Working Principles of ICU ventilators

Dr. Ananya Click to edit Master subtitle style

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Contents
Classification History Introduction Indications Key terms- compliance , ventilatory work Components Control mechanism Variables Triggering Factors to consider in mechanical ventilation
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Classification
According to Robert chatburn Broadly classified into

Negative pressure ventilators And

manner in which according to the

ventilators

Positive pressure

they support ventilation

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Negative pressure ventilators

Exert a negative pressure on the external chest during inspiration allows air to flow into the lung, filling its volume ventilation is similar to spontaneous ventilation

Decreasing the intrathoracic pressure

Physiologically, this type of assissted

It is used mainly in chronic respiratory

failure associated with neuromascular conditions such as poliomyleitis, muscular dystrophy, a myotrophic lateral sclerosis, and 5/30/12 mysthenia gravis.

The iron lung, often

referred to in the early days as the "Drinker respirator", was invented byPhillip Drinker(1894 1972) andLouis Agassiz Shaw Junior,professors ofindustrial hygiene at theHarvard School of Public Health .
The machine was

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powered by an electric motor with air pumps from two vacuum

Biphasic cuirass ventilation

Biphasic cuirass ventilation(BCV) is a

method ofventilation which requires the patient to wear an upper body shell orcuirass, so named after the body armour worn by medieval soldiers. cuirass is attached to a pump which actively controls both theinspiratory andexpiratory phases of the respiratory cycle .

The ventilation is biphasic because the

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Disadvantages
Complex and Cumbersome Difficult for transporting Difficult to access the patient in emergency claustrophobic

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Positive pressure ventilators

Inflate the lungs by exerting positive

pressure on the airway, similar to a bellows mechanism, forcing the alveoli to expand during inspiration
Expiration occurs passively. modern ventilators are mainly PPV s and

are classified based on related features, principles and engineering.

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History
Andreas Vesalius (1555) Vesalius is credited with the first description

of positive-pressure ventilation, but it took 400 years to apply his concept to patient care. The occasion was the polio epidemic of 1955, when the demand for assisted ventilation outgrew the supply of negative-pressure tank ventilators (known as iron lungs).
In Sweden, all medical schools shut down and

medical students worked in 8-hour shifts as human ventilators, manually inflating the lungs of afflicted patients.
5/30/12 Invasive ventilation first used at

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INTRODUCTION TO MECHANICAL VENTILATION: CONVENTIONAL MECHANICAL

VENTILATION
Mechanical ventilation is a useful modality for

patients who are unable to sustain the level of ventilation necessary to maintain the gas exchange functions-oxygenation and carbon dioxide elimination
The first positive-pressure ventilators were

designed to inflate the lungs until a preset pressure was reached.

5/30/12 In contrast, volume-cycled ventilation, which

INDICATIONS FOR MECHANICAL VENTILATION

Respiratory Failure Cardiac Insufficiency Neurologic dysfunction Rule 1. The indication for intubation and mechanical

ventilation is thinking of it.

Rule 2. Endotracheal tubes are not a disease, and

ventilators are not an addiction

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Key terms
Ventilatory workDuring inspiration , the size of the thoracic cage

increases overcoming the elastic forces of the lungs and the thorax and resistance of the airways. As the volume of the thoracic cage increases, intrapleural pressure becomes more negative, resulting in lung expansion.
Gas flows from the atmosphere into the lungs as a result

of transairway pressure gradient.

During expiration, the elastic forces of the lung and

thorax cause the chest to decrease in volume and exhalation occurs as a result of greater pressure at the alveolus compared to atm. Press.
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This ventilatory work is proportional to the pressure

required for inspiration times the tidal volume.

LOAD The pressure required to deliver the tidal volume is

referred to as the load that the muscles or ventilator must work against. elastic ( volume & inv. Prop t0 compliance)
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load

( Raw & inspiratory flow)

Equation of motion for respiratoryventilator pressure = system Muscle pressure +

(volume / compliance)+ (resistance x flow)
Flow- its the unit of volume by unit of time. Resistance- it is the force that must be

overcome to move the gas through the conducting airways.

It is described by the poiseulles law.
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Lung compliance
Lung compliance: Is the change in volume per

unit change in pressure COMPLIANCE = Volume / Pressure

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Types
Static compliance- is measured when there

is no air flow.

Reflects the elastic properties of the lung and

the chest wall

Dynamic compliance is measured when air

flow is present

Reflects the airway resistance (non elastic

resistance) and elastic properties of lung and chest wall

Static compliance=Corrected tidal volume

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Plateau pressure-

What is a mechanical ventilator?

substitute for the ventilatory work accomplished by the patients muscles. Components INPUT POWER DRIVE MECHANISM CONTROL CIRCUIT OUTPUT WAVEFORMS ALARMS
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A machine or a device that fully or partially

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INPUT POWER
It can be Pneumatically powered(uses compressed

gases)

Electrically powered(uses 120 Volts

AC/12Volts DC) Here the electric motor drives pistons and compressors to generate gas flows .
Microprocessor controlled- combined.

Also called as 3rd generation ventilators.

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Source of Gas Supply

Air - Central compressed air, compressor,

turbine flow generator, etc concentrator, O2 cylinder

Oxygen Central oxygen source, O2 Gas mixing unit O2 blender

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DRIVE MECHANISM
Its the system used by the ventilator to

transmit or convert the input power to useful ventilatory work. pressure patterns produced by the ventilator. pistons bellows reducing valves

This determines the characteristic flow and

It includes

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pneumatic circuits

Piston mechanism
Bellows mechanism Pneumatic mechanism

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Pneumatic circuits- uses pressurized gas as

power source.
these are microprocessor controlled with

solenoid valves.
use programmed algorithms in

microprocessor to open and close solenoid valves to mimic any flow or pressure wave pattern.

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Control circuit
Its the system that governs the ventilator

drive mechanism or output control valve.

Classified as Open circuits- desired output is selected and

venti. achieves it without any further input from clinician.

Closed circuits- desired output is selected

and venti. Measures a specific parameter (flow/vol/press) continuously and input is constantly adjusted to match desired output.

a.k.a SERVO controlled.

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Control parameters
Pressure Volume Flow Time

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Ventilators deliver gas to the lungs using

positive pressure at a certain rate. The amount of gas delivered can be limited by time, pressure or volume. The duration can be cycled by time, pressure or flow. If volume is set, pressure varies..if pressure is set, volume varies.. .according to the compliance...
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 Mechanical- employs levers or pulleys to

control drive mechanism.

Pneumatic Fluidic- applies gas flows and pressure to

control direction of other gas flows and to perform logic functions based on the COANDA effect.
Electronic- uses resistors and diodes and

integrated circuits to provide control over the drive mechanism.

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Pressure controller
Ventilator controls the trans-respiratory

system pressure .

This trans-respiratory system gradient

determines the depth or volume of respiration.

Based on this a ventilator can be positive or

negative pressure ventilator.

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Volume controller
Volume cycled ventilation delivers a: set volume; with a variable Pressure - determined by

resistance, compliance and inspiratory effort

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Flow controller
Allows pressure to vary with changes in

patient s compliance and resistance while controlling flow. venturi pnemotachometers.

This flow is measured by vortex sensors or

Time controller
measures and controls inspiratory and expiratory time.

These ventilators are used in newborns and infants 5/30/12

Normal inspiratory time of a spontaneously breathing healthy adult is approximately 0. 8- 1.2 seconds, with an inspiratory expiratory (I: E) ratio of 1:1.5 to 1:2 2. Its advantageous to extend the inspiratory time in order to: improve oxygenation - through the addition of an inspiratory pause; or to increase tidal volume - in pressure controlled ventilation Adverse effects of excessively long inspiratory times are haemodynamic compromise, patient ventilator dysynchrony, and the development of autoPEEP.
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Phase variables
A. Trigger .
What causes the breath to begin?

B A

B. Limit
What regulates gas flow during the breath?

C. Cycle .
What causes the breath to end?

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Phases of ventilator supported breath

inspiration change from inspiration to expiration expiration change from expiration to inspiration Types of ventilator breathsMandatory breath
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Trigger variable
Its the variable that determines start of

inspiration

Triggering refers to the mechanism through

which the ventilator senses inspiratory effort and delivers gas flow or a machine breath in concert with the patients inspiratory effort.
Can use pressure or volume or time or flow as

a trigger.

In modern ventilators the demand valve is

triggered by either a fall in pressure (pressure 5/30/12 triggered) or a change in flow (flow triggered).

Time triggering

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Pressure Triggering
spontaneous inspiratory effort.

Breath is delivered when ventilator senses patients sensitivity refers to the amount of negative pressure the

patient must generate to receive a breath/gas flow.

If the sensitivity is set at 1 cm then the patient must

generate 1 cm H2O of negative pressure for the machine to sense the patient's effort and deliver a breath.
Acceptable range - -1 to -5 cm H2O below patient s

baseline pressure
If the sensitivity is too high the patient's work of breathing

will be unnecessarily increased. It is not a reasonable course of action to increase the sensitivity to reduce the 5/30/12 patient's respiratory rate as it only increases their work of

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Flow Triggering

The flow triggered system has two preset

variables for triggering, the base flow and flow sensitivity.

The base flow consists of fresh gas that

flows continuously through the circuit. The patients earliest demand for flow is satisfied by the base flow.
The flow sensitivity is computed as the

difference between the base flow and the exhaled flow flow

Here delivered flow= base flow- returned Hence the flow sensitivity is the magnitude of
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the flow diverted from the exhalation circuit

Flow trigger Advantages -The time taken for the onset of inspiratory effort to the onset of inspiratory flow is considerably less. -decreases the work involved in initiating a breath.

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Limit variable

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Cycle variable
Defined as the length of one complete

breathing cycle. is reached.

Inspiration ends when a specific cycle variable This variable is used as a feedback signal to

end inspiratory flow delivery which then allows exhalation to start. as a feedback signal. time

Most new ventilators measure flow and use it So volume becomes a function of flow and 5/30/12

Baseline variable
The variable controlled during expiration

phase.

Mostly its pressure

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Basic definitions
Airway Pressures
Peak Inspiratory Pressure (PIP) Plateau pressures Positive End Expiratory Pressure (PEEP) Continuous Positive Airway Pressure (CPAP)

Inspiratory Time or I:E ratio Tidal Volume: amount of gas delivered with each

breath

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Pressures
Mechanical ventilation delivers flow and

volume to the patients as a result of the development of a positive pressure gradient between the ventilator circuit and the patients gas exchange units as illustrated in the diagram above. There are four pressures to be aware of in regards to mechanical ventilation. These are the:

Peak Plateau
5/30/12 Mean; and

Peak Inspiratory Pressure (PIP)-

The peak pressure is the maximum pressure obtainable during active gas delivery. This pressure a function of the compliance of the lung and thorax and the airway resistance including the contribution made by the tracheal tube and the ventilator circuit.

Maintained at <45cm H2O to minimize barotrauma

Plateau Pressure-

The plateau pressure is defined as the end 5/30/12 inspiratory pressure during a period of no gas

As the plateau pressure is the pressure when

there is no flow within the circuit and patient airways it most closely represents the alveolar pressure and thus is of considerable significance as it desirable to limit the pressure that the alveoli are subjected to. extrapulmonary air (eg pneumothorax) and acute lung injury. ETT resistance) will result in an increase in PIP.

Excessive pressure may result in

An increase in airways resistance (including An increase in resistance will result in a

widening of the difference between PIP and plateau pressure. 5/30/12

It is generally believed that end inspiratory

occlusion pressure (ie plateau pressure) is the best clinically applicable estimate of average peak alveolar pressure. Although controversial it has been generally recommended that the plateau pressure should be limited to 35 cms H2O.

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Mean Airway Pressure-

The mean airway pressure is an average of the system pressure over the entire ventilatory period.

End Expiratory Pressure-

End expiratory pressure is the airway pressure at the termination of the expiratory phase and is normally equal to atmospheric or the applied PEEP level. 5/30/12

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PEEP

Positive end expiratory pressure (PEEP) refers

to the application of a fixed amount of positive pressure applied during mechanical ventilation cycle refers to the addition of a fixed amount of positive airway pressure to spontaneous respirations, in the presence or absence of an endotracheal tube.

Continuous positive airway pressure (CPAP)

PEEP and CPAP are not separate modes of

ventilation as they do not provide ventilation. Rather they are used together with other modes of ventilation or during spontaneous 5/30/12

Advantages
ability to increase functional residual capacity

(FRC) and keep FRC above Closing Capacity.

The increase in FRC is accomplished by

increasing alveolar volume and through the recruitment of alveoli that would not otherwise contribute to gas exchange. Thus increasing oxygenation and lung compliance
The potential ability of PEEP and CPAP to open

closed lung units increases lung compliance and tends to make regional impedances to ventilation more homogenous. 5/30/12

Airway Pressures (Paw) For gas to flow to occur there must be a

positive pressure gradient. In spontaneous respiration gas flow occurs due to the generation of a negative pressure in the alveoli relative to atmospheric or circuit pressure (as in CPAP) (refer to following diagram).

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Physiology of PEEP
Reinflates collapsed alveoli and maintains

alveolar inflation during exhalation

PEEP Decreases alveolar distending pressure Increases FRC by alveolar recruitment Improves ventilation
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Physiological Responses to CPAP / PEEP

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Dangers of PEEP
High intrathoracic pressures can cause

decreased venous return and decreased cardiac output

May produce pulmonary barotrauma May worsen air-trapping in obstructive

pulmonary disease

Increases intracranial pressure Alterations of renal functions and water

metabolism

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AutoPEEP
During expiration alveolar pressure is greater

than circuit pressure until expiratory flow ceases. If expiratory flow does not cease prior to the initiation of the next breath gas trapping may occur. Gas trapping increases the pressure in the alveoli at the end of expiration and has been termed:

dynamic hyperinflation; autoPEEP; inadvertent PEEP; intrinsic PEEP; and

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 effects of autoPEEP can predispose the

patient to:

an increased risk of barotrauma; fall in cardiac output; hypotension; fluid retention; and an increased work of breathing

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I:E ratio
This defines the inspiration to expiration ratio. I:E ratios are normally set as 1:2 as expiration requires a longer

time .

In severe obstructive disease such as status asthamaticus it can

be set as 1:4

Factors affecting I:E Ratio1. Tidal volume 2. Respiratory rate 3. Flow rate
Increasing inspiration time will increase TV, but may lead to
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auto-PEEP

Tidal Volume
Tidal volume refers to the size of the breath that is

delivered to the patient.

Normal physiologic tidal volumes are approximately 5-7

ml / kg whereas the traditional aim for tidal volumes has been approximately 10 - 15 ml / kg.
The rationale for increasing the size of the tidal volume in

ventilated patients has been to prevent atelectasis and overcome the deadspace of the ventilator circuitry and endotracheal tube.
Inspired and expired tidal volumes are plotted on the y
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axis against time as depicted in the following diagram.

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The inspired and expired tidal volumes should

generally correlate.
Expired tidal volumes may be less than

inspired tidal volumes if:

there is a leak in the ventilator circuit -

causing some of the gas delivered to the patient to leak into the atmosphere
there is a leak around the endotracheal /

tracheostomy tube - due to tube position, inadequate seal or cuff leak

there is a leak from the patient, such as a

bronchopleural fistula

Expired tidal volumes may be larger than 5/30/12

Flow (V) to the speed at which a Flow rate refers

volume of gas is delivered, or exhaled, per unit of time. Flow is described in litres per minute . the maximum flow delivered to a patient per ventilator breath.

The peak (inspiratory) flow rate is therefore

Flow is plotted on the y axis of the ventilator

graphics against time on the x axis .

In the following diagram that inspiratory flow

is plotted above the zero flow line, whereas expiratory flow is plotted as a negative deflection. When the graph depicting flow is at 5/30/12

Flow

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primary factors to consider when applying mechanical ventilation of each individual breath, the components
the method of triggering the mechanical

specifically whether pressure, flow, volume and time are set by the operator, variable or dependent on other parameters ventilator breath/gas flow,

how the ventilator breath is terminated: potential complications of mechanical

ventilation.

methods to improve patient ventilator 5/30/12

synchrony; and

Time (Ti)
Time in mechanical ventilation is divided between

inspiratory and expiratory time.

Inspiratory Time In most volume cycled ventilators used in the intensive

care environment it is not possible to set the inspiratory time.

The inspiratory time is determined by the peak inspiratory

flow rate, flow waveform and inspiratory pause. Where inspiratory time is able to be set, flow becomes dependent 5/30/12 on inspiratory time and tidal volume.

The following example illustrate how these parameters

effect inspiratory time.

Ventilator settings Tidal volume 1000mls Peak Flow 60 lpm Flow Waveform square / constant Insp. Pause 0 secs The inspiratory time for this patient would be 1 second

because gas is constantly being delivered at a flow rate of 60 lpm, which equals 1 litre per second. If an inspiratory pause of 0.5 seconds were applied then the inspiratory time would be increased to 1.5 seconds.
Changing the patients flow waveform from a square to a

decelerating 5/30/12

flow waveform, without changing the flow

Output waveforms
Graphical representation of the control or

phase variables in relation to time. pressure waveforms flow volume

presented as

The ventilator determines the shape of control

variable whereas the other two depend on the patient compliance and resistance.

Conventionally flow above X-axis is

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Advantages
Allows user to interpret, evaluate, and troubleshoot

the ventilator and the patients response to ventilator. Monitors the patients disease status (C and Raw). Assesses patients response to therapy.
Monitors ventilator function Allows fine tuning of ventilator to decrease WOB,

optimize ventilation, and maximize patient comfort.

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Flow Waveforms

inspiratory flow is controlled by setting the

peak flow and flow waveform.

The peak flow rate is the maximum amount

of flow delivered to the patient during inspiration, whereas the flow waveform determines the how quickly gas will be delivered to the patient throughout various stages of the inspiratory cycle.
There are four different types of flow

waveforms available. These include the square, decelerating (ramp), accelerating

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Square waveform The square flow waveform delivers a set flow rate

throughout ventilator inspiration. If for example the peak flow rate is set at 60 lpm then the patient will receive 60 lpm throughout ventilator inspiration.
Decelerating waveform The decelerating flow waveform delivers the peak flow at

the start of ventilator inspiration and slowly decreases until a percentage of the peak inspiratory flow rate is attained.
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Accelerating waveformThe accelerating flow waveform initially

delivers a fraction of the peak inspiratory flow and steadily increasing the rate of flow until the peak flow has been reached.

Sine / sinusoidal waveform The sine waveform was designed to match

the normal flow waveform of a spontaneously breathing patient.

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Setting the Peak Flow and Flow Waveform the The flow rate should be set to match
patients inspiratory demand. Where the patients inspiratory flow requirements exceed the preset flow rate there will be an imposed work of breathing which may cause the patient to fight the ventilator and become fatigued.
Where flow rate is unable to match the

patients inspiratory flow requirements the pressure waveform on the ventilator graphics screen may show a depressed or scooped out pressure waveform.
5/30/12 This is often referred to as flow starvation.

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The decelerating flow waveform is the most

frequently selected flow waveform as it produces the lowest peak inspiratory pressures of all the flow waveforms.

This is because of the characteristics of

alveolar expansion. Initially a high flow rate is required to open the alveoli. Once alveolar opening has occurred a lower flow rate is sufficient to procure alveolar expansion.
Flow waveforms which produce a high flow

rate at the end of inspiration (ie. square and accelerating flow waveforms) exceed the flow 5/30/12 requirements for alveolar expansion, resulting

Pressure waveforms
Rectangular Exponential rise Sine

Can be used to monitor Air trapping (auto-PEEP) Airway Obstruction Bronchodilator Response Respiratory Mechanics (C/Raw) Active Exhalation Breath Type (Pressure vs. Volume) PIP, Pplat CPAP, PEEP Asynchrony
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References
Guide to mechanical ventilation- chang s Breathing and mechanical support- wolfgang

oczenski

Internet references

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Thank you

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Advantages of Volume Cycled Ventilation

Ease of Use Set Volumes: One of the major advantages of volume cycled

ventilation is the ability to set a tidal volume. This is of critical importance to patients requiring tight regulation of carbon dioxide elimination. Neurosurgical patients - post surgery / head injury and patients suffering a neurological insult (eg post cardiac arrest) often require CO2 regulation. This is because carbon dioxide is a potent vasodilator.

Increased levels of carbon dioxide, in these groups of patients, may

therefore increase cerebral blood volume with a concomitant elevation of intracranial pressure. A raised intracranial pressure may decrease the delivery of oxygenated blood to the brain - resulting in cerebral ischaemia. Conversely a low CO2 may cause constriction of the cerebral vasculature also resulting in decreased oxygen delivery and cerebral ischaemia. For these reasons volume cycled ventilation is 5/30/12the mode of choice for patients requiring CO2 regulation. often

Disadvantages
The major disadvantages of volume cycled

ventilation are the variable pressure and set flow rate. It is therefore a necessary part of nursing practice to closely monitor the patient's inspiratory pressure and observe the patient for signs of flow starvation.

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