GUIDE - Dr.Vairavarajan M.D

GUIDE.Dr.Vairavarajan M.D.
LOGO
Copyright © Wondershare Software
LOGO
Functional design
Input power Limit variable
Drive mechanism Cycle variable
Control circuit Out put wave
Controlvariables forms
Trigger variable Alarmsystems

• Energy from power source
• Pneumatic powered-compressed gas (anhydrous,

oil free gas at 50 psi)
Eg- Bennet PR2, Bird mark7
• Electrically powered-120v 60Hz AC /12V DC
• Combined: pneumatic power-drive inspiration

electric power- breath
characteristics

• To convert input power to useful ventilatory
work
• Determines the flow & pressure patterns
• Volume controllers flow controllers

-spring loaded bellows -solenoid valve
-linear drive pistons -stepper motors
-rotary drive pistons -digital valves

• Controls the drive mechanism
• Responsible for output wave forms
• Open, closed, mechanical, pneumatic, fluidic,

electric, electronic

• Closed loop
-Desired output selected
-ventilator measures the flow/ pressure/
volume continuously
-Input adjusted to match output
• Open loop
-set control variable is delivered
-cannot respond to changing conditions

PNEUMATIC CIRCUIT
• Internal Pneumatic circuit
-single circuit
-double circuit
• External pneumatic circuit

-main inspiratory line
-Y connector
-main expiratory line
-expiratory valve

• Flow (volume) controlled
• pressure may vary
• Pressure controlled
• flow and volume may vary
• Time controlled (HFOV)

• pressure, flow, volume may vary

􀁺Guaranteed tidal volume
VT is constant even with variable
compliance and resistance.
􀁺Less atelectasis compared to PC
􀁺VT increase is associated with a linear
increase in minute ventilation

􀁺The limited flow available may not meet
the patient’s desired inspiratory flow rate
􀁺If the patient continues to inspire

vigorously→ Patient Vent Asynchrony:
↑WOB → fatigue
􀁺Can cause ↑ airway pressure leading to

barotrauma, volutrauma, & adverse
hemodynamic effects

Volume Control Breath Types
60
Paw SEC
cmH20
1 2 3 4 5 6
-20
120 INSP
Flow SEC
L/min 1 2 3 4 5 6
120 EXH
If compliance decreases the pressure increases to

maintain the same Vt
􀁺 Increases mean airway pressure by
constant inspiratory pressure.
􀁺 Limits excessive airway pressure
􀁺 Improves gas distribution
􀁺 ↓ WOB

􀁺VT is variable, as pulmonary mechanics
change
􀁺Potentially excessive VT as compliance
improves
 VT decreases if airway resistance increases

Volume/Flow Control Pressure Control
Inspiration Expiration Inspiration Expiration
20 20
Paw
Pressure Paw
0 0
1 2 0 1 2
20 20
Volume
0 0
0 1 2 0 1 2
3 3
Flow 0 Time (s) 0 Time (s)
-3 Copyright © Wondershare Software -3

• Ventilator delivered breaths divided into four
phases
• 1.change from expiration to inspiration

(TRIGGER)
• 2.inspiration(LIMIT)
• 3.change from inspiration to expiration(CYCLE)
• 4.expiration(BASELINE)

• Variable that determines the start of inspiration
• Pressure, volume, flow/time
• Time- RR set
• Pressure – drop in airway pressure at spontaneous

attempts(pressure gradient)
• Flow - more sensitive, less WOB
No spont- delivered flow=returned flow
Spontaneous-delivered flow>returned flow

• Infant ventilator
• Inductive plethysmography-initiate ventilator
supported breath
• Chest expands-electrical signals is generated

between two leads-Triggers inspiration
• Faster & responsive than pr / flow trigger

• The maximum value, a variable(pressure,
volume, flow, time) can attain
• Constant throughout inspiration but

Does not result in the termination of inspiratory
time

• The variable measured by the ventilator to
terminate inspiration
• Pressure / time / volume / flow

• Expiration is passive except in high frequency
oscillation
• Pressure is controlled during the expiratory

phase
• Baseline pressure- ZEEP/PEEP
• Time limited exhalation - APRV

• Input power alarms
• Control circuit alarms
• Output alarms

LOGO
• Conventional modes are uncomfortable
• Need for heavy sedation & paralysis
• Patients should be awake and interacting

with the ventilator
• To enable patients to allow spontaneous

breath on inverse ratio ventilation

NEWER MODES
VAPS MMV
PRVC ATC
AUTOMODE VS
ASV IRV
PAV NAVA
BVV
APRV

• Dual : switch between PC and VC breaths
• Allow the ventilator to control V or P based

on a volume feedback
• Switch within a single breath- VAPS
• Switch between breaths:

-Volume Support
-Pressure-Regulated Volume Control(PRVC)

• Available on the VIP Gold
• Once the breath is triggered the ventilator first

reaches the PS level fastly- pressure limited
portion(high variable flow)
• Microprocessor compares delivered & desired VT
• If desired volume is not obtained, inspiration

cont. according to peak flow setting
• Now, breath changes from pressure limited to

volume limited

Pressure limit
40 overridden
Set pressure limit
Paw
cmH20
-20
0.6 Set tidal volume cycle threshold

Tidal volume
Tidal volume
Volume met
not met
L
0
Inspiratory flow
60 greater than set flow
Inspiratory flow
Flow cycle equals set flow
Set flow limit
Flow
L/min
Switch
Copyright © Wondershare Software from Pressure control to
60 Volume/flow control
• ↓ WOB: higher inspiratory flow which
provided larger Vt
• ↓ Raw
• ↓ PEEP
• Better patient-ventilator synchrony
• Amato et al. Chest 1992

􀂃 Inspiratory pressure is regulated based on
the Pressure/Volume calculation of the
previous breath, compared to a target
tidal volume
􀂃 The ventilator continuously adapts the

inspiratory pressure in responses to
changing compliance and resistance to
maintain the target tidal volume
􀂃 Results in breath-to-breath variation of

inspiratory pressure
 Available in servo 300

• Pressure automatically adjusted for
changes in compliance and resistance
within a set range
• Tidal volume guaranteed
• Limits volutrauma
• Prevents hypoventilation
• Automatic weaning of the pressure as the

patient improves

• The ventilator switch between mandatory and
spontaneous breathing modes
• Combines volume support (VS) and pressure-

regulated volume control (PRVC)
• If patient is paralyzed; the ventilator will

provide PRVC. All breaths are mandatory that
are ventilator triggered, pressure controlled
and time cycled; the pressure is adjusted to
maintain the set tidal volume.
• If the patient breathes spontaneously for two

consecutive breaths, the ventilator switches to
VS. All breaths are patient triggered, pressure
limited, and flow cycled.
• If the patient becomes apneic for 12 seconds;

the ventilator switches back to PRVC
• A dual control mode that uses
pressure ventilation (both PC and
PSV) to maintain a set minimum
VE (volume target) using the least
required settings for minimal WOB
depending on the patient’s
condition and effort
• It automatically adapts to patient demand
by increasing or decreasing support,
depending on the patient’s elastic and
resistive loads

• The clinician enters the patient’s IBW, which
allows the ventilator’s algorithm to choose a
required V E. The ventilator then delivers 100
mL/min/kg.
• A series of test breaths measures the C,
resistance and auto-PEEP
• If no spontaneous effort occurs, the ventilator
determines the appropriate respiratory rate,
VT, and pressure limit delivered for the
mandatory breaths
• I:E ratio and TI of the mandatory breaths are
continually being “optimized” by the
ventilator to prevent auto-PEEP
• If the patient begins having spontaneous
breaths, the number of mandatory breaths
decrease and the ventilator switches to PS at
the same pressure level
• Pressure limits for both mandatory and
spontaneous breaths are always being
automatically adjusted to meet the V E target
• Advantages
• Guaranteed VT and VE
• Minimal patient WOB
• Ventilator adapts to the patient
• Weaning is done automatically and
continuously
• Decelerating flow waveform for improved gas
distribution
• Breath by breath analysis

• Provides pressure, flow assist, and volume
assist in proportion to the patient’s
spontaneous effort.
• greater the patient’s effort, the higher the
flow, volume, and pressure support given
• The operator sets the ventilator’s volume and flow assist

at approximately 80% of patient’s elastance and
resistance. The ventilator then generates proportional
flow and volume assist to augment the patient’s own
effort
• DRAGER EVITA 4

• Advantages
• The patient controls the ventilatory
variables ( I, PIP, TI, TE, VT)
• Trends the changes of ventilatory effort
over time
• When used with CPAP, inspiratory
muscle work is near that of a normal
subject and may decrease or prevent
muscle atrophy
• Lowers airway pressure

• Allows spontaneously breathing patients to
breathe at a high CPAP level, but drops briefly
(approximately 1 second) and periodically to
allow CPAP level for extra CO2 elimination
(airway pressure release)
• Mandatory breaths occur when the pressure

limit rises from the lower CPAP to the higher
CPAP level

• Allows inverse ratio ventilation (IRV) with or
without spontaneous breathing (less need for
sedation or paralysis)
• Improves patient-ventilator synchrony if

spontaneous breathing is present
• Improves mean airway pressure
• Improves oxygenation by stabilizing collapsed

alveoli
• Lowers PIP
• May decrease physiologic deadspace

• Expiratory time variable: ↓ enough to prevent
derecruitment & ↑enough to obtain a suitable
TV (0.4 to 0.6 s) – Target TV (4-6ml/kg)
• If the TV is inadequate → expiratory time is

lengthened
• If TV too high (>6ml/kg) → expiratory time is

shortened

• Phigh level set at the MAP level from the previous
mode (pressure control, volume control)
• Starting off with APRV→start high(28cmH2O of

less) and work way down.Higher trans alveolar
pressures recruit the lungs.
• Low PEEP is set at 0-5 cmH2O.

• The inspiratory time is set at 4-6 seconds(the
respiratory rate should be 8 to 12breaths per
minute - never more)
• I:E ratio: at least 8:1 and
• Time at low pressure level should be brief(0.8
sec)
• Neuromuscular blockade should be avoided:
the patient allowed to breath spontaneously
(beneficial)
• The breaths can be supported with pressure
support - but the plateau pressure should not
exceed 30cmH2O

Two different ways to wean
• If lung mechanics rapidly return to normal,
patient should be weaned to pressure support.
• If ARDS is prolonged→ the high CPAP level is

gradually weaned down to 10cmH2O→
standard vent wean

• AKA: Minimum Minute Ventilation or
Augmented minute ventilation
• Operator sets a minimum VE which usually is

70% - 90% of patient’s current VE. The
ventilator provides whatever part of the VE
that the patient is unable to accomplish. This
accomplished by increasing the breath rate or
the preset pressure.
• It is a form of PSV where the PS level is not

set, but rather variable according to the
patient’s need

• Closed loop ventilation: ventilator changes
it’s output based on measured input variable
• Spontaneous breaths: pressure control is used
• If anticipated VE < set (based on MV of past 30
sec): Mandatory breaths which are VC, time
triggered
• In contrast to SIMV: MMV gives mandatory
breaths only if spontaneous breathing has
fallen below a pre-selected minimum
ventilation

• Indications
• Any patient who is spontaneously
breathing and is ready to wean
• Patients with unstable ventilatory drive
• Advantages
• Full to partial ventilatory support
• Allows spontaneous ventilation with safety
net
• Patient’s V E remains stable
• Prevents hypoventilation
LOGO
LOGO
• ARDS and severe hypoxemia
• Prolonged inspiratory time (3:1) leads to
better gas distribution with lower PIP

• Elevated pressure improves alveolar
recruitment
• No statistical advantage over PEEP, and
does not prevent repetitive collapse and

reinflation

• I:E =2:1/4:1
• Improves oxygenation by
-reduction in intrapulmonary shunting
-improvement of V/Q matching
-decreased dead space ventilation
-auto- PEEP

• Barotrauma
• Worsening of pulmonary edema
• patient Agitation
• Pressure controlled IRV may reduce those

problems

• Use of supraphysiologic ventilatory rates
above 60 rpm
• Use of tidal volume smaller than the anatomic

dead space
• High Frequency Oscillatory Ventilation
• High Frequency Jet Ventilation
• High Frequency Positive Pressure Ventilation

• Direct alveolar ventilation
• Pendelluft effect
• Convective streaming
• Augmented (Taylor) dispersion
• Cardiogenic mixing
• Molecular diffusion

• Neonatal Respiratory Distress Syndrome
• Persistent Pulmonary Hypertension
• Neonatal Meconium Aspiration Syndrome
• Congenital Diaphragmatic Hernia
• Neonatal Lung Hypoplasia
• Neonatal Air Leak Syndrome with PIE
• Pediatric ARDS
• RSV Pneumonia (not bronchiolitis!!)

• New approach to mechanical ventilation based
on neural respiratory output.
• The act of breathing depends on rhythmic
discharge from the respiratory center of the
brain.
• This discharge travels along the phrenic nerve,
excites the diaphragm muscle cells, leading to
muscle contraction and descent of the
diaphragm dome.
• As a result, the pressure in the airway drops,
causing an inflow of air into the lungs.

• Conventional mechanical ventilators sense a
patient effort by either a drop in airway
pressure or a reversal in flow.
• Hence, creating a system that is sensitive to

hyperinflation, intrinsic PEEP and secondary
triggering problems

• With NAVA, the electrical activity of the
diaphragm (Edi) is captured, fed to the
ventilator and used to assist the patient’s
breathing.
• As the ventilator and the diaphragm work with

the same signal, mechanical coupling between
the diaphragm and the ventilator is practically
instantaneous.

• Improved synchrony:
In NAVA the ventilator is cycled-on as soon as
neural inspiration starts.
Moreover, the level of assistance provided
during inspiration is determined by the
patient’s own respiratory center demand.
• The same applies for the cycling-off phase -
the ventilator cycles off inspiration the instant
it is alerted to the onset of neural expiration.
• By utilizing the Edi signal, maintenance of
synchrony between the patient and the
ventilator is improved.

• NOISY VENTILATION
• The addition of noise results in a higher mean
volume, which is associated with higher
arterial oxygen tensions, more compliant lungs
and enhanced gas exchange.
• The important point is that this happens

without a corresponding increase in mean
pressure, which would place additional stress
on the lungs.

Thanks

GUIDE - Dr.Vairavarajan M.D

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GUIDE.Dr.Vairavarajan M.D.

Copyright © Wondershare Software

• Pneumatic powered-compressed gas (anhydrous,

• Electrically powered-120v 60Hz AC /12V DC

• Combined: pneumatic power-drive inspiration

Copyright © Wondershare Software

• Volume controllers flow controllers

Copyright © Wondershare Software

• Responsible for output wave forms

• Open, closed, mechanical, pneumatic, fluidic,

Copyright © Wondershare Software

Copyright © Wondershare Software

• External pneumatic circuit

Copyright © Wondershare Software

• Time controlled (HFOV)

Copyright © Wondershare Software

VT is constant even with variable

compliance and resistance.

􀁺Less atelectasis compared to PC

􀁺VT increase is associated with a linear

increase in minute ventilation

Copyright © Wondershare Software

􀁺If the patient continues to inspire

􀁺Can cause ↑ airway pressure leading to

Copyright © Wondershare Software

If compliance decreases the pressure increases to

constant inspiratory pressure.

􀁺 Limits excessive airway pressure

􀁺 Improves gas distribution

Copyright © Wondershare Software

􀁺Potentially excessive VT as compliance

Copyright © Wondershare Software

Flow 0 Time (s) 0 Time (s)

-3 Copyright © Wondershare Software -3

• 1.change from expiration to inspiration

Copyright © Wondershare Software

• Pressure, volume, flow/time

• Pressure – drop in airway pressure at spontaneous

No spont- delivered flow=returned flow

Spontaneous-delivered flow>returned flow

Copyright © Wondershare Software

• Chest expands-electrical signals is generated

• Faster & responsive than pr / flow trigger

Copyright © Wondershare Software

• Constant throughout inspiration but

Copyright © Wondershare Software

• Pressure / time / volume / flow

Copyright © Wondershare Software

• Pressure is controlled during the expiratory

• Time limited exhalation - APRV

Copyright © Wondershare Software

• Control circuit alarms

Copyright © Wondershare Software

• Need for heavy sedation & paralysis

• Patients should be awake and interacting

• To enable patients to allow spontaneous

Copyright © Wondershare Software

Copyright © Wondershare Software

• Allow the ventilator to control V or P based