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1. Deranged Physiology

2.  CICM Primary Exam

3.  Required Reading

4.  Respiratory system

Basic components of a mechanical ventilator

Created on Fri, 06/12/2015 - 05:59
Last updated Fri, 09/14/2018 - 02:22
Topic
Respiratory system
Previous chapter: Principles of measuring pCO2 with the
Severinghaus electrode
 
Next chapter: Power and gas supply requirements for mechanical
ventilators
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It is a widely recognised fact that ICU doctors are going to

spend much of their working life using ventilators, staring at
their screens, making fine adjustments to them, talking about
them, and generally appreciating them. One might describe the
whole cohort of critical care specialists as the “Mechanical
 Ventilator Fancier’s Society”. It is therefore quite remarkable
how little attention is paid to the exploration of these apparatus
in the expectations of the formal training process.  Judging by
the 2017 CICM Primary Syllabus, college examiners expect
absolutely nothing from their primary candidates in this
cognitive territory. Then, after an unregulated gap in training,
the Fellowship candidates find themselves in a position where
this area is assumed knowledge, and are asked questions about
pragmatic matters such as troubleshooting the circuit of the
inexplicably breathless patient or interpreting abnormal
waveforms. 
One might, of course, make the argument that it is quite
possible to be a safe and proficient user of a device without
expert familiarity with its inner workings, pointing to the
personal computer as an example. Moreover, because this topic
has zero exam value, and the trainees’ time is finite, one might
accuse the author of wasting valuable revision time with this
self-indulgent gibberish.  The counterargument is that an in-
depth understanding of our instruments informs our use of
them, and enriches our practice. To claim mastery of the field of
Intensive Care Medicine should probably mean a claim to an
understanding which goes somewhat beyond the pragmatic
requirements of routine bedside work. 
However, there’s something to be said for satisfying pragmatic
requirements.  To define what those might be, one could use the
official CICM “Work-Based Competency Assessment:
Ventilation”, which mentions that an “acceptable”
trainee “describes the principle (sic) components of
bellows and turbine ventilators”. In brief, the
following components are usually seen in a modern mechanical
ventilator:
Sources of power: Monitoring
 Gas supply  Sensors 
 Power supply o Gas concentration
 Pressure generator  o Flow
o  Pressure
Control of gas delivery: o  Volume

 Gas blender Safety features

 Gas accumulator
 Inspiratory flow regulator
 Humidification equipment
 Patient circuit
 Expiratory pressure regulator (i.e PEEP
valve)
 Filters
o Gas intake particle filters
o Pre-circuit bacteria filters
o Moisture traps and heat/moisture exch
systems
o Expired gas filter
 Alarms

This list is neither exhaustive (listing every valve and bolt) nor
sufficiently broad to cover every possible variation on this
theme. Rather, it was designed to cover the main components
which one might find inside a normal ICU ventilator, a
transport ventilator, or an anaesthesia ventilator. The specific
functions of these components are discussed in greater detail in
the subsequent chapters of this section. It would certainly be
pointless to take this subject back to a time when  “an
average clinician could …completely disassemble
and reassemble a mechanical ventilator as a
training exercise or to perform repairs”, but some
detail is probably warranted, given our reliance on these
devices.
There are not many good peer-reviewed resources for the topic
of ventilator design, but wherever one looks one finds an article
by Robert L. Chatburn. For instance, much of this chapter is
based on the excellent article by Chatburn & Branson
(1992) which discusses an all-encompassing taxonomy to
classify mechanical ventilator systems. Chatburn seems to have
been writing about mechanical ventilation since 1982 and was
 invited to write the classification chapter for
Tobin’s Principles and Practice of Mechanical
Ventilation  (p.45 - Chapter 2 of the 3rd Ed, 2012). He is also
the co-author of Chapter 3 from the same book (“Basic
Principles of Ventilator Design”, p. 65-95).

Definition of what a mechanical

ventilator actually is
According to the definition offered by Chatburn, a mechanical
ventilator is an automated machine in which
“...energy is transmitted or transformed (by the
ventilator’s drive mechanism) in a predetermined
manner (by the control circuit) to augment or
replace the patient’s muscles in performing the
work of breathing.”
This definition must be qualified by mentioning that the
mechanical ventilator should be automated. The self-
inflating bag-valve-mask resuscitator is a ventilator by the
above definition, as the user’s muscle energy acts as a drive
mechanism and is used to augment or replace the patient’s
muscles. However, it would be plainly mad to consider that a
mode of mechanical ventilation. Thus, a mechanical ventilator
needs to be a device which you can set and walk away from,
knowing that it will continue to safely perform its role.

Classification of ventilator system

designs
Until surprisingly recently, people have been using variants of a
classification system which has undergone little modification
since the 1950s. William Mushin’s  Automatic Ventilation
 of the Lungs  (1959) was an early textbook of mechanical
ventilation which is much referenced, and it was probably quite
good in its time (contemporaries gushed that it “deserves to
be closely studied by all
anaesthetists” and “provides salutary reading for
those who feel the urge to design, make or
modify an apparatus of this kind”). Of course, it is
well out of print, and given its vintage and irrelevance in the
modern era, even a veteran software pirate would be entirely
unable to track down an illegally scanned copy.
In short, mechanical ventilator classification systems have
historically been so pointless and inadequate that Chatburn
opened his 1991 article with a quote from Genesis (11:7),
“Come, let us go down and there confuse their language, that
they may not understand one another’s speech”.  The more
mature taxonomy offered by Chatburn is used here to classify
ventilators according to the mechanisms and principles of their
function. It omits such anachronisms as the inevitable
discussion of positive and negative pressure ventilators (of
course these days they are all positive pressure devices). The
model is extensive, as it covers not only engineering aspects of
mechanical ventilator design but also such detail as flow
waveform shape and different possible alarm settings. It is
reproduced here with minimal modification:
Input Output

 Pneumatic  Pressure waveforms

 Electric o Rectangular
o AC o Exponential
o DC (battery) o Sinusoidal
o Oscillating
Power conversion and transmission
 Volume waveforms
 External compressor o Ascending ramp
 Internal compressor o Sinusoidal
  Output control valves
Control scheme
 Control circuit
 Flow waveforms
o Rectangular
o Ascending ramp
o Descending ramp
o Sinusoidal

 Mechanical
 Pneumatic Fluidic
 Electric
 Electronic
 Control variables
 Pressure
 Volume
 Time
 Phase variables
o Trigger
o Target
o Cycle
o Baseline
 Modes of ventilation
 Control variable
 Breath sequence
 Targeting schemes
Alarms
 Input power alarms
o Loss of electric power
o Loss of pneumatic power
 Control circuit alarms
o General systems failure
o Incompatible ventilator settings
o Warnings (e.g., inverse inspiratory-to-exp
ratio)
 Output alarms (high/low conditions)
o Pressure
o Volume
o Flow
o Time
 Frequency
 Inspiratory time
 Expiratory time
o Inspired gas
 Temperature
 FIO2

Though it is useful later to classify modes of ventilation and

make sense of the massive array of totally random-seeming
ventilator nomenclature, for the purposes of this engineering-
oriented chapter a classification like this is too broad. What the
CICM trainee needs is something quick, to memorise and
reproduce for the purposes of passing their ventilation WCA.

Basic ventilator components

If one were to behold a ventilator with a critical eye, one would
find that it is really composed only of four main parts:
 Power source
 Controls
 Monitors
 Safety features

The power source consists of something to supply the gas

which will be delivered to the patient, as well as the energy
required to run the ventilator components. Thus, this category
encompasses the gas supply system, the batteries and power
source for the mechanical ventilator.
The controls are some means of regulating the timing and
characteristics of the delivered gas. These components consist
of an entire array of parts, each of which probably merits an
entire chapter of their own:

 A gas blender is required to control the mixture of air,

oxygen, anaesthetic gas or whatever else you might be using
the ventilate your patient. One may not need any such gas
blender if one is discussing some sort of stripped-down
domiciliary model which runs on room air alone, and which
does not accept an exogenous oxygen source.
 A gas accumulator might be a component of a ventilator
which requires a precise control of gas mixtures and which
cannot rely on proportioning valves to produce this level of
precision, eg. where the gas flows are very low. An example
of this is the accordionlike “bellows” of an anaesthetic
machine; it is used to maintain a reservoir of a stable gas
mixture.
 Inspiratory flow regulator – basically, any device which
ensures that the respiratory circuit receives the prescribed
gas flow. This is usually a solenoid valve. This thing sits in
front of the gas supply (either from the wall or from the
compressor turbine) and ensures that the patient is only
exposed to carefully measured amounts of that gas. Given
 that the wall gas in ICU piping outlets is supplied at a
standard pressure of 400kPa (approximately 4 atmospheres),
it is obviously an essential component. 
 Humidification equipment is a requirement in most
settings. This can take the shape of an active humidifier (i.e.
a device which heats and evaporates water into the supplied
gas mixture) or a passive humidifier like a heat/moisture
exchanger. Generally, domiciliary CPAP machines which
supply room air via some sort of face mask can rely on the
patient’s own upper airway for humidification.
 The circuit, that wobbly mess of corrugated tubing, is often
forgotten in discussions of ventilator equipment, but it plays
an important role (try to ventilate the patient without one).
Its characteristics, for example its compliance and resistance
to air flow, are important features.
 Expiratory pressure regulator (i.e PEEP valve) is a means
of maintaining and controlling positive airway pressure.
These are basically carefully controlled expiratory flow
obstructions, usually in the form of a solenoid valve (though
crude mechanical models also exist for old-school
ventilators).

The monitors are means of sensing and presenting the

characteristics of gas delivery so that one might be able to
assess the ventilator’s performance (and probably also the
patient’s condition).

 Gas concentration is usually measured by either voltaic

cells or spectrophotometers. For example, the oxygen supply
sensor is usually an oxygen cell, which produces an output
voltage proportional to the partial pressure of oxygen in the
inspiratory gas pipe.  
 Flow is pretty much the main thing the ventilator supplies,
so it makes sense to want to monitor it in some way. All
 commercially available mechanical ventilators have some
method of monitoring flow. These methods include:
o Hot wire anemometry, where the effect of gas flow on
cooling a heated platinum wire is detected as a change in
the wires' resistance
o Variable orifice flowmeters, where a pressure drop across
a narrow pipe is used to calculate flow
o Screen pneumotachography, where a pressure drop across
a mesh screen is used to calculate flow
o Ultrasonic flowmeters, where two transducers are used to
analyse changes in ultrasound wave transit time caused by
the velocity of the intervening medium.
 Pressure in the circuit had historically been accomplished
by means of aneroid manometers, i.e. pressure sensors that
measure air pressure by the action of the air in deforming
the elastic lid of an evacuated box. In modern ventilators,
these have been superceded by integrated silicon wafer
pressure transducers, at a fraction of the cost and with
greatly improved accuracy.
 Volume is not measured directly in modern ventilators it is
calculated from flow measurements. In older ventilator
designs (eg. the bellows and the piston models) a directly
measure volume was the main variable over which the
intensivist had any control.

The safety features are some devices and measures which

ensure that the patient does not come to any additional harm
from being ventilated (beyond the already brutal effects which
are integral to the process). These consist of filters and alarms.

 Inspiratory filters of the ventilator promote purity of

inspired gas (eg. by removing airborne particles and bacteria
from the inspired gas mixture).
 Expiratory filters protect the ICU staff. Expired gas is
filtered to prevent the ventilator from constantly belching
 out great clouds of aerosolised pathogens generated in
the horrific toilet-like bog water of the patient’s airways.
 Expiratory filters are also usually needed to protect the
ventilator components from the necessarily hot and humid
expired gases, which would degrade the quality of sensor
measurements and decrease the lifespan of the device
 Alarms are usually integrated into the software as
safeguards against unintentional changes to the ventilator
settings and weird misapplications of ventilation. Broadly,
these are systems to let you know that the patient condition
or ventilator performance has trespassed the parameters
which (you decided) are safe. Nonsoftware alarm-like
features are also integrated into ventilators, for example
mechanical blow-off valves to release excess pressure when
the patient coughs.


Previous chapter: Principles of measuring pCO2
with the Severinghaus electrode

 

Next chapter: Power and gas supply
requirements for mechanical ventilators

References
Chatburn, Robert L.; Branson R.  "Classification of Mechanical
Ventilators." Respiratory Care 37.9 (1992): 1009-1025
Chatburn, Robert L. "Classification of mechanical ventilators
and modes of ventilation." Principles and practice of
mechanical ventilation. 3rd ed. New York: McGraw-Hill
(2012).
Kacmarek R., Chipman D.; “Basic Principles of Ventilator
Machinery.” In Tobin MJ (ed): Principles and Practice of
Mechanical Ventilation. New York, McGraw-Hill, 2006 (2nd
Ed)  p 53-96
Chatburn, R.L; Mireles-Cabodevila. E.  “Basic principles of
ventilator design.” In Tobin MJ (ed): Principles and Practice of
Mechanical Ventilation. New York, McGraw-Hill, 2006 (3rd
Ed)  p.65-95
Mushin, William W., et al. Automatic ventilation of the lungs.
ed. Blackwell Scientific Publications, Oxford and Edinburgh,
1969.
Chatburn, Robert L. "A new system for understanding
mechanical ventilators." Respiratory care 36.10 (1991): 1123.
Chatburn, Robert L. "Fundamentals of mechanical ventilation."
Cleveland Heights: Mandu Press Ltd (2003).
Branson RD, Hess DR, Chatburn RL. “Respiratory Care
Equipment.” 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 1999.
MacIntyre, Neil. "Design Features of Modern Mechanical
Ventilators." Clinics in chest medicine 37.4 (2016): 607-613.
Sinclair, Colin M., Muthu K. Thadsad, and Ian
Barker. "Modern anaesthetic machines." Continuing Education
in Anaesthesia, Critical Care & Pain 6.2 (2006): 75-78.
Thille, Arnaud W., et al. "A bench study of intensive-care-unit
ventilators: new versus old and turbine-based versus
compressed gas-based ventilators." Intensive care medicine
35.8 (2009): 1368-1376.
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