ASV use and algorithm

HAMILTON MEDICAL AG
Switzerland
February 2001
Contents

•Introduction
•Clinical use of ASV
•Functional description of ASV
•Scientific basis
Introduction
a) Problems with conventional ventilators
Too many knobs, too many controls, very few guidelines
for setting controls

b) The obvious but difficult solution

Remove as many knobs as possible while still giving
the user control over the pertinent parameters

c) Definitions of pertinent parameters

V'A To control pH/PaCO2 and WOB
PEEP To control FRC and thus PaO2
FiO2 To control PaO2
Introduction (cont.)
CMV
Vt Rate Pinsp @ PEEP
Conventional SIMV
PCV Tp Psup Ti Te FiO2
PSV

Alveolar Ventilation Oxy.

PEEP
ASV
VA
FiO2
Uses of ASV

•As start-up procedure only

•To critique the actual settings
•During weaning with and w/o protocol
•For post-cardiac surgery patients only
•For all patients, including ARDS
How to use ASV clinically (1)

1) Set Body Wt of patient and high Pressure

limit to 45 mbar (will yield Pmax < 35
mbar)

2) Set %MinVol to 100% (except COPD)

3) Set PEEP & FiO2 according to clinical

requirements
4) Connect patient
How to use ASV clinically (2)

5) Ventilate for some minutes and

assess blood gases and/or WOB Repeat steps 5-9
(clinically) until you consider
extubation
6) Adjust %MinVol to meet pH/PaCO2
targets or WOB targets
7) Adjust PEEP and FiO2

8) Review high Pressure limit setting,

consider changes only in exceptions
9) Observe Ppeak and fSpont trends
Practical use Prepare GALILEO

Set high Pressure limit, Body Wt, %MinVol

Ventilate patient

Optimize %MinVol Set alarms

Check blood gases and clinical status

Plot Pinsp, fTotal, fSpont trend

No fSpont and
ABG OK?
Consider reducing
Yes %MinVol

Pinsp No
< 8 cmH2O

Yes

Consider weaning complete

Optimize %MinVol
see Operator‘s Manual p.D-13 and D-14

%MinVol change Remarks

Normal art. blood gases None
High PaCO2 Increase %MinVol Pay attention to
inspiratory pressures
Low PaCO2 Decrease %MinVol Pay attention to Pmean,
CO2 status
High respiratory drive Consider Increase in Consider sedation,
%MinVol analgesia, other treatment
Low O2 saturation None Consider PEEP and/or
FiO2 increase
How to monitor the patient

• Target graphics window shows

– ASV target MinVol, Vt, f
– Actually achieved values for MinVol, Vt, f
– Safety limits for Vt and f
– Check feasibility of %MinVol settings

• Trends show
– level of support provided by the ventilator vs. level of patient
activity
ASV Target Graphics
Window
How to monitor the patient:
Trend and track

Pinsp

fSpont
I I I I I I I
1h 2h 3h 4h
How does ASV work?
CMV
Vt Rate Pinsp @ PEEP
Conventional SIMV
PCV Tp Psup Ti Te FiO2
PSV

Alveolar Ventilation Oxy.

PEEP
ASV
VA
FiO2
Input: Minute ventilation
2000

V
1500
MinVol (l/min)
Vt (ml)

1000

500

0
0 20 40 60
f (b/min)
ASV is a "servant" to achieve a preset
MinVol while respecting boundary
conditions.
Command to servant

"Maintain at least 100% of normal ventilation,

take spontaneous breathing into account,
prevent tachypnea,
prevent AutoPEEP,
prevent excessive dead space ventilation,
fully ventilate in apnea or low drive,
give control to patient in case breathing activity
is okay, and do this without exceeding a 35 mbar
plateau pressure."
Functional description of ASV
see also
flow chart in ASV brochure
Appendix D of Operator‘s Manual
ASV User‘s Guide

1) Calculation of minute ventilation

2) Application of lung-protective rules
3) Optimal breath pattern
4) Approach the target
 1. Calculation of MinVol (trivial)
2000

V IBW

1500
Vt (ml)

1000
0.1 l/min (adults)
0.2 l/min (pediatric)
500

MinVol (l/min)

0
0 20 40 60
f (b/min)
IBW: Ideal Body Weight
2. Lung-protective rules (boundary conditions)
2000
5 test breaths
1500 10*Vd
A
Vt (ml)

1000 5
D b/min C
20/RCexp

500
B
2*Vd

0
0 20 40 60
f (b/min)
 3. Optimal breath pattern
2000

1500 1+2a*RCexp*(MV-V‘D)/VD -1
f-target =
a*RCexp
Vt ml

1000

500

0
0 20 40 60
f bpm
4. Adjust Pinsp & fSIMV to meet target
2000

1500 5 test breaths

Vt ml

1000

500

0
0 20 40 60
f bpm
Summary of functions

1. Calculate MinVol (trivial)

2000
2. Lung-protective rules
1500

3. Optimal breath pattern

Vt ml
1000

500

4. Approach the target

0
0 20 40 60

Repeat 2,3,4 breath-by-breath f bpm

Scientific basis

Machine- or patient-triggered Dead space ventilation

Effects of PSL

Role of RCexp

Choice of breathing pattern

Scientific basis (1)

Machine- or patient-triggered Dead space ventilation

FSIMPV

Effects of PSL

Role of RCexp

Choice of breathing pattern

Machine- or patient-triggered
ventilation

Fully
FullySynchronized
SynchronizedIntermittent
IntermittentMandatory
MandatoryPressure
Pressure
Ventilation
Ventilation(FSIMPV)
(FSIMPV)
"FSIMPV"

• Machine- and/or patient-triggered.

• Gas delivery is pressure-controlled for both the

mandatory and the spontaneous breaths. Pressure
levels are identical.

• Mandatory breaths are time-cycled if they were NOT

triggered by the patient, spontaneous breaths are flow-
cycled.

Control settings are: inspiratory pressure, respiratory rate, I:E ratio,

pressure ramp, and expiratory trigger sensitivity. Other controls include
FiO2 and PEEP/CPAP.
"FSIMPV"

Flow I + +
Flow E
* *
Pinsp

PEEP

No patient activity: Patient is active:

* Machine-triggered * Patient-triggered
+ Time-cycled + Flow-cycled
"FSIMPV"

Pinsp To adjust Vt and fspont

f To adjust the rate

Ti To adjust I:E

PEEP To control FRC

FiO2 To control PaO2
Scientific basis (2)

Machine- or patient-triggered Dead space ventilation

FSIMPV

Effects of PSL

Role of RCexp
Flow-volume loop
Choice of breathing pattern
Flow, volume, and pressure tracings: Dynamic hyperinflation
750
500
250
V'aw (ml/s)

0
-250
-500
-750
0 1 2 3 4 5 6 7 8 9 10 11
700
600 Time (s)
500
400
Vol (ml)

300
200
100
0
-100
0 1 2 3 4 5 6 7 8 9 10 11
35
30
25
Paw (cmH2O)

20
15
10
5
0
0 1 2 3 4 5 6 7 8 9 10 11
Expiratory time constant
600

500

400

E
300
I
Vol (ml)

200

100

-100
-1200 -800 -400 0 400 800

V'aw (ml/s)
Scientific basis (3)

Machine- or patient-triggered Dead space ventilation

FSIMPV

Effects of PSL

Role of RCexp
Flow-volume loop
Choice of breathing pattern
Minimal WOB (Otis)
Scientific basis (4)

Machine- or patient-triggered Dead space ventilation

FSIMPV Radford 2.2 ml/kg

Effects of PSL

Role of RCexp
Flow-volume loop
Choice of breathing pattern
Minimal WOB (Otis)
 Dead space guesstimation
250

200

Vd (Hart)
Vd - female (Radford)
Vd (ml)

150 Vd - male (Radford)

100

50

0
0 50 100 150 200 250
Height (cm)
Scientific basis (5)

Machine- or patient-triggered Dead space ventilation

FSIMPV Radford 2.2 ml/kg

Effects of PSL
Vt and f
Role of RCexp
Flow-volume loop
Choice of breathing pattern
Minimal WOB (Otis)
Effect of PS level in spontaneous breathing

600 30

500 25

400 20
Vt

/min
ml

300 15
f
200 10

100 5

0 0
PS 0 PS 4 PS 8 PS 12

Borchard et.al. 1991, Anesthesiology 75:739-745

Effect of PS level in spontaneous breathing

700 35

600 30

500 25

400 20 Vt

/min
ml

300 15 f

200 10

100 5

0 0
BPS-5 BPS BPS+5 BPS+10

G.Iotti et.al. 1995 Int Care Med 21:406-413

Scientific basis: Summary

Machine- or patient-triggered Dead space ventilation

FSIMPV Radford 2.2 ml/kg

Effects of PSL
Vt and f
Role of RCexp
Flow-volume loop
Choice of breathing pattern
Minimal WOB (Otis)
Benefits
•ASV works in passive and in active patients

•ASV promotes weaning from minute one

•ASV employs lung-protective strategies to minimize

complications from AutoPEEP and thus barotrauma

•ASV prevents tachypnea, apnea, excessive dead space

ventilation, and excessive breaths

•ASV adapts continuously to the needs of the patient

When technology is master
we shall reach disaster
faster
Piet Hein