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Mycobacterium avium-intracellulare ,cpap and distilled water for humidifier
I have recently been diagnosed wit Mycobacterium avium-intracellulare (MAI). It is a cousin of Tuberculosis. It can also be referred to as NTM ( non tuberculosis mycobacteria) It is not contagious. Mine infection is in the dormant stage. As long as it is dormant I am OK. If it starts growing and I get symptomatic I will be put on a hardcore antibiotic treatment. The treatment is between 1 and 2 years of 4 different antibiotics. It is so harsh that people say it is like being on chemotherapy. And the worst part is that I will always have it, even after treatment.

The bacteria is found everywhere including tap water. You can inhale it while taking a shower or the steam from a hot tub. The bacteria is very hardy. People with weakened immune systems ,poor lung functions and GURDs are more prone to get it. I have moderate to severe COPD , some emphyzema and GURDs. I do not know how long or how I got it and I have always used steam distilled water. It showed up in a chest xray and then a CT scan was ordered.

I am not trying to be an alarmist or to scare anyone but when my grandson asked if I got it because of cpap, I initially said no. After researching I believe that if you don't use distilled water in your humidifier there is a chance of getting it.

Here is a link with articles so you can read for yourself and make your own decision.


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I would still argue that the CPAP humidifier is a less likely pathway for exposure than the aerosols inhaled from shower water and ingestion from drinking, swimming and untreated ambient water. The NCBI article states "Contaminated potable water sources associated with human infection included warm water distribution systems, showers, faucets, household drinking water, swimming pools and hot tub spas."

The humidifier in CPAP does not aerosolize water, but evaporates small quantities. The use of tap water is safe, and the articles in the search you provided do not suggest a widespread contamination of the public drinking water supplies with this organism, but point to its potential for survival in potable water treatment systems. The concern is mainly with water system components that may support reproducing colonies of the bacteria and pose an infection risk.

The EPA Mycobacteria Health Advisory says:
No evidence was found that water serves as a source of infection for tuberculosis or leprosy.
Because the bacterial species that cause these diseases have not been recovered from water
sources, the remaining sections of this health advisory will focus only on NTM species.
These infections are more likely transmitted from environmental sources by
ingestion, inhalation and inoculation of Mycobacterium bacilli. These environmental sources
may include aerosols, water, soil, dust, food products and contaminated medical equipment
(Gangadharam & Jenkins, 1998). https://www.epa.gov/sites/production/fil...report.pdf

In my opinion, the suggestion that CPAP humidifiers using tap water are a potential source of infection is an unwarranted and alarmist leap of the available evidence. You would be better served to avoid questionable water sources, and especially warm springs, hot tubs and spas that have undocumented disinfection. maintenance or are in poor condition. Based on available evidence and the life cycles of these organisms, I think the potential for infection via CPAP is nil, with the possible exception of grossly contaminated, unsanitary systems with visible biofilms.
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You probably have the same chance of contacting it while taking a shower or using a sauna. Sorry to hear your going thru so much though. Here's praying you don't need treatments!
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(08-12-2018, 07:26 AM)car54 Wrote: ...
I am not trying to be an alarmist or to scare anyone but when my grandson asked if I got it because of cpap, I initially said no. After researching I believe that if you don't use distilled water in your humidifier there is a chance of getting it...


There are two practical ways of purifying water: distillation and reverse-osmosis.  Distillation involves water molecules leaving the surface of water due to vapour pressure locally.  Bacteria are millions of times larger than a single molecule of evaporating water.  So, no worries about inhaling bacteria.  A shower is different.  It sprays water, and of course that means many zillions of evaporated water molecules from the droplets and micro-droplets.  But, it's still evaporated...no bacteria.  However...……...them pesky micro-droplets and aerosols...they are what you must worry about.  

Our evaporative PAP systems don't produce airborne pathogen transfer.  Their mediums might encourage the growth of those pathogens locally/internally to the machine and its airway, but you won't get anything from that except spores.  And that term 'myco-x' is a problem there because myco generally infers spore production...molds.  In this case, it has to do with mycolic acid, not spore production.

To summarize, you can't get airborne infection from your PAP's airway supply unless it harbours spores.  If it is mold-free, and only evaporates water, then you get nothing more than water vapour which is akin to distilled water anyway.
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(08-12-2018, 08:12 AM)Sleeprider Wrote: The humidifier in CPAP does not aerosolize water, but evaporates small quantities...

In my opinion, the suggestion that CPAP humidifiers using tap water are a potential source of infection is an unwarranted and alarmist leap of the available evidence.

I think you are right about the relative risk is low compared to other sources, but I think that it might be going too far to say that concern about CPAP is completely unwarranted. There are case reports where CPAPs may be involved (I didn't pay for the article to chase the citations down.)

Quote:Mycobacterium gordonae pneumonia was reported in an immunocompromised kidney transplant patient who inadequately cleaned a home CPAP unit used to treat OSAH.


CPAP humidifiers are warmed to a temperature that is excellent for incubation when in use. And forcing air over water in the humidifier chamber does appear to aerosolize *some* water, which can transmit bacteria through the supply tube, as this study found:

Quote:Conclusion: Data suggest that patients with OSA being treated with nCPAP fitted with humidifiers may be aerosolizing bacteria,


But at least one study found that the subjects they studied did not have a higher incidence of infection even if they had detectable bacteria in their humidifiers:

Quote:No significant difference was seen in the prevalence of rhinosinusitis, lower respiratory tract infections and hospital admissions for pneumonia between CPAP and non-CPAP treated patients. The presence of a humidifier did not influence the prevalence of infections. Commensal flora was predominantly cultured from nasal swabs from both patient groups. Coagulase Negative Staphylococci and Diphtheroids were the main organisms cultured from masks and humidifiers respectively.


But that doesn't mean we can't get infected fromCPAP. Here's an extreme case of Legionella pneumophila possibly transmitted via a very dirty CPAP (with pictures to remind you that, yes, you really do need to clean your mask elbow), an outlier, to remind us that while it is uncommon CPAP may be able to harbor and  transmit infectious disease:

Quote:Environmental health officers visited the case’s house and found the CPAP machine in a poorly maintained state (Figures 1 and 2). The device was retrieved and swabs of the internal chamber, filter, and mouth piece were positive for LP1.


So, I can't say the OP is wrong, but I would say that regular cleaning may be more important than using distilled water.
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As a microbiologist, I would not state that it is impossible to acquire an infection from CPAP but the probability is much lower than from other potential sources to which we are routinely exposed. As has been mentioned, Mycobacterium avium-intracellulare organisms are widespread in fresh water, soil, house dust and even food products (Have you ever seen a soil free potato?). The disease can be acquired by inhalation or ingestion. Sleeprider is correct in saying we are much more likely to inhale the organisms from the shower than CPAP. Although I believe he is incorrect in stating that no aerosol is generated from our humidifiers, it is much less than we are likely to inhale in almost any other activity involving water such as simply running water in a sink, filling a glass for a drink, washing our hands, etc. It’s virtually impossible to disturb the surface of water without generating an aerosol. We also routinely inhale airborne dust which is known to carry the organisms. So those who are not using CPAP are as likely to have significant exposure to these organisms those who are. Unfortunately, short of living in a sterile isolator with filtered air and sterilized food and water, it is probably impossible for susceptible individuals to avoid exposure.

It is true that steam distilled water should be sterile but only if everything it contacts downstream of the point of distillation is sterile. In the case of inexpensive distilled water purchased at supermarkets and other vendors, it is unlikely that the condensers, piping, storage tanks, bottling equipment, or the plastic bottles into which the water is dispensed are sterilized or that the operation is conducted in a sterile environment. The cost would be too great to allow a price of $1 or less per gallon. Such distilled water, therefore, will contain a variety of environmental organisms. As I have pointed out in the past, the only commercially available sterile water is sterile water for injection or irrigation which costs $20-25 per liter.

Even if one were to go to the expense of using such water, how would sterility of the humidifier chamber be assured? Simply washing and rinsing it with tap water is likely to result in the presence of environmental organism that may be a threat to immunocompromised individuals.
The only advantage to using distilled water is to avoid mineral deposits. Even if it were to eliminate exposure to potential pathogens it would be ineffectual given the exposure from so many other environmental sources.
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Nice to see Melman back on the job of microbiologist police, even if he did correct me.   Dont-know

We'll even the score later... Big Grin
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Yah, I'll probably regret that...but not too much Grin
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(08-12-2018, 06:13 PM)Melman Wrote: As a microbiologist, I would not state that it is impossible to acquire an infection from CPAP but the probability is much lower than from other potential sources to which we are routinely exposed.  

Melman, I saved the link to your post above so I can refer to it in the future. Unless you have a better one?

Car54, I'm sorry you have this. And I understand the swinging pendulum you must feel about having this inside you. My mother contracted histoplasmosis and we 3 kids had to be tested (since we are all exposed to the same source). I was clear but my brothers tested positive. For many years, they had to have a chest xray every six mos to watch for it to become active. Even now, it is something they have to keep in mind with medical histories.

As an aside, I was so young when this started, that I thought the chest xrays were their treatment!
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"Every breath you take ..."
Last, but not least we should consider the time of exposure to the air pushed to our lungs every night.
Dose is the important thing.
Immune system can cope with a certain amount of pathogens. If overwhelmed, fails.
Live long, vent proper.
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