ASV use and algorithm

HAMILTON MEDICAL AG
Switzerland
February 2001

Contents
Introduction
Clinical use of ASV
Functional description of ASV
Scientific basis

Introduction
a) Problems with conventional ventilators
Too many knobs, too many controls, very few guidelines
for setting controls
b) The obvious but difficult solution
Remove as many knobs as possible while still giving
the user control over the pertinent parameters
c) Definitions of pertinent parameters
V'A
To control pH/PaCO2 and WOB
PEEP
To control FRC and thus PaO2
FiO2
To control PaO2

Introduction (cont.)
Conventional

CMV
SIMV
PCV
PSV

Vt

Rate

Pinsp

PEEP

Tp

Psup

Ti

Te

FiO2

Alveolar Ventilation

ASV

Oxy.

PEEP

VA
FiO2

Uses of ASV
As start-up procedure only
To critique the actual settings
During weaning with and w/o protocol
For post-cardiac surgery patients only
For all patients, including ARDS

How to use ASV clinically (1)

1) Set Body Wt of patient and high Pressure
limit to 45 mbar (will yield Pmax < 35
mbar)
2) Set %MinVol to 100% (except COPD)
3) Set PEEP & FiO2 according to clinical
requirements
4) Connect patient

How to use ASV clinically (2)

5) Ventilate for some minutes and
assess blood gases and/or WOB
(clinically)
6) Adjust %MinVol to meet pH/PaCO2
targets or WOB targets
7) Adjust PEEP and FiO2
8) Review high Pressure limit setting,
consider changes only in exceptions
9) Observe Ppeak and fSpont trends

Repeat steps 5-9

until you consider
extubation

Practical use

Prepare GALILEO
Set high Pressure limit, Body Wt, %MinVol

Ventilate patient
Set alarms

Optimize %MinVol

Check blood gases and clinical status

Plot Pinsp, fTotal, fSpont trend

No

fSpont and
ABG OK?

Consider reducing
%MinVol

Yes

Pinsp
< 8 cmH2O

No

Yes

Consider weaning complete

Optimize %MinVol

see Operators Manual p.D-13 and D-14

%MinVol change

Remarks

Normal art. blood gases None

High PaCO2

Increase %MinVol

Pay attention to
inspiratory pressures

Low PaCO2

Decrease %MinVol

Pay attention to Pmean,

High respiratory drive

Low O2 saturation

Consider Increase in
%MinVol
None

CO2 status
Consider sedation,
analgesia, other treatment
Consider PEEP and/or
FiO2 increase

How to monitor the patient

Target graphics window shows
ASV target MinVol, Vt, f
Actually achieved values for MinVol, Vt, f
Safety limits for Vt and f
Check feasibility of %MinVol settings

Trends show
level of support provided by the ventilator vs. level of patient
activity

ASV Target Graphics

Window

How to monitor the patient:

Trend and track

Pinsp

fSpont
I
1h

I
2h

I
3h

I
4h

How does ASV work?

Conventional

CMV
SIMV
PCV
PSV

Vt

Rate

Pinsp

PEEP

Tp

Psup

Ti

Te

FiO2

Alveolar Ventilation

ASV

Oxy.

PEEP

VA
FiO2

Input: Minute ventilation

2000
V

Vt (ml)

1500

MinVol (l/min)

1000

500

0
0

20

40
f (b/min)

60

ASV is a "servant" to achieve a preset

MinVol while respecting boundary
conditions.

Command to servant
"Maintain at least 100% of normal ventilation,
take spontaneous breathing into account,
prevent tachypnea,
prevent AutoPEEP,
prevent excessive dead space ventilation,
fully ventilate in apnea or low drive,
give control to patient in case breathing activity
is okay, and do this without exceeding a 35 mbar
plateau pressure."

Functional description of ASV

see also
flow chart in ASV brochure
Appendix D of Operators Manual
ASV Users Guide

1) Calculation of minute ventilation

2) Application of lung-protective rules
3) Optimal breath pattern
4) Approach the target

1. Calculation of MinVol (trivial)

2000
IBW

Vt (ml)

1500

1000

0.1 l/min (adults)

0.2 l/min (pediatric)

500
MinVol (l/min)

0
0
IBW: Ideal Body Weight

20

40
f (b/min)

60

2. Lung-protective rules (boundary conditions)

2000

5 test breaths
10*Vd
A

Vt (ml)

1500

5 b/min
D

1000

C
20/RCexp

500

B
2*Vd

0
0

20

40
f (b/min)

60

3. Optimal breath pattern

2000

Vt ml

1500

f-target =

1+2a*RCexp*(MV-VD)/VD
a*RCexp

1000

500

0
0

20

40
f bpm

60

-1

4. Adjust Pinsp & fSIMV to meet target

2000

5 test breaths

Vt ml

1500

1000

500

0
0

20

40
f bpm

60

Summary of functions
1. Calculate MinVol (trivial)
2. Lung-protective rules

2000

3. Optimal breath pattern

4. Approach the target

Vt ml

1500

1000

500

Repeat 2,3,4 breath-by-breath

20

40
f bpm

60

Scientific basis
Machine- or patient-triggered

Dead space ventilation

Effects of PSL
Role of RCexp
Choice of breathing pattern

Scientific basis (1)

Machine- or patient-triggered

Dead space ventilation

FSIMPV
Effects of PSL
Role of RCexp
Choice of breathing pattern

Machine- or patient-triggered
ventilation

Fully
FullySynchronized
SynchronizedIntermittent
IntermittentMandatory
MandatoryPressure
Pressure
Ventilation
Ventilation(FSIMPV)
(FSIMPV)

"FSIMPV"
Machine- and/or patient-triggered.
Gas delivery is pressure-controlled for both the
mandatory and the spontaneous breaths. Pressure
levels are identical.
Mandatory breaths are time-cycled if they were NOT
triggered by the patient, spontaneous breaths are flowcycled.
Control settings are: inspiratory pressure, respiratory rate, I:E ratio,
pressure ramp, and expiratory trigger sensitivity. Other controls include
FiO2 and PEEP/CPAP.

"FSIMPV"

Flow E

Flow I

No patient activity:
* Machine-triggered
+ Time-cycled

Patient is active:
* Patient-triggered
+ Flow-cycled

Pinsp
PEEP

"FSIMPV"
Pinsp

To adjust Vt and fspont

f

To adjust the rate

Ti

To adjust I:E

PEEP
FiO2

To control FRC
To control PaO2

Scientific basis (2)

Machine- or patient-triggered

Dead space ventilation

FSIMPV
Effects of PSL
Role of RCexp
Flow-volume loop

Choice of breathing pattern

Paw (cmH2O)

Vol (ml)

V'aw (ml/s)

Flow, volume, and pressure tracings: Dynamic hyperinflation

750
500
250
0
-250
-500
-750
700
600
500
400
300
200
100
0
-100
35
30
25
20
15
10
5
0

10

11

Time (s)

10

11

10

11

Expiratory time constant

600
500

Vol (ml)

400
E

300

200
100
0
-100
-1200

-800

-400
V'aw (ml/s)

400

800

Scientific basis (3)

Machine- or patient-triggered

Dead space ventilation

FSIMPV
Effects of PSL
Role of RCexp
Flow-volume loop

Choice of breathing pattern

Minimal WOB (Otis)

Scientific basis (4)

Machine- or patient-triggered
FSIMPV

Dead space ventilation

Radford 2.2 ml/kg
Effects of PSL

Role of RCexp
Flow-volume loop

Choice of breathing pattern

Minimal WOB (Otis)

Dead space guesstimation

250

Vd (ml)

200

150

Vd (Hart)
Vd - female (Radford)
Vd - male (Radford)

100

50

0
0

50

100

150
Height (cm)

200

250

Scientific basis (5)

Machine- or patient-triggered
FSIMPV

Role of RCexp
Flow-volume loop

Dead space ventilation

Radford 2.2 ml/kg
Effects of PSL
Vt and f

Choice of breathing pattern

Minimal WOB (Otis)

600

30

500

25

400

20

300

15

200

10

100

0
PS 0

PS 4

PS 8

/min

ml

Effect of PS level in spontaneous breathing

PS 12

Borchard et.al. 1991, Anesthesiology 75:739-745

Vt
f

700

35

600

30

500

25

400

20

300

15

200

10

100

0
BPS-5

BPS

BPS+5 BPS+10

G.Iotti et.al. 1995 Int Care Med 21:406-413

/min

ml

Effect of PS level in spontaneous breathing

Vt
f

Scientific basis: Summary

Machine- or patient-triggered
FSIMPV

Role of RCexp
Flow-volume loop

Dead space ventilation

Radford 2.2 ml/kg
Effects of PSL
Vt and f

Choice of breathing pattern

Minimal WOB (Otis)

Benefits
ASV works in passive and in active patients
ASV promotes weaning from minute one
ASV employs lung-protective strategies to minimize
complications from AutoPEEP and thus barotrauma
ASV prevents tachypnea, apnea, excessive dead space
ventilation, and excessive breaths
ASV adapts continuously to the needs of the patient

When technology is master

we shall reach disaster
faster
Piet Hein