PEER-REVIEWED PAPER

A Simple Methodology to Verify

Heat and Moisture Exchangers' Efficiency
Paolo Cappa, Zaccaria Del Prete
Dept. u(Jfec/Jonics (!//{/ .-lernnttlltics
Cni!'ersity u( Nontc "!.a SofJicn:::a
Nome. !T! O.
The capability or' Heat and Moisture Exchangers in "trapping"heat and moisture was experimentall,v evaluated IJ,v
means ot' an procedure. The proposecl methoclology is basecl on the current measurement or' temperature
a nel relative humidit,v in r'our unidirectional r'low wavs: both sicles or' patient a nel servoventilator ha ve t1vo-way
flow. two of which !et the medicai into the H/viE a nel two that /et outthe elaborateci ai r. Starting t'rom the
relative humiclity data measurecl by tour miniaturized capacitance sensors. the uncertainty associateci to the
absolute humiclity cletermination was a/so evaluatecl ancl comparecl to the or'r'-balance recorclecl cluring measure-
ments. Finaily, the proposed methoclologv was verHiecl by testing a couple or' clitlerent HAI Es ancl the erfective-
ness in assessing H/viE er'r'icacy has clearlv emergecl.
lndex Under: Heat c\ /v1oisture exchangers; H/viE; Heat c\ ,vloisture exchanger edectiveness; medicai gases venti-
lation; relative absolute humiclitv
INTRODUCTION
W
hen a patient is incapable of adequate respira-
tion. mechanical ventilation must be prmided so
that suftcient oxygen is delivered ami excessive
levels of carbon dioxide are not permitted to accumulate
into body tissues. However. when an endotracheal tube is
inserted. the delivery of gases with non-physiological tem-
perature and humidity causes patient discomfort ami may
bring about serious ainvay damage. Hence. severa! devices
(nebulizers. heated humidifiers, beat ami moisture
cxchangers) based on different designs bave been pro-
posed and effectively utilized in operating theaters ami
intensive care units. Their goals are to add the required
amount of water va por ami to regulate the temperature of
inspired gas.
Among the previously indicated devices. the heat ami
moisture exchangcrs (HME) are widely utilized because
thev are disposable. cheap and light. \Yhich implies a
reduct:d probability of element disconn<:ction associated
\Yith the breathing system. They are intrinsically safe
because they do not require external energy and \Vater
vapor ami the consequent periodica! water leve! monitor-
ing. associated with hot water heated humiditers. They
provide eftcient bacterial tlters capable of panially pro-
tecting the in-circuir equipment from contamination. ami.
Cappa and Del Prete
tnally. they are able to deliver gas with temperature a!1LI
humidity values comparable to those produced in the
upper trachea during norma! breathing through the nose.
In order to ascertain the performances of the Hi\-1Es
commercially available. se\eral cxperimental studies bave
been conducted to measure the humidiry ami temperature
values of the administered gases during the inspiration.
These studies were carriCll out both "in \itro"
1
' ami "in
vivo"'. The obtained experimental results demonstrate
that H;\!Es are effective in shon term utilization while in
long term use endotracheal tube occlusion and contami-
nation of external breathing circuir ca n occur ''.
11
Moreover,
Hi\!Es add breathing resistance to the patient ami this may
cause an excessive respiratory muscle fatigue for criticai
and weak patients"
1
'.
The experimental methodologies utilized up unti! now
by almost ali anesthesiology departments bave focused on
the determination of the moisture ami gas temperature
delivered to thc patient rather than a rea! evaluation of
HME eftciency in "trapping" beat ami moisture during
expiration ami returning them to the inhaled gas. This is
probably du<: to the lack of a cheap but reliable absolute
)ournal o i Clinica! Engineering Vol. 22, No.1, )anuary/February 1997
Copyright r 1997, lippincott-Raven Publishers
)ournal of Clinica! Engineering january/February 1997 49
(Patient side)


rneasuring
poi n t
"in"



(Ventilator side)
FIG.1 Scheme of the comprehensive HME
performance evaluation.
humidiry sensor \Yhich could satisfy the require-
ments of such a measurement. Therefore the goab of the
present experimental stucly are nvofold. First. the proposal
of a methodologY capable of eyaJuating the global H?IIE
thermohyf.!rometric behaYior. utilizing some miniaturized
capacitiYe humidity sensors. Second. the validation of the
proposed methodology bY testing a couple of H:'IIEs pro-
duce<.! by different manufacrurers.The scheme inYolves the
real-time of: (l) the Yentilator outlet ).!:ts: (?.) the
in ha led i 11 the patient: (:)) the gas exhaled by t h e
patient: an d. Jnalh (-l) t h e ventilator in l et gas.
METHODOLOGY
A simplc: scheme \Yhich realizes the thorough evaluation of
the fundamental H\IE performances is reponed in Fig.l.A
generai 1-L\IE is represented in thc: center. when: the four
measurement points. indicated with in - 1:--JH - EXH - out.
complete!\ contro! temperature: ami humidity 1:tlues of
medicai gas. follmYing the fiO\\. sense asi t is when the H \! E
applied to t h e patient. The nomencbture 1:\H an d EXH
st:mds for the gas flmy o n t h e patient 's si dc whereas in ami
out stand for the gas flow of the HME on the senolemila-
tor sicle. The aclopted nomencl:nure is considered from a
H.\JE point of view. Each of tht: four points combine
Tt:mpt:r:nure C[) ami lklatil'e Humidity (10-!) mt:asure-
ment. Doing an RH mc:asurement was not a choice hut
r;tther a constraint: from thc authors markt:t research
the impossibilir, of lnding an adequate absolute
humiditY sensor 11hich is :tt the same time simple. rdiahle
and readilY alailable.,\n dkctive humidin transduct:r has
to fuiJll the follm1 ing requiremt:nts to m:nch the c:xperi-
mental st:t-up design: it should be small enough as w he
e:tsih inserted into standard l't'ntilatory tubing. sufJciently
sensiti1e as to resohe humidit ,. l':triations of O. l mg/1. an d i t
should ha\e a good dn1amic response so as to follow the
:;o
journal oi Clinica! Engineering january/February 199i
\Yater 1apor variations uring a breathing cyck. To 111lTt
these requirt:menrs. the authors wert: compellecl to utilil.c
four integrated units with the electrical outputs propor-
tional t o T ami RH measured Yalues.
Ali these problems can be solved by turning RH into
absolute humiditY (AH). Considering the relative low frc-
quency range of measured humidity. it is possible to ohtain
tbe transformation in real-timt: after nery acquisition h1 ;t
personal computt:r. Tbe calculation is based on thc fu n da-
menta!, classica! Boyle ami Clapeyron laws. \\'hicb com-
bined are known as Clausius - Clapeyron recalled bere: lr
convc:niencc
p= C ei#
( l )
where p is the saturation pressure.T is the phase transition
temperature. H is the associared enthalpy change (or latent
beat). R is tbe molar gas constant and C is an integration
constant.
Tht: equation (l) applies to any p ha se change ami is
also effective for tbt: va por saturation pressure J\, (T'l. In
order to determine the rwo constant parameters C :md
H/R. ;t least-squares ft to the data. which minimizes thc
errors. starting from the p".(T) data of the steam tables' '.
has been pointed out.AH. expressed in mg/1. has therdort:
been obtaine from tbe equation
Il
RH. Ce .TIT
Il p
P - (!ili) Ce - TIT (2)
v,here IO-l is rh e relatil'e humidity. P is the running prc:ssurc
imo ventilaton tubing. r is the medicai air clensity ami the
other tt:rms are the same as above.
Ih mt:ans of equation (2) the Yalues of AH for each of
the four ain,ay channels have been calculated, utilzing thc
T ami RH running measurements. Fora frst approach. \T Il
tuhing pressurt: P and air density p (lttle differcnce
from :nmospheric 1alues) were considc:red constant: in bel
thcir fluctu:ttions are small compared to tbose ofT ami Hl l.
"J( > prm l' tlll' eJfectiveness of t h e methodologY. :t dcdi-
c:nnl p:tramellT 11as calculated: the resultant absolutc
humidit1 olfh:tlance error AH,b. With refercnce to Fig. l.
par:tmeter results from the simple algebraic sum:All.,h
=AH (in) + Al l (L'X//) AH(/;\'/I) - AH(out). The absolutt:
humidit1 error yields. for every acquisition
sc:m. a balance ahout ho\\' mucb moisture enters across
thc tl\o H.\lE input:->. i.e. AHUn) and AH(l:"XH). :md exits
from its t\\ o i.c:.AHUNH) and AH(ouf).
lf a me:tsurement system witb ideai metrologic:tl per-
l(mn:ttKTs. i. c. rotai precision. woul be available. tht: AH.,h
c:dculation should equa! .. /.ero .. for each breathing cycle.
This e\identll' true ht:c:tust:. once HME reaches steady
state tht: amount of water vapor rhat globally
1ia tbc ti\ o input outlets (in and EY.H) must be
Cappa and Del Prete
F
c
<:qual to th<: amount of vapor that Iene; the 1-L\IE \ia th<:
two output outkts (!NH ami out) o\er nerY breathing
cvcle. Obviously. HME cannot produc<: nor can it consunH:
water: it is only a passive disposable exchang<:r_ :\one-
theless. the off-balance error can be considerably difkrem
from zero due to propagation of uncertaintie". As a mattn
of J:lct. each OJK of the four measuremem points is afkct-
ed by its mvn error due to propagation of uncertainti<:s
through the equation (2).This outcome Ieads t o ca eh of tlw
<:rrors lw means of the generai frmula \\hich gi\es the
uncertaintY as a function of severa! variables" "'
.\H,
w h ere RH. T P p are the variables: RH. T P r are the
associated uncertainties ami the base i is respecti\elv equa!
to: in, !NH. EXH. out so t ha t we dispose of a value for each
flow channd. \Ve considered T ami RH the declared
instrument accur.JC}. whereas 8P ami p represenred the
small fluctuation present in ventilatory tubing for pressure
P ami air density p, due ro the ventilation mode! chosen for
breathing cydes.
Finally. the four results have been used to estimate the
error AHob by using the follo\ving equation
obtained by means of the propagation of unccrtaimv'' "'.
We that the quantity AHob is a function of
quantities that are independent from each other.Thus. the
values of the quantit:y AH
0
b result from the characteristic
values of random errors (8AH;
11
8AH
1
,
11
. 8AHEXI! and
6,\H
0
"
1
) for the measured values according to the squared
error-propagation law.
In the end. the pammeter AHob takes imo account bot h
1'.1!1t:rll
FIG.2 Experimental test set-up.
Cappa and Del Prete
the methodologv and the humiditv sensor reliahilitv.
EXPERIMENTAL SETUP
The expnimental setup proposed for eftcienc} measure-
ment of a generai I-L'.! E is shown in Fig.2.The schemc could
be considered as a compact instrument proton-pe. T ile
patient simulator has been schematized in the tllowing
two sections:
- Mechanical to provide th<: necessan compliance.
It >vas realized \\'ith a standard test lung which prmides a
maximum rida! ,olume of l !iter (S!E.\IE:\'S 190)
- Thermal to appropriate h condition .. exhaled .. air a t
an a\erage temperature of :-f o c an d with a relati\e h umid-
i t;> (RH) that should be dose to the saturation condition.
Thermal section was realized with a senocontrolled beat-
ed humiditer CF&P .\IIC30) equippeJ \\ith a heating wire
o n the humidifer outlet. The presence of a heating w ire a t
the 1-L\IE Y poi n t prevented condensation of va por aro un d
tube si d es \\'ithout the need of a thermostatic c ha m ber-.
Air flmv \Yas comrolled by the pulmonary ventilator
(SIE:'IIENS 900A) and the test conditions were selected foi-
Imving one set of the ISO 9360 prescription;- as in the fol-
lowing table:
TABLE 1: Ventifatlorrte8t'.conditi<ni _.;,..:,:
' _.. , .,,._ ,.. .. ............ __ _
Ti dal respiratorv min volume lnsp:Exp Pause
Volume trequency [//mi ratio
[m/] !breaths/min]
500 20 lO l :2 o
hence. by acting on the servoventilator controls. it is also
possible to select other ventilation conditions.
Four units (C
1
... C,) for simultaneous tem-
perature ami relative humidity measurement were utilized
(Rotronic Hygromer I-1 00). Temperature range is from -20
to + IOOOC. with 0 . .:;o c accuracy: relative humidity range is
from O to l 00'!., RH. with l '!<,RH accuracy. The combined
probes lla,e been bctory calibrated but the RH pertr-
mances \Vere preliminarily tested by means of a calibmtion
cllamber set. using a two-point calibration technique: the
sensors were exposed to two manubcturer-supplied cali-
bration cartridges containing salts which pro\ided head-
space humidities of 35'.'<, ami 80'/;, RH.
As shown in Fig. l and Fig.2, temperature and relative
humidit\ \\ere measured a t four different points near the Y
flow di\iders. equipped \Vith two one-\Yay valves which
di\ide "inspir:nory" from "expiratory" flo\v. Each couple of
sensors (T :111d RH) therefore will measure in a unidirec-
tional fl<m horh input ami output to the H:'IIE being test-
)ournal oi Clinica! Engineering )anuary/February 1997 51
97
96.5

f'
" .E
95.5

>

95
S4.5
lnhaled Blr
o 6 9 12
FIG.3 15 seconds Relative Humidity spot acquisition
45
AUEXH
40
35
AUINH
t-
:E 25
__ ;
20
o
"Uoltl
15
] :: J . ' " "' . ' ' ., ..... ' ' . . . .. ,, ' ' ' v ' '
AUin
s '.! \<'-}' .. { )" .... <-/: } ...
60 120 180
Time lminj
240 300 360
FIG.4 Absolute Humidity test results for an unsatisfactory HME
50
40
30 '
!.
,.,
'C
20

=
c
AUDH
10 AUovt i
..
10
o 60 120 180
Time l mini
240

300
FIG.5 Absolute Humidity test results for a satisfactory HME
52 )ournal of Clinica! Engineering )anuary/February 1997
360
ed. TI1is way it is possible to monitor tem-
perature and humidity condition on the
patient's side but also on the ventilator side.
By monitoring the latter one can contro! the
temperature and humidity supplied on the
HME input (in) during the "inspiration", but
also contro! the water Yapor amount that the
HME lets flow through (aut) during the
"expiration .
TI1e methodology was verified by testing a
couple of HMEs, which differed in the inter-
nai active exchanging material.After the test
set-up had been warmed for one hour. a six-
hour test was carried out, acquiring a set of
data (four temperatures an d four humidities)
every minute. Each T an d RH point consisted
of a mean value calculated over a complete
breathing cycle which lasted three seconds.
Acquisition of the data could be done at a
variable rate t o a maximum of l OkHz for
each flow channel.Temperature values were
stored at once, whereas RH measurements
were first converted into AH values before
being stored in memory. TI1e sensor outputs
were automatically gathered by an acquisi-
tion contro! unit (HP 3852A) equipped with
a FET multiplexer (HP 44711A) and a digitai
voltmeter (HP 44702B). The acquisition sys-
tem was controlled by a computer which
processed and stored the data.
RESUlTS AND DISCUSSIONS
The INH and EXH humidit:y traces measured
for a 15-second spot acquisition after one
hour warm-up are reported in Fig.3. The
humidity values are reported in percemages
as they were measured, nevertheless a satis-
factory sensitivity for the RH sensors has
been confirmed. in fact. the due
to respiration cycle are clearly visible.
In Fig.4 an d Fig. 5 the results of two sample
HME efficiency tests are schematized. The
two HMEs differ in the active exchanging
filling materia!. Considering that nowadays a
water vapor amount supplied to the patient
of 30mg/l is considered satisfactory'. we
could conclude that the HME protorype,
illustr&ted in Fig.4. needs to undergo some
improvemems, whereas the one reported in
Fig.5 seems to provide good patient humidi-
fication (Absolute Humidity of INHaled air >
30mg/l). Comparing the equiYalent traces in
Figs. 4 and 5. it is easy to see that the higher
efficiency of HME in Fig.5 is due to a higher
Cappa and Del Prete
capability of trdpping EXHaled water vapor and returning
i t to the patient.The HME input humidity was not as low as
prescribed in the ISO 9360'-. which is 0.88mg/l, but it was
sufficiently low and it did repeat in the two tests, and,
moreover. it was accurdtely measured for hoth HMEs. It
seems possible, therefore. to evaluate the efficiency of a
generdl H:VIE in terms of: AH(INH) = AH(EXH) +AH( in) -
AH(out) and to compare that result with the measured
value.
Since we could not utilize a more accur.1te absolute
humidity sensor. the difference between HME's input and
output vapor amount was calculated and is also reported
in the Figs. 4 and 5.The values traced were compared with
the results of uncertainties propagation. In the calculation
we utilized forT and RH the mean values computed over a
breathing cycle acquisition for each of the four flow chan-
nels. we assumed a constant in-circuir pressure
P=l02325Pa ami an air density p=l.l9kg/m'. For T and
RH we assigned the declared sensor accur.1cy (T=O.;oc
an d RH= l'){,) an d for P an d p we considered the small
in-circuit pressure and air densit)' fluctuations due to the
breathing cycles (P= 1500Pa and p=O.Olkg/m'). The
results we obtained for the two sample H:VlEs were
AU =I. 728mg/I for the case reported in Fig.4 an d
for the case reported in Fig.5.The calcula-
tion for the Iatter was stopped after 3 hours, when the INH
humidit) sensor saturated, as reported in the figure. and
;vas no Ionger able to measure consistent values.
From an examination of the f)btained results. we dis-
covered that more than 6'% of the values cal-
culated and traced in the two Figs. 4 and 5 are within the
calculated uncertainties.This observation leads to the con-
clusion that the methodology could really represent an
improvement in HME's efficiency testing.Also strongly rec-
ommended is that miniaturized absolute humidit) sensors
should be utilized in order to minirnize the errors due to
uncertainties propagation in the evaluation of AH values
from relative humidity measurements, and to avoid the
undesired sensors saturation.
CONCLUSIONS
In the last twenty years severdl different methods to assess
the relative merits of different HME types have been pro-
posed''' but only few of them really focused on the inwsti-
gation of the HMEs efficiency' .-. While the studies carried
out evaluated "in vivo the clinica! aspects involved by the
insertion of different HMEs into the breathing circuits. the
aim in this experimental work is to propose an "in vitro"
methodology that could return affordable results about
HME efficiency without test circuir complication and, most
of ali. \Vithout patient risks or danger (see Fig. l). Only very
recently has some accurate research'- considered the ISO
9:160 prescriptions as a methodoiOb'Y reference'-. In partic-
ular. the authors noted that there is little reported data
Cappa and Del Prete
about the temperature and h umidi t)' of HME's output flow.
but virtually no one paid attention to the rea! values of tem-
perature and humidity of HME air inilow. Nevertheless,
with regard to the INHaled air conditions, those values
could heavily affect the relative efficiency of HMEs. lt
seems worthwhile to highlight that ISO 9360'- prescribes a
humidit) not exceeding 0.88mg/l. equivalent to a dew
point of -20C at atmospheric pressure, for the HME's test
input gas. Unfortunately, it is not always easy to guarantee
this value, therefore many researchers simply omit infor-
mation about HME input gas. On the contrary, the authors'
opinion is that only a fully closed contro! system based on
temperdture and humidit)' measurements in the four uni-
directional flow points named, as previously indicated, in -
!NH- EXH- out (see Fig. l and Fig.2), could return truthful
results about an HME's actual efficiency
From an overdll examination of the proposed methocl-
ology to verify the HME effectiveness and from the tests
carried out, the following conclusions can be drawn.
The methodology is sufficiently safe to verify the HME
performances in both "in vitro" and "in vivo" utilization.
The inaccuracy of absolute humidit) values associateci
with the measurements conducted with commercially
available relative humidity sensors can be consiclered suffi-
ciently small.
Acknowledgments
The authors wish to thank the support of both the Department
of :\lechanics and Aeronautics of the Universi() of Rome "L1
Sapienza and the Clinica! Engineering Service of Rome's
Children's Hospital "Bambino Ges" for the experimental facili-
ties provided. They also Iike to acknowledge BAXTER Ltd which
partially funded the research.
REFERENCES
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Una!. N. ( 1995),"An experimental set-up to test Heat-Moisture
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54 )ournal of Clinica! Engineering )anuary/February 1997
l(,_ S1denham. P l l. ( l 9H2 ) ... Handh< Jok of me;tsurement scie n cc
Volume l Theoretical fundamentals ... .John Wi!t:1 & Sons.
Salisbury (C.K.) chapter (,,pp. 2-1 l -2-(l
1-. ISO 9)(JO (l 992) (E) "Anaesthetic ami respir.tton equiprnent
- Heat and :Vloisture Echangcrs tr use in humiuit\ing
respired gases in humans ...
AUTHOR'S BJOGRAPHIES
Paolo Cappa recei1ed his degree in .\Iechanical Engineering with
lwnors fmm the Lnin:rsity of Rome "La Sapienza" in 19110. In
l 911 l hc oined the Department of .\lechanics and Aeronautic; at
"La Sapienza ... where he is currenth an .-bsociate Professor of
"Sensors for :Vlechanical :\leasuremems ... Since its establishment
( 1')1-) l) h e has bee n the Assist;mt Director of the Clinica!
Engineering Senice at the Children's llosptal "Bambino Gesti".
His main scientitc interests are electmmedical equipmem man-
agement. mechanical and thermal m<:asurcment technologies ami
biomedica! instrumentation.
Zaccaria Del Prete received his "Lnrre:r" degree in .Vlechanical
Engineering from Rome's l'ni,ersitY "La Sapienza .. in 1990. l-le
oined the Department of :Vlechanics an d Aeronautics at .. La
Sa pienza in 199 2 as a research Assistant Professor in
Experimental .\lechanics. His main scientific interests are
mechanical and thermal measurement technologies and hiomed
ical instrumentation.
,\ddress ali correspondence and reprint requests to P:10lo Cappa.
Department of :\lechanics and Aeronautics. t:niversita Degli Studi
di Roma "La Sapienza".Yia Eudossiana. !H. 0018--. Rome.ltaly.
Cappa and Del Prete