2Advanced Settings User Interface Module Advanced Settings Feature
3Accessing Advanced Features Press “Adv Settings” hard key on left side panel of the Avea monitor to access the Advanced Settings Window
4Advanced Settings Window Yellow triangle indicates this parameter has Advanced Settings
5Activating an Advanced Setting Press the desired parameter. The parameter will then be high-lighted with a blue background.The Advanced Settings features will then appear in the window above for the parameter
6Universal Features: Sensitivity & Pressure Support Advanced SettingsUniversal Features:Sensitivity & Pressure Support
8Sensitivity “Bias Flow” “Pressure Trigger” Bias Flow enables Flow TriggeringTo have adequate Flow Triggering, the Bias Flow should be set 0.5 liters above the Flow Trigger settingExample: Bias Flow set at 2.0 litres, Flow Trigger should be set no higher than 1.5 litres“Pressure Trigger”The Avea has both a pressure and a flow trigger active at the same time. Whichever signal (flow or pressure) is triggered first, the ventilator will then cycle into inspiration
9Pressure Support Ventilation PSV Setting has 4 Advanced SettingsMax Inspiratory TimeVolume LimitRise TimeFlow Cycle %
10Pressure Support Ventilation “Volume Limit”Every pressure type breath on the Avea has “Volume Limit” as an Advanced Setting featureThe clinician can enter a maximum volume limit. Once the ventilator has reached this limit during the delivery of the breath, it will then cycle the breath to exhalation using volume as the cycle criteriaWhen the volume limit is reached, a visual display appears in the alarm area. The display remains illuminated as long as the volume limit is active“PSV Rise Time”Setting range is from 1 to 9, 1 being fastest and 9 slowest.Allows the clinician to adjust the speed at which flow is delivered to the patient during a Pressure Support breath
11Pressure Support Ventilation “PSV Flow Cycle %”The Flow Cycle works as a percentage of the peak flow of the PSV breathThe Flow Cycle can be set in increments of 5% up to 45%Example: If the flow cycle is set at 10% and the peak flow for the PSV breath is 60 lpm, the breath will cycle when the decelerating inspiratory flow curve decays to 6 lpm“PSV Tmax”The PSV Maximum Inspiratory Time setting allows for an adjustable back up inspiratory time setting in circumstances where flow cycling is unreliable (i.e. endotracheal tube leaks)PSV Tmax should be set at X the set Inspiratory Time for Control breathsThe PSV Tmax is adjustable from 0.2 to 5.0 seconds
12Pressure Control Ventilation - PCV Advanced SettingsPressure Control Ventilation - PCV
13PCV - Pressure Control Inspiratory Pressure Inspiratory Time Flow Trigger
14Inspiratory Pressure in PCV Touch Insp Pres and these settings become availableMachine VolumeVolume LimitInspiratory Rise Time
15Advanced Settings Inspiratory Pressure in PCV “Mach Vol” (Machine Volume)This feature allows the clinician to set a target tidal volume during a Pressure Control breathWhen Machine Volume is active, the “Mach Vol” icon appears in the modes display windowMachine Volume icon
16Machine VolumeIs a Dual Control Mode; Ventilator delivers Volume Controlled Flow signal and Pressure Control signal to gas delivery system simultaneously.Sets the minimum tidal volume delivered from the ventilator in a pressure control breath.Always used with the time cycling criterion in pressure control ventilation.Circuit compliance compensated in adult and pediatric applications.
17Machine VolumeAllows for the maintenance of traditional Volume Control Ventilation while allowing the ventilator to vary peak flow to meet the patient’s inspiratory flow demandsIncorporates a decelerating/ variable inspiratory flow waveformCan be thought of as a variable flow-volume ventilation
18Machine VolumeVentilator calculates the decelerating inspiratory flow required to deliver the Machine Volume (Minimum Tidal Volume) in the set inspiratory time.When Peak Flow decelerates to this calculated peak inspiratory flowIf Machine Volume has not been deliveredtransition to a continuous flow until the Machine Volume has been deliveredInspiratory Time will remain constantmaximum Peak Inspiratory Pressure is determined by the High Peak Pressure alarm settingIf the Machine Volume is met or exceeded during delivery of the pressure control breath, the ventilator will complete the breath as a normal Pressure Control breath.
19Pressure Control- Volume Control Transition Pressure is increased within the breathThe constant, square wave flow continues until the pre-set tidal volume is delivered
20Pressure Control Adjustments with Machine Volume Guarantee DecreasedComplianceLungChest WallNeuromuscular BlockersIncreased AW ResistanceMucousBonchospasmPressure ControlIncreasedComplianceLungChest WallSpontaneous BreathingDecreased AW ResistancePost SuctioningPost Bronchodilators
21Machine VolumeNote Inspiratory Pressure set at zero, breath is decelerating flow pressure controlled breath. (Set Mach Volume 350cc) Inspiratory time is constant
22Machine VolumeNote transitions in flow between Pressure Control and Volume Control flow waveforms
23Machine Volume Vs. PRVCMachine Volume can respond to changes in compliance within 2-4 msec. PRVC will update on next breath.Compliance decreases ventilator responds within the breathCompliance increases ventilator responds within the breath
24Inspiratory Pressure in PCV “Vol Limit” (Volume Limit)This feature allows the clinician to set a maximum volume limit that cannot be exceeded during a Pressure Control breathWhen the volume limit is reached, a visual display appears in the alarm area. The display remains illuminated as long as the volume limit is active“Insp Rise” (Inspiratory Rise Time)Setting range from 1 to 9, 1 being fastest and 9 slowest.Allows the clinician to adjust the speed at which flow is delivered to the patient during a Pressure Control breath
25Volume Limit Active in: Pressure, PRVC Vsync TCPL PSV breaths only. Neonatal applications Volume LimitTM requires the use of a wye flow sensor.If a proximal flow sensor is usedVolume Limit is activated by the inspiratory tidal volume measured by the wye flow sensor.If Volume Limit threshold has been reached:Alarm status indicator will change to yellow and display the words Volume Limit.Cannot be reset until the ventilator has delivered a breath, which does not meet the Volume Limit threshold.To reset the alarm status window use the alarm-reset buttonDo not use with leaky ET tube
26Volume limit with Neonatal Flow Sensor 2 KGInspiratory VT limit 16 ml=8 cc/kgVolume limit can be used in conjunction with Machine volume to allow volume bracketing in Pressure Control. Machine volume is the minimum volume guarantee and Volume Limit will terminate the breath based on a maximum inspiratory tidal volume threshold. When used with only PCV, as compliance improves, so will volume. Patient will be protected from inadvertent volutrauma. Volume Limit may limit gas flow during hiccups or during increased flow demands of the patient.
27Inspiratory Time in PCV “Flow Cycle” is the only Advanced Setting feature for Inspiratory Time.
28Inspiratory Time in PCV “Flow Cycle”In addition to time cycling in PCV, the Avea allows the clinician the ability to add flow cycling to the inspiratory cycle criteria of the PCV breathThe Flow Cycle works as a percentage of the peak flow of the PCV breath (mimicking a Pressure Support Breath)When a Flow Cycle percentage is set, the PCV breath can either be cycled into expiration by the percentage of Flow Cycle or Inspiratory Time depending on which criteria is met first
29Flow Cycle The default setting is 0 (off) Can be set in increments of 5% to 45%10050Breath termination at 45%Breath termination at 5%Flow cycle can be more comfortable for spontaneously breathing patientsIt can reduce mean airway pressure and VT
30Flow CycleAllows patient to determine their own I- time by terminating the breath once a certain percentage of the peak inspiratory flow is metMay improve preload and eliminate V/Q mismatchingImproves patient/ventilator dsy-synchronyMay tremendously improve oxygenation and ventilation in spontaneously breathing patients
31Expiratory Flow Cycling Peak Inspiratory FlowV40%20%5%TSimply put, the lower the ESENS, the longer the time before inspiration ends. The higher the ESENS setting, the shorter the inspiratory time. In general, the most appropriate ESENS setting is compatible with the patient’s condition, neither extending nor shortening the patient’s intrinsic inspiratory phase. ESENS can be adjusted by patient assessment. If inspiratory times appear to exceed the inspiratory efforts of the patient, a higher ESENS can be attempted to see if patient comfort improves. If the breath appears to be terminating prematurely, a lower ESENS can be set and patient comfort re-evaluated as well as it’s effect on tidal volume.3636363636
32Fixed Inspiratory Time No Flow CycleFlow Cycle OnFlow Cycled Breath
33Flow Cycle Volume Cycled Breath Flow Cycled Breath If Flow Cycle is set with Machine Volume the breath will not Flow Cycle unless the Machine Volume (Minimum Tidal Volume) has been delivered
34Patient Comfort Dial in a Flow Cycle % May apply Flow Cycle transiently to measure pt’s true I time and set IT accordinglyFlow Cycling can only occur if target tidal volume has been reached in PRVC and Machine VolumeShould only be used with patients that have low FiO2 requirements because by limiting IT Mean Airway Pressure may be affected
35Breath Termination Hierarchy AlarmSupercedes all other criteriaVolume LimitIf set, supercedes all lesser criteriaFlow Cycle*In volume targeted and controlled modes only after set volume is achievedTime / Volume CycledIf no other criteria intercede
36Volume Control Ventilation - VCV Advanced SettingsVolume Control Ventilation - VCV
38Volume Parameter in VCV Vsync On/OffVsync Rise TimeSigh Select
39Volume Parameter in VCV When Vsync is selected, Volume Limit becomes apparent and the Vsync icon appears on screen.0=Off1=On
40Advanced Settings Vsync Vsync operates similar to PRVCFlow is only differenceSet in VsyncAutomatic in PRVCThe maximum step change between two consecutive breaths is 3 cm H2O.
41Volume LimitThis feature allows the clinician to set a maximum volume limit that cannot be exceeded during a Vsync breath.When the volume limit is reached, a visual display appears in the alarm area. The display remains illuminated as long as the volume limit is active
42Advanced Settings Volume Parameter in VCV “Vsync Rise Time”Setting range from 1 to 9, 1 being fastest and 9 slowest.With Vsync active, this control allows the clinician to adjust the speed at which flow is delivered to the patient.“Sigh”A sigh volume breath is delivered every 100th breath in place of the next normal volume breath.The sigh volume breath is 1.5 times the set tidal volume
44Intra-Breath Demand Flow Peak Inspiratory Pressure (Ppeak) every 2 milliseconds throughout the breath cycle“Virtual” Pressure Support Target of the greater of:PEEP + 2 cmH2O orPpeak – 2 cmH2OMaximum PEEP x 2Ppeak decrease by 2 cmH2O“switch over” to Pressure Support at virtual PSV Target.Once Tidal volume has been delivered“looks” at the inspiratory flowInspiratory Flow > set peak flowflow cycled at 25% of peak inspiratory flowInspiratory Flow = set flowends as Volume Control breath
45Intra-Breath Demand Flow in VCV Note augmented flow to meet patients inspiratory demand. Demand ends before set volume has been delivered.Demand continues through end of breath. Breath is FLOW CYCLED at 25% of PIFR.
46Intra-Breath Demand Flow ON / OFF Double cycling in periods of high demand
47PSV & Flow Trigger in VCV These Advanced Settings are the same for all modes and types of ventilation
48Pressure Regulated Volume Control - PRVC Advanced SettingsPressure Regulated Volume Control - PRVC
49PRVC – Pressure Regulated Volume Control Flow TriggerInspiratory TimeVolume
50Volume Parameter in PRVC Similar settings to PCV since PRVC is a hybrid of PCV
51PRVC / Vsync Logic controlled Volume TARGETED breath Decelerating flow, VC test breath with a 40 msec pauseEnd inspiratory pressure is Target Pressure for the first pressure control breathSubsequent breaths are delivered as pressure control breaths based on the dynamic compliance of the previous breath.Inspiratory pressure is adjusted automatically by the ventilator to maintain the target volume.Maximum step change between two consecutive breaths is 3 cmH2O.Maximum tidal volume delivered in a single breath is determined by the Volume Limit setting.Vsync NOTE:The Peak Flow control sets the flow rate, which is used by the ventilator for the test breath only. The ventilator uses the Peak Flow setting and Inspiratory Pause to determine the maximum inspiratory time during Vsync ventilation.Flow Cycling can only occur if target tidal volume has been reached
52PRVC / VsyncThis test breath sequence is initiated in the event any of the following occur:Entering the Mode (PRVC or Vsync)Changing the set tidal volume while in PRVC or VsyncReaching the Volume Limit settingDelivered tidal volume > 1.5 times the set volumeFlow termination of the test breathIntrabreath demand system is active for all test breathsExiting StandbyActivation of any of the following alarmsHigh Peak Pressure AlarmLow Peak AlarmLow PEEP AlarmPatient Circuit Disconnect AlarmI-Time LimitI:E LimitFlow Cycling can only occur if target tidal volume has been reached
57APRV Allows spontaneous breathing over a high mean airway pressure. High mean airway pressure may improve lung recruitment.Pressure support available .Apnea back-up parameters available.
58APRV Advanced settings Time high sync period-allows the operator to allow a period in which the ventilator will synchronize (during expiration) from high to low pressure phase.Adjustable from 0-50% of Time high.Time high PSV-on or off-allows the user to have pressure support on or off during the time high phase.Time low sync- allows the operator to allow a period in which the ventilator will synchronize (during inspiration) from 0-50%Adjustable from 0-50% of Time high
59APRV Proposed Benefits 1. Lower Paw for a given tidal volume comparedwith volume-targeted modes, e.g., AC, SIMV2. Lower minute ventilation, i.e., less dead spaceventilation3. Limited adverse effects on cardio-circulatoryfunction4. Spontaneous breathing possible throughoutentire ventilatory cycle5. Decreased sedation use6. Near elimination of neuromuscular blockade
61Advanced Settings Time High in APRV “Time High Sync %”Synchronizes transition from Pressure High to Pressure LowOccurs with the first end of inspiration detected after the Time High Sync % window opens.The Time High Sync %window is adjustable from 0 to 50%, in 5% increments of set Time High.The default setting for Time High Sync % is 0 (off)
62Advanced Settings Time High in APRV “Time High PSV”Time High PSV is either turned on (position 1) or off (position 0)The PSV is delivered above the current phase baseline pressure.If Time High PSV is activated as Time High Advanced Setting, the ventilator will deliver the same PSV level for both Pressure High and Pressure Low.Example: If Plow= 5cmH2O and Phigh= 25cmH2O, then a PSV breath set at 5 cmH2O will result in a Plow increase to 10cmH2O and Phigh increase to 30cmH2O
64Advanced Settings Time Low in APRV “Time Low Sync %”The ventilator synchronizes the change from Pressure Low to Pressure High with the detection of inspiratory flow or the first inspiratory effort detected within the Time Low Sync % window.The Time Low Sync % window is adjustable from 0 to 50%, in 5% increments of set Time Low.The default setting for Time Low is 0 (off)
65Synchronization Window Gives a range of possible I-times if Sync is activatedActual Time High or Time Low can change if Sync is activatedDepends on when the patient triggers to go from High to Low or Low to High
66PSV & Flow Trigger in APRV Both PSV & Flow Trigger Advanced Settings in VCV function as previously discussed on earlier slides
67Automatic Airway Compensation (AAC) AAC when applied, will supplement spontaneous pressure support or or pressure control flow cycled breaths based on calculated endotracheal tube resistance.Has no role in other pressure control or volume breath types.To activate, select “AAC On” and dial in tube size and length. An indicator saying “AAC” will appear in the mode bar.
68How Does Tube Compensation Work? Positive pressure added based on the inspired flow and tube curvature, diameter, and lengthPatient doesn’t have to experience the resistive work due to the artificial airway
69AAC Calculation based on: ETT Size 2.0 to 10.0 Length flow pharyngeal curvatureFiO2 / gas densitytransitions from turbulent to laminar flow Only ventilator with AAC available for controlled breaths
70(length) x (viscosity) (radius4) AAC(length) x (viscosity) (radius4) This equation is used during periods of laminar flow where resistance is primarily determined by gas viscosity. (density 0.75) x (viscosity .025) x (flow 1.75) x (length) (radius 4.75)This equation is used during periods of turbulent flow where resistance is primarily determined by gas density.
71What The Ventilator Circuit Sees Circuit PressureFlow triggering can be effective in minimizing imposed workPaw
72What The Carina SeesCircuit pressureLower pressure at the carinaPaw
73What the Carina SeesHigher circuit pressureAAC adds appropriate pressure to keep carina pressure at preset inspiratory pressureNo decrease in pressure at carinaPaw
74Considerations when using AAC Monitor pressure support level to achieve desired volumes. Supported breaths may be augmented above pressure support, so less pressure support may be needed.Compensatory support varies with many factors, and will vary with patient effort and other factors.Monitor volumes and pressures carefully, with special considerations with neonates.
75Set-up for Patient Use (cont) Automatic Airway Compensation-suggestedreading:Wrigge H, Zinerling J, Hering R,Swafenberg N, Stuber F, et al, Cardiopulmonary effects of automatic tubing compensation during airway pressure release ventilation in patients with acute lung injury Anesthesia 2001 Aug;95(2)382-9Guttmann J, Haberthur C, Mols G.Related ArticlesAutomatic tube compensation.Respir Care Clin N Am. 2001Sep;7(3):
77AutoPEEP AirwayAutoPEEPaw is the airway pressure at the end of exhalation immediately prior to the beginning of the next mandatory inspiration.
78AutoPEEP Airway Timing The ventilator will establish the AutoPEEP measurement when the system pressure reaches equilibration, at the next mandatory breath interval or 6 seconds whichever is shorter.
79Normal: 0 cm H2O above the applied PEEP AutoPEEP Airway Gas TrappingNormal: 0 cm H2O above the applied PEEPNote:Requires a passive patient and a cuffed endotracheal tube.Occurs when either insufficient expiratory time is present or in dynamic flow limitation conditions such as asthma or severe COPD. This results in gas trapping in the lungs.
81MIP ManeuverThe MIP (Maximum Inspiratory Pressure) / P100 maneuver measures the negative deflection in the pressure tracing during the patient’s active effort to demand a breath.
82MIP ManeuverMaximum Inspiratory Pressure (MIP), is the maximum negative airway pressure that is achieved by the patient, during an expiratory hold maneuver.
83MIP ManeuverNormal: Adults < -70 to -100 cm H2OPediatrics < -20 to -100 cm H2OReadiness for extubation < -20 cm H2ONote:Patient effort variable.Indicator of inspiratory muscle strength.Useful in weaning and progression of neuromuscular disease.Will be decreased in conditions such as kyphoscoliosis, advanced age, COPD and neuromuscular disease
84P100 ManeuverRespiratory Drive (P100), is the negative pressure that occurs 100 ms after an inspiratory effort has been detected.
85P100 ManeuverNormal: to -4 cm H2O Adults-0.5 to -4 cm H2O PediatricsNote:The pressure that occurs 100 milliseconds (ms) after the onset of inspiration while the inspiratory valve remains closed. Because it normally takes at least 300 ms for the patient to become aware of the occluded airway this is a good test of the respiratory center output. There is no change in lung volume or airflow during this initial 300 ms, therefore abnormalities in lung mechanics have no effect on the measurement.Values in excess of -5 cm H2O may indicate a high respiratory drive that may result in increased work of breathing and subsequent fatigue.