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Physics of Ventilation

National Chairperson (Ex) Intensive Care Chapter I A P Founder Chairman..... National conference on pediatric critical care Professor of pediatrics ( Hon ) JNMC:Wardha Nagpur : INDIA

Dr Deopujari

The evolution of Ventilator

Three problems of ventilation

Applied Physics
What can we manipulate ?

Compliance Static compliance Dynamic compliance Resistance Work of breathing Flow Pressure Volume Surface area

Evolution of Ventilators

What can we manipulate ? 1)Minute ventilation 2)Pressure gradient 3)Surface are 4)Pulmonary vasculature 5)Solubility How can we do this ?

Compliance
Compliance is a quotient between volume and corresponding pressure change.
V
C=

Dynamic compliance

Static compliance

C O M P L I A N C E The compliance of any structure is the ease is with which the structure distends ( C= V / P)

c.c.p. = critical closing pressure c.o.p. = critical opening pressure


PEEP
V O L U M E

C.C.P. C.O.P.
PRESSURE

Volume

EX.

INS.
Optimal Benefit Of PEEP

Pressure

Static compliance
Time Tidal volume.

Inspiratory pause

Cst =
Static pressure end expiratory pressure

Cc

Flow

Cst : static compliance Cc : circuit compliance end expiratory pressure (Pend-ex) Pend-ex = Peep + P peep

Pressure

Peak pressure Plateau pressure

Resistance Compliance

Flow .

Flow indicates circulation of an element per unit of time through a given place Flow. Linear Turbulent

FLOW

Pmo
FLOW THROUGH A PIPE LIKE STRUCTURE REQUIRES A DRIVING PRESSURE (PalvPmo) TO OVERCOME THE FRICTIONAL RESISTANCE Palv FLOW DEPENDS ON Pressure Difference and Resistance V=P/R

Pressure .
Represents the force that a volume of gas exercises upon a unit area. Kinetic theory states that gas molecules bomb the walls of a container .

If volume remains constant , pressure varies in direct proportion to Temperature. If temperature remains constant , pressure varies in inverse relation to Volume .

Increase in pressure decreases volume

Resistance

Resistance is defined as the relationship between pressure (p) and flow ( 0 ) Therefore important when there is air flow. P R = ----------O Resistance depends upon Diameter of airway Length of airway Viscosity and density of air Resistance during inspiration Resistance during expiration

And how can we do this ?

Mechanical Ventilation Concept

Conditional variables Control variables Phase variables Trigger variables Limit variables Cycle variables Base line

CONDITIONAL VARIABLE

Conditional variables alone or in combination are analyzed by Ventilators control logic. The state of this variable determines as to which of two types of breath would be delivered. SIMV is based on timing window and accordingly the ventilator delivers . a pressure triggered ( patient ) or time triggered ( machine) breath. In this situation the patient effort and time are conditional variables for determining triggering.

Conditional variables Pressure Volume Flow Time

CONRTOL VARIALBE
Control variable manipulates the conditional to cause inspiration. Pressure , volume , flow and time are control variables.
The behavior of control Variable Ventilatory load.

remains constant in spite of changed

CONRTOL VARIALBE

Control variable manipulates the conditionals to cause inspiration. PRESSURE , VOLUME , FLOW and time are control variables.
The behavior of control Variable Ventilatory load.

remains constant in spite of changed

Pressure
Rectangular Exponential

CONRTOL VARIALBE
Control variable manipulates the conditional to cause inspiration. Pressure , VOLUME , FLOW and time are control variables.
The behavior of control Variable Ventilatory load.

remains constant in spite of changed

Volume
Ramp Sinusoidal

CONRTOL VARIALBE
Control variable manipulates the conditional to cause inspiration. PRESSURE , VOLUME , FLOW and time are control variables.
The behavior of control Variable Ventilatory load.

remains constant in spite of changed

Flow
rectangle sinusoidal ramp

ramp

exponential

LIMIT VARIBALE
During pressure support ventilation though one selects a level of support the Inspiration continues till predetermined flow rate or termination criteria is reached. During PSV patient determines the Rate .. Inspiratory time Flow..

Volume control
Volume

Flow

End of inspiration

Pressure

Peak pressure Plateau pressure

Resistance Compliance

Pressure control
Volume

Flow

End of insp. flow

What does not change . 1)Volume curve 2)Exp. Flow curve

Pressure

Pressure control
Volume Volume End of insp. flow

Volume control

Flow

End of insp. flow

Flow

Pressure Pressure

Peak p. Plateau p.

Resist.

Compliance

Volume limited and pressure limited ventilation .


Volume limited pressure limited

Advantages Tidal Volume guaranteed Precise control of Inspiratory flow Easy detection of changed respiratory impedance
Precise control pf pressure Decelerating flow reported to improve distribution of ventilation decrease dead space ventilation decrease PIP match Inspiratory flow

Disadvantages

PIP vary Inspiratory flow may not match the patients needs

Variable tidal volume Changes in impedance not easily detected

Modes of ventilation or moods of ventilation

Controlled Ventilation.

P R E S S U R e

F L O w

V O L U M e

A normal lung

B decreased compliance

C increased resistance

SIMV
Patient triggered ventilation Synchronized to patient breath if the threshold is met .
Patient controlled variables Respiratory rate Inspiratory time Clinician controlled variables PIP if pressure limited Tidal volume if volume cycled Inspiratory time if time cycled Flow SIMV rate

Flow cycling . Insp. Terminated at % of peak flow rather than time Synchronizes expiratory and Insp. flow thus total synchrony achieved.

When SIMV is used, the patient receives three different types of breath: The controlled (Mandatory) breath. Assisted (synchronized) breaths. Spontaneous breaths, which can be pressure supported.
A B

Flow
Trigger

PaW

Volume

A .Controlled and time triggered B .Spontaneous C .Synchronized and assisted

Pressure

Trigger

Spontaneous breath
Spontaneous breath Volume Assisted breath Back up ventilation period Controlled breath

Spontaneous volume

Pressure support
Pressure support ventilation is a spontaneous mode of ventilation. Inspiratory effort is assisted by the ventilator at an airway pressure that remains constant during the phase of inspiration. Inspiration is terminated when the peak Inspiratory flow reaches a preset level. (usually 25%)

Patient determines Rate Inspiratory time Airflow

PRVC A control mode, which delivers a set tidal volume with each breath at the lowest possible peak pressure. Delivers the breath with a decelerating flow pattern that is thought to be less injurious to the lung

Volume Support Equivalent to pressure support set a goal tidal volume the machine watches the delivered volumes and adjusts the pressure support to meet desired goal within limits set by you.

Airway Pressure Release Ventilation Can be thought of as giving a patient two different levels of CPAP Set high and low pressures with release time. Length of time at high pressure generally greater than length of time at low pressure. By releasing to lower pressure, lung volume is allowed to decrease to FRC

Certain other issues

Fixed insp. Time Termination sens. off

Termination sens. on

Pressure

Flow

Inspiratory cycle off


Proper Inspiratory cycle termination avoids lung hyperinflation and Increased work of breathing

10 % 5% 1%

40 % 10 %

Pressure limited
COMPLIANCE LINE

Vt.

PEEP Over distension

PIP

Pressure Volume loops

Pressure limited
COMPLIANCE LINE

Volume limited
COMPLIANCE LINE

Vt.
Low compliance

Vt.

PEEP

PIP

PEEP

PIP

Normal resistance B C D

Volume

A B C

Pressure in CM

Increased resistance D

Volume

Pressure in CM

volume Pressure

Triggering

Triggering
Neuro Ventilatory coupling .
Central Nervous System Ideal technology Neurally Adjusted Ventilatory Assist NAVA Ventilator

Phrenic Nerve

EA di Waveform

Diaphragmatic contraction

Chest Wall and Lung expansion

Air way pressure , flow and volume

Current Technology

Tidal volume P plat PEEP Tidal volume PIP PEEP

PIP P plat Flow rate

PIP- P2 Flow rate

Static compliance

Dynamic characteristics

Maximum resistance index

Minimum resistance index

Elastic and resistive property of respiratory System

Time constant

Resistive property

Conditional variables

Control variables
Pressure : Volume : Flow

Phase Variables Trigger : Limit : cycle : Base line

SLEEP even in difficult situation You can comfortably SLEEP if you know your physiology well

Thanks