1. Go to ASL Last edited: 30-Sep-10 1 IngMar Medical, Ltd. Respiratory Simulation Specialist Tutorial Active Servo Lung 5000 (ASL 5000) High Fidelity Adult/Pediatric/Neonatal Breathing Simulator IngMar Medical, Ltd. P.O. Box 10106 Pittsburgh, PA 15232 T: 800.583.9910 or 412.441.8228 www.ingmarmed.com

2. 2 Go to ASL Last edited: 30-Sep-10 2 Tutorial Overview ASL 5000™ Active Servo Lung This tutorial is being provided with gratitude to our valued customers to enhance your experience with the ASL 5000. It is not intended to replace the User’s Manual, but rather to complement it. Most of the information contained in this tutorial can also be found in the User’s Manual. However, some additional detail has been added to the tutorial in order to provide a more complete step-by-step process. Authors: Cathy Brennan, Jenn Bacior, Stefan Frembgen

3. 3 Go to ASL Last edited: 30-Sep-10 3 The tutorial is designed to offer additional guidance in preparing and running respiratory simulations with the IngMar Medical ASL 5000. You may choose to follow along slide by slide. Or you may prefer to skip to those slides that appear to be most relevant to your use of the ASL 5000. HyperlinksHyperlinks have been provided to facilitate moving quickly to the slides of interest to you. (Please refer to the Table of Contents for a detailed listing of the tutorial contents.)ontents for a det Tutorial Overview

4. 4 Go to ASL Last edited: 30-Sep-10 4 In addition to hyperlinks, the tutorial takes advantage of other PowerPoint features such as Action Buttons and Action Settings. Clicking on these buttons will take you to other slides in the tutorial. Some examples are: Tutorial Overview Review slide #8: Synchronizing with the ASL 5000 Returns you to the last slide viewed. Takes you to the next slide. Hyperlinked to the indicated slide.

5. 5 Go to ASL Last edited: 30-Sep-10 5 Tutorial Overview Sample Cases ASL 5000 Included with the tutorial are several sample case files (in addition to scripts in the scenarios folder). These files can be easily loaded into the ASL 5000 folder on your computer. By doing so, you will have a head start in setting up your simulation models. Please see the ASL Sample Cases slides later in this tutorial for instructions on loading the sample case files into your ASL 5000 directory.)ASL Sample Cases

6. 6 Go to ASL Last edited: 30-Sep-10 6 Slide Number: 2 – 5Tutorial Overview 6 – 7Table of Contents 8Synchronizing the ASL 9 – 17Opening the ASL Software Creating a Simulation Model 19 – 34 The Script 35 – 39 Step 2: Choose a Lung Model 40 – 44 Step 3: Choose a Chest Wall Model 45 Step 4: Save Simulation Parameter Set 46 – 53Running a Simulation ASL Tutorial: Table of Contents

7. 7 Go to ASL Last edited: 30-Sep-10 7 Slide Number: 54 – 60Adjusting the Run Time Display 61 – 73The Interactive Control Panel 74 – 80Time-Varying Parameters 81 – 84Non-Linear Compliance 85 – 104ASL Sample Cases: 89 – 81 Apnea 92 – 95 Bagging a Patient 96 – 98 Compliance Step-Down 99 – 101 Overdistension 102 – 104 Trigger Challenge 105 – 107Troubleshooting 108 – 109Glossary of Terms ASL Tutorial: Table of Contents

8. 8 Go to ASL Last edited: 30-Sep-10 8 Synchronizing with the ASL 5000 Turn on the ASL first. Then, start up Host PC software application. It is best if the ASL 5000 is started first, in order to allow proper synchronization with the computer. Wait until the red light of the Motor Enable/Disable switch goes out (ASL has finished booting up) before starting the software. 1 2 Depress the Enable Switch if red light is still on after 20 seconds. Note:

9. 9 Go to ASL Last edited: 30-Sep-10 9 Opening the ASL 5000 software Select the application from the Windows Start menu or open the ASL 5000 executable, (the application, file with the IngMar Medical icon). from the installation folder (Windows Explorer).

10. 10 Go to ASL Last edited: 30-Sep-10 10 The Welcome screen appears and offers you several choices for operation and utility. Click on the desired mode of operation. Note: Stand-alone (demo) mode requires no access to the ASL device. Use the demo mode to create or modify scripts, review archived data or to practice with or train on the software. Opening the ASL 5000 software

11. 11 Go to ASL Last edited: 30-Sep-10 11 You may also customize graph colors (see Slide 58) or check the version of the software by clicking the About ASL 5000 key.Slide 58 Opening the ASL 5000 software

12. 12 Go to ASL Last edited: 30-Sep-10 12 The Welcome screen appears and offers you several choices for operation and utility. Click on the desired mode of operation. Note: Stand-alone (demo) mode requires no access to the ASL device. Use the demo mode to create or modify scripts, review archived data or to practice with or train on the software. Opening the ASL 5000 software

13. 13 Go to ASL Last edited: 30-Sep-10 13 Choose “Use software with ASL Simulator” and several stacked windows will open at once. Opening the ASL 5000 software Note: As the ASL 5000 software opens, it begins to search for the ASL device immediately.

14. 14 Go to ASL Last edited: 30-Sep-10 14 Notice the panel at the top of the Run Time window labeled Status. This panel tracks the progress of the synchronization between the computer and the ASL device. Opening the ASL 5000 software Note: Depending on the installation, connection may only occur specifically with one serial number.

15. 15 Go to ASL Last edited: 30-Sep-10 15 As the “Waiting for synchronization…” message appears, the iteration numbers will count upwards. Opening the ASL 5000 software

16. 16 Go to ASL Last edited: 30-Sep-10 16 At this point, if the ASL had not yet been turned on, you will see the dialog box at the right. To correct this issue, switch the green On/Off power switch on the back of the ASL to the On position. Wait until the red light of the Motor Enable Switch is off, then try again. Opening the ASL 5000 software The Emergency Stop switch needs to be in the depressed position for motor operation (red light OFF after ASL start-up). DO NOT push this button unless you are trying to stop the ASL mid-operation for some reason.

17. 17 Go to ASL Last edited: 30-Sep-10 17 Upon successful completion of the synchronization process, you will see this message in the Status panel. Opening the ASL 5000 software

18. 18 Go to ASL Last edited: 30-Sep-10 18 If your computer has successfully synchronized with the ASL device, you should hear a soft “click” from inside the ASL 5000 as the piston stops at the home position. Please go on to the next slide.the next slide If the synchronization process was not successful, consult the Troubleshooting section of this tutorial.g section of th Opening the ASL 5000 software

19. 19 Go to ASL Last edited: 30-Sep-10 19 Now, open the window that is labeled Script Editor. Click on this window to activate the Script Editor function. Creating a Simulation Model: The Script Note: If you can’t see the Script Editor window, you can use the drop-down menu at the top of the screen to navigate from one screen to another. Click on “Windows” for a listing of all available ASL 5000 screens. Alternatively, you can click on the ASL 5000 folder marked with the IngMar Medical icon that has been minimized and placed on the taskbar at the bottom of your screen.

20. 20 Go to ASL Last edited: 30-Sep-10 20 In the ASL 5000: Simulation Script Editor window - Scenario Scripts tab, double-click on one of the listed scripts, or highlight an item and click “Choose Scenario Script File”. Creating a Simulation Model: The Script

21. 21 Go to ASL Last edited: 30-Sep-10 21 Alternatively: In the ASL 5000: Simulation Script Editor window, click on the “ScriptFile” drop down menu to display its selections. Click “Open Script.” Creating a Simulation Model: The Script

22. 22 Go to ASL Last edited: 30-Sep-10 22 This will bring up a file dialog box listing all of the files with the extension.sct. in the \vars - subdirectory These are the simulation scripts that have already been created. Creating a Simulation Model: The Script

23. 23 Go to ASL Last edited: 30-Sep-10 23 Note: It is important to distinguish between a patient parameter file (.vr3) and a script file (.sct)! A script file is made up of one or more parameter files. The.vr3 files are the parameter sets for a simulation. The script shown here consists of seven different.vr3 files. The file called “..\pause.vr3” is used several times for two repetitions each. Creating a Simulation Model: The Script

24. 24 Go to ASL Last edited: 30-Sep-10 24 Note: Once you have created specific patient parameter sets (.vr3 files), you can call them up again and again to run in different combinations. Different combinations of patient parameter sets run in sequence make up the simulation scripts. For selecting and editing the patient parameter files, see slide 26slide 26 Creating a Simulation Model: The Script

25. 25 Go to ASL Last edited: 30-Sep-10 25 If this is your first time opening the software, and you have not yet created your own scripts, click on the script labeled Bag_Patient.sct.in the..\vars\examples subdirectory Creating a Simulation Model: The Script

26. 26 Go to ASL Last edited: 30-Sep-10 26 The filename and path for the script file now appear in the box in the upper part of the Script Editor window - Manual Scripting tab. The color of this box indicates whether the opened script file has been saved or not. The patient parameter files of the chosen script are listed in the window. Each.vr3 file has a number of repetitions assigned to it. Creating a Simulation Model: The Script

27. 27 Go to ASL Last edited: 30-Sep-10 The script has only been saved as a current.sct, for immediate use with the simulator, but not as a script with its ow name The script has both been saved with a unique name after changes were made, and also as a current.sct, for immediate use with the simulator 27 The background color scheme of the Script File Name box can assume five colors. A red background indicates that files listed in the script are not available under the defined name Creating a Simulation Model: The Script The script has not been saved at all after a change or when invoked for the first time The script has only been saved with a unique name after changes were made, but not as a current.sct, to be used with the simulator right away

28. 28 Go to ASL Last edited: 30-Sep-10 28 Directory Tokens are shortcuts used to label file paths. They allow easy change of path names (creating relative paths) when collections of files are moved on a PC or network. Click “Configure Token/Path” to create or edit tokens. Creating a Simulation Model: Directory Tokens

29. 29 Go to ASL Last edited: 30-Sep-10 29 Creating a Simulation Model: Directory Tokens To create a token, click “New” An Editor window will open where you can browse for a path to create the shortcut for

30. 30 Go to ASL Last edited: 30-Sep-10 30 Creating a Simulation Model: Directory Tokens The actual path can be given a meaningful token name (a configurable relative path name)

31. 31 Go to ASL Last edited: 30-Sep-10 31 Creating a Simulation Model: Directory Tokens In the Relative Path Configuration window, the token is now available to replace long, absolute pathnames. You can choose to have a single or all path names showing or to use token names (single file or for all parameter files)

32. 32 Go to ASL Last edited: 30-Sep-10 32 You can also change the number of repetitions that will run with this parameter set during your simulation. Double click on the second.var file in the default script (segment1.var). The “Select Simulation Parameter Set” dialog box will appear. From this dialog box, you can also browse for a different.vr3 file to use in your script. Creating a Simulation Model: Editing Parameter Sets

33. 33 Go to ASL Last edited: 30-Sep-10 33 To continue with editing a vr3-file, click on the “Edit” button in the lower right corner of the Select a Parameter File dialog box. Creating a Simulation Model: The Script

34. 34 Go to ASL Last edited: 30-Sep-10 34 Click on the line drawing of a lung model or pump model to choose among four options: The Lung Model A.One compartment B.Two compartments C.Flow pump D.Volume pump A B C D

35. 35 Go to ASL Last edited: 30-Sep-10 35 From the Lung Model screen, set the desired Resistance and Compliance for your “patient.” Do this either by using the up and down arrows; or by highlighting the numbers that are currently in the value boxes and by changing them to the desired values. The Lung Model

36. 36 Go to ASL Last edited: 30-Sep-10 36 (See slide 61 for instructions on setting time-varying parameters.)61 Turn Compensations on or off by clicking on the On/Off button. With Compensations on, the desired values may be entered to the right of the respective compensations. Choose between Constant and Time- Varying Parameters by clicking on the button below the Time-Varying Parameters label. The Lung Model

37. 37 Go to ASL Last edited: 30-Sep-10 37 Choose between parabolic and linear resistance. Click on the button under Independent Exp. Resistance if you wish to simulate an expiratory resistance that is different from inspiratory. The Lung Model

38. 38 Go to ASL Last edited: 30-Sep-10 38 If you are using a two- compartment model, you have the option of simulating a compliance that is non-linear. Click on the button below the “Non-Linear Compliance” label to do so. (See slide 69 for more details on creating a non- linear compliance curve.)69 The Lung Model

39. 39 Go to ASL Last edited: 30-Sep-10 39 On the Lung Model page, you can also choose the update rate for waveform sampling. Choices are from ultra- high resolution (512 Hz) to 64 Hz. Click on the “Next >” button to move to Step 3, the Chest Wall Model. The Lung Model

40. 40 Go to ASL Last edited: 30-Sep-10 40 From the Chest Wall Model screen, the respiratory profile is created, including the following parameters: The Chest Model Pressure Waveform Breath Rate (bpm) Muscle Pressure (Pmax) in cm H 2 O Expiratory, Hold, Release Time (%) Insp/Exp for real-time patient effort adaptations

41. 41 Go to ASL Last edited: 30-Sep-10 41 Click on the waveform sketch in the upper right quadrant of the screen or on the black triangles to choose a spontaneous breathing profile. You may also make the patient passive The Patient Effort Model

42. 42 Go to ASL Last edited: 30-Sep-10 42 When a spontaneous pattern is chosen, you will need to provide values for the parameters listed, i.e.: The Chest Model Spontaneous Rate (in bpm) Muscle Pressure (in cm H 2 O) Insp. Effort Rise Time (as % of the breath cycle time) Insp. Hold Time (as %) Insp. Effort Release Time (as %)

43. 43 Go to ASL Last edited: 30-Sep-10 43 In ”sinusoidal” and “trapezoidal” patterns, you can also define forced expiration (new in SW 3.1) The Chest Model Muscle Pressure (in cm H 2 O) Exp. Effort Rise Time (as % of the breath cycle time) Exp. Hold Time (as % of the breath cycle time) Exp. Effort Release Time (as % of the breath cycle time)

44. 44 Go to ASL Last edited: 30-Sep-10 44 Click on the “Next >” button to proceed to Step 4. The Chest Model

45. 45 Go to ASL Last edited: 30-Sep-10 45 Click in the filename box (Path to parameter file) to edit the name of the parameter set you have created. Click on “Browse” to navigate to another folder and/or to overwrite another file. -or- Click on “Save >” to save the parameter set with the name that is displayed in the box. Save Simulation Parameter Set

46. 46 Go to ASL Last edited: 30-Sep-10 46 Move the cursor onto the Central Run Time Display window and click to bring the window to the top. Note: If the message in the status box at the top of the Variable Parameters Run Time display is anything other than “Ready. Use Simulation switch to begin…”, please return to slide number 8 “Synchronizing with the ASL.”8 Running a Simulation

47. 47 Go to ASL Last edited: 30-Sep-10 47 Click on the Simulation switch to move from “Off” to “On.” The message in the status bar will change to “Host data path and file name selection” and a dialog box will appear. Running a Simulation

48. 48 Go to ASL Last edited: 30-Sep-10 48 The Select an Output File dialog box requires that you choose a destination file for the data to be collected during the simulation run. Running a Simulation Click “OK” if you wish to retain the filename displayed. Otherwise, click in the filename box to change the name. You may also click on the button with a folder on it to browse for an existing file that you want to overwrite.

49. 49 Go to ASL Last edited: 30-Sep-10 49 Note: You have the option of saving the simulation data either to the default data file, as shown in the dialog box, or with a filename of your choice. The default data file, as well as the filename you choose, are base file names, requiring no extensions. Data is actually saved to a set of files that together facilitate analysis of the simulation data. Running a Simulation

50. 50 Go to ASL Last edited: 30-Sep-10 50 You may, at this point, elect to save waveform data for the simulation run by checking this box Running a Simulation With this option chosen, data will be saved at a rate of 512 Hz, or lower, if desired. The waveform data sample rate is determined by the first patient file in a script only.

51. 51 Go to ASL Last edited: 30-Sep-10 51 If you wish to save some of the waveform data later, you may do so at any time via the Breath Detection/Real Time Analysis (RTA) window. Access the RTA window via the “Windows” drop- down menu or via the ASL 5000 icon on the dock at the bottom or top of your screen. Running a Simulation -or-

52. 52 Go to ASL Last edited: 30-Sep-10 52 Click in the Save Waveform Data box at the top of the screen to start saving data to high resolution waveform files. This option can be turned on and off at any time throughout the simulation run. Running a Simulation

53. 53 Go to ASL Last edited: 30-Sep-10 53 After initialization is completed, the status bar will now read “Running simulation” and the simulation will begin. You will now see waveforms moving across the screen, displaying flows, pressures and volumes. Running a Simulation

54. 54 Go to ASL Last edited: 30-Sep-10 54 Adjusting the Run Time Display To change from a waveform to loop display, click the “Display” switch in the upper right corner of the Central Run Time Display screen.

55. 55 Go to ASL Last edited: 30-Sep-10 55 Clicking on the “Freeze” switch next to the “Display” switch will allow you to freeze the waveforms display without stopping the simulation. Adjusting the Run Time Display

56. 56 Go to ASL Last edited: 30-Sep-10 56 Adjusting the Run Time Display Click on the Pause switch to suspend the simulation without losing data. Click again to start the simulation back up where it stopped.

57. 57 Go to ASL Last edited: 30-Sep-10 57 From the Help/Customize menu, you can also access he “About” window. Specifically, you can check the software version and build no. Adjusting the Run Time Display

58. 58 Go to ASL Last edited: 30-Sep-10 58 The scheme for background and line colors can be easily modified by selecting Graph Colors from the Help/Customize menu. Click in the box labeled “Bkgr. Color” or on one of the plot lines above it. Use the pop-up color palette to choose the colors you want. Adjusting the Run Time Display

59. 59 Go to ASL Last edited: 30-Sep-10 59 Click in the box labeled “Bkgr. Color” or on one of the plot lines above it. Use the pop-up color palette to choose the colors you want. Adjusting the Run Time Display

60. 60 Go to ASL Last edited: 30-Sep-10 60 Clicking on Launch Script Progress Window allows for a detailed view of the simulation in progress. The Overall Script Progress shows the current and total number of repetitions from all script elements. The Current Progress shows shows the current and total number of repetitions from the running script element. Running a Simulation

61. 61 Go to ASL Last edited: 30-Sep-10 61 Use the Interactive Control Panel (ICP) for making rapid adjustments to a simulation “on the fly,” i.e. while the simulation is running. Switch to the ICP by clicking on the button in the upper left-hand corner of the Run Time Display screen. The ICP can also be accessed via the “Windows” drop-down menu at the top of any of the ASL screens. The Interactive Control Panel

62. 62 Go to ASL Last edited: 30-Sep-10 62 The breath rate (bpm) and inspiratory tidal volume, Insp Vt (ml), are displayed in real time in the labeled windows on the left side of the screen. The next window below indicates the type of patient model running in the current simulation. In this example, a passive patient has been modeled. The Interactive Control Panel

63. 63 Go to ASL Last edited: 30-Sep-10 63 The two blue buttons below the patient model display are controls for setting up a patient model. You can choose to start with the “Default Lung Parameters.” Or click on “SETUP Lung Model” to access the existing list of simulation parameter files. Use one of these files as it is or click on the “Edit” button to modify it. (See slide 19 – “Creating a Simulation Model.”)19 The Interactive Control Panel

64. 64 Go to ASL Last edited: 30-Sep-10 64 The Interactive Control Panel In the panel to the right of the breath rate and Insp Vt windows, the filename and path to the originating parameters, (.var file), for the current simulation are displayed.

65. 65 Go to ASL Last edited: 30-Sep-10 65 The last three buttons along the left side of the ICP allow you to start the simulation, record data to a high-res. file or quit the ICP and return to the Run-Time screen. The Interactive Control Panel

66. 66 Go to ASL Last edited: 30-Sep-10 66 Click on the Lung Model Param. tab to access the controls for Resistance and Compliance. Use your mouse to click and drag the applicable knob. Alternatively, you can enter the desired value for Resistance or Compliance directly into the window below the corresponding control knob. The Interactive Control Panel

67. 67 Go to ASL Last edited: 30-Sep-10 67 The Spontaneous Breath Parameters tab provides an overview of the chest wall model parameters for the current simulation. Changes can be made to these, as well as the Inspiratory, Hold and Release times using the “click-and-drag method” to turn the control knobs. Alternatively, simply highlight and change the displayed values. The Interactive Control Panel

68. 68 Go to ASL Last edited: 30-Sep-10 68 Trends for tidal volume, Pmax and breath rate for the current simulation are displayed under the Trends tab. The Interactive Control Panel

69. 69 Go to ASL Last edited: 30-Sep-10 69 To maintain a constant volume during a simulation, click the Closed Loop Control slider to activate this feature. The Interactive Control Panel

70. 70 Go to ASL Last edited: 30-Sep-10 70 In the case of a Constant Vt setting, the patient effort limits can be titrated by clicking on the Closed Loop Vt tab and using the “click-and-drag method” to manipulate the dials. The Interactive Control Panel

71. 71 Go to ASL Last edited: 30-Sep-10 71 The Interactive Control Panel In the case of a Minute Volume Closed Loop setting, both the Pressure and Breath Rate limits can be manipulated by clicking on the Closed Loop MV tab and using the “click-and-drag method” to manipulate the dials.

72. 72 Go to ASL Last edited: 30-Sep-10 72 The Interactive Control Panel In the Closed Loop for CO2 (CO2Y) setting, both patient effort pressure and breath rate are algorithmically controlled to achieve a desired end- tidal CO2 value. Clicking on the Closed Loop CO2Y tab you can enter a value for CO2 production for the patient model and the target end-tidal CO2 level.

73. 73 Go to ASL Last edited: 30-Sep-10 73 The Interactive Control Panel From the New File tab you can specify a different patient parameter set as your starting point for making further interactive changes to the model

74. 74 Go to ASL Last edited: 30-Sep-10 74 In Step 2 of the model creation process, you have several options for more advanced modeling. One of these is the ability to vary certain respiratory model parameters over the course of the simulation. To choose this option, click on the Time-Varying Parameters switch in the Lung Model screen. The switch will go from “Constant” to “Time Varying” and an “Edit” button will appear. Time-Varying Parameters

75. 75 Go to ASL Last edited: 30-Sep-10 75 Clicking on the “Edit” button brings up the Time Varying Parameter Menu. Double-click on the parameter you wish to profile to call up the Variable Parameters Editor screen. Time-Varying Parameters

76. 76 Go to ASL Last edited: 30-Sep-10 76 The graph at the top of the screen shows a breath-by-breath plot of the parameter to be profiled. The equation for this plot, or line, is displayed in the large white field in the bottom half of the screen. Double-click on the line equation. Time-Varying Parameters

77. 77 Go to ASL Last edited: 30-Sep-10 77 Another screen appears-- the Edit Curve Segment dialog box Choose the type of line equation by clicking the down arrow under “Curve Type” on the upper left side of the screen. Insert the desired values either by replacing current values in the boxes or by using the up/down arrows. Click “OK” to return to the Variable Parameters Editor screen. Time-Varying Parameters

78. 78 Go to ASL Last edited: 30-Sep-10 78 When you are finished creating the profiles for the time-varying parameters, click “OK” in the Variable Parameters Editor to go to the Time- Varying Parameter Menu. Click “Done” in the Time- Varying Parameter Menu dialog box to return to the Lung Model screen. Time-Varying Parameters

79. 79 Go to ASL Last edited: 30-Sep-10 79 Note: If you have chosen the “Time-Varying Parameters” option in the Lung Model screen, you are required to use this type of parameters throughout the rest of the modeling process. Click on the “Next >” button in the Lung Model screen to edit the pressure profile in the Chest Wall Model (Step 3). Time-Varying Parameters

80. 80 Go to ASL Last edited: 30-Sep-10 80 Click on “Edit” beneath the grayed-out Pressure Profile graph of the Chest Wall Model window to bring up the Time-Varying Parameter Menu. From there, parameters can be edited individually as in the Lung Model stage. Time-Varying Parameters

81. 81 Go to ASL Last edited: 30-Sep-10 81 When working with two- compartment lung models, you have the option of creating a non- linear compliance model. (Please see slide number 33, “The Lung Model.”) 33 Click on “Non-Linear Compliance” in the lower right corner of the Lung Model screen. Non-Linear Compliance

82. 82 Go to ASL Last edited: 30-Sep-10 82 To edit the compliance curves, click on the “Edit C1” or “Edit C2” button. -or- Click in the white box next to “C2 = C1” to use the same compliance curve in both compartments of your lung model. Then click the “Edit C1” button. Non-Linear Compliance

83. 83 Go to ASL Last edited: 30-Sep-10 83 The Non-Linear Compliance Editor presents an interactive graph of the Volume- Pressure relationship. Click and drag the red dots to modify the Compliance. -or- Enter the desired values for the x- and y- coordinates, i.e. Pressure and Volume. Non-Linear Compliance

84. 84 Go to ASL Last edited: 30-Sep-10 84 The section between the two red horizontal lines is an area of proportional p/v response. The green line represents the alternative “Nominal Compliance” value used when switching back to linear C response. Click “OK” when finished to return to the Lung Model screen. Non-Linear Compliance

85. 85 Go to ASL Last edited: 30-Sep-10 85 ASL Sample Cases Scenario:Objectives: 1. ApneaManaging Backup Ventilation 2. Bagging a PatientTeaching Resuscitation Skills 3. Compliance Step-Down Managing Alarming Events -Low minute ventilation -High pressure 4. OverdistensionIdentifying Excessive Pressures 5. Trigger ChallengeFinding Appropriate Trigger Thresholds

86. 86 Go to ASL Last edited: 30-Sep-10 86 Review slide #8: Synchronizing the ASL 5000 Review slide #10: Demo Mode ASL Sample Cases Note: Before executing any of the Sample Cases included in this tutorial, please remember to… Make sure that the software is not in “Demo” mode Start-up and synchronize the ASL 5000

87. 87 Go to ASL Last edited: 30-Sep-10 87 ASL Sample Cases Each of the Sample Cases includes a link to an associated script file. Make sure you have the ASL program open and open the Script Editor. In the Sample Case slides, you will be asked to use particular Script files. Be sure to choose the correct file name. To return to the Tutorial from the ASL program, click on the Microsoft PowerPoint icon on the dock at the bottom of your screen. Sample Cases ASL 5000 General Instructions:

88. 88 Go to ASL Last edited: 30-Sep-10 88 Scenarios: Apnea 2. Bagging a PatientPatient 3. Compliance Step-Downnce Step-D 4. Overdistension 5. Trigger Challenge ASL Sample Cases Sample Cases ASL 5000

89. 89 Go to ASL Last edited: 30-Sep-10 89 Ventilator settings: 1. Ventilation Mode:VCV - A/C 2. PEEP:3 cmH2O 3. Breath Rate (back-up):8 bpm 4. Tidal Volume:700 mL 5. Pressure (or Flow) trigger:1 cmH2O (1 L/min) High Pressure Alarm:20 cmH2O Low Minute Vent. Alarm:7 L/min Apnea Delay Time:30 s From the Script Editor screen in your ASL 5000 program, choose the script file below and save it as “current.sct.” Sample Cases: Apnea C:\program files\ASL Software 3.2\vars\Examples\Apnea.sct Open this script from your ASL 5000 program.

90. 90 Go to ASL Last edited: 30-Sep-10 90 Review slide #46: Running a Simulation Using your choice of patient circuit, connect the ventilator to the ASL 5000 at the port on the front of the unit. Begin the simulation by clicking the “Simulation On” button in the Run Time screen. Sample Cases: Apnea

91. 91 Go to ASL Last edited: 30-Sep-10 91 Observe the following: Let the simulation run for several minutes… Sample Cases: Apnea 1.Apnea alarm sounds. 2.Low minute ventilation volume alarm sounds. 3.Back-up breath rate kicks in--8 bpm.

92. 92 Go to ASL Last edited: 30-Sep-10 92 Scenarios: Apnea 2. Bagging a PatientBagging a 3. C3. Compliance Step-DownDown 4. Overdist4. Overdistension 5. Trigger Challenge ASL Sample Cases Sample Cases ASL 5000 Please select another scenario or Return to the Table of Contents

93. 93 Go to ASL Last edited: 30-Sep-10 93 From the Script Editor screen in your ASL 5000 program, choose the script file below and save it as current.sct. Connect resuscitation bag with circuit to the vent port at the front of the ASL. (See next slide for an alternate set-up.) Sample Cases: Bagging a Patient C:\program files\ASL Software 3.2\vars\Examples\Bag_Patient.sct Open this script from your ASL 5000 program.

94. 94 Go to ASL Last edited: 30-Sep-10 94 Alternate Setup: Connect a manikin head with a functioning airway to the vent port at the front of the ASL 5000. Use your choice of resuscitation bag with mask. Sample Cases: Bagging a Patient

95. 95 Go to ASL Last edited: 30-Sep-10 95 Have students bag the patient and ask them to feel the difference in compliance as it changes throughout the simulation. Review Analysis Menu - Multi-Parameter Trend Display and evaluate consistency of delivered volumes, the presence or absence of excessive pressure peaks. Sample Cases: Bagging a Patient

96. 96 Go to ASL Last edited: 30-Sep-10 96 Scenarios: Apnea 2. Bagging a PatientPatient 3. Compliance Step-Downnce Step-D 4. Overdistension 5. Trigger Challenge ASL Sample Cases Sample Cases ASL 5000 Please select another scenario or Return to the Table of Contents

97. 97 Go to ASL Last edited: 30-Sep-10 97 From the Script Editor screen in your ASL 5000 program, choose the script file below and save it as “current.sct.” Sample Cases: Compliance Step-Down Ventilator settings: 1. Breath Rate (back-up):8 bpm 2. High Pressure Alarm:20 cm H2O 3. Low Minute Vent. Alarm:7 L/min C:\program files\ASL Software 3.2\vars\Examples\ C_Step_Down.sct Open this script from your ASL 5000 program.

98. 98 Go to ASL Last edited: 30-Sep-10 98 Observe the following: Let the simulation run for several minutes… 1.High pressure alarm sounds. 2.Minute ventilation changes very little. Sample Cases: Compliance Step- Down ??? What could cause this to happen? ??? Answer: A dislocated ET tube could leave just one lung compartment being ventilated. The ventilator will attempt to deliver the same volume into the remaining lung compartment, effectively over-inflating it.

99. 99 Go to ASL Last edited: 30-Sep-10 99 Scenarios: Apnea 2. Bagging a PatientPatient 3. Compliance Step-Downnce Step-D 4. Overdistension 5. Trigger Challenge ASL Sample Cases Sample Cases ASL 5000 Please select another scenario or Return to the Table of Contents

100. 100 Go to ASL Last edited: 30-Sep-10 100 From the Script Editor screen in your ASL5000 program, choose the script file below and save it as “current.sct.” Sample Cases: Overdistension Ventilator settings: 1. Breath Rate (back-up):8 bpm 2. Tidal Volume:varying 800- 600 3. High Pressure Alarm:50 cm H 2 O C:\program files\ASL Software 3.2\vars\Examples\ Overdistension.sct Open this script from your ASL 5000 program.

101. 101 Go to ASL Last edited: 30-Sep-10 101 Observe excessive pressure peaks. Sample Cases: Overdistension Let the simulation run for several breaths…

102. 102 Go to ASL Last edited: 30-Sep-10 102 Scenarios: Apnea 2. Bagging a PatientPatient 3. Compliance Step-Downnce Step-D 4. Overdistension 5. Trigger Challenge ASL Sample Cases Sample Cases ASL 5000 Please select another scenario or Return to the Table of Contents

103. 103 Go to ASL Last edited: 30-Sep-10 103 From the Script Editor screen in your ASL5000 program, choose the script file below and save it as “current.sct.” Sample Cases: Trigger Challenge Ventilator settings: 1. Ventilation Mode:VCV - A/C 2. PEEP:3 cm H 2 O 3. Breath Rate (back-up):8 bpm 4. Tidal Volume:700 mL 5. Pressure (or Flow) trigger:1 cm H 2 O (1 L/min) 1. High Pressure Alarm:20 cm H 2 O 2. Low Minute Vent. Alarm:7 L/min 3. Apnea Delay Time:30 s C:\program files\ASL Software 3.2\vars\Examples\ trigger_challenge.sct Open this script from your ASL 5000 program.

104. 104 Go to ASL Last edited: 30-Sep-10 104 Use the Analysis Menu’s Real Time Graph Display option to show the trigger points. Observe: 1. As Pmus decreases, at what point does the ventilator fail to trigger? ASL Sample Cases: Trigger Challenge Let the simulation run for several minutes…

105. 105 Go to ASL Last edited: 30-Sep-10 105 No communication with the simulator! Ensure that the correct Ethernet cable is connected to the RJ45 and/or a secure connection is made with the serial DB9 to the port labeled “Host”. The respective ports must also be connected and active on your PC. Is the ASL device turned on? If not, it will take approximately 20 seconds to initialize after switching on.. Troubleshooting blue cable for connection through a hub/switch (DHCP)

106. 106 Go to ASL Last edited: 30-Sep-10 106 Did you choose “Use software with ASL Simulator” in the Welcome screen? If using the connection by serial no. method (aslident.txt in installation folder), make sure that the ASL serial no. is entered that matches your hardware. Troubleshooting

107. 107 Go to ASL Last edited: 30-Sep-10 107 If you have confirmed the above four items, then try switching off the ASL device again. Close down the software by clicking on the “Exit ASL” button on the Variable Parameters Run Time screen. Troubleshooting

108. 108 Go to ASL Last edited: 30-Sep-10 108 Start up the ASL 5000 software again, then turn on the ASL device. (See slide # 10.)# 10 On slower computers, it might be helpful to turn off any virus scan programs running on the computer. If you are still unable to establish communication with the ASL 5000 device, please call IngMar Medical at: 1-800-583- 9910. Troubleshooting

109. 109 Go to ASL Last edited: 30-Sep-10 109 An array of additional information for the ASL is available online: User’s Manual Instructional videos User Forum FAQs All of these can be accessed via our website Additional Information

110. 110 Go to ASL Last edited: 30-Sep-10 110 Glossary of Terms HyperlinkHyperlinks are groups of text that are typically a different color than the balance of text on a particular slide or document. They are often underlined. When the mouse pointer is rolled over the underlined hyperlink text, the pointer converts to a hand with the index finger pointed at the text. Clicking on the text while the pointing hand is visible will advance you to some designated slide or file.

111. 111 Go to ASL Last edited: 30-Sep-10 111 Glossary of Terms Script File A Script File is a file containing various parameter sets that together form a specific simulation that you wish to run. A script file has the extension.sct. Variable File Individual parameter sets are stored in files with the extension.var (for variables up to SW 2.2.) or vr3 (for variable sets made with SW 3.n).