Medical Training: - Ventilation Options - For Internal Use Only

Medical Training
- Ventilation Options For internal use only
WEINMANN GERTE FR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Objective of Presentation
This presentation on ventilation gives the reader an overview of the available pressure and volume-controlled types of ventilation.. The conventional processes, including setting options on the ventilators, are explained. The reader will also learn about the use of Non Invasive Ventilation (NIV) with MEDUMAT Transport.
Contents
Functions and Physiological Goals of Ventilation Ventilation Basics Terminology Assisted Ventilation Modes Controlled Ventilation Modes
Volume-controlled Ventilation Pressure-controlled Ventilation
Non-Invasive Ventilation (NIV)
Oxygen or Ventilation ?
Ventilation Functions
Influence gas exchange Take over the work of respiration The type of ventilation describes the changing relationship between patient and ventilator: Controlled: The device takes over the work of breathing. Augmented/ assisted/ supported: The work of breathing is shared by the device and patient. Spontaneous: The patient takes on the work of breathing.
Physiological Goals of Ventilation

Alveolar ventilation Arterial oxygenation Increase of end-inspiratory and end-expiratory lung volume Unloading respiratory musculature
Clinical Goals of Ventilation

Treatment of hypoxemia Treatment of respiratory acidosis Treatment of dyspnea Prevention/treatment of atelectasis Treatment of respiratory muscle fatigue Allow analgesic sedation and muscle relaxation Reduction of systemic and/or myocardial oxygen need Reduction of intracranial pressure Stabilization of thoracic wall
VS
CPAP
CPAP/ ASB
PSV NIV VC SVV
CPPV
SPV PC PCV
ASB
BIPAP
BiLevel/ ASB PEEP
IPPV
PLV
SIMV
Spontaneous Breathing
Inspiration: Negative pressure Expiration: Positive pressure
10
Ventilation - Terminology
11
Spontaneous Breathing vs. Ventilation

Spontaneous breathing: Passive volume expansion of lungs effected by pulling of rib musculature and diaphragm Ventilation: Active volume expansion by introducing volume or ventilation pressure.
12
Ventilation Systems
Terminology
Assisted ventilation Controlled ventilation Volume-controlled Pressure-controlled Combinations
13
PEEP
Definition: Positive End Expiratory Pressure
In controlled ventilation PEEP corresponds to CPAP of spontaneous breathing Advantages: Decline in atelectasis Higher volume per unit of pressure increase (predilation) Disadvantages: Increase of maximum ventilation pressure Impairment of venous blood backflow Application: With every type of ventilation at least PEEP 5
14
Assisted Ventilation Modes

CPAP mode increases respiratory pressure level to raise the Functional Residual Capacity (FRC). This mode is used only on patients with sufficient spontaneous breathing. Assisted Spontaneous Breathing (ASB) mode provides pressure support in cases of insufficient spontaneous breathing. The patient can breathe spontaneously without restriction, but gets support for his respiratory work from MEDUMAT Transport.
15
Supporting Mode (CPAP)

Continuous Positive Airway Pressure (CPAP)
Supports the respiratory work of the patient Respiratory rate, pattern and tidal volume are determined by patient Respiratory work is made easier.
16
Assisted Spontaneous Breathing (ASB)

Assisted spontaneous breathing Pressure support of every breath of patient Patient has to trigger the device Can combine CPAP, BIPAP, SIMV
Spontaneous breathing CPAP / PEEP 10 cm H2O ASB 7 cm H2O
17
Controlled Ventilation
Takes over all respiratory work of patient
Determines tidal volume by ventilation modes of
pressure-controlled volume controlled
Assisted modes (ASB/CPAP) can be combined
18
Volume vs. Pressure-controlled Ventilation

Volume-controlled modes ensure tidal and Respiratory Minute Volume (RMV) with adherence to an upper pressure limit. Pressure-controlled modes maintain maximum ventilator pressures and have a more physiological character. There is no volume guarantee, which makes monitoring of tidal volume and RMV necessary. Supporting modes combine the advantages of both systems.
19
Volume-controlled Ventilation
The inspiratory gas flow is maintained until a certain volume is reached. Airway pressure is passive (danger of barotrauma). Combination with pressure limit makes sense. Initially areas with high compliance and low resistance are ventilated and then plateau pressure is reached.
20
Advantage: Tidal volume is maintained even when pulmonary mechanics change. Disadvantage: Danger of pressure-caused damage to lungs when pulmonary mechanics deteriorate
Settings: Respiratory Minute Volume (rate x tidal volume) Limit or control dimension: maximum airway pressure
21
Abbreviations in Volume-controlled Ventilation

IPPV: Intermittent Positive Pressure Ventilation PLV: Pressure Limited Ventilation CPPV: Continuous Positive Pressure Ventilation (with set PEEP level) VC: Volume Control SVV: Smart Volume Ventilation
22
IPPV/CPPV Intermittent Positive Pressure Ventilation With PEEP = CPPV : Continuous Positive Pressure Ventilation Corresponds to completely controlled ventilation Time-controlled, constant volume, limited pressure
23
IPPV Settings
Respiratory rate: Choice between 10 to 20 /minute Tidal volume: 6 to 10 ml kg KG I:E ratio: 1:1 or 1:1,7 Oxygen concentration: FiO2 0,3 1,0 Pressure limit: pMax 30 cm H2O PEEP: 5 cm H2O Inspiration segmentation (plateau)
24
Special Emergency Mode

IPPV ventilation Pre-set for Baby (10 kg) Child (20 kg) Adult (75 kg)
25
Special Emergency Mode
26
SIMV
Synchronized Intermittent Mandatory Ventilation Patient is given a pre-set minimum number of breaths with a defined volume (see IPPV) Combination of controlled ventilation, synchronized mechanical breaths triggered by the patient, and spontaneous breathing The patient may breathe independently (see CPAP-ASB) and direct the device. Synchronized mechanical breaths are possible only within an anticipated breath window.
27
SIMV Settings
Settings for IPPV/CPPV breaths Tidal volume 6 to 10ml kgKG Respiratory rate: 4 to 10 I:E 1:1 1.7 PEEP/CPAP 5 cm H2O Setting for SIMV Trigger threshold (l/min) of patient 3 l/min Oxygen concentration: FiO2 0.3 1,0 Pressure limit: pMax 30 cm H2O
28
SVV
Smart Volume Ventilation Weinmanns special mode of volume-controlled ventilation All pressure-controlled ventilation modes can be set
29
Pressure-controlled Ventilation
Application of gas flow until a pre-set airway pressure is reached. The pressure is maintained for a certain amount of time and then reduced again during expiration. Tidal volume results from the ventilation pressure and the mechanical characteristics of the lungs. Tidal volume and gas flow are dependent on the mechanical characteristics of the lungs. Initially high and then decreased flow = decelerated flow
30
Pressure-controlled Ventilation
Disadvantage: Advantage: When respiratory mechanics The optimum pressure range deteriorate, tidal volume decreases and with it the can be set individually for each ventilation. lung. The lung is protected and Tidal volume has to be measured ventilator-induced lung at end-expiratory point when damage can be avoided. pressure-controlled or nonvolume constant ventilation is used.
Settings: Airway pressure, respiratory rate Limit or control dimension: Tidal or respiratory minute volume
31
Abbreviations in Pressure-controlled Ventilation Modes

PCV: Pressure Control Ventilation allows no spontaneous breathing by patient. BIPAP: Biphasic Positive Airway Pressure BiLevel: Combination of timed change of two pressure levels SPV: Smart Pressure Ventilation Weinmann-specific platform for set up of pressurecontrolled ventilation mode.
32
SPV
Smart Pressure Ventilation Weinmanns special mode of pressure-controlled ventilation All pressure-controlled ventilation modes can be set up CPAP/ASB can be used only at the lower pressure level
33
Bi-level Ventilation
Biphasic Positive Airway Pressure = ventilation with two pressure levels (also known as BI-level Positive Airway Pressure) Pressure and time-controlled ventilation mode Volume is not constant ! State-of-the-art ventilation mode in Intensive Care Unit (ICU)
34
Bi-level
Mode of Operation: Combination of CPAP and pressure-controlled ventilation Two (2) different pressure levels Spontaneous breathing at both levels is allowed at any time during ventilation ASB support is possible
35
Bi-Level: Settings
Rate calculation: 60 sec. / targeted rate e.g., 10 rate = 6-second respiratory cycle Respiratory cycle: Set I:E via time selection e.g.: T1(Inspiration) 2 seconds / T2 (Expiration) 4 seconds Pressure level P1(high pressure/ inspiration) P2 (CPAP/PEEP/low pressure / expiration)
36
Combinations and Special Modes

ASB: BiLevel ASB: Assisted Spontaneous Breathing Each breath of the patient triggers a gas flow which leads to the set inspiratory pressure level.
CPAP: CPAP/ ASB
Continuous Positive Airway Pressure Spontaneous breathing mode, maintains positive pressure in airways during the entire spontaneous breathing cycle + assisted spontaneous breathing
37
Ventilation Parameters
Rate
Pinsp Pressure PEEP
Ratio Inspiration:Expiration I:E Ramp Pmax FiO2 Minute volume
Delta ASB Tidal volume

Trigger
38
Non-Invasive Ventilation (NIV)

For Non invasive Ventilation the patient is given a mask which, depending on type, covers the nose and mouth or the entire face or goes on the patients head like a helmet. Basically all the ventilation modes used in invasive ventilation (via tube or tracheostoma) can be used in non-invasive ventilation.
39
Advantages of NIV
Avoidance of intubation Airways remain intact Reduction in ventilator-induced pneumonia Relaxation/sedation not required: gastrointestinal atony weaning symptom Patient can communicate Increase in mobility Intermittent treatment as needed Maintenance of glottal closure function
40
Indications and Contraindications of NIV

Indications: -Neuromuscular diseases (ALS, polio) -Mechanical disorders (kyphoskoliosis, etc.) -COPD -Pulmonary edema -Pneumonia -Weaning -ARDS Contraindications: Coma or amentia Severe cooperation problems Acute life-threatening hypoxia Cardiac arrest Hemodynamic instability Increased risk of aspiration Swallowing disorders, ileus, GI bleeding, abdominal surgery (?) Obstruction in upper airways Secretion retention
41
NIV Operational Principle

Unloading of respiratory pump Increase in intrathoracic pressure
- counteracts a pathological collapse of the alveolar sector
Reduction in development of atelectasis and ventilation disorders Increase to FRC
Decline in pulmonary shunt volume

Improvement of pulmonary oxygen transfer Improvement in oxygenation
42
Assessment of NIV in Clinical Use

Criteria for success
Improvement in alveolar ventilation (PaCO2 falls) Improvement in pulmonary gas exchange (SaO2 rises) Unloading of respiratory pump Decrease in cardiac rate Decrease in respiratory rate Reduces agitation, angst Reduction in dyspnea
Cancellation criteria
Hypercapnia during NIV Hypoxemia with SaO2< 85% Acidosis (pH < 7,2) Rise in respiratory rate
Dyspnea
Loss of consciousness Circulatory instability Increasing agitation, angst
43
Summary
Every existent respiratory activity of the patient should be utilized ! The device should adjust to the patient the patient should not adjust to the device ! Pressure and volume-controlled modes offer the best selection options and adaptation to patient needs. Ventilation setup is one task; the monitoring of respiratory parameters is the second.

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Medical Training

- Ventilation Options For internal use only

Non-Invasive Ventilation (NIV)

Physiological Goals of Ventilation

Clinical Goals of Ventilation

Spontaneous Breathing vs. Ventilation

Assisted Ventilation Modes

Supporting Mode (CPAP)

Assisted Spontaneous Breathing (ASB)

Spontaneous breathing CPAP / PEEP 10 cm H2O ASB 7 cm H2O

Assisted modes (ASB/CPAP) can be combined

Volume vs. Pressure-controlled Ventilation

Abbreviations in Volume-controlled Ventilation

Special Emergency Mode

Special Emergency Mode

Abbreviations in Pressure-controlled Ventilation Modes

Combinations and Special Modes

CPAP: CPAP/ ASB

Ratio Inspiration:Expiration I:E Ramp Pmax FiO2 Minute volume

Delta ASB Tidal volume

Non-Invasive Ventilation (NIV)

Indications and Contraindications of NIV

NIV Operational Principle

Reduction in development of atelectasis and ventilation disorders Increase to FRC

Decline in pulmonary shunt volume

Assessment of NIV in Clinical Use

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