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1.1 Anatomy Of Respiratory System………………………….……….5
1.1.1 Function Of Respiratory System………………………….……….………..5 1.1.2 Components Of Respiratory System……………………………..…………5
1.2 Physiology Of the Respiratory System…………………………….7 1.2.1 Gas Exchange…………………………………………….…..…7 1.2.2 Pulmonary Ventilation………………………………….….…...9 1.2.3 Breathing Cycle……………………………………….……...…9 1.2.4 Change In Volume Of Thoracic Space To The Lungs……..….11 1.2.5 Difference Between Spontaneous and Artificial Respiratory….12
1.3 Respiratory Failure………………………………………………..13
2. RESPIRATORY MECHANICS VALUES
2.1 Static Lung Volume……………………………………………….17 2.2 Lung Resistance…………………………………………………...19 2.2.1 Alterations of Resistance during respiratory cycle……………20 2.3 Lung Compliance………………………………………………….21 2.3.1 Static Compliance………………………………….………….22 2.3.2 Dynamic Compliance……………………………………...….23 2.3.3 Effective Compliance……………………………………...….23
3. MECHANICAL VENTILATOR
3.1 Mechanical Ventilator Definition………………………………...24 3.2 Mechanical Ventilator Classification……………………………..25 3.3 Pressure , Volume , Flow And Time Diagram…………………...27 3.3.1 Pressure – Time Diagram……………………………………....27 3.3.2 Volume – Time Diagram……………………………………….27 3.3.3 Flow – Time Diagram……………………………………….…28 3.3.4 Pressure – Volume Diagram…………………………………...28 3.4 Ventilator Mode …………………….……………….…………….29 3.4.1 Spontaneous…………………………………………………....31 3.4.2 Positive End Expiratory Pressure (PEEP)………….…………..31 3.4.3 Continuous Positive Airway Pressure (CPAP)………….……..34 3.4.4 Different Between PEEP and CPAP ………………………..…36 3.4.5 Controlled Mechanical Ventilation (CMV)……………………36 3.4.6 Synchronized Intermittent Mandatory Ventilation (SIMV)……38 3.4.7 Different Between CMV and SIMV……………………………41
4. THEORY OF OPERATION
4.1 Ventilator Block Diagram…………………………………………42 4.1.1 Gas Supply System……………………………………………..42 4.1.2 Microprocessor Electronic…………………………………...…44 4.1.3 Keyboard display panel………………………………………...44 4.1.4 Patient Service System (Patient Circuit)……………………….44 4.1.5 Pneumatic System………………………….………………….45
4.2 Pneumatic Block Diagram………………………………………..46
5. APPLICATION - DRAEGER-EVITA4
5.1 Introduction………………………………………………………48 5.2 Basic principle…………………………………………………….48 5.3 Block Diagram…………………………………………………….49 5.3.1 Electronics System…………………………………………...50 5.3.2 Pneumatics System…………………………………………..52
126.96.36.199 Gas Connection Block……………………………………………....54 188.8.131.52 Parallel mixer or mixer block…………………………………….55 184.108.40.206 Pressure sensor …………………………………………………....56 220.127.116.11 PEEP/PIP valve……………………………………………………57 18.104.22.168 Inspiration block…………………………………………………...58 22.214.171.124 patient system………………………………………………………59 126.96.36.199 Air supply…………………………………………………………..59 188.8.131.52 O2 supply…………………………………………………………...60 184.108.40.206 Inspiration………………………………………………………….61 220.127.116.11 Expiration…………………………………………………………62 18.104.22.168 Neubilizer…………………………………………………………62
6. TYPES AND PROBLEMS VENTILATORS
6.1 Intensive care ventilator………………………………………...64 6.1.1 purpose………………………………………………………64 6.1.2 problems……………………………………………………..64
6.2 Portable ventilator………………………………………….65
6.2.1 purpose……………………………………………………...65 6.2.2 problems ……………………………………………………66
6.3 Transport ventilator………………………………………..66
2 Positive-pressure ventilation……………………………………….67 7.2.1 History of Ventilator…………………………………………68 7.1 Absolute…………………………………………………………….22.214.171.124.2 Independent lung ventilation (ILV)……………………….. HISTORY AND DEVELOVMENT PFVENTILATOR 7.3 Applictions………………………………………………….2.69 7.1.2 Chest Cuirass /Chest Shell………………………….2 Development Of Ventilator……………………………….69 7.1.1 Negative-pressure ventilation………………………………..1.88 REFERENCES ………………………………………………..2.2.2..2.3.66 6.1 Iron Lung………………………………………………..69 7.69 7.74 7.3 State of the art………………………………………………………75 7.4 Emerging…………………………………………………………….2.5 visoniary…………………………………………………………….84 7.79 7.78 7..1.2.71 7..3..3..2.89 -4- .3..1 High Frequency Ventilation (HFV)……………………….2 problems…………………………………………………….2.75 7..1 purpose……………………………………………………..
which plays an important role in other biological systems. the process of bringing one in and excreting the other is called gas exchange . Trachea is lined with fine hairs called cilia which filter air before it reaches the lungs. After full expansion the brain command to inhale ceases and the thoracic cage passively returns to its resting position. Trachea: Tube from pharynx to bronchi rings windpipe of cartilage provide structure. lead to trachea. at the same time allowing the lungs to return to their resting size. if breathing stops. With each expansion of the lungs we inhale a breath of fresh air containing 21% oxygen and almost no carbon dioxide.1 Anatomy of Respiratory System 1. -5- . carbon dioxide will quickly accumulate to a toxic level in the blood.1. 1. containing about 16% oxygen and 6% carbon dioxide. where vocal chords are located. Oxygen is necessary for normal metabolism. 1. the brain stem sends nerve impulses that tell the diaphragms and thoracic cage muscles to contract. Carbon dioxide is a waste product of metabolism. Contraction of these muscles expands the rib cage. keeps the windpipe open .1. moistens and filter air. and effortless. the organs that exchange O2 and CO2 with the atmosphere are vital since their total failure is quickly fatal.1 Function of Respiratory System The function of the respiratory system is rather simple in concept: to bring in oxygen from the atmosphere and get rid of carbon dioxide from the blood.2 Components of Respiratory System Nose /Nasal Cavity: Warms. As the lungs return to their resting position we exhale a breath of stale air.1. In health this breathing cycle is silent. INTRODUCTION In this chapter will talk about general information in respirator system . Thus our lungs. We will talk about anatomy. automatic. Larynx: The voice box. Approximately 10 12 times a minute. Since oxygen (O2) and carbon dioxide (CO2)are gases. lack of it leads to death in a few minutes. Pharynx “throat”: Passageway for air. physiology and associated disease of this system. leading to the expansion of the lungs contained within.
and pleural membranes.Bronchi: 2 branches at the end of trachea. and all the nerves that lead into these muscles. Figure1. each lead to lung. The chest bellows component of the respiratory system includes the bony thoracic cage that contains the lungs. Alveoli: The functional respiratory units in the lung where gases O2 & CO2 are exchange enter and exit the blood stream. the muscles and connective tissues that tie the ribs together. The thoracic or chest cage consist of the ribs that protect the lungs from injury.1 anatomy of respiratory system -6- . Intercostals muscles: Thin sheets of muscle between each rib that expand when air inhaled and contract when air is exhaled . which air the major muscles of breathing. separate the chest cavity from the abdominal cavity. Diaphragm: The main muscle used for breathing. thin tissues that line both the outside of the lungs and the inside of the thoracic cage. the diaphragms. Bronchioles: Network of smaller branches leading from the bronchi into the lung tissue and ultimately to air sacs. .
or frequency. trachea. 1.03%). The nitrogen is inert and does not take part in gas exchange. It is then exhaled back through the same airways to the atmosphere. we inhale is delivered to tiny sacs (alveoli) which are the terminal or end units of the airways. a volume of air is inhaled through the airways (mouth and/or nose. the carbon dioxide humans and animals exhale is a negligible part of the entire atmosphere. pharynx. To accomplish gas exchange the air. Biologic oxidation (combustion) of nutrients by means of oxygen (O2) to carbon dioxide (CO2) and water (H2O) is referred to as internal respiration. larynx. external respiration includes ventilation and gas exchange.2 Physiology of the Respiratory System Respiration is defined as the gas exchange between the organism and its surroundings.2. There is almost no CO2 in air (about 0. and bronchial tree) into millions of tiny gas exchange sacs (the alveoli) deep within the lungs.Anatomy of respiratory system 1. At rest the body of a healthy adult utilizes about 300 ml/min oxygen and simultaneously produces about 250 ml/min carbon dioxide. During breathing.1 Gas Exchange The atmosphere contains approximately 21% oxygen and 78% nitrogen. of about 12 breaths a minute (breaths/min) when we are at -7- . There it mixes with the carbon dioxide-rich gas coming from the blood. Normally this cyclic pattern repeats at a breathing rate.
rest (a higher resting rate for infants and children).2 gas exchange through alveoli One of the major factors determining whether breathing is producing enough gas exchange to keep a person alive is the 'ventilation' the breathing is producing. Gas exchange is the function of the lungs that is required to supply oxygen to the blood for distribution to the cells of the body. times the breathing rate (e. 0. It does not take place in the airways (conducting airways) that carry the gas from the atmosphere to these terminal regions. The breathing rate increases when we exercise or become excited. Figure1. It can be calculated by multiplying the volume of gas. either inhaled or exhaled during a breath (called the tidal volume). or leaving.5 Liters x 12 breaths/min = 6 L/min). The size (volume) of these conducting airways is called the anatomical "dead space" because it does not participate directly in gas exchange between the gas space in the lungs and the blood. and to remove carbon dioxide from the blood that the blood has collected from the cells of the body. -8- .g. Gas exchange in the lungs occurs only in the smallest airways and the alveoli as (figure 1.2). Gas is exchanged between the pulmonary gas space and the blood by a process called "diffusion".. Gas is carried through the conducting airways by a process called "convection". the lungs in a given amount of time. Ventilation is expressed as the volume of gas entering.
the spine. Each alveolus is surrounded by blood capillaries. if we were to develop a machine to help a person breathe.2. it would have to be able to produce a tidal volume and a breathing rate which. • The physical basis of the mechanics of respiration is the Boyle-Mariotte Law of the Gases : P x V = constant 1. • Contraction of the diaphragm pulls it down. to supply the gas exchange needs of the body.3 Breathing Cycle • Breathing cycle consist of 2 phases : inspiration and expiration. The processes of alveolar ventilation (bringing air into the lungs for transfer of oxygen and carbon dioxide). These bronchi end in clusters of air sacs the (alveoli). and a breathing rate that assures the correct amount of ventilation is produced. Air enters through the (mouth or nose) and then travels down the (larynx and trachea).2 Pulmonary Ventilation • Describes the procedure of inspiration and expiration and thus the inflow and outflow of the gases we breathe between the alveolus and the atmosphere. The volume of the thoracic cage increases and the pressure in the alveoli becomes negative -9- .Therefore. the ribs and the sternum. 1. This overview can be expanded by dividing gas exchange into: 1. causing it to flatten. Pulmonary circulation (bringing blood to the lungs to take up oxygen and excrete carbon dioxide). During normal breathing the body selects a combination of a tidal volume that is large enough to clear the dead space and add fresh gas to the alveoli. but not too much ventilation. produce enough ventilation. or to take over his or her breathing altogether. which take up the oxygen and give off carbon dioxide. Air then enters the (lungs).2. 2. • The diaphragm is a dome-shaped muscular plate consisting of a central beanshaped tendon that is attached to the thoracic cage. when multiplied together. which consist of multiple branching airways called (bronchi).
• During normal quiet breathing this change in volume represents two thirds of one breath. A pressure gradient toward the alveoli arises.10 .1.3 and 1. There also is an equilibrium between the forces within the lung and in the thoracic wall .4). Only in case of deep (maximal) and/or accelerated exhalation (Fig. causing inspiration. During inspiration the elastic retraction forces (elastance) of the lungs must be overcome. The volume in the lung at this time is being called functional residual capacity(FRC).with respect to atmospheric pressure. which work in the opposite direction.3 Ventilation of the lungs • After normal quiet expiration the retraction forces of the expanded lung equal those of the thoracic wall. to be released again when the inspiratory muscles relax. Fig. . 1. The remainder is produced by contraction of the external intercostals muscles that function as inspiratory muscles by lifting the ribs. • Expiration can thus take place as a passive procedure requiring support by the muscles of expiration.
The only connection is a very thin liquid layer between the two pleural membranes. 1.2. During inspiration the difference increases as breaths get larger and may reach -40 mbar. . In forced expiration the intrapleural pressure can reach positive values of up to +40 mbar. This liquid layer prevents the two pleural membranes from being separated from one another. Conversely.• The driving force for gas exchange between the alveoli and their surroundings. 1. that is for pulmonary ventilation. adhere closely to the inner walls of the chest cavity. During inspiration the pressure within the alveoli must be lower than the atmospheric pressure of the surrounding air. are the different pressures between the alveoli at inspiration and expiration. the intrapleural pressure. whereas expiration will result in positive values (Fig.4 Energy sources for inspiration and expiration and alveolar pressure changes 1. which are completely surrounded by pleura. the opposite pressure gradient must exist during expiration. The pressure between both pleural membranes.4). is lower than atmospheric pressure during normal quiet breathing varying from -4 to -8 mbr.4 Change in volume of thoracic space to the lungs The lungs. the values of inspiration pressure will be negative.11 . Fig. If the atmospheric pressure is assumed to be zero.
giving rise to air flow in direction of the alveoli.2. This promotes venous blood flow to the heart. .5) reducing the venous return.1. that a positive end expiratory pressure is applied (PEEP).5 Difference Between Spontaneous and Artificial Respiratory Pulmonary ventilation occurs both in spontaneous or artificial respiration. A negative pressure gradient arises in the pulmonary alveoli with respect to atmospheric pressure.12 . The functional residual capacity is increased and in the case of reduced compliance may be brought back to normal. In spontaneous breathing. In both cases ventilation of the alveoli results from cyclical changes in intrathoracic pressure. inspiration is primarily elicited by expansion of the chest. • The maximal midexpiratory flow rate can be altered in such a way. Due to the positive pressure the intrapleural pressure as well as the intrathorcic pressure rise at the end of inspiration (Fig1. Artificial respiration usually involves applying positive pressure to the airways. • Both in spontaneous breathing as well as artificial respiration expiration is almost entirely a passive process elicited by the elastic recoil of the lung and chest. This also gives rise to a pressure gradient towards the alveoli. During inspiration the intrapleural as well as the intrathoracic pressure are negative.
5 Pressure-time-diagram in spontaneous and artificial respiration 1.3 Respiratory Failure Definition and Clinical Signs Respiratory failure is a state in which the pulmonary oxygen uptake is so severely disturbed that O2-supply to and the CO2-elimination from the tissues are inadequate.13 . confusion tachycardia. Metabolism at rest including the O2-demand arising from the work of breathing can no longer be met.Fig1. hypertension possibly cyanosis . Respiratory failure can usually be recognised clinically: Clinical symptoms of impending respiratory failure: Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ tachypnea (respiratory rate > 35/ min CARDINAL SYMPTOM!) dyspnea paradoxical breathing agitation.
Table 1 summarizes the causes of parenchymal lung failure. The indication for respiratory support is therefore based on two pathophysiological mechanisms: 1. The cardinal symptom of acute respiratory failure is a drop of the PaO2 below 6.7 kPa during spontaneous breathing of room air in combination with tachypnea > 35/ min. Overview of the different causes of parenchymal lung failure Causes of parenchymal lung failure All disorders of the alveolo-capillary membrane Ÿ Ÿ Ÿ Ÿ Ÿ pulmonary edema ARDS pneumonia atelectasis pulmonary fibrosis . The hallmark of pulmonary parenchymal failure is inadequate oxygenation.Ÿ blood gas analysis Only blood gas analysis allows precise evaluation of the extent and type of respiratory failure.0 kPa). Table 2 gives an overview of the different causes of pulmonary ventilatory failure. Ÿ Ÿ Pulmonary ventilatory failure is characterized by insufficient elimination of CO2. Inadequate oxygenation Reduced CO2-elimination There are two types of acute respiratory failure: Pulmonary ventilator failure with reduced alveolar ventilation and reduced CO2elimination (PaCO2) and pulmonary parenchymal failure with reduced oxygenation (PaO2) and an increased alveolarterial oxygen difference (A-aDO2).14 . Hypoventilation is defined as inadequate clearance of CO2 a phenomenon that can only be confirmed by arterial blood gas analysis (arterial hypercapnia PaCO2 > 6. PaO2 and PaCO2 are essential parameters for initiation and administration of ventilator support. 2. Table 1.
Overview of the different causes of pulmonary ventilatory failure Causes of ventilatory failure 1. Guillain-Barre-syndrome.g. whereas postoperative respiratory failure is usually caused by mechanical factors. Causes of postoperative respiratory failure Ÿ Reduced lung volume due to elevated diaphragm abdominal distension (intestinal paralysis.Table 2. botulism) polyneuritis (e. intoxication) Cervical or thoracic spinal cord injury (e. tetanus) Peripheral causes a) Ÿ Ÿ Ÿ b) Ÿ Ÿ Ÿ Ÿ peripheral neuromuscular causes: neuromuscular transmission defect (e.g.15 . traumatic paralysis. The most important causes of postoperative respiratory failure are listed in Table 3.. Ÿ Ÿ 2. infectious) muscular weakness after long term mechanical respiration Disorders of breathing mechanics: obstructive and restrictive ventilation disorders injury of the chest wall (e. myasthenia gravis.. after effects of muscle relaxants. ileus) atelectasis retention of secretions pulmonary oedema . multiple rib fractures after thoracic trauma kyphoscoliosis rupture and/ or herniation of the diaphragm Pathomechanics of Postoperative and Posttraumatic Respiratory Failure The main difference between both of the types of respiratory failure lies in the fact that posttraumatic respiratory failure often involves acute lung failure with activation of endogenous cascades and mediator systems. cranio-cerebral trauma.g. Central causes Respiratory centre dysfunction (e. Table 3.g. toxic.g.
g. peripheral neuropathies. large diaphragmatic hernia) • Chronic Obstructive Pulmonary Disease (e. hypothyroidism. neonatal RDS. ARDS.g. chronic bronchitis. airway mucosal edema) Altered Ventilatory Drive (e. bronchiectasis. polio militias. congestive heart failure. pneumonia). intracranial • Cardiopulmonary Problems (e. in neonates: hyper compliant rib cage [prematurely]. malnutrition.g. rheumatoid spondylitis.g.g.g.pleural effusion pneumothorax Ÿ Reduced movement of the diaphragm and chest wall due to pain central suppression abdominal distension Ÿ Impediment of coughing pain central suppression (e. hemorrhage) dyspnea-related anxiety.g. severe obesity. emphysema. sedation!) abdominal distension tenacious bronchial secretions Diseases: • • Acute Obstructive Disease (e.g. cystic fibrosis) • • Chronic Restrictive Pulmonary Disease (e. apnea of prematurity. massive pulmonary hemorrhage) • Chest Wall Deformities (e.. in neonates: persistent bradycardia. pulmonary fibrosis) Neuromuscular Disease (e. Guillain-Barre syndrome. asthma. hyaline membrane disease. .. infections) • Atelectatic Disease (e. idiopathic central alveolar hypoventilation. cancer... kyphoscoliosis..g. amyotrophic lateral sclerosis. acute severe asthma.16 .. Duchene muscular dystrophy...
Inspiratory Reserve Volume (IRV): the volume that can be inhaled further after quiet inhalation. Normal value: 3 to 3. It results from the balance between the opposite elastic forces exerted by the lungs and chest.Functional Residual Capacity (FRC): the volume left in the lungs at the end of quiet expiration.5 L about 1/3 of the VC.5 L. that is the difference between normal and maximal expiration. 2. 4.17 . that can be further exhaled after quiet expiration. that is. RESPIRATORY MECHANICS VALUES 2. 1.Residual Volume (RV): the volume remaining after maximal expiration in the lungs.1): The normal values refer to an adult weighing about 70 kg. FRC = RV + ERV • The FRC is by definition the gas volume remaining in the lungs during quiet breathing. It can be considered a measure for the gas exchange area.Tidal Volume (VT): the volume inhaled and exhaled during quiet breathing. • The FRC falls by 20% within a few minutes after initiation of anaesthesia. Normal value: about 1. Normal value: about 0. the difference between normal and maximal ventilation.1 Static Lung Volume The following static lung volumes are differentiated from one another (Fig 2.6 L.Expiratory Reserve Volume (ERV): the volume. Normal value: about 2.5 L 0.5 L about 2/3 of the VC.2.5 to 2 L. Normal value: about 1. 3. 5. .
TLC = VC + RV Fig. 2.1: Static lung volumes . 6. restrictive ventilation disorders to a decreased FRC. Normal value: approximately 6 L. It is calculated from the sum of the VC and RV. Normal value: 3.18 .• Obstructive ventilation disorders lead to an increased FRC. Total Lung Capacity (TLC): Maximal air capacity of the lung. It is therefore a measure for the largest possible breathing excursion.5 5. Vital Capacity (VC): the volume difference between maximum inspiration and maximum expiration.5 L 7.
2 Obstructive ventilation disorder Resistance is measured in mbar/l/sec. both the anatomical as well as the physiological features of the respiratory organs cause considerably higher airflow resistance: Normal values: Newborn Infants Small children Adults 30 20 50 mbar/l/sec 30 mbar/l/sec 20 mbar/l/sec 2 4 mbar/l/sec . 2. It is defined by the pressure difference between the beginning and end of a tube and the flow of gas volume per time unit.2.2). 6 In intubated patients with healthy lungs the inspiratory resistance lies between 4 mbar/l/sec.19 . In the case of the pulmonary airways it would be the difference between atmospheric pressure at the mouth minus the alveolar pressure (Fig2. R = ∆p/V In healthy adults normal values of airway resistance lie between 2 4 mbar/l/sec.2 Lung Resistance Resistance (R) is a measure of airway resistance (airflow resistance). Fig. In children.
the flow resistance increases (Fig. Fig 2. Palv = Pple + Pelast . 2. Even during forced expiration an increase of intrapleural pressure to more than +40 mbar can cause dynamic compression of the small airways. That is also why expiration always plays a larger role in obstructive ventilation disorders than does inspiration.20 .1 Alterations of Resistance during respiratory cycle During inspiration elongation of the elastic pulmonary fibers increases the elastic retraction pressure. The bronchioles are stretched by the stronger radial pull. 2.2.3 Bronchial lumen variation with phase of respiration These cyclical changes of flow resistance explain why the expiratory phase is always slightly longer than the inspiratory phase. This results in extreme narrowing or even closure of the bronchioli and occurs when the intrapleural pressure is considerably larger than the intraluminal pressure (Fig. The alveolar pressure (Palv) is the sum of the intrapleural pressure (Pple) and the elastic recoil pressure (elastance) of the lungs (Pelast). bronchial flow resistance falls.3). With expiration the elastic recoil decreases. the bronchioles become narrower.4).Determination of an effective resistance: Resistance effective =(maximum pressure-plateau pressure)/ flow.2.Accordingly expiration becomes prolonged and more difficult and expiratory stenosis sounds such as wheezing or ronchi can be auscultaled over the lungs.
5 .5 Model of lung compliance .Fig. 2. 2.4 Dynamic airway compression 2.6). By definition it is the relationship of the volume change in the lungs for each unit change in intra-alveolar pressure (Fig. Fig.3 Lung Compliance Compliance (C) is a measure of the expansibility of the lungs and describes the elastic features of the breathing apparatus.21 . 2. 2.
6 Model of lung compliance under artificial ventilation Vml p mbar C= If additional volume is pressed into an elastic body such as a ballon.22 . which usually can only be reached by deep sedation or relaxation.1 Static Compliance For clinical needs the static compliance can be calculated as follows: expiratory tidal volume (ml) Plateau pressure . that has a certain volume and is under a certain pressure. The volume change involves complete filling of the lungs from the beginning to the end of a taken breath. 2. The larger the compliance the less the pressure increases at a certain filling volume. the volume changes by the value ∆V and the pressure increases by the value ∆p.PEEP (mbar) Cstat = The Cstat lies between 50 and 70 ml/mbar in the intubated patient without lung disease A further requirement for correct measurement of the static compliance is a completely relaxed respiratory musculature. that is a complete lack of muscular activity. .3.Fig 2.
23 . 2.2 Dynamic Compliance As artificial respiration methods without a plateau phase do not fulfil a static state. 1 c total 1 c lung 1 c thorax Total Compliance : = + Normal values: Newborn: Infants: Small children Adults 3 10 20 70 5 ml/mbar 20 ml/mbar 40 ml/mbar 100 ml/mbar The compliance of the lungs depends on the elasticity of the pulmonary fiber structure. namely Flow = 0. the chest expands simultaneously.3 Effective Compliance If the pressure and volume are not measured close to the endotracheal tube for technical reasons. expiratory tidal volume (ml) peak pressure . . as it measures resistive components in addition to the elastic forces. The compliance of the lung is 200 ml/mbar in the healthy adult.3.3. only the dynamic compliance Cdyn can be calculated. but rather far away from the patient within the ventilator. The chest and the lungs represent two elastic systems connected in parallel. the compliance of the chest equaling that. The total compliance consists of the compliance of the lungs and that of the chest. the intrapulmonary fluid content and the surfactant activity.2.PEEP (mbar) Cdyn = Cdyn is of very little clinical use. As the lungs fill. the so-called effective compliance is determined instead of the static compliance.
The act of moving air into and out of the lungs is called breathing.3. The rate pattern and duration of gas flow control the interplay between volume and pressure. Gas exchange occurs in both phases. Ventilator "cycling" refers to the mechanism by which the phase of the breath switches from inspiration to expiration. rate and duration of flow are determined by the operator. the gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2). more formally. volume cycled or flow cycled. Oxygen and air are received from cylinders or wall outlets. The magnitude. a desired tidal volume is delivered at a specific flow (peak flow) rate. In "controlled ventilation" a number of mandatory breaths are delivered to the patient at a predetermined interval. Flow is controlled by an array of sensors and microprocessor is passive (although modern ventilators has active exhalation valves). In pressure controlled modes. The pattern of flow may be either sinusoidal (which is normal).24 . flow occurs until a preset peak pressure is met over a specified inspiratory period. 3. accumulated in a receptacle within the machine. using constant decelerating or sinusoidal flow.1 Mechanical Ventilator Definition A mechanical ventilator is a machine that generates a controlled flow of gas into a patient's airways. or pressure limited and volume variable. Inhalation serves to replenish alveolar gas. while increasing intrathoracic pressure and reducing time available for CO2 removal. There are two phases in the respiratory cycle. decelerating or constant. the flow pattern is always decelerating. . In volume controlled modes. and delivered to the patient using one of many available modes of ventilation. Prolonging the duration of the higher volume cycle enhances oxygen uptake. or. Mechanical Ventilator A ventilator is an automatic mechanical device designed to provide all or part of the work the body must produce to move gas into and out of the lungs. The central premise of positive pressure ventilation is that gas flows along a pressure gradient between the upper airway and the alveoli. high lung volume and lower lung volume (inhalation and exhalation). Flow is either volume targeted and pressure variable. Modes of ventilation are time cycled. ventilation. Time cycling refers to the application of a set "controlled" breath rate.
3. ratio is an indication of the portioning of a breath into inspiration & expiration Both a controlled rate and inspiratory time/ expiratory time ratio (I/E) are accomplished by four basic procedures. In this fashion rate is controlled directly. it controls the time it will take to deliver a certain volume. Control: How the ventilator knows how much flow to deliver a) b) c) Volume controlled (volume limited. rate can be controlled either by adjusting a transmission-type gearing mechanism or by changing motor speed. First. Pressure Controlled (pressure limited. the shorter the inspiratory time will be.E. Flow and tidal volume controls can be used to control inspiratory time. Dual Controlled (volume targeted pressure limited). expiratory timer.2 Classification of Mechanical Ventilator The classification of ventilators refers to the following elements 1. Fourth. inspiratory time and expiratory time can be controlled separately to acquire rate and desired I/E ratio. pressure targeted) and Volume Variable.25 . and the I/E ratio is fixed at a certain value such as 1:1 or 1:2. . tidal volume and flow controls can be used to establish inspiratory as just described. In essence.Controlling rate and I/E ratio I. volume targeted) and Pressure Variable. with the rate set on a rate control I/E can be controlled by altering the inspiratory time component of the ventilator's cycle. Decreasing the tidal volume or increasing gas flow will decrease inspiratory time and decrease the I/E ratio. the higher the flow is at a set volume. Third. rate can be acquired from the adjustment of the two (inspiratory and expiratory) time. Flow and volume are the important ingredients in controlling inspiratory time . and a timer can be used to control expiratory time. This technique can be accomplished with a inspiratory and an Inspiratory time can also be controlled directly with a timer or flow transducer that can control flow to maintain a set I/E ratio.because flow is volume per unit of time. Second.
2. accelerating. pause is added. a) b) Sinusoidal = this is the flow pattern seen in spontaneous breathing and CPAP. c) Flow: modern ventilators deliver a constant flow around the circuit throughout the respiratory cycle. synchronized intermittent mandatory ventilation. Most intensives and respiratory therapists use this pattern in volume targeted ventilation also. is monitored by the ventilator and it delivers a breath. a) b) Time: the ventilator cycles at a set frequency as determined by the controlled rate. decelerating or sinusoidal. Breaths are either: what causes the ventilator to cycle from inspiration. Cycling: how the ventilator switches from inspiration to expiration: the flow has been delivered to the volume or pressure target a) b) c) Time cycled Flow cycled how long does it stay there? such in pressure controlled ventilation such as in pressure support the ventilator cycles to expiration once a set tidal volume has If an inspiratory Volume cycled been delivered: this occurs in volume controlled ventilation.26 . 4. Pressure: the ventilator senses the patient's inspiratory effort by way of a decrease in the baseline pressure. Ventilators may be time triggered. Spontaneous (no additional assistance in inspiration). Assisted (as in assist control. Decelerating = the flow pattern seen in pressure targeted ventilation: inspiration slows down as alveolar pressure increases (there is a high initial flow). pressure triggered or flow triggered. 3. A deflection in this flow by patient inspiration. Triggering: what causes the ventilator to cycle to inspiration. Flow pattern: constant. pressure support). c) 5. . and better distribution characteristics. This mechanism requires less work by the patient than pressure triggering. c) Constant = flow continues at a constant rate until the set tidal volume is delivered. as it results in a lower peak airway pressure than constant and accelerating flow. a) b) Mandatory (controlled) which is determined by the respiratory rate. then the breath is both volume and time cycled.
3.3. Volume.2 Volume-Time diagram .1 Pressure–Time Diagram Figure 3. Mode or Breath Pattern: there are only a few different modes of ventilation: We will discuss it later in section 3.d) Accelerating = flow increases progressively as the breath is delivered. 6. Flow and Time Diagrams 3.4 (ventilator mode). This should not be used in clinical practice.2 Volume – Time Diagram Figure 3.3.3 Pressure.1 Pressure-Time diagram 3.27 .
3 Flow-Time Diagram 3.) is too low end expiratory closure of the small airways (airway closure) and collapse of the distal alveoli will occur.3. Alveolar opening pressure = pressure necessary to open collapsed alveoli (recruitment) The alveolar opening pressure is always higher than the alveolar closing pressure. 2.3 Flow-Time Diagram Figure 3. Middle steep (linear) portion of the curve: In this portion of the curve the least breathing work is necessary. They are thus also referred to as the relaxation curve of the lung. The compliance thus varies with the lung volume. The curve can be divide into 3 parts: 1. A decrease or an increase of the functional residual capacity from 2 or 5 litres respectively . that is the pressure at which the alveoli collapse. Flat lower portion of the curve: If the end expiratory lung volume (L vendexp. The curve takes a characteristic S-shaped course. It is highest in the area of the normal functional residual capacity (about 3 litres). During every inspiration the so-called alveolar opening pressure must be applied to that these collapsed lung areas can open. the maximal steepness gives rise to the maximal static compliance.4 describes the so-called static compliance of the lung and chest.4 Pressure – Volume Diagram The pressure-volume-diagram in Fig.28 .3. 3.3.
increase in volume. . In clinical practice the ventilation parameters should be set such that the endinspiratory and end expiratory volumes lie in the linear part of the pressurevolume-curve. Flat upper portion of the curve: This part of the curve shows the maximal alveolar elasticity. As a set of operating characteristics that control how the ventilator functions. This means that the application of the same volumes of air requires twice the difference in pressure. An operating mode can be described by the way ventilator is triggered into inspiration and cycled into exhalation. Figure 3. The force required for breathing is much less in the steep portion of the pressurevolume-diagram than outside both of the inflection points .lowers the compliance by half.4 Pressure-volume diagram 3. The lower inflection point lies in the area of the closing volume. Further increase in pressure does not lead to any further Overextension of the alveolar septa involve a loss of elasticity. There is danger of structural damage to the alveoli and decrease in perfusion due to capillary compression.29 .4 Ventilator Modes A ventilator mode can be defined: 1. 3. Both bending points of the curve are referred to as inflection points .
3. some of the these modes represent a stage that will be developed to generate another mode. Spontaneous. Pressure Support Ventilation (MMV). Spontaneous. Intermittent Mandatory Ventilation (IMV). Bi-level Positive Airway Pressure (BIPAP). There are 13 essential ventilator modes available in different ventilators. 12. 10.30 . two or more of these modes are often used together to achieve certain desired effect. Positive End-Expiratory(PEEP) . and whether or not the mode allows only mandatory breaths. What variables are limited during inspiration. 5. 2. 1. 11. which are: 1.Control of various alarms. 8. spontaneous breaths.Control of the F1O2 (F1O2 is the oxygen fraction). 13. Mandatory Minute Ventilation (MMV). Continuous Positive Airway Pressure (CPAP). Pressure Control Ventilation (PCV). 2. 7. We will concentrate mainly on only five modes which are the most important in ventilation and are common on all ventilator equipments. It is convenient here to refer that not all these operating modes are used to aid patient. 6. These functions include: 1. 3. 4. Inverse Ration Ventilation (IRV). Airway Pressure Release Ventilation (APRV). 2. Positive End-Expiratory Pressure (PEEP). Assist Control (AC). or both? Many different functions are commonly available on modern ventilators regardless of the mode.2. 9. Synchronized Intermittent Mandatory Ventilation (SIMV).Control of the inspiratory flow rate. Controlled Mandatory Ventilation (CMV).
The useful effect of PEEP is exhaust at about 15 cm H2O.4. The effect begins at PEEP levels of cm H2O. The term PEEP is usually used only in context with mechanical ventilation. The level of PEEP can be pre-set in the ventilator. 5. 15 20 . It is often used to improve the patient's oxygenation status.1 Spontaneous mode Essential where the patient control breathing.3. Controlled Mandatory Ventilation (CMV). The alveolar tissue cannot be stretched further by higher pressure so there is a danger of "over distension" and alveolar rupture. Patient can breath normally but he has a problem with gas exchange.2 Positive End-Expiratory Pressure (PEEP) Positive end-expiratory pressure (PEEP) increases the end-expiratory or baseline airway pressure to a value greater than atmospheric.4. 3. Continuous Positive Airway Pressure (CPAP). especially in hypoxemia that is refractory to increasing FIO2. Synchronized Intermittent Mandatory Ventilation (SIMV). 4. At pressure exceeding 15 cm H2O the alveolar diameter does not increase with increasing PEEP levels. Breathing rate (Br) and Tidal Volume (TV) are controlled by the patient. The machine supply O2 and air and take away CO2 at rate which determined. It is very simple mode and available in every types of ventilators. figure 3.5 Spontaneous Mode 3. In practice PEEP levels between 5 and 15 cm H2O are generally used. Spontaneous ventilation with continuously increased positive airway pressure is referred to as CPAP (continuous positive airway pressure).31 . Barotrauma may be the result.
Decreased functional residual capacity (FRC) and lung compliance.32 .6 PEEP mode Indications for PEEP Two major indications for PEEP are: 1. Intrapulmonary shunt and refractory hypoxemia. This condition may be caused by a reduction of the functional residual capacity (FRC). Intrapulmonary Shunt and Refractory Hypoxemia The primary indication for PEEP is refractory hypoxemia induced by intrapulmonary shunting.figure 3. 2. A helpful . To moderate to high levels of oxygen. atelectasis. Refractory hypoxemia is defined as hypoxemia that responds poorly. 1. or low Ventilation to Perfusion (V/Q) mismatch.
clinical guideline for refractory hypoxemia is when the patient's PaO2 is 60 mm Hg or less at an FIO2 of 50% or more. 2. Decreased FRC and Lung Compliance A severely diminished FRC and reduced lung compliance greatly increase the alveolar opening pressure. If the patient is breathing spontaneously, a decreased lung compliance always increases the work of breathing and if severe enough can lead to fatigue of the respiratory muscles and ventilatory failure. Since PEEP increases the FRC, this pulmonary impairment may be prevented or improved by early application of PEEP therapy. Advantage of PEEP PEEP produces an increase in PaO2 by Ÿ Ÿ Ÿ Ÿ Ÿ increasing the functional residual capacity (FRC) (increasing the gas-exchange area) reopening atelectatic lung areas ("alveolar recruitment") reducing the right-to-left shunt avoiding end-expiratory alveolar collapse improving the ventilation/ perfusion ration
PEEP opens up the alveoli and keeps those alveoli open. Side-Effect 1. 2. 3. 3. Decreased venous return and cardiac output. Barotrauma. Increased intracranial pressure, and ICP increases due to impedance of venous return. Alterations of renal functions and water "metabolism".
When ventilating with PEEP considerations must be given to venous return ↓ cardiac output ↓ blood pressure ↓ organ perfusion ↓
PEEP should therefore only be reduced when there is adequate pulmonary gas exchange at an FIO2 < 0.5. Abrupt termination of PEEP therapy can result in pleural effusions.
3.4.3 Continuous Positive Airway Pressure (CPAP)
By this we mean spontaneous breathing with a continuous positive respiratory tract pressure in all phases of the respiratory cycle. The patient breathes spontaneously with an increased level of respiratory tract pressure (Figure 3.7)
Figure 3.7 Continuous Positive Airway Pressure(CPAP)
CPAP can be applied with an endotracheal tube or via a tight fitting face or nose mask. CPAP breathing requires the patient to be awake and co-operative, to have adequate spontaneous breathing, i.e. sufficient pulmonary pumping function.
CPAP improves gas exchanges, particularly in lung diseases.
The combination of intra-operative ventilation with PEEP and post-operative CPAP therapy has proved particularly successful in the prophylaxis of atelectasis.
CPAP is now part of every ventilator.
Advantage of CPAP Ÿ Improved oxygenation (rise in PaO2) through increasing the functional residual capacity.
↓ PaO2 ↓ FRC Ÿ with CPAP the breathing effort is reduced, because the inspiratory gas flow makes breathing in easier Ÿ Reduced likelihood of small airway collapse because of the continuous positive respiratory tract pressure Ÿ Ÿ Ÿ Re-opening of atelectatic areas of the lung ("alveolar recruitment") Reduction of the intra-pulmonary right-left shunt Improvement of the ventilation/ perfusion ration
Indications Ÿ Post-traumatic (lung contusion) and post-operative (atelectasis particularly after upper abdominal surgery) gas exchange disturbances Ÿ Ÿ Ÿ Ÿ Pulmonary oedema Pneumonias Weaning from mechanical ventilation RDS-Syndrome of new-borns Failure to oxygenate is caused by reduced diffusing capacity and ventilation perfusion mismatch. This can often be overcome by restoring FRC by increasing baseline airway
pressure using CPAP. If the problem is atelectasis due, for example, to mucus plugging or diaphragmatic splinting following abdominal surgery, or moderated amounts of pulmonary edema, CPAP, as delivered by facemask or endotracheal tube, may sufficiently restore pulmonary mechanics to avoid addition inspiratory support. CPAP is easy to apply: all that is required is a PEEP valve and a flow generator.
Side-Effects Are similar to PEEP ventilation because of the increased intra-thoracic pressure.
3.4.4 Different between PEEP & CPAP
1. PEEP mode is not stand alone in ventilator machine. It comes as assistance mode in big and complex ventilators. 2. PEEP is a part of the CPAP. CPAP = PEEP + spontaneous breath. 3- A. PEEP indicates: a) b) Intra pulmonary shut and refractory hypoxemia. Decrease lung compliance and functional residual capacity.
B. CPAP indicates: 1) 2) 3) 4) 5) Post-traumatic and post-operative Pulmonary odema. Pneumonias Weaning RDS-syndrome of new born.
3.4.5 Controlled Mandatory Ventilation (CMV)
In this mode, it introduce automatically and independently from any possibly existent spontaneous breathing, that is no synchronization. It is a control mode. Why? Because the ventilator controls both respiratory rate and tidal volume and triggered breaths are allowed. This mode is used when the patient in operation room or after operation when he still unconscious, because all his muscles are in hebted (do not work). It used for paralyzed or apneic patient.
This figure shows the controlled mandatory ventilation wave:
Figure 3.8 CMV mode
If PEEP = O, the type of ventilation is called IPPV (intermittent positive pressure ventilation). (figure 3.9)
PEEP is grater than O, the type of ventilation is called CPPV (CPPV =
continuous positive pressure ventilation). (figure 3.10)
Figure3.9 CPAP without PEEP(IPPV)
38 . with modern ventilators the ventilatory pattern of the mandatory breath can also be varied via the adjustable variable VT. whereby IPPV frequency and I/E ratio determine the duration of the mandatory breath The expectation window is 5 . IPPV frequency. Apart from the number of mandatory breaths. inspiratory flow and I/E ratio. a finely adjusted trigger mechanisms (variable flow trigger) ensures that. This minimum minute volume is determined by setting tidal volume and IMV frequency. within a trigger window. the mandatory breath can be activated by the patient and is therefore synchronous with spontaneous breathing.4.6 Synchronized Intermittent Mandatory Ventilation (SIMV) SIMV ventilation is a mixture between spontaneous breathing and mechanical ventilation. In order to prevent the mechanical breath being applied in the expiratory spontaneous breathing phase. Minimum minute volume = VT x f lMV SIMV differs from IMV because mandatory breaths are synchronized with the breathing of the patient. seconds long.3. The mechanical breath is therefore triggered when the patient initiates an inspiratory effort after the end of the spontaneous breathing phase and within the expectation window. The mandatory breaths ensure a certain minimum ventilation of the patient.
the other factor responsible for the minimum ventilation.Figure 3.11 SIMV mode The SIMV breaths can be volume SIMV pressure-Controlled). because. through is reduced average ventilation pressure. the ventilator reduces the following mandatory breath by reducing the time for the inspiratory flow phase and the inspiration time. the spontaneous . An increase in the frequency of SIMV is therefore avoided. until the required minute volume is achieved by spontaneous breathing. Because synchronization of the mandatory breath shortens the effective SIMV time and would therefore undesirably increase the effective IMV frequency. The other factor (apart from VT) responsible for the minimum ventilation. If the patient has inhaled a significantly larger volume at the beginning of the trigger window. modern ventilators increase the following spontaneous breathing time by the missing time difference T. remains constant. Furthermore. SIMV has proved successful for weaning patients after long periods of mechanical ventilation. During spontaneous breathing the patient can be pressure supported with ASB (SIMV + Pressure Support). SIMV can also be used for long-term ventilation. During weaning. the tidal volume. Thus. or pressure-controlled (SIMV Volume-Controlled. the SIMV frequency of the ventilator is gradually reduced. it causes less stress on the circulation.39 . and therefore the break times are prolonged. VT. F IMA remains constant.
With spontaneously breathing patients. no spontaneous inspiratory effort exists while the synchronization window is active. the ventilator automatically becomes sensitive to any spontaneous effort. If the SIMV rate is set above the patient's own respiratory rate. the result is complete mechanical ventilation or CMV. so that there is less risk of ventilator dependency than with controlled ventilation. If the patient makes a spontaneous inspiratory effort when the synchronization window is active. an appropriate mandatory tidal volume and a minimum mechanical ventilation rate must be selected.5 second is representative. If the synchronization window is 0. negating the benefit of SIMV. i. . the ventilator is patient triggered to deliver an assisted mandatory breath. the ventilator would be expected to time trigger every 6 seconds. given an SIMV mandatory rate of 10 breaths per minute. Patient triggering may be based either on pressure or flow. If however. the inspiratory time is used to establish the timing of the breath. If the SIMV rate is set at a high rate. The objective of SIMV is to provide a measure of ventilation back-up while permitting spontaneous breathing to continue. Unlike volume control ventilation. which lowers the PaCO2 below the patient resting PaCO2. 0. the synchronization window becomes active. the patient's spontaneous rate must be considered. * It trains the lung to go back to its original action. When selecting the ventilator rate.e. apnea will result. If implemented as SIMV (volume mode). the I:E ratios will be altered as the patient's respiratory rate and rhythm change. so that minimum ventilation is ensured. then at 5. the ventilator will time trigger when the full time triggering interval elapses.breathing rhythm of the patient remains largely intact. This determines the minimum minute volume that the ventilator will provide. Although the exact time interval of the synchronization window is slightly different from manufacturer to manufacturer..40 . In SIMV.5 seconds from the beginning of the previous mandatory breath. Synchronization Window The time interval just prior to time triggering in which the ventilator is responsive to the patient's spontaneous inspiratory effort is commonly referred to as the "synchronization window".5 second. and that the ventilator offers mechanical breaths with a very low safety frequency. For example. The basic idea of SIMV is that the patient breathes largely spontaneously. setting an I:E ratio is not required. How to Initiate SIMV The use of SIMV is very similar to CMV.
. the ventilator will assist a patient's own breath when that breath falls within the synchronization window as specified by the operator. On the other hand. If a patient's breath happens to coincide with the mechanical ventilation. the ventilator initiates a time-cycled ventilation.7 Different between CMV & SIMV The most significant difference between CMV and SIMV is in the ability of SIMV to both sense and respond rapidly to a patient's own breathing efforts. In conventional CMV.3. Because of the synchronization provided in SIMV mode. historically employed as volume control ventilation. requiring additional intervention. when the mechanical ventilation interrupts a patient's own exhalation. Synchronising the patient's efforts with those of the ventilator provides a clinically significant advantage. irrespective of any patient-initiated breath. the impact may be minimal. This may also occur as the patient attempts to terminate a mechanical ventilation.4.41 . These synchronised ventilations overcome difficulties experienced when patients attempt to compete with CMV mode ventilations. Either condition may produce unacceptable ventilation. SIMV allows the ventilator to sense a patient's own breathing and permit spontaneous breathing between mechanical ventilations while ensuring sufficient mandatory breaths should the patient's own rate fall below a preset value. This combination can maintain a more appropriate minimum minute ventilation. the resulting abrupt and unexpected rise in airway pressure may produce conditions where the patient 'fights' the ventilator.
Gas supply to ventilators can utilise cylinders or pipeline gas supply. and . and the Ventilator • • 1.1.42 .1 Gas Supply System Tow gas supplies one providing O2 and other providing air gas supply system (compressor may be used as alternate air source). operator and machine. This figure shows relationship between patient.1 Functional Relationship of the operator. 5.1 Ventilator Block Diagram Fig. 3. Gas cylinders and pipeline have to be colour coded to avoid confusion. 4. THEORY OF OPERATION 4.4. Patient. 4. 4. 2. Almost the ventilator consist of: Gas Supply System: Microprocessor Electronic Keyboard display panel Patient Service System Pneumatic System. The German DIN Standard prescribes for: • • • Oxygen: blue Nitrous oxide: grey Pressurised air: yellow.
9 1/min with 100% O2 ( No AirMix ).g.51 Cylinder pressure: 200 bar (1 bar = 10 5 Pa) ⇒ available oxygen reserve: 2.5 bar. which can only be opened with special couplings.5 litre cylinders used in emergency medicine contain 500 L oxygen at 200 bar. which cannot be turned off . these connectors are gas specific. the O2 supply will last 50 minutes. If the pressure in the oxygen pipeline drops below a value specified by the manufacturer. an O2 gas deficiency alarm sounds.5 x 200 = 500 litres With the following equation one can easily calculate. the supply duration is increased to about 100 minutes. the reseve in litres can be calculated using the Boyle-Mariotte gas law (volume x pressure = const. The equation allows for the gas demand of the transport ventilator. Because oxygen in cylinders exists in gas form. Regulating valves reduce the gas pressure to 4 bar. To avoid confusion. . 1. e. Duration = V x P : (MV + 1) The 2. how long a patient can be ventilated with an O2 cylinder. If the transport ventilator is switched over to the Air-Mix (60% oxygen) mode. Gases from cylinders are under high pressure: maximum 147 bar for oxygen.) by multiplying the volume of the cylinder with the pressure shown at the pressure gauge . In the UK • • • • Oxygen: white Nitrous oxide: blue Pressurised air: black Vacuum: yellow The supply points of central gas supplies are secured with check valves. If the patient is ventilated with a volume of. Boyle-Mariotte gas law: volume x pressure = constant Example: Cylinder volume: 2.• Vacuum: white labelling.43 . for example. The pressures at the supply points of central gas supplies are also at 4 bar.
The microprocessor. volume. 5.1. 2.3 Keyboard display panel • It is used to operation of pneumatic system. 4.4. rate are stored by microprocessor and can be retrieved at any time.2 Microprocessor Electronic: • • It is controlls and monitors the pneumatic system. 6. 4. Patient data such as breath type. keyboard display panel. The major components of the ventilator s microprocessor electronics are: 1.1.1. and memory as well as from pressure switches and temperature/flow sensors in the pneumatic system. 3. monitor patient and ventilator performance and signal operator with alarm. rate and I. Keyboard control Display control Conversion circuitry Interface circuitry The microprocessor receives information from keyboard.E.4 Patient Service System (Patient Circuit): It is mixed the gases to and from the patient . Information sent to the displays indicates ventilator status and patient data. 4. utility panel. The signals sent to the pneumatic system to control gas flow and pressure delivered to the patient. Memory.44 . pressure. DC power supply.
for transporting the from the pneumatic system to the patient and back to the ventilator.Patient service circuit. because exhalation compartment components are the last elements in the pneumatic system. 2.Filters in its inspiratory and expiratory limbs that confine bacterial. 3. and exhalation flow circuit. for adding medications to the gas. 4.Humidifier circuit. for warming and humidifying the inspiratory gases. An important element of the pneumatic . 5.Nebulizer circuit. under control of the microprocessor in the electrical system. that prevents retrograde gas flow and an exhalation valve that seals the system during inspiration.A check valve. 4.45 .2 patient circuit The patient service system consists of the: 1. The internal exhalation valve is housed in the exhalation compartment. supplies air and oxygen to the patient.fig4.1. for monitoring and calculating the volume of exhaled gas.5 Pneumatic System The pneumatic system. The primary pneumatics system consists of two parallel circuits one for oxygen and one for air.
water traps.2 Pneumatic Block Diagram The following pneumatic is general block and common for many ventilators We will discuss it in details in section 5 . a nebulizer. which precisely control the flow delivered to the patient. this patient system may be composed to tubing. the ventilator is able to supply air and oxygen to a patient according to requirements pre-selected by an operator at the ventilator keyboard.system is the two proportional solenoid valves (PSOLS). The output of mixed air and oxygen passes through a patient system external to the ventilator. filters. As a result.46 . and a humidifier 4. Air and oxygen flow sensors provide feedback. which is used by the microprocessor to control the PSOLS.
It is EVITA 4 ventilator. we will discuss in detail one of the most used ventilator in most Ministry Of Health hospitals in Kingdom of Saudi Arabia. This ventilator is the state of the art equipment from draeger company. constant-volume long-term ventilator for adults and children. The features and ventilation modes depend on the specific device and its optional features.48 .1 (fast serial interface). Improved monitoring functions. Pneumatics 1. First ventilator to have tube compensation. they are described in the instructions for use of the specific device. EVITA 4 has the following characteristic : § § § § Evita 4 First touch screen ventilator on the market. 1.2 Basic principle The Evita 4 consists of three components which communicate via a CAN as figure5.5. APPLICATION . Control Unit . Ventilator for all applications. The Evita 4 is a time-cycled.1 Introduction In this chapter. Control unit 2. 5. Electronics 3.DRAEGER-EVITA4 5.
In the pneumatics the Pneumatics Controller PCB. It includes an independent microprocessor system and the valve control. Paediatric Flow. It includes the CPU 68332 PCB. pneumatics. the HPSV Controller AIR/O2 PCB. the flow sensor and the O2 sensor are accommodated. Electronics The electronics is the central control unit of the Evita. Pneumatics The pneumatics controls the pneumatic valves following preset ventilation parameters. Figure5. to display measured values and to generate alarms. Control unit. 5. and the optional SpO2 PCB). 3. touch screen and Graphics Controller PCB are accommodated.3 Block Diagram This figure shows the block diagram of EVITA4 which consist of three systems: 1. 2. the pressure connection. 2. IFCO PCB. the CO2 Carrier PCB with the Processor Board PCB and Power Supply PCB and the power Pack (Communication PCB. The control unit serves to make adjustments.The control unit is the interface between the device and the operator. the PEER valve. In the control unit the display.49 .2 1 Keys 13 Supply voltages . 3. Electronics. the mixer. membrane keypad.
EEPROm The EEPROM is connected to the synchronized. serial number. 2. three internal interfaces. The EEPROm characterizes the Evita (enabled options.50 .1 Electronics System The CPU 68332 PCB is integrated in the electronic unit of the Evita.2 Rotary knob including acknowledgement (by pressing knob) Touchscreen TFT display 640 x 480 14 Power switch 3 4 15 16 Second inspiratory Paw Reset pneumatics processor and venting Electronics processor reset and second loudspeaker alarm Inspiratory Paw O2 sensor FiO2 (HPSV mixer) AIR (HPSV mixer) Flow sensor Expiratory valve with PEEP 5 Information LEDs and Alarm LEDs 17 6 7 8 9 10 11 CAN bus Graphics processor reset Not applicable Loudspeaker with sound chip Second loudspeaker (piezo) Voltage monitoring (activates reset of the processors and the piezo) Rechargeable battery (Goldcap capacitor) 18 19 20 21 22 23 12 24 Expiratory Paw 5. 1. the loudspeaker control and a serial EEPROM. two external interfaces. serial interface 68832.3. etc). The board includes an independent processor system. When replacing the CPU 68332 PCB the EEPROM has to be transferred to the new printed circuit board. Processor System .
This filler plug prevents confusion with the RS232 interface.51 . 7. DUART The DUART (Dual Universal Asynchronous Receiver / Transmitter) has two serial interfaces and digital inputs and outputs. The ILV interface is not electrically isolated. It has a battery back-up and continues to operate even after the Evita has been switched off. 4. a 512 kBytes RAM and a 1 Mbyte flash EPROM (electrically programmable and erasable read-only memory). The input voltage of the DC/DC converter is +5 V. The control unit. Bus Driver . 8. CAN The CAN interface is a fast. Pin 3 of the ILV interface is provided with a filler plug. RS232 interface The CPU 68332 PCB provides an RS232 interface in the Evita.The processor system comprises a 68332 CPU. DC/DC converter The DC/DC converter provides the voltage supply (+5 V ISO) required for the interface. Clock The clock gives the current time. serial interface (Controller Area Network). 10. The interface is elecrtrically isolated from the Evita. Driver The driver adjusts the access times between the 68332. 3. Electrical isolation is made by means of optocouplers. 9. When the battery is being replaced a Goldcap capacitor ensures voltages voltage supply of the RAMs. The transmission rate is 800 kbit/s. ILV interface The ILV interface is required for independent-lung ventilation with two Evita units. The serial interfaces are intended for connection of the SpO2 and the CO2 module. Programming of the flash EPROMS is only possible if the system identified the SERVICE-Q signal. The interface is labeled COM1. 5. 6. The RAM has a battery back-up. the clock and the DUART. the electronics and the pneumatics communicate via a CAN interface.
3. Sound generator The sound genrator controls the loudspeaker in the control unit. A reset is also triggered if there is an undervoltage or overvoltage of the +5 Vvoltage. The sound generator incorporates the vlume control and sound generation for the loundspeaker.2 Pneumatics System Compressed air(AIR) and compressed oxygen(O2) must be available at a supply pressure of 2.The address bus.The pneumatics can also reset the CPU 68332 PCB. Reset logic The CPU 68332 can reset the control unit and the pneumatics. 12. Currently. figure5. The volume is controlled by the DUART.52 . The reset logic controls and displays the resets. the data bus and the check-back signals are transferred by the bus driver to the motherboard. The pneumatics consist of the following components: . The 68332 CPU communicates with the optional printed circuit boards located on the motherboard via the bus driver. 11.3 5.7 to 6 bar to drive the machine. it is only the Pediatric Flow PCB (Neoflow option).
1 Filter Y5. Patient system Figure 5.3 Y4.1.4 pneumatic diagram AIR O2 Compressed air connection Compressed oxygen connection Y3.1 Y3.1 Emergency air valve Inspiratory valve PEEP/PIP valve Expiratory valve F1. PEEP/PIP valve 5.53 . Pressure sensors 4. Gas connection block 2.1 . Parallel mixer or mixer block 3. Inspiration Block 6.
2 S6.2 R1.08 L/min/2 bar Restrictor 9 L/min/2 bar Restrictor 0.2 HPSV AIR (high-pressure servo-valve) parallel mixer HPSV O2 (high-pressure servo-valve) parallel mixer 5.3 D5. 3/2-way solenoid valve.1 Y6.2 D3.4 3/2-way solenoid valve.1 and F1.1 S6.3. exp.1 R1.2 (metal fiber web).F1.1 AIR pressure sensor (HPSV) O2 pressure sensor (HPSV) Inspiratory pressure sensor Expiratory pressure sensor O2 Sensor Flow sensor Restrictor 0.3 Y1. nebulizer Y2.1 S2.2 3/2-way solenoid valve.1 D3. venting 3/2-way solenoid valve.2 Y1.1 S5.2 O2 pressure regulator R4.1 D1.4 bar Restrictor 3.1 Y1. O2/AIR 3/2-way solenoid valve calibration O2 sensor 3/2-way solenoid valve. § The connections are fitted with filters F1.2 Filter Filter Y6.1 Y1.1 AIR pressure regulator DR1. .2 F3. D1.1 Y2.1 Non-return valve Non-return valve Non-return valve Non-return valve Ý 10 mbar Non-return valve Ý 100 mbar Non-return valve S2.2 S3.3) 0.54 .5 L/min/2 bar DR1.1 Gas Connection Block § The gas connection block comprises the O2 gas connection and the compressed air connection.2.2 D3.25 L/min/1.4 L/min/2 bar Restrictor (hole in the diaphragm in Y3.1 R1.3 R3. insp.
if appropriately adjusted. to the PEEP/PIP valve Y4. the machine will switch over to O2 supply.1 and DR1. Partial flows of less than 5L/min are pulsed at a constant flow of 5 L/min.1 to the 3/2-way valve Y1.7bar to6 bar in the parallel mixer the two gases are mixed in accordance with the set parameters. § The pressure regulators DR1.5 Gas connection diagram 5.3. § Gas flows to the nebulizer via the 3/2-way valve Y1.1 and finally to the emergency valve Y3.2.2 (O2) prevent the gas from flowing back into the central gas supply system.2 (purge flow) via the restrictor R1. The parallel mixer supplies the inspiratory gas to the patient. Fig. Switchover function . § In the event of AIR supply failure. electrically controllable proportional valve for gas flows between 5 and 180 L/min at supply pressures of 3 to 6 bar.1 (AIR) and D1.1.1. .1 (0.3. § The gas also flows to the expiratory prsessure sensor S6. from there to the emergency valve Y1.4. The control gas flows past the DR1.55 .2 are set to 2 bar.5.§ The diodes or check valves D1.2 Parallel mixer or mixer block The parallel mixer is a fast. The supply gases compressed air (AIR) and oxygen (O2) available at the parallel mixer have a supply pressure of 2.08 L/min).
1 for the inspiratory side and S6.Displacement sensor system.3.6 mixer block a) Mixer connection block.56 . leak flow compensation. 2. .2 for the expiratory side.3 Pressure sensor The Pressure sensor mount comprises the airway pressure sensors S6. S6.2. The two cartridge valves are mounted to the mixer connection block. The respiratory gas available at the outlet of the cartridge valves is mixed in the mixer connection block and supplied to the inspiratory unit. The inspiratory gases in the mixer connection block are supplied to the respective cartridge valve.The parallel mixer consist of the following components: a) Mixer connection block. trigger pressure. b) 2 cartridge valves with displacement sensor system for compressed air (AIR)and oxygen(O2). The cartridge valve or HPS valve (HPS= high-pressure servo valve) supplies a defined amount of gas to the patient in accordance with the preset adjustment parameters for inspiration.1 monitors the inspiratory Paw high and Paw low. c) 2 supply pressure sensors measuring the inlet pressure of the supply gases. figure 5. c) 2 supply pressure sensors measuring the inlet pressure of the supply gases 1.Supply pressure sensor. Measuring range :140mbar. 5. b) Cartridge valves with displacement sensor system for compressed air (AIR) and oxygen (O2).
1 controls the expiratory valve Y5. 500 mA to 120 mbar. The software compares the preset and measured airway pressures. The values are set via the ventilation settings.57 . Pneumatic Controller PCB.1.1 supplies the patient system with control gas.3.3 and the restrictor R4.1 in the patient system via a servo-line.7 Pressure sensor 5. The PEEP/PIP valve is calibrated to the electronics. These setting are a processed by a computer program and the coil is driven by an appropriate current. A coil drives the PEEP valve Y4. 0. The solenoid valve Y1.Sensitivity: 36. The PEEP valve opens and adjusts a pressure proportional to the adjusted electric current 0 mA will correspond to 1 mbar. The calibration data are stored on the .74V 0.04V Figure 5. The valve Y4.2.4 PEEP/PIP valve The PEEP valve Y4. This comparison is a measure of the Pneumatic Controller PCB s control action on the PEEP/PIP valve.5mV/mbar Offset voltage:1.3mV/mbar.1 consists of a diaphragm valve acting as a flow-control device and the linear drive whose plunger closes the diaphragm valve.
The patient can breath spontaneously via filter F3.1. The emergency valve Y3. The inspiration block is provided with the plug-in connection for the oxygen sensor.5 Inspiration Block The safety valve D3.3 limits the pressure in the inspiratory line to 100 mbar max.Figure5.1 and the emergency air valve Y3. The spring-loaded check valve D126.96.36.199 PEEP/PIP valve diagram 5. the patient can breath spontaneously via filterF3.1 .1.check valve D3. In the case of emergency air spontaneous breathing the patient can expire through the expiratory valve Y5.2 limits the medicament nebulizer flow to 9 L/min. In the event of a gas or power supply failure.1 on account of the spring loading (5 mbar) thus preventing rebreathing. In the event of compressed air failure or power failure the pneumatically controlled emergency air valve Y3.1 will open so that the patient can breathe ambient air passing the filter F3. The restrictor R1.1 will in this case no longer be controlled.1 opens.1.2 allows pressure to drop if valve Y3. The check valve D3.1 prevents rebreathing of the air through the inspiratory line.58 .
2 connecting line on the patient side. The expiratory flow is measured with flow sensor S5.1 and from there depending on the setting to the expiratory valve Y5.5.3 to the emergency air valve Y3.1). at the same time. 5.2 to the mixer and flow control unit (pressure sensor S2. Finally. Fig.6 Patient System The expiratory gas flows from the patient directly to the expiratory valve Y5. At this point.1.9: Inspiration Block diagram 5.1. AIR passes the restrictor R1. The copper measuring line at the 8a connection has a germicidal effect and connects the expiratory side to the pressure sensor S6.59 . expiratory humidity is prevented from reaching the pressure sensor S6.1 via the check valve D1.3.1 which closes. 1:1 The check valve D5.1 via the pressure regulator DR1.1 and HPSV Y2.2.1 to reach the PEEP/PIP valve Y4.1.10 Patient system diagram The ratio between the control pressure at th 7a connection of the PEEP/PIP valve and the resulting pressure at the expirartory port is linear of the following values. . AIR flows to the 3/2-way solenoid valve Y1. From here the gas flows through the 3/2-way solenoid valve Y1.2.1 allows flow in one direction only and makes sure that gases do not travel backwards. The expiratory valve has a transmission ratio of approx.3.1 which is set to 2 bar. AIR passes the restrictor R4.2.7 AIR supply AIR flow through the filter F1.2.1 to flow to the expiratory pressure sensor S6. Control pressure of 3 mbar = > expirarory pressure of 0 mbar Control pressure of 33 mbar => expiratory pressure of 33 mbar.Fig. 5. Furthermore.
Fig.2).3. At the same time.12 O2 supply diagram .1 via the pressure regulator which is set to 2 bar.60 . O2 flows to the 3/2-way solenoid valve Y1.11 AIR supply diagram 5.2 to the mixer and flow control unit (pressure sensor S2. Fig 5.2 via the check valve D1. 5.8 O2 Supply Compressed oxygen flows through the filter F1.2 and HPSV Y2.2.
1 the sensor will be disconnected with valve Y3.1 and S188.8.131.52 monitor the inspiratory pressure.3. the restrictor R1.1 is purged with calibration gas via the valve Y1.3. from there.1 provides pressure to the expiratory valve Y5.2. When calibrating the O2 sensor S3. The O2 concentration and the inspiratory gas flow are not affected.1.1 and to the safety valve D3. frequency. it flows through the 3/2-way solenoid valve Y6. The pressure sensors S6.9 Inspiration Depending on the setting (O2 concentration. Fig5. the restrictor R3. inspiratory pressure) the HPSVs Y2. T1. During the entire inspiratory time the PEEP/PIP valve Y4.3 from the inspiratory gas. The gas flows via the inspiratory connector to the patient.1.5.1 to the inspiratory pressure sensor S6.1 and Y2.2. The O2 sensor S3.2 open. At the same time.3 is fixed to 100 mbar and serve as an additional safety device in the event of a complete failure of the electronic control. inspiratory volume. inspiratory flow.2. The safety valve D3.13 Inspiration Function Diagram .61 . gas flows to the O2 sensor S3. and the valve Y3.
1 is automatically glowed clean.4 is also switched back.3. the HPSV Y2.1.1 will also be relieved and the patient can exhale via check valve D5. after termination of the medicament nebulization the flow sensor S5.14 Expiration Diagram 5.2. No gas will be supplied to the patient. Note: the minimum inspiratory flow required by the medicament nebulizer is 16l/min.10 Expiration At the start of expiration. The flow sensor S5.62 . After completion of the inspiratory gas supply phase the solenoid valve Y1. Fig5.2. The minute volume remains constant while the flow setting is being corrected.11 Nebulizer After pressing the button the medicament nebulizer is switched on for 30 minutes.1 is switched to the set PEEP value.3. At the same time the solenoid valve Y1.1 and Y2. .4 is switched through in the flow active inspiratory phase.2.2 are closed.1 measures the expiratory volume. The medicament nebulizer is supplied with drive gas by the restrictor R1. The PEEP/PIP valve Y4. The expiration valve Y5.5.1 and the flow sensor S5.
63 .14 Nebulizer Diagram .Fig5.
Figure 6. but following proper infection control procedures in maintaining the ventilator.64 . Leaks. are another problem that can affect the ventilator s ability to maintain the PEEP level.6.2 problems The most common problem with intensive care ventilators is the risk of a patient Acquiring ventilator associated pneumonia (VAP). including those of the ventilator breathing circuit.1. the breathing circuit. and all associated equipment can minimize patient risk. . congenital defects.1. This in turn may affect oxygen saturation and can result in autocycling. It is generally accepted that prolonged ventilation periods greatly increase a patient s risk of acquiring VAP.1 Intensive Care 6. The link between prolonged ventilation and VAP is unclear.trauma. or drugs .1 6. TYPES AND PROBLEMS 6.1 Purpose It provide temporary ventilatory support or respiratory assistance to patients who cannot breathe on their own or who require assistance to maintain adequate ventilation because of illness.
65 . Patient-ventilator dyssynchrony refers to the situation in which a mechanically ventilated patient fails to trigger the ventilator.When gas delivery is not synchronized with the patient s efforts to initiate a breath. They can also be used for short-term transport or in emergencies. can inhibit pulmonary gas exchange.2 Portable 6. One cause for patient-ventilator dyssynchrony is improper setting of trigger sensitivity. These portable units are commonly used in special extended care facilities. and can make weaning the patient from mechanical ventilation more difficult. 6.1 Purpose Portable ventilators provide long-term ventilatory support for patients who do not require complex critical care ventilators. in step-down respiratory care units. and patients with patient-ventilator dyssynchrony often have heightened and prominent accessory muscle activity associated with inspiratory efforts. or in the home.2.Leaks may also prevent the ventilator from delivering a preset tidal volume or accurately sensing flow and terminating a pressure-supported breath. This is also called trigger failure or desynchronization. and fighting the ventilator. or the ventilator erroneously senses a patient s effort and delivers breaths. mismatching. Clinical observation is highly specific in identifying patient-ventilator dyssynchrony. increased patient discomfort and work of breathing can result. This can also lead to respiratory distress. The friction-fit connector that attaches a ventilator to a patient s artificial airway can be accidentally disconnected if it is not attached securely by the clinician. . since observation of thoracoabdominal movement has been the standard method of determining respiratory rate. The result is amachine breath rate that is inappropriate to the rate of the patient s inspiratory efforts.
and other trained professionals.Hand ventilation. Ventilator failures can be caused by improper equipment care.3. poorly maintained exhalation valve assemblies. even by nurses.Figure 6. respiratory therapists. Many reported incidents of a patient s inability to exhale are suspected to be caused by jammed mushroom valves in the exhalation-valve. tends to be at too fast a rate and at an unstable tidal volume when performed for extended periods and can produce unintended acute respiratory alkalosis and its sequelae (e.2. tampering. Disconnection of the breathing circuit from the device is one of the most commonly reported problems.g. Caring for a patient receiving mechanically assisted ventilation in the home is potentially dangerous due to the possibility of equipment failure. acute electrolyte imbalances and coronary . 6. emergency medical technicians.1 Purpose Transport ventilators are designed to take the place of manual bagging in emergency or transport situations.2 6.. resulting in hypoxic brain damage or death. or incorrect use by caregivers.3 Transport 6.2 Problems Most of the reported problems involving portable ventilators arise from user error. or the use of poor-quality breathing circuits. damage.66 .
2 problems Inherent in the use of transport ventilators are problems associated with both general patient transport (e.g.emergency vehicle noise interfering with monitors).g.vasoconstriction. . poorly maintained units.which can lead to arrhythmias).3..67 .Other problems are associated with user error..Transport ventilators are well suited for both prehospital and emergency department applications. accidental extubation) and emergency transport (e. disconnection of the breathing circuit. 6. and use of poor-quality breathing circuits.
Pressure controlled ventilation has emerged as a viable alternative. to prevent stretch injury. using (conventional) positive pressure or negative pressure. There was renewed interest in plateau pressure limitation and increasing mean airway pressures. A severe poliomyelitis epidemic broke out in Northern Europe in the mid 1950s. Volume controlled ventilators became ubiquitous in the 1960s as this mechanism was perceived to be more reliable at delivering minute ventilation. During the 1970s and 1980s ventilators were developed which allowed patients breathe spontaneously. Medical students were assigned to manually ventilate paralysis victims until restoration of neuromuscular activity occurred. Accumulating evidence revealed that larger tidal volume. Using the ventilator as an interactive weaning device emerged at this time. leading to reduced end inspiratory volumes. and lower tidal volumes. with full patient interaction. The latter was the first mode to allow partial ventilatory support and thus gradual liberation from the ventilator. Patients suffering with this virus die from asphyxia respiratory muscle paralysis and failure Some of the earliest ventilators were negative pressure to ventilate. Physicians rapidly discovered that this could be used as a primary ventilation mode. expensive and somewhat unhygienic. using PEEP to maintain alveolar recruitment (the "open lung" approach). . although all strategies involve tidal volume targeting. and thus normalizing blood gases. Various strategies have been developed to achieve this goal.1 History of Ventilator There really is only two ways to ventilate a patient. Pressure support was initially developed as a method of lending partial support to the patient's spontaneous breaths. The first positive pressure ventilators were pressure controlled. The machines were bulky. During the 1990s widespread concern developed about ventilator induced lung injury. but were of little value in diseases characterized by failure to oxygenate.68 . History and Development of Ventilator 7. and interactivity became a function of microprocessor driven ventilators. low PEEP.7. initially with assisted breaths (assist control ventilation) and subsequently with spontaneous breathing limbs (synchronized) intermittent mandatory ventilation (SIMV). Iron lungs mimicked the chest cage's activity in generating minute ventilation. This has led to the development of lung protective ventilator strategies. ventilation strategies were damaging the lungs. This made sense as the chest is a negative pressure ventilator. chambers (iron lungs).
but they inadequately ventilated patients with significant respiratory disorders. 7. automatic tube compensation and. rise time control. The units were reasonably effective on patients who had relatively normal airways. the physician sets the mean airway pressure. Also. nor was there any means of regulating I/E ratios or respiratory flow rates. of course.1. These units were difficult or impossible to sterilize and were often noisy as well. negative pressure exerted on the abdomen often caused abdominal pooling of blood called tank shock. However. decreasing venous return and cardiac output. such as polio victims.2 Development of Ventilator 7. have been developed.1 abdominal pooling of blood can occur.2. Tracheotomy or intubation of the patient was usually not necessary for long-term ventilation because maintaining an airway was not a crucial .H. Modern ventilators deliver enhanced patients interactivity using better triggering sensors. Using this technique. It consisted of an airtight cylinder that enclosed the patient up to his neck. AN exciting prospect is the gradual arrival of high frequency oscillation into adult critical care units. waveform analysis. dynamic inspiration valves. The cylinder made isolation of the patient's body unavoidable. 7. Because the abdominal wall is flaccid and thus extremely subject to the negative pressure. A seal was formed with foam rubber around the neck so that there was no leak.1 Iron Lung The first iron lung to have widespread use was invented by Drinker and Shaw in 1928 and was produced commercially by J. Physicians are now demanding more control over gas flow than before hence the development of active exhalation valves. combing pressure limitation with tidal volume. the units had no assist mode. and even ports on the side made it difficult to provide adequate patient care. which is a chest shell piece. In addition.69 .2. Dual modes.Technology has played a large part in the development of modern ventilators. There are basically two types of negative-pressure ventilators employed in respiratory therapy: (1) the body tank respirator (commonly called the iron lung) (Figure 825) and (2) the cuirass. and more comfortable spontaneous breathing even in inverse ratio ventilation.1 Negative-pressure ventilation The use of negative pressure to expand the lungs dates back to the start of the nineteenth century.1. Emerson Company.1 Absolute 7.2. the introduction of a multitude of new modes has not been accompanied by good quality outcomes research.1. and there is minimal tidal gas movement.
When bellows expand. Slowly revolving wheel imparts reciprocal motion to bellows assembly connected to chamber. Lung. Amount of positive and negative pressure can be controlled independently. Chest recoils to normal position and exhalation begins. During upward motion of bellow a one-way valve opens and returns pressure within chamber to atmospheric. with little maintenance or down time. The newer isolate negative-pressure ventilators for newborns works basically as an iron. Iron lungs were also rugged and dependable. subatmospheric pressure generated within chamber causes chest to rise and inspiration to begin.1 * Iron lung.problem affecting volume delivery. and were easy to operate by personnel. This aspect reduced the chance of incurring pulmonary infection or other problems associated with artificial airway. . All but the head is enclosed in a sealed chamber. Figure 7.70 .
2 Chest Cuirass of Chest Shell Drinker and Collins collaborated in 1939 to produce a cuirass or shell unit in hopes that they would eliminate the abdominal pooling. exhalation begins.71 . .7. It confined the thorax so that subatmospheric pressure could be exerted within the shell and only around the chest Figure 7.2.2 Position of chest shell used for negative-pressure ventilation.1.1. When subatmospheric pressure is released. the unit consisted of a rigid shell that came in varying sizes. Inspiration is initiated when pump unit generates subatmospheric pressure in airtight shell. Basically.
the lungs expand and the pressure within them becomes less than atmospheric. similar in design to a vacuum cleaner. Units a pump (Fig 7. At that moment inspiration ends. and the chest rises.72 . and gas leaves the lungs until lung pressure and atmospheric pressure are again equal. . This reduction causes the pressure surrounding the chest to drop below the pressure within the lungs.Figure7. Patient's is placed in supine position and cuirass is stabilized with the use of straps and posts. Maximum pressure was less than that attainable with an iron lung and was dependent on the tightness of the fit of the shell. As the chest rises. Method of ventilation is identical to chest shell unit. was used to generate negative extrathoracic pressure. The natural elastic recoil of the lungs and thoracic cage causes lung pressure to exceed atmospheric pressure.3 Cuirass shell used for negative pressure ventilation. Atmospheric gases are thus drawn into the lungs until equilibrium between lung pressure and surrounding pressure is reached. To allow exhalation the subatmospheric pressure surrounding the chest is released. An electric pump.4) reduce the pressure within the chamber to below atmospheric level.
which often made the unit periodically undependable. so it was impossible to totally ventilate a patient who has no respiratory drive. and (5) the negative pressure was not as great as in the iron lung.1 These units. (4) the seal around the chest was difficult to achieve.4 Schematic representation of pump unit used to provide negative pressure ventilation to shell or garments. the modification of adding a flow sensor at the patient's nose for a triggering mechanism during an assist mode provided easier synchronization of the ventilator and the patient than could be achieved with the iron lung. however. pressure generated can be controlled independently. (3) regulation of I/E ratios was difficult.73 .Figure7. although improved over the body-respirator type. The downward stroke of the piston releases the subatmospheric pressure and allows chest to recoil to normal resting position and allow exhalation. . these devices provided for an increased venous return compared with the tank units. Because the negative pressure was primarily extrathoracic only. In addition. (2) providing patient care was still hampered. Cuirass-type units also fell into disuse for some of the same reasons as did body-tank Amount of negative or positive respirators: (1) they were excessively noisy. Pump unit consists of piston connected off center to a slowly revolving wheel. were used to augment patients with weakened respiratory muscles to ventilate adequately through the night. and there was no consideration for the regulation of inspiratory flow rates.
When the victim's chest has expanded to a suitable level the rescuer stops exhaling and releases the pressure. During inspiratory gas delivery. Most intensive care ventilators use a double-limb breathing circuit made of corrugated plastic tubing to transport the gas from the ventilator to the patient and return the exhaled gas to the ventilator through one of the limbs (referred to as the expiratory limb). such as during intra-hospital patient transport. as well as the fraction of inspired oxygen (FiO2). Most ventilators are microprocessor controlled.2. plus monitors and alarms.7. an exhalation valve is closed to maintain pressure in the breathing circuit and lungs. Communications interfaces are also typically included so that information on control settings. and alarm status can be transferred to a bedside monitor. some models regulate the 50 psi pressure source to a lower pressure and then control the breath to the patient through venture or bellows components. most ventilators mix air and oxygen internally. the device is called a ventilator. although some models require an external gas blender. In this approach the rescuer exhales into the victim's airway and directs positive pressure into the victim's lungs. The gas is delivered to the patient through the flexible breathing circuit. or some other interfaced device. When a device is used to inflate the lungs. and the victim's lungs are allowed to empty. Principles of operation A ventilator in general consists of a flexible breathing circuit. an information system. Heating and humidification devices are available as add-on components. Alternately. . and they regulate the pressure.74 . battery power is used for short-term ventilation. Power is supplied from either an electrical wall outlet or a battery. To obtain the desired FiO2 for delivery to the patient. volume. Some intensive care ventilators can receive gas (both air and oxygen) from a wall outlet that generally provides gas at a pressure of approximately 50 pounds per square inch (psi) The flow of gas to the patient can be regulated by a flow-control valve on the ventilator.2 Positive-pressure ventilation The process of lung inflation by use of positive pressure is similar in principle to mouthto-mouth artificial ventilation. The procedure is then repeated at a frequency appropriate to the victim's size. based on control settings. monitored variables. or flow of the delivered positive-pressure breath. a control system a gas supply. During inspiratory gas delivery.
minute volume (the volume inhaled during a minute). and conditioned with nebulized medications and where condensation may be collected. 1.an external exhalation valve or one within the ventilator is closed to maintain pressure in the breathing circuit and lungs. breathing rate). monitored for proximal airway pressure. the gas is released to ambient air through this valve. High Frequency Positive Pressure Ventilation (HFPPV) This is basically positive pressure ventilation with ventilatory frequencies of I-2Hz.3 State of the art 7.figure 7. Inspiratory gas is supplied at a frequency of 1-2 Hz into the endotracheal tube via one arm of a Y-piece. Tidal volumes are in the range 2-4 ml/kg. Three high frequency ventilatory modes depend on applied Ventilatory.5 . several parameters can be independently set.75 . After the inspiratory phase.1 High Frequency Ventilation (HFV) High Frequency Ventilation is a collective description of all high frequency ventilation techniques.g.2. ratio of inspiratory time to expiratory time (I:E ratio). tidal volume. peak inspiratory flow. For the ventilator to produce a prescribed breathing pattern. and positive end-expiratory pressure (PEEP). rate of mechanical breaths. Many model have sensors within the ventilator or flow and provide feedback to the ventilator to automatically adjust its output. such as length of the inspiratory or expiratory phase. During expiration. humidified.3. The controls system are used to select breathing mode and ventilation pattern parameters (e. this valve opens and exhalation occurs passively ..2. a pneumatic valve occludes the expiratory limb. The breathing circuit also provides sites where the delivered gas may be heated. 7. tidal volume. peak pressure. During inspiration. wave-form shape. Applied tidal volumes are some times smaller than anatomical dead space (= 2ml/kg).
.6 High Frequency Jet Ventilation The tidal volume is also between 2-4 ml/kg .The jet gas is applied via the injector cannula into the open endotracheal tube with a ventilatory frequency between 2 and 10Hz (Fig. 2.76 .7. This technique can be used with some conventional ventilators.Fig7. High Frequency Jet Ventilation (HFJV) This ventilatory technique is applied via a cannula (injector cannula) introduced directly into an endotracheal tube or integrated wall of a special tube. there is no air entrainment.6) Fig 7.5 High frequency positive pressure ventilation Because the valve is closed during inspiration.
which cause the gas column in the tube to oscillate (Fig7. because of this there is a danger of "air trapping" with consequent over-stretching and . High frequency (sine wave) oscillations up to 50 Hz are produced by a piston pump. HFJV can be combined with conventional ventilators modes (IPPV or IMV) with low tidal volume.8 ) High Frequency Oscillation .High Frequency Oscillation (HFO) This ventilatory technique differs from other methods in having active expiration. which is connected to the endotracheal tube via an adapter and a T piece.77 .7) Fig 7.8) Fig (7. Exhalation is passive between jet gas impulses. Gas volumes are enhanced through entrainment . barotrauma if expiratory times are too short.The lack of an expiratory valve in this technique (open system) allows Venturi effect to occur which enhances inspiration.(Fig7.7 Combined high frequency ventilation 3.
Inspiratory and expiratory times are equal and not adjustable. The exhaust arm of this lateral flow has a resistive tube ("impedance tube") to avoid excess oscillatory volume loss at the "bias flow .78 . Fresh gas is supplied via a T piece lateral to the direction of oscillation. tidal volumes are distributed according to compliance. which cannot be treated adequately with conventional ventilation techniques. 7.2 Independent lung ventilation (ILV) Separate ventilation of the lungs is called independent lung ventilation. septic lung failure. . The crucial criterion is lateralisation. synchronous independent lung ventilation is used .These sine pressure waves propagate down the bronchial system into the lungs. bronchopleural fistula or following a single sided lung transplant is of secondary importance. the term asynchronous independent lung ventilation is used. If the I:E ratio is the same. This lateral respiratory gas flow is called "bias flow". High Frequency ventilatory techniques are not widely used clinically. Synchronization of the ventilators may appear physiologically correct but ventilation without synchronization does not appear to have any negative effects. ventilation with two ventilators (Master. Principle of Operation Because of the differing mechanical properties of the lung. Slave). Furthermore.2. Separation is achieved with a double lumen tube. The mechanical effect of PEEP leads to compression of lung capillaries.3. and over-stretching of the healthy lung with increased ventilation perfusion disturbance. The active expiratory flow avoids "air trapping". Indications for independent lung ventilation in the intensive care unit are single sided lung diseases. with an increase in pulmonary vascular resistance in the healthy parts of the lung. ILV offers the opportunity to adjust the I: E ratios according ted to the different compliance of each lung. If the lungs are ventilated with different I:E ratios. lung contusion. with deteriorating oxygenation and increasing right-left shunt. PEEP in the healthy lung with the better compliance results in a greater increase in lung volume than in the damaged lung with lower compliance. This results in increased circulation in the damaged lung. whilst the type of disease be it pneumonia. or lung diseases with emphasis on one side. Finally. With conventional ventilation. This results in reduced ventilation of the diseased lung.
Pressure controlled ventilation with Option (BIPAP). tidal volumes. augmented spontaneous breathing. independent lung ventilation offers the opportunity to specifically treat ventilation/perfusion mismatches with SPEEP. For use in recovery rooms. This ensures that.and inter-hospital transport.3 Applications we will consider some models of draeger ventilators. and oxygen availability is optimised for metabolic demand. 7. sub-acute care facilities.2. intensive care units. . Savina continues to work without any interruption for one hour with internal battery (smart power management). With asymmetric lung diseases. intra. and to improve pulmonary gas exchange.79 . general haemodynamics are less affected. 1.3.9 Savina ventilator Ÿ Ÿ Ÿ Ÿ Ÿ Ÿ • Savina is a Critical Care Ventilator for advanced long term ventilation.Savina Fig 7. For adult and paediatric application with tidal volumes in volume controlled ventilation starting from 50ml. both lungs are ventilated with identical but reduced.The term inverse I:E ratio is used when the inspiration of the slave machine begins with the expiration of the master machine and vice versa . in the event of inadvertent separation of the machines. Ventilation modes for volume controlled ventilation. the lungs are not ventilated at different frequencies (safety measure). Furthermore. Volume oriented ventilation with automatic adjustment of the flow rate: Option (Auto Flow) In case of failing electricity supply. Usually.
Flow rise can be adjusted to the patient by Flow Acceleration. . in inhomogeneous lungs. With Option AutoFlow Savina offers automatic adjustment of the flow rate to deliver the set volume with the least possible pressure Benefits: 1. Expiration Valve. 2. Improved gas distribution esp. No nuisance alarms if patient coughs. Y-piece. For inner clinical transport .80 . • Autoclavable Parts (steam sterilisation 134°C): 1. you do not have to disconnect the patient from Savina just take it along. water traps).• • • • up to seven hours with internal and external batteries (smart power management). 3. Peak pressures are reduced. 5.10 Front view of the savina ventilator. Trigger indicator Display with real-time curves Alarm LEDs AC / DC LED Standby key Flow sensor Exhalation valve O2 inlet on the right side of the device Fig 7. 4. Autoclavable Hose sets (incl. The patient can breathe spontaneously during all phases of the ventilatory cycle. 2.
EVITA 2 dura.AC inlet DC inlet Main switch Nurse call (option) Side rail (option) Serial port Inlet for breathing air Fig 7.12 Display showing different parameters 2.2 Advice Advice Fig 7. This device have and will do the following function s § § Select-Adjust-Confirm .520 f 12 MV 6.81 .11 Back phase of the savina ventila Ÿ Display Mode Mode Alarm Alarm message message IPPV Real-time Real-time curve curve 30 20 10 0 Assist Paw mbar -10 0 2 4 6 8 10 12 s Measured Measured values values V Te . Start-up settings. .
Guided checklist. Fig 7. Optimised Mask Ventilation (optional).§ § § § § § § § § Standby function. Alarms with priorities and clear messages .82 . Automated calibration .13 Expiratory Valve With Option (Auto Flow) Evita 2 dura offers automatic adjustment of the flow rate to deliver the set volume with the least possible pressure Peak pressures are reduced. Expiratory Valve easy to sterilise. Intelligent Alarm management: • • Volume Strategy: Paw high alarm. no filters needed. Nurse Call (optional). exchange in seconds. Intelligent alarm management. Improved gas distribution esp. low exhalatory Resistance. The patient can breathe spontaneously during all phases of the ventilatory cycle. Pressure Strategy: Tidal Volume high alarm. Remote Control for Routine functions (optional). in inhomogeneous lungs. No nuisance alarms if patient coughs. Advisory Information.
The patient can breathe spontaneously during all phases of the ventilatory cycle. Evita 2 dura is your tailor-made solution all times and in all situations. First ventilator to have tube compensation. Ventilator for all applications. 3. Improved monitoring functions.EVITA 4.! !! § § § Advisor y Caution !! Warning Evita 2 dura offers exactly the right parameters for clinical routine. Improved gas distribution esp.83 . Evita Remote (Remote pad for routine functions). external flow source. No nuisance alarms if patient coughs. § Nurse Call (Multifunction board (required for Evita Remote). With AutoFlow in Evita 4 offers automatic adjustment of the flow rate to deliver the set volume with the least possible pressure: § § § Peak pressures are reduced. options such as Ventilation Plus or Monitoring Plus are available to extend the range of functions. (newest) EVITA 4 Is the same as Evita 2 dura but it has additional characteristic : § § § § Evita 4 First touch screen ventilator on the market. § § § § Additional functions : Power Back Up. . in inhomogeneous lungs. In addition. Draeger. Software Updates with PC-Download. open communication interface.
2. User Interface Up to 12 values shown on the screen. Only displays essential settings for easier readability.4 Emerging Evita XL from draeger. Easy to move. no openings.2. which it is not available in others. Operation Panel § § § § § § § § § § 15 colour Touch screen. The difference in some characteristic. Fig 7. because it has some new technology. Easy to clean and disinfect. Central rotary knob.7. Sealed unit.14 Evita XL Venilator This ventilator is different from other ventilators. which is: 1. Easy to clean and disinfect. . Rail connector for standard rail. Swivel mounted.84 .
patient monitoring and patient care during weaning. 2004 Protocol based weaning defines and organizes a process for ventilator adjustments.§ § § § § § Additional settings. March. alarms or diagnostic data readily available in the background and easily configurable to the screen. Measured values configurable to clinical standards. 3.15 Screen displaying three curves 4. 2 min postoxygenation The most important function is to control weaning process (SMART CARE) 30.85 . up to 2 min time for suction procedure. Intelligent logbook and trends. Several studies have shown . expected outcomes. User Interface Screen displays three curves Every curve can be replaced by two loops or one trend Loop can be zoomed to the size of two curves Fig 7. Special Functions § § § § § § § Inspiration hold Expiration hold Maximum time for both functions (15 seconds) Nebulizer activation and deactivation Nebulization time 30 minutes Suction Procedure 3 min pre-oxygenation.
Step 3: Testing readiness for extubation by maintaining the patient at the lowest limit of support. configuration. Smart Care. A knowledge-based system has clear advantages over one based on a preset minute ventilation (MV). and temporary situations such as increased secretion or suction stress may lead to a higher MV demand.or five-minute intervals on whether to adapt pressure support. A knowledge-based approach to therapy can.that implementation of protocols to aid the weaning process results in a significant reduction in ventilation days. by this ventilator. certain settings and patient information are required for operation. tidal volume and end tidal CO2. Smarter device EvitaXL has been designed to follow the path of innovation as an integrative platform. which has to be counterbalanced by an increase in MV. it is equipped for: Powerful monitoring: Respiratory mechanics. rapidly and with few or no complications. we are freeing the clinician for the "art of medicine . which could lead to a significant decrease in costs. In order to wean successfully. Preset MV systems cannot automatically adjust to such changes. knowledge based weaning system. Infections or fever may induce a higher metabolic rate.86 . display space. contains automated clinical guidelines based on recognized medical expertise. SmartCare Pressure Support is based on a clinical protocol for weaning. The complete weaning process is continuously monitored by the EvitaXL. Consequently. Improved modes: Ready for the challenges of today s and tomorrow s ICU. SmartCare divides the control process into three steps: Step 1: Stabilizing the patient within a respiratory comfort zone by regulating the level of pressure support based on the three parameters breathing rate. Step 2: Reducing invasiveness by testing if the patient can tolerate a lower pressure support level without leaving the comfort zone. Due to shortened ventilation. possible complications may be reduced. tracheotomized or intubated and has an adequate oxygenation. provided that the patient is hemodynamically stabile. Smart Care continuously takes data and uses the mean parameter values to take decisions in two. Settings: Patient range: body weight (BW) between 35 and 100 kg CPAP/ASB in adult mode Apnoea ventilation activated .
16 SmartStim . (see # 1) 2) Connect SmartStim to the power supply.Automatic tube compensation (ATC) deactivated CO2 and flow monitoring activated Patient Information Patient weight Type of intubation Type of humidification Medical history of neurologic disorder or COPD SmartStim mounting 1) Place the SmartStim at the device side rail. (see # 4) 5) Place the CO2 sensor on the reference cell (provided with the CO2 Sensor) (see # 5) Fig 7.87 . 4) Regulate the desire virtual frequency using the rotary knob on the SmartStim. 3) Connect with the provided hose (see # 2) the SmartStim with the Filter (see # 3).
Fig 7.2. 3. 2. When connected to a patient.Future ventilators will use fresh air and do not need to O2 and air containers. it will be very smart and sensitive to detect diseases and lung damage. flexible tube is connected to it and it uses regular battery.It will be portable and very small in size (hand size) . . 4.some models will use solar cells to provide power instead of electricity .16 CO2 sensor 7. it will directly select the appropriate mode.88 .5 Visionary 1.
More than 12 references used to get information.corexcel.vent6. Ventilators –Theory and clinical Application (version 1991) 4. Draeger medical company (Riyadh.stemnet. National guard hospital 9. Most benefit reference are: .ca/~dpower/resp/exchange. ECRI 5.g.ccmtutorials.htm#Cellular TRUES ABOUT THIS REPORT § § § § § This report talk about one of the most important life support medical device which can be used in many area as(e. Service manual of Draeger-EVITA4 (version2002) 6. It talk 3 months of hard work and we face many complication. but we pass it.com/education/wiav-part1. www. critical care units. Mohmmad Shaban 8. www.com/rs/mv/page2. Course 335 BMT prepared by Dr. Bassim Odah 7. Lectures with Eng. Respiratory therapy equipment(version 1985) 3. www.ventworld. patient room.8. Breathing and mechanical support (version1993) 2. REFERENCE 1. emergency and house).htm 13.com/courses/body. www.nf.htm 12.89 . Germany) 10. Successfully by god mercy and insist to finish it.asp 11.
Thank to other people we did not mention This report prepared by ventilator group 1.Draeger company (RIYADH-GERMANY) § § § With. 2.Mohmmad Ahmad Maghrbi 4.National guard hospital. thanks to eng.Muhannad Nasser Alshiban § We ask god to benefit all student and Muslims from this report .90 .Mohammod Shaban who helped and instruct us.Abdulaziz Ahmad AL Somali 3.1.Ali Mohmmad Al Hawwas 2.