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Ven$lator
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• Posi$ve pressure • Nega$ve pressure
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• The first iron lung was used on october 12 at children hospital boston
• used in a child unconscious from respiratory failure
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Iron lung ward filled with Polio pa$ents, Rancho Los Amigos Hospital, ca. 1953
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Sessions
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• Mechanical ven$lators used increasingly in
• Anesthesia and intensive care • To treat polio pa$ents and • The increasing use of muscle relaxants during anesthesia
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Indica$on for intuba$on
• Protect airway • Maintain airway • Mechanical ven$la$on • Bronchial toile$ng
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Indica$on for mechanical ven$la$on
• Ven$la$on Failure • Oxygena$on Failure
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. gas flows along a pressure gradient between the upper airway and the alveoli
Flow is either volume targeted and pressure variable, or pressure limited and volume variable.
The pattern of flow may be either sinusoidal (which is normal), decelerating or constant. Flow is controlled by an array of sensors and microprocessors.
expiration is passive
Mechanical ven$lator
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Control
• Either Volume Controlled (volume limited, volume targeted) and Pressure Variable or
• Pressure Controlled (pressure limited, pressure targeted) and Volume Variable or
• Dual Controlled (volume targeted (guaranteed) pressure limited)
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Cycling
• Time cycled -‐ such as in pressure controlled ven$la$on
• Flow cycled -‐ such as in pressure support
• Volume cycled -‐ the ven$lator cycles to expira$on once a set $dal volume has been delivered: this occurs in volume controlled ven$la$on
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Triggering
• what causes the ven$lator to cycle to inspira$on? • Ven$lators may be $me triggered, • pressure triggered or • flow triggered. • Time: the ven$lator cycles at a set frequency as determined by the controlled rate.
• Pressure: the ven$lator senses the pa$ent's inspiratory effort by way of a decrease in the baseline pressure.
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Flow trigger
• modern ven$lators deliver a constant flow around the circuit throughout the respiratory cycle (flow-‐by).
• A deflec$on in this flow by pa$ent inspira$on, is monitored by the ven$lator and it delivers a breath
• This mechanism requires less work by the pa$ent than pressure triggering.
•
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Breath are either
• Mandatory (controlled) -‐ which is determined by the respiratory rate.
• Assisted -‐ (as in assist control, synchronized intermi^ent mandatory ven$la$on, pressure support)
• Spontaneous-‐ (no addi$onal assistance in inspira$on, as in CPAP)
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Flow pa^ern
• Sinusoidal = this is the flow pa^ern seen in spontaneous breathing and CPAP
• Decelera$ng = the flow pa^ern seen in pressure targeted ven$la$on
• inspira$on slows down as alveolar pressure increases (there is a high ini$al flow).
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Flow pa^ern
• Constant -‐ flow con$nues at a constant rate un$l the set $dal volume is delivered
• Accelera$ng -‐ flow increases progressively as the breath is delivered. This should not be used in clinical prac$ce.
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Various modes of mechanical ven$la$on
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Control Modes
– every breath is fully supported by the ventilator – in classic control modes, patients were unable
to breathe except at the controlled set rate – in newer control modes, machines may act in
assist-control, with a minimum set rate and all triggered breaths above that rate also fully supported.
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CMV
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Assist-‐control
Ingento EP & Drazen J: Mechanical Ven$lators, in Hall JB, Scmidt GA, & Wood LDH(eds.): Principles of Cri.cal Care
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SIMV
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SIMV
Ingento EP & Drazen J: Mechanical Ven$lators, in Hall JB, Scmidt GA, & Wood LDH(eds.): Principles of Cri.cal Care
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Volume Ven$la$on Tidal volume, is not affected by the
rapidly changing pulmonary mechanics
Compliance ↓
Pressure Ven1la1on: Volume Ven1la1on: Decreased Tidal Volume Increased Pressure
Volume
Pressure Pressure
Volume
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Volume targeted
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Pressure Control vs. Pressure Support
Constant insp. pressure Decelera$ng, variable
inspiratory flow rate Time cycled: (A) • Pressure Control Flow cycled: (B) • Pressure Support
Pressure
Flow
A B
Time Cycled
Flow Cycled
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Pressure targeted
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Posi$ve Airway Pressure Can Be Either Pressure or Flow Controlled—But Not Both Simultaneously
Dependent Variable
Dependent Variable Set Variable
Set Variable
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Rise $me
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How to set Ti in a spontaneous breathing pa$ent on a pressure support mode ?
Flow
Pressure
Tinsp. PIP
Peak Flow
25%
Pressure Control Pressure Support
“Flow termination criteria”
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Termina$on Sensi$vity = Cycle-‐off Criteria
Flow
Peak Flow (100%)
TS 5%
Tinsp. (eff.) Set (max) Tinsp.
Leak
Time
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Combina$on “Dual Control” Modes
Combina$on or “dual control” modes combine features of pressure and volume targe$ng to accomplish ven$latory objec$ves which might remain unmet by either used independently.
Combina$on modes are pressure targeted
Par$al support is generally provided by pressure support Full support is provided by Pressure Control
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Combina$on “Dual Control” Modes
Volume Assured Pressure Support (Pressure Augmentation)
Volume Support (Variable Pressure Support) Pressure Regulated Volume Control
(Variable Pressure Control, or Autoflow) Airway Pressure Release (Bi-Level, Bi-PAP)
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PRVC (Pressure regulated volume control)
A control mode, which delivers a set tidal volume with each breath at the lowest possible peak pressure.
Delivers the breath with a decelerating flow
pattern that is thought to be less injurious to the lung…… “the guided hand”.
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PRVC Automa$cally Adjusts To Compliance Changes
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Servo PRVC
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PRCV: Advantages
Decelera$ng inspiratory flow pa^ern Pressure automa$cally adjusted for changes in compliance and resistance within a set range Tidal volume guaranteed Limits volutrauma Prevents hypoven$la$on
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PRVC: Disadvantages Pressure delivered is dependent on $dal volume achieved on
last breath Intermi^ent pa$ent effort ⇒ variable $dal volumes
Pres
sure
Fl
ow
Volu
me
Set tidal volume
© Charles Gomersall 2003
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Pres
sure
Fl
ow
Volu
me
Set tidal volume
PRVC: Disadvantages Pressure delivered is dependent on $dal volume achieved on
last breath Intermi^ent pa$ent effort ⇒ variable $dal volumes
© Charles Gomersall 2003
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APRV
• BiVent -‐ (Servo-‐i ven$lator by Maquet) • BiLevel -‐ (Puritan Benne^ 840 ven$lator by Covidien)
• DuoPAP -‐ ( C-‐1 ven$lator by Hamilton)
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APRV
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• An applica$on of CPAP • Con$nuous posi$ve airway pressure (CPAP) with an intermi^ent release phase.
• Pa$ent cycles between two levels of CPAP—higher one P High(P1), the lower P Low(P2)
• The pa$ent can breath spontaneously at either level • Maintains an op$mal FRC maintain adequate lung volume and alveolar recruitment.
• Occasional pressure releases augments CO2removal
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• P High–the upper CPAP level. Analogous to MAP (mean airway pressure) and thus affects oxygena$on
• P Low/PEEPis the lower pressure seong. • T High-‐is the $me spent at P High • T Low-‐is the release $me allowing CO2elimina$on
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• Applica$on of ‘P high’ and ‘T high’:(80-‐95%) of the cycle $me—”open lung”
• Mean airway pressure (MAP) is increased • Insures almost constant lung recruitment
– Decreases repe$$ve infla$on/defla$onDecreases risk of VILI
– Decreases need for recruitment maneuvers
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• Minute ven$la$on/CO2 removal depend upon:Lung compliance
• Airway resistance • Magnitude and dura$on of pressure release • Pa$ent’s spontaneous breathing efforts
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• Pressure seongs P High–desired mean airway pressure + 3 cmH2O (20 to 30 cm)
• P Low–usually set at 0 cm H2O ( 0 to 5 cm) • Time SeongsT High–usually set at 5.0 seconds (4.5-‐6.0 sec)
• T Low–usually set at 0.6 seconds (0.5-‐.8 sec) • FiO2
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1) Volume support monitors minute
ven$la$on and $dal volume , changing the level of pressure support to achieve a volume target.
2) Volume assured pressure support allows the pa$ent to breathe with pressure support, supplemen$ng the breath with constant flow when needed to achieve the targeted $dal volume within an allocated $me.
3) Propor$onal assist varies pressure output in direct rela$on to pa$ent effort.
Several modes allow for variability in pa$ent efforts while achieving a targeted goal.
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• Pa$ent status
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• Alarm