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

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

5.  THE TERM HYGROSCOPIC REFERS TO THE ABILITY OF A MATERIAL TO ABSORB HUMIDITY FROM THE AIR. (HYGROSCOPE INDICATES CHANGES IN HUMIDITY.)  HYDROPHILIC REFERS TO SUBSTANCES THAT ABSORB WATER.  HYDROPHOBIC MATERIALS HATE WATER AND REPEL IT. WHICH TERM(S) DO YOU THINK APPLIES TO THERMOFLO™? THIS IS WHY WE ARE DIFFERENT FROM THE COMPETITION! WHY IS THIS IMPORTANT?

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 MEDIA: Spun Polypropylene with a calcium chloride coating FILTER: 3M Filtrete with a hydrophobic membrane UNITIZED CONSTRUCTION: The device will not fit together if the filter is not properly in place within the wall of the device.

8. 33 32 31 30 29 28 27 Conventional “Passive Humidifiers” ThermoFlo™ @ 10L V E @ 20L V E @ 10L V E @ 20L V E Mg H 2 0 / L Air Exceeds Standards @ 20L V E Data on file

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

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

12. 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): Watery Moderate Tenacious 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 COMPARISON OF LONG TERM USE OF A HYGROSCOPIC CONDENSING HUMIDIFIER VERSUS HEATED WIRE CIRCUIT

13.  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 H 2 0/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. RELATIVE CLINICAL PRACTICE GUIDELINES 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. ...when you can use ThermoFlo™ and have a clean, dry circuit? Why connect your ET tube to red bag waste… “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 PROVIDING A 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 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. ELIMINATES ADDITIONAL COSTS

17. Use on NEW patients when possible. Conversion with existing patients requires additional effort, and psychiatric preparation. MDI or Neb treatments may be given between patient and filter. Check for increased resistance after treatment. Follow manufacturers’ directions for lavaging using closed suction devices. Do not allow lavaging solution to flow into the device. 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 45 o 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. 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. CLOSED SUCTION SYSTEM NEBULIZATION

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

22. June 2005 “HMEs should be used in all patients in whom there is no contraindication. ” Richard D. Branson MSc RRT FAARC

23. 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. RELY ON THE SIGNS

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. Put us to the test, and document your secretions. ThermoFlo™ PROTOCOL AND SPUTUM EVALUATION

27. 1.Watery: Sputum that can be suctioned like water. After suctioning, no secretions remain attached to the inner surface of the suction catheter. 2.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. 3.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 IDENTIFYING SPUTUM CHARACTERISTICS

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

29. 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. DISPOSAL No need to touch the device.

30. The End