1. Medical Training - Ventilation Options - For internal use only

2. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 20082 Objective of Presentation This presentation on ventilation gives the reader an overview of the available pressure and volume-controlled types of ventilation.. The conventional processes, including setting options on the ventilators, are explained. The reader will also learn about the use of Non Invasive Ventilation (NIV) with MEDUMAT Transport.

3. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 20083 Contents Functions and Physiological Goals of Ventilation Ventilation Basics Terminology Assisted Ventilation Modes Controlled Ventilation Modes –Volume-controlled Ventilation –Pressure-controlled Ventilation Non-Invasive Ventilation (NIV)

4. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 20084 Oxygen or Ventilation ?

5. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 20085 Ventilation Functions Influence gas exchange Take over the work of respiration The type of ventilation describes the changing relationship between patient and ventilator: –Controlled: The device takes over the work of breathing. –Augmented/ assisted/ supported: The work of breathing is shared by the device and patient. –Spontaneous: The patient takes on the work of breathing.

6. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 20086 Physiological Goals of Ventilation Alveolar ventilation Arterial oxygenation Increase of end-inspiratory and end-expiratory lung volume Unloading respiratory musculature

7. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 20087 Clinical Goals of Ventilation Treatment of hypoxemia Treatment of respiratory acidosis Treatment of dyspnea Prevention/treatment of atelectasis Treatment of respiratory muscle fatigue Allow analgesic sedation and muscle relaxation Reduction of systemic and/or myocardial oxygen need Reduction of intracranial pressure Stabilization of thoracic wall

8. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 20088 VS CPAP CPAP/ ASBCPPV PSVSVVSPV NIV VCPCPCV ASBBIPAPIPPVSIMV BiLevel/ ASBPLV PEEP

9. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 20089 Spontaneous Breathing Inspiration: Negative pressure Expiration: Positive pressure

10. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200810 Ventilation - Terminology

11. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200811 Spontaneous Breathing vs. Ventilation Spontaneous breathing: Passive volume expansion of lungs effected by pulling of rib musculature and diaphragm Ventilation: Active volume expansion by introducing volume or ventilation pressure.

12. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200812 Ventilation Systems Terminology Assisted ventilation Controlled ventilation Volume-controlled Pressure-controlled Combinations

13. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200813 PEEP Definition: –Positive End Expiratory Pressure –In controlled ventilation PEEP corresponds to CPAP of spontaneous breathing –Advantages: Decline in atelectasis Higher volume per unit of pressure increase (predilation) –Disadvantages: Increase of maximum ventilation pressure Impairment of venous blood backflow Application: –With every type of ventilation at least PEEP 5

14. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200814 Assisted Ventilation Modes CPAP mode increases respiratory pressure level to raise the Functional Residual Capacity (FRC). This mode is used only on patients with sufficient spontaneous breathing. Assisted Spontaneous Breathing (ASB) mode provides pressure support in cases of insufficient spontaneous breathing. The patient can breathe spontaneously without restriction, but gets support for his respiratory work from MEDUMAT Transport.

15. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200815 Supporting Mode (CPAP) Continuous Positive Airway Pressure (CPAP) Supports the respiratory work of the patient Respiratory rate, pattern and tidal volume are determined by patient Respiratory work is made easier.

16. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200816 Assisted Spontaneous Breathing (ASB) Assisted spontaneous breathing Pressure support of every breath of patient Patient has to “trigger” the device Can combine CPAP, BIPAP, SIMV Spontaneous breathing CPAP / PEEP 10 cm H2O ASB 7 cm H2O

17. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200817 Controlled Ventilation Takes over all respiratory work of patient Determines tidal volume by ventilation modes of –pressure-controlled –volume controlled Assisted modes (ASB/CPAP) can be combined

18. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200818 Volume vs. Pressure-controlled Ventilation Volume-controlled modes ensure tidal and Respiratory Minute Volume (RMV) with adherence to an upper pressure limit. Pressure-controlled modes maintain maximum ventilator pressures and have a more physiological character. There is no volume guarantee, which makes monitoring of tidal volume and RMV necessary. Supporting modes combine the advantages of both systems.

19. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200819 Volume-controlled Ventilation The inspiratory gas flow is maintained until a certain volume is reached. Airway pressure is passive (danger of barotrauma). Combination with pressure limit makes sense. Initially areas with high compliance and low resistance are ventilated and then plateau pressure is reached.

20. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200820 Volume-controlled Ventilation Settings: Respiratory Minute Volume (rate x tidal volume) Limit or control dimension: maximum airway pressure Advantage: Tidal volume is maintained even when pulmonary mechanics change. Disadvantage: Danger of pressure-caused damage to lungs when pulmonary mechanics deteriorate

21. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200821 Abbreviations in Volume-controlled Ventilation IPPV: Intermittent Positive Pressure Ventilation PLV:Pressure Limited Ventilation CPPV: Continuous Positive Pressure Ventilation (with set PEEP level) VC:Volume Control SVV:Smart Volume Ventilation

22. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200822 Volume-controlled Ventilation IPPV/CPPV –Intermittent Positive Pressure Ventilation –With PEEP = CPPV : Continuous Positive Pressure Ventilation –Corresponds to completely controlled ventilation –Time-controlled, constant volume, limited pressure

23. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200823 IPPV Settings Respiratory rate: Choice between 10 to 20 /minute Tidal volume: 6 to 10 ml kg KG I:E ratio: 1:1 or 1:1,7 Oxygen concentration: FiO 2 0,3 – 1,0 Pressure limit: pMax 30 cm H 2 O PEEP: 5 cm H 2 O Inspiration segmentation (plateau)

24. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200824 Special Emergency Mode IPPV ventilation Pre-set for –Baby (10 kg) –Child (20 kg) –Adult (75 kg)

25. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200825 Special Emergency Mode

26. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200826 SIMV Synchronized Intermittent Mandatory Ventilation Patient is given a pre-set minimum number of breaths with a defined volume (see IPPV) Combination of controlled ventilation, synchronized mechanical breaths triggered by the patient, and spontaneous breathing The patient may breathe independently (see CPAP-ASB) and direct the device. Synchronized mechanical breaths are possible only within an “anticipated breath window”.

27. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200827 SIMV Settings Settings for IPPV/CPPV breaths –Tidal volume 6 to 10ml kgKG –Respiratory rate: 4 to 10 –I:E 1:1 – 1.7 PEEP/CPAP 5 cm H2O Setting for SIMV –Trigger threshold (l/min) of patient 3 l/min Oxygen concentration: FiO 2 0.3 – 1,0 Pressure limit: pMax 30 cm H 2 O

28. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200828 SVV Smart Volume Ventilation Weinmann‘s special mode of volume-controlled ventilation All pressure-controlled ventilation modes can be set

29. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200829 Pressure-controlled Ventilation Application of gas flow until a pre-set airway pressure is reached. The pressure is maintained for a certain amount of time and then reduced again during expiration. Tidal volume results from the ventilation pressure and the mechanical characteristics of the lungs. Tidal volume and gas flow are dependent on the mechanical characteristics of the lungs. Initially high and then decreased flow = decelerated flow

30. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200830 Pressure-controlled Ventilation Settings: Airway pressure, respiratory rate Limit or control dimension: Tidal or respiratory minute volume Advantage: The optimum pressure range can be set individually for each lung. The lung is protected and ventilator-induced lung damage can be avoided. Disadvantage: When respiratory mechanics deteriorate, tidal volume decreases and with it the ventilation. Tidal volume has to be measured at end-expiratory point when pressure-controlled or non- volume constant ventilation is used.

31. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200831 Abbreviations in Pressure-controlled Ventilation Modes PCV: Pressure Control Ventilation allows no spontaneous breathing by patient. BIPAP: Biphasic Positive Airway Pressure ® BiLevel:Combination of timed change of two pressure levels SPV: Smart Pressure Ventilation Weinmann-specific platform for set up of pressure- controlled ventilation mode.

32. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200832 SPV Smart Pressure Ventilation Weinmann’s special mode of pressure-controlled ventilation All pressure-controlled ventilation modes can be set up CPAP/ASB can be used only at the lower pressure level

33. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200833 Bi-level Ventilation Biphasic Positive Airway Pressure = ventilation with two pressure levels (also known as BI-level Positive Airway Pressure) Pressure and time-controlled ventilation mode Volume is not constant ! State-of-the-art ventilation mode in Intensive Care Unit (ICU)

34. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200834 Bi-level Mode of Operation: –Combination of CPAP and pressure-controlled ventilation –Two (2) different pressure levels –Spontaneous breathing at both levels is allowed at any time during ventilation –ASB support is possible

35. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200835 Bi-Level: Settings Rate calculation: –60 sec. / targeted rate –e.g., 10 rate = 6-second respiratory cycle Respiratory cycle: –Set I:E via time selection –e.g.: T1(Inspiration) 2 seconds / T2 (Expiration) 4 seconds Pressure level –P1(high pressure/ inspiration) –P2 (CPAP/PEEP/low pressure / expiration)

36. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200836 Combinations and Special Modes ASB: Assisted Spontaneous Breathing BiLevel ASB:Each breath of the patient triggers a gas flow which leads to the set inspiratory pressure level. CPAP: Continuous Positive Airway Pressure CPAP/ ASB Spontaneous breathing mode, maintains positive pressure in airways during the entire spontaneous breathing cycle + assisted spontaneous breathing

37. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200837 Ventilation Parameters Rate P insp Pressure PEEP Delta ASB Tidal volume Ratio Inspiration:Expiration I:E Minute volume Ramp FiO2 P max Trigger

38. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200838 Non-Invasive Ventilation (NIV) For Non invasive Ventilation the patient is given a mask which, depending on type, covers the nose and mouth or the entire face or goes on the patient‘s head like a helmet. Basically all the ventilation modes used in invasive ventilation (via tube or tracheostoma) can be used in non-invasive ventilation.

39. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200839 Advantages of NIV Avoidance of intubation Airways remain intact Reduction in ventilator-induced pneumonia Relaxation/sedation not required: –Ø gastrointestinal atony –Ø weaning symptom Patient can communicate Increase in mobility Intermittent treatment as needed Maintenance of glottal closure function

40. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200840 Indications and Contraindications of NIV Indications: -Neuromuscular diseases (ALS, polio) -Mechanical disorders (kyphoskoliosis, etc.) -COPD -Pulmonary edema -Pneumonia -Weaning -ARDS Contraindications: –Coma or amentia –Severe cooperation problems –Acute life-threatening hypoxia –Cardiac arrest –Hemodynamic instability –Increased risk of aspiration Swallowing disorders, ileus, GI bleeding, abdominal surgery (?) –Obstruction in upper airways –Secretion retention

41. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200841 NIV Operational Principle -Unloading of respiratory pump -Increase in intrathoracic pressure -counteracts a pathological collapse of the alveolar sector -Reduction in development of atelectasis and ventilation disorders -Increase to FRC -Decline in pulmonary shunt volume -Improvement of pulmonary oxygen transfer -Improvement in oxygenation

42. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200842 X Assessment of NIV in Clinical Use Criteria for success –Improvement in alveolar ventilation (PaCO 2 falls) –Improvement in pulmonary gas exchange (SaO 2 rises) –Unloading of respiratory pump –Decrease in cardiac rate –Decrease in respiratory rate –Reduces agitation, angst –Reduction in dyspnea Cancellation criteria –Hypercapnia during NIV –Hypoxemia with SaO 2 < 85% –Acidosis (pH < 7,2) –Rise in respiratory rate Dyspnea –Loss of consciousness –Circulatory instability –Increasing agitation, angst

43. © WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 200843 Summary Every existent respiratory activity of the patient should be utilized ! The device should adjust to the patient – the patient should not adjust to the device ! Pressure and volume-controlled modes offer the best selection options and adaptation to patient needs. Ventilation setup is one task; the monitoring of respiratory parameters is the second.