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Modes of Mechanical Ventilation. P OINTS OF D ISCUSSIONS Advanced Basics: Flow and Time Limit and cycling Rise Time Volume vs Pressure Control Mandatory.

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Presentation on theme: "Modes of Mechanical Ventilation. P OINTS OF D ISCUSSIONS Advanced Basics: Flow and Time Limit and cycling Rise Time Volume vs Pressure Control Mandatory."— Presentation transcript:

1 Modes of Mechanical Ventilation

2 P OINTS OF D ISCUSSIONS Advanced Basics: Flow and Time Limit and cycling Rise Time Volume vs Pressure Control Mandatory Modes of Ventilation Controlled Mandatory Ventilation (CMV or IPPV) Triggered Modes of Ventilation Continuous Positive Airway Pressure (CPAP) Pressure Support Ventilation (PSV) Hybrid Modes of Ventilation Assist Control Mode (A/C) Synchronized Intermittent Mandatory Ventilation (SIMV)

3 TRIGGERED MODES OF VENTILATION CPAP and PSVV

4 S PONTANEOUS B REATHING Time (sec) Flow (L/m) Pressure (cm H 2 O) Volume (mL)

5 C ONTINUOUS P OSITIVE A IRWAY P RESSURE (CPAP) Time (sec) Flow (L/m) Pressure (cm H 2 O) Volume (mL) CPAP Level

6 P RESSURE S UPPORT V ENTILATION (PSV) Time (sec) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Set PS Level Flow Cycling Better Efforts Longer Inspiration Patient Triggered, Flow Cycled, Pressure limited Mode

7 CPAP+PSV Time (sec) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Set PS Level Flow Cycling Patient Triggered, Flow Cycled, Pressure limited Mode CPAP Level

8 T RIGGERED M ODES OF V ENTILATION P RESSURE S UPPORT V ENTILATION ControlTriggerLimitTargetCycle PressurePatientPressureFlow Patient Triggered Flow Cycled Ventilation

9 MANDATORY MODES OF VENTILATION CMV or IPPV

10 M ANDATORY M ODES OF V ENTILATION CMV ControlTriggerLimitTargetCycle Pressure Or Volume Time Time Triggered Time Cycled Ventilation

11 C ONTROL M ODE (P RESSURE -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Time Triggered, Pressure Limited, Time Cycled Ventilation Time (sec) Time Cycling Set PC Level

12 C ONTROL M ODE (V OLUME -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Time Triggered, Flow Limited, Volume Cycled Ventilation Time (sec) Preset V T Volume Cycling Time Cycling Dependent on C L & R aw

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14 HYBRID MODES OF VENTILATION SIMV and A/C

15 H YBRID M ODES OF V ENTILATION A/C ControlTriggerLimitTargetCycle Pressure Or Volume Time Or Patient Time Time or PatientTriggered Time Cycled Ventilation

16 A SSISTED M ODE (V OLUME -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Patient Triggered, Flow limited, Volume Cycled Ventilation Time (sec) Preset peak Flow Time Cycling

17 A SSISTED M ODE (P RESSURE -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Patient Triggered, Pressure Limited, Time Cycled Ventilation Time (sec) Time Cycling Set PC Level

18 H YBRID M ODES OF V ENTILATION SIMV/PS Breath Type ControlTriggerLimitCycle MandatoryPressure Or Volume Time Or Patient Time SpontaneousPressurePatientPressureFlow

19 SIMV (V OLUME T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Spontaneous Breaths M MM Time (sec)

20 SIMV+PS (V OLUME T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) M T supp T synch Set PS Level Flow-cycled Time (sec)

21 SIMV + PS (P RESSURE -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) T supp T synch Time Cycled Flow-cycled T synch Set PC Level Set PS Level Time (sec)

22 H YBRID M ODE V ENTILATION : S YNCHRONIZATION (SIMV+PSV) Time (sec) Flow (L/m) Pressure (cm H 2 O) Cycles Triggered window for supported breaths Triggered window for synchronized breaths Mandatory Cycle Time M T supp T synch M T supp

23 ADVANCED MODES OF MECHANICAL VENTILATION

24 P OINTS OF D ISCUSSION Triggered Modes of Ventilation Volume Support (VS) Proportional Assist Ventilation (PAV or PPS) Hybrid Modes of Ventilation Volume Assured Pressure Support Pressure Regulated Volume Control (PRVC) Auto mode: VS and PRVC Adaptive Support Ventilation: ASV Bi-level Ventilation (APRV and Bi-vent) Mandatory Minute Ventilation (MMV)

25 N EW M ODES OF V ENTILATION D UAL -C ONTROLLED M ODES Type Manufacturer; ventilator Name Dual control within a breath VIASYS Healthcare; Bird 8400Sti and Tbird VIASYS Healthcare; Bear 1000 Volume-assured pressure support Pressure augmentation Dual control breath to breath: Pressure-limited flow-cycled ventilation Pressure-limited flow-cycled ventilation Siemens; servo 300 Cardiopulmonary corporation; Venturi Volume support Variable pressure support Dual control breath to breath: Pressure-limited time-cycled ventilation Pressure-limited time-cycled ventilation Siemens; servo 300 Hamilton; Galileo Drager; Evita 4 Cardiopulmonary corporation; Venturi Pressure-regulated volume control Adaptive pressure ventilation Autoflow Variable pressure control Dual control breath to breath: SIMV SIMV Hamilton; Galileo Adaptive support ventilation

26 D UAL C ONTROL B REATH - TO -B REATH PRESSURE - LIMITED FLOW - CYCLED VENTILATION V OLUME S UPPORT ControlTriggerLimitTargetCycle PressurePatientPressureVolumeFlow Pressure Limited Flow Cycled Ventilation

27 VS (V OLUME S UPPORT ) (1), VS test breath (5 cm H2O); (2), pressure is increased slowly until target volume is achieved; (3), maximum available pressure is 5 cm H2O below upper pressure limit; (4), VT higher than set VT delivered results in lower pressure; (5), patient can trigger breath; (6) if apnea alarm is detected, ventilator switches to PRVC Pressure Upper Pressure limit 5 cm H 2 O Flow Apnea 5 cm H 2 O Constant exp. Flow

28 Volume from Ventilator= Set tidal volume Pressure limit Based on VT/C Cycle off Calculate compliance Calculate new Pressure limit nono yes no Control logic for volume support mode of the servo 300 Trigger Flow= 5% of Peak flow

29 D UAL CONTROL BREATH TO BREATH : P ROPORTIONAL A SSIST V ENTILATION (PAS)/P ROPORTIONAL P RESSURE S UPPORT (PPS) ControlTriggerLimitTargetCycle PressurePatientPressureVolumeFlow Pressure Limited Flow Cycled Ventilation

30 P ROPORTIONAL A SSIST V ENTILATION (PAV) Pressure Flow Time Rregulates the pressure output of the ventilator moment by moment in accord with the patient’s demands for flow and volume. Thus, when the patient wants more, (s)he gets more help; when less, (s)he gets less. The timing and power synchrony are therefore nearly optimal—at least in concept. Changing pressure support based on patient’s efforts

31 P ROPORTIONAL A SSIST A MPLIFIES M USCULAR E FFORT Muscular effort (P mus ) and airway pressure assistance (P aw ) are better matched for Proportional Assist (PAV) than for Pressure Support (PSV).

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33 D UAL C ONTROL WITHIN A B REATH VOLUME - ASSURED PRESSURE SUPPORT ControlTriggerLimitTargetCycle Dual Pressure/ Volume PatientPressureVolumeFlow or volume Volume Assured Pressure Support Ventilation

34 Paw cmH Flow L/min Volume Set flow Set tidal volume cycle threshold Set pressure limit Tidal volume met Tidal volume not met Switch from Pressure control to Volume/flow control Inspiratory flow greater than set flow Flow cycle Inspiratory flow equals set flow Pressure limit overriddenL

35 Pressure at Pressure support delivered V T ≥ set V T flow= 25% peak Cycle off inspiration Insp flow > Set flow PAW

36 D UAL C ONTROL B REATH - TO -B REATH P RESSURE R EGULATED V OLUME C ONTROL ControlTriggerLimitTargetCycle VolumePatient or Time PressureLowest pressure for set volume Time Pressure-limited Time-cycled Ventilation

37 PRVC (P RESSURE R EGULATED V OLUME C ONTROL ) PRVC. (1), Test breath (5 cm H 2 O); (2) pressure is increased to deliver set volume; (3), maximum available pressure; (4), breath delivered at preset E, at preset f, and during preset T I ; (5), when V T corresponds to set value, pressure remains constant; (6), if preset volume increases, pressure decreases; the ventilator continually monitors and adapts to the patient’s needs Upper Pressure Limit 5 cm H 2 O Pressure Floe Time

38 PRVC A UTOMATICALLY A DJUSTS T O C OMPLIANCE C HANGES Pressure control Ventilation PRVC

39 Volume from Ventilator= Set tidal volume Time= set Inspiratory time Pressure limit Based on VT/C Trigger Cycle off Calculate compliance Calculate new Pressure limit nono yes no Control logic for pressure-regulated volume control and autoflow

40 PRVC (P RESSURE R EGULATED V OLUME C ONTROL ) Indications Patient who require the lowest possible pressure and a guaranteed consistent VT ALI/ARDS Patient with the possibility of CL or Raw changes

41 A UTOMODE MandatorySpontaneous PRVCVS Ventilator triggered, pressure controlled and time cycled; the pressure is adjusted to maintain the set tidal volume Patient triggered, pressure limited, and flow cycled. Apnea for 12 secondsTwo consecutive breaths

42 D UAL C ONTROL B REATH - TO -B REATH ADAPTIVE SUPPORT VENTILATION

43 ASV (A DAPTIVE S UPPORT V ENTILATION ) A dual control mode that uses pressure ventilation (both PC and PSV) to maintain a set minimum E (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

44 ASV (A DAPTIVE S UPPORT V ENTILATION ) The clinician enters the patient’s IBW, which allows the ventilator’s algorithm to choose a required E. The ventilator then delivers 100 mL/min/kg. A series of test breaths measures the system 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 E target

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46 + + Target Current MinVol 7.0 L/min T HE S AFETY W INDOW : LOW RATE / VOLUME LIMITS V mL fSpont 0 b/min fControl 11 b/min Pinsp 18 cmH 2 O f b/min 5 b/min 2 * V d (P max -PEEP)*C dyn f=60/[1RC insp +2RC exp ]

47 M ANDATORY M INUTE V ENTILATION A minimum minute ventilation is set by the operator The ventilator monitors the spontaneous MV The part of the pre-selected MV that the patient is not able to accomplish is provided by the ventilator to make up the difference by automatically changing the breath rate

48 MMV time Min.Vent. MMV SMV

49 MMV S ETTINGS time Min.Vent. SMV MMV MMV = 70-90% of SMV

50 B I L EVEL V ENTILATION PEEP H PEEP L Pressure Support PEEP High + PS P aw cmH

51 T high T low P low P high Time Pressure P supp

52 T high T low P low P high Time Pressure P high P supp

53 T high T low P low P high Time Pressure P high P supp

54 A IRWAY P RESSURE R ELEASE V ENTILATION ControlTriggerLimitCycle PressureTimePressureTime Time Triggered Time-cycled Ventilation

55 A IRWAY P RESSURE R ELEASE V ENTILATIONPaw cmH Spontaneous Breaths Releases

56 APRV (A IRWAY P RESSURE R ELEASE V ENTILATION ) Spontaneous breaths CPAP Level CPAP Level 2 CPAP Level 1 CPAP ReleasedCPAP Restored Time Airway Pressure

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58 Q UESTIONS


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