use an HME
MYTH! Speaking valves do not provide heat or humidification. Their function is to redirect exhaled airflow through the upper airway to enable phonation. HMEs should be used whenever a speaking valve is not in place, such as overnight or during periods of non‑speech, to ensure consistent airway humidification.
Dual function devices, such as TrachPhone and Freevent DualCare, combine a speaking valve and an HME in a single unit. Dualcare allows patients to alternate between speech and humidification as needed, with a simple twist, supporting both communication and airway health. Similarly, TrachPhone HME can be depressed (finger occlusion) for voicing.
Freevent DualCare
TrachPhone
Myth or fact: HMEs make communication and suctioning more difficult
MYTH! While traditional HMEs do not support both speaking and efficient suctioning, the TrachPhone HME combines these capabilities with the heat and humidification patients need. Its calcium chloride–treated foam core provides optimal heat and moisture exchange, while integrated features enhance everyday use. A push to speak valve redirects exhaled air to the upper airway to enable phonation, and a built-in suction port allows for effective suctioning without removing the HME. When oxygen support is required, a convenient oxygen port makes it easy for patients to continue using an HME while receiving supplemental oxygen.
TrachPhone
Myth or fact: HMEs can provide some filtration properties, while active humidification cannot
FACT! HMEs can act as a barrier to gross airborne particulates because they attach directly to the tracheostomy tube and provide a physical barrier. However, most HMEs are not true filters for viruses and bacteria. When both humidification and viral or bacterial filtration are required, Freevent XtraCare HME should be considered since it functions as both an HME and a filter. It provides warmth and humidification while filtering inhaled and exhaled air with a filtration efficiency greater than 99% for airborne particles, including viruses and bacteria (Nelson Laboratories, 2014), offering an added layer of protection for both individuals and caregivers.
Freevent XtraCare HME
Myth or fact: HMEs can be used in pediatric patients
FACT! HMEs can be used in pediatric patients, but careful patient assessment is essential. Many HMEs are appropriate for children when weight, added dead space, and airflow resistance are taken into consideration. Most HMEs have minimum weight requirements due to the added dead space they introduce. Selecting an HME that matches the child’s size and respiratory needs is critical. For example, Freevent XtraCare Mini is approved for use in children weighing as little as 7 kg, while TrachPhone HME can be used in children weighing 10 kg or more. As with all patients, clinicians should monitor tolerance, work of breathing, and secretion management when initiating HME use in pediatric populations.
Freevent XtraCare Mini
Myth or fact: All HMEs are the same, so it doesn’t matter which HME is used
MYTH! HMEs vary significantly in their design and performance characteristics, and device selection can directly impact patient outcomes. Key differences include the material and structure of the HME core (such as corrugated paper, foam, or treated foam) which influence the efficiency of heat and moisture exchange. Hygroscopic compounds such as calcium chloride have been found to provide better moisture output to the respiratory system, when compared to non-hygroscopic HMEs. All Atos Medical HMEs contain a hygroscopic compound embedded in the polyurethane foam. Additional considerations include whether the patient requires supplemental oxygen, filtration, or compatibility with the patient’s tracheostomy tube. At Atos Medical, our range of HMEs are available to meet diverse patient needs while optimizing heat and moisture exchange. Selecting the appropriate HME allows clinicians to tailor humidification to the individual patient rather than relying on a one‑size‑fits-all approach.
Final thoughts:
Restoring effective humidification is a critical component of care for patients with tracheostomies, as bypassing the upper airway eliminates the body’s natural ability to warm, humidify, and filter inspired air. HMEs play an important role in supporting mucociliary function, secretion management, and overall pulmonary health. They offer a practical, evidence supported option that can be safely and effectively used across patient populations, including pediatric patients and those requiring speech, suctioning, oxygen, or overnight humidification. Individualizing HME choice based on patient needs allows clinicians to optimize airway humidification, enhance comfort and safety, and support long term respiratory outcomes for patients with surgical airways.
Visit our Heat and Moisture Exchangers webpage for additional information on all our HMEs, including whitepapers and learning opportunities!
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References:
1. Foreman A, De Santis RJ, Sultanov F, Enepekides DJ, Higgins KM. Heat and moisture exchanger use reduces in-hospital complications following total laryngectomy: a case-control study. J Otolaryngol Head Neck Surg. 2016;45(1):40
2. Ebersole B, Moran K, Gou J, Ridge J, Schiech L, Liu JC, et al. Heat and moisture exchanger cassettes: results of a quality/safety initiative to reduce postoperative mucus plugging after total laryngectomy. Head Neck. 2020
3. Nelson Laboratories, Bacterial Filtration Efficiency (BFE) GLP Report, Salt Lake City, USA. Available on request from Atos Medical. www.atosmedical.com. 2014.
4. Nelson Laboratories, Viral Filtration Efficiency (VFE) GLP Report, Salt Lake City, USA. Available on request from Atos Medical. www.atosmedical.com. 2014.