UNIT - IV

Equipment for Critical Care

 Equipment for Critical Care
• Therapeutic equipment
( an instrument or an apparatus intended for use in diagnosis or treatment
and in the prevention of disease or maintenance or restoration of health)
– Pacemaker
– Defibrillator
– Shortwave diathermy
– Haemodialysis machine

• Respiratory Instrumentation
– Mechanism of respiration
– Spirometry
– Pneumotachograph
– Ventilators
 PACEMAKERS

• The rhythmic action of the heart is initiated

by regularly recurring action potentials
(electrochemical impulses) originating at
the natural cardiac pacemaker, located at
the Sino-Atrial (SA) node.

• Each pacing impulse is propagated

throughout the myocardium, spreading
over the surface of the atria to the
atrioventricular (AV) node and
depolarizing atria.

• After a brief delay at the AV node, the

impulse is rapidly conducted to the
ventricles to depolarize the ventricular
musculature.
• A normal sinus rhythm (NSR) depends on the
continuous, periodic performance of the pacemaker
and the integrity of the neuronal conducting pathways.
– Any change in the NSR is called an arrhythmia (abnormal
rhythm).

• The heart is paced at a much slower rate than normal,

ranging between 30 and 50 beats per minute (BPM).
– The result is a condition called bradycardia (slow heart)
– heart cannot provide sufficient blood circulation to meet the
body's physical demands
– dizziness and loss of consciousness (syncope) may occur
because of diminished cardiac output
• Heart block occurs whenever the conduction system fails to transmit the
pacing impulses from the atria to the ventricles properly.

• In first-degree block an excessive impulse delay at the AV junction occurs

that causes the P-R interval to exceed 0.2 second for normal adults.

• Second-degree block results in the complete but intermittent (not

continuous) inhibition of the pacing impulse, which may also occur at the
AV node.

• In third-degree block, total and continuous impulse blockage is occurred.

It may occur either at the AV node or elsewhere in the conduction
system.

• In all these conditions, an artificial method of pacing is generally required

to ensure that the heart beats at a rate that is sufficient to maintain
proper circulation.
For Ref.
 Pacemaker Systems
• A device capable of generating artificial pacing impulses and delivering
them to the heart is known as a pacemaker system (commonly called a
pacemaker).
– A pacemaker consists of a pulse generator and appropriate electrodes.

• Pacemakers are available in a variety of forms.

– Internal pacemakers may be permanently implanted in patients whose SA nodes

have failed to function properly or who suffer from permanent heart block
because of a heart attack.
– An internal pacemaker, the entire system is inside the body.

– An external pacemaker consists of an externally worn pulse generator connected

to electrodes located on or within the myocardium (muscular tissue of the heart).
– External pacemakers are used on patients with temporary heart irregularities
 Pacing Modes and Pulse Generators
• Several pacing techniques are possible with both internal and
external pacemakers.
– They can be classed as either competitive and noncompetitive pacing modes
as shown in below Figure.
• The noncompetitive method, which uses
pulse generators that are either ventricular
programmed or programmed by the atria.

– Ventricular-programmed pacemakers are

designed to operate either in a demand (R-wave-
inhibited) or standby (R-wave-triggered) mode

– Atrial-programmed pacers are always

synchronized with the P wave of the ECG
• In Competitive method, the Fixed-rate or
Asynchronous devices that produced pulses at a
fixed rate (set by the physician or nurse) and were
independent of any natural cardiac activity.

• Asynchronous pacing is called competitive pacing

because
– the fixed-rate impulses may occur along with natural
pacing impulses generated by the heart and in
competition with them in controlling the heartbeat

• This competition is largely eliminated through use of

ventricular or atrial-programmed pulse generators
• Fixed-rate pacers

– are sometimes installed in elderly patients whose SA nodes

cannot provide proper stimuli

– are also used temporarily to determine

• the amplitude of impulses needed to pace OR capture the heartbeat of
a patient, prior to or during the implantation of a permanent unit

– amplitude at which capture occurs is referred to as the pacing

threshold

– While the implantable fixed-rate units tend to fail less

frequently than the more sophisticated demand or standby
pacers, their battery life (if the batteries are not rechargeable) is
generally shorter because they are in constant operation.
• The problems of shorter battery life and competition for control of
the heart led to the development of ventricular-programmed
(demand or standby) pulse generators.

• Ventricular-programmed pulse generator,

– when connected to the ventricles via electrodes, is able to sense the
presence (or absence) of a naturally occurring ‘R’ wave.
– As long as natural (intrinsic) R waves are present, output of an R-wave-
inhibited unit (demand type) is suppressed (no output pulses are
produced).
– Thus, pulse generator output is held back or inhibited when the heart is
able to pace itself.
– When intrinsic rate fall below the preset rate of the pacer (around 70 BPM)
occur, the unit will automatically provide an output to pace the heart.

• In this way, ventricular-inhibited pacers are able to pace on demand.

– A Demand Pacer, in the absence of R waves, automatically reverts to a
fixed-rate mode of operation.
• For testing purposes (at the time of implantation and for evaluation
later), implanted demand pacers are purposely placed in a fixed-
rate mode, by means of a magnet provided by the manufacturer.

– When placed over the skin layer covering the pacer, the magnet activates a
magnetically operated switch that prevents the pacer from sensing R-wave
activity.

– This process causes the pacer to operate in a fixed-rate mode at a slightly

higher rate (about 10 BPM higher than the demand-mode pacing rate that
had been preset).

• Earlier implanted pacers may be changed with the use of a needle-

like screwdriver (a Keith surgical skin needle) that is inserted to
alter the rate control in the pulse generator.
• R-wave-triggered pulse generators,

– sense each intrinsic R wave and pacer emits an impulse with the occurrence of
each sensed R wave.

– Thus, the unit is triggered rather than inhibited by each R wave.

– The pacing impulses are transmitted to the myocardium during its absolute
refractory period, however, so they will have no effect on normal heart activity.

– When the intrinsic (natural) heart rate fall below the preset rate of the pacer, the
pacer will automatically operate synchronously at its preset rate to pace the heart.

– Thus, this pacemaker stands by to pace when needed.

• Ventricular-triggered pacing is used less frequently than inhibited-mode

pacing.
• Atrial synchronous pacing may be used,
– in cases of complete heart block (where
the atria are able to depolarize but the
impulse fails to depolarize the ventricles)

• Here the pulse generator is connected

through wires and electrodes to both
the atria and the ventricles.

• The atrial electrode couples atrial

impulses to the pulse generator, which
then emits impulses to stimulate the
ventricles via the ventricular electrode.

• In this way, the heart is paced at the

same rate as the natural pacemaker.
• Pulses applied directly to the heart are usually rectangular in
shape with a duration of from 0.15 to 3 msec, depending on
the type of pulse generator used and the needs of the
patient.

• Pulse amplitudes may range from 5 to 15 mA for adults,

while infants and children require less.

• The quality of the electrode-heart muscle contact also

affects a demand pacer's inhibition capability or sensitivity

• Two types of electrodes are used in pulse generators,

– Unipolar electrodes have one electrode placed on or in the heart
and the other (reference) electrode located somewhere away from
the heart
– Bipolar electrodes have both electrodes on or in the heart.
• The pulse generators are powered by a hermetically (air-
tight) sealed lithium iodine power source and utilize air
tight sealed hybrid electronic circuitry.

• The power source is rated at 5.6 V with 1.1-Ahour capacity

and is expected to last for 7 to 10 years with continuous
pacing at 72 pulses per minute.

• Nominal dimensions of the circular-shaped pulse

generators are 56 mm (2.2 in.) in diameter by 18 mm (0.71
in.) in thickness.

• Weight is a nominal 95 grams.

 Internal Pacemaker (Demand type)
Block Diagram

Figure: Block diagram - components of the circuitry (Demand type)

• The timing circuit (which consists of an RC network, a reference voltage source,
and a comparator ) determines the basic pacing rate of the pulse generator.

• Timing circuit output signal feeds into a pulse width circuit (second RC
network ), which determines the stimulating pulse duration.

• Rate-limiting circuit (a third RC network), disables the comparator for a preset

interval and thus limits the pacing rate to a maximum of 120 pulses per minute

• Output circuit provides a voltage pulse to stimulate the heart

• Voltage monitor circuit senses cell depletion and signals the rate slowdown
circuit and energy compensation circuit of this event.

• When cell depletion has occurred, Rate slowdown circuit shuts off some of the
current to the basic timing network to cause the rate to slow down 8 ± 3 beats
per minute

• Energy-compensation circuit causes the pulse duration to increase as the

battery voltage decreases, to maintain nearly constant stimulation energy to
the heart.
• There is also a feedback loop from the output circuit to the refractory circuit,
– which provides a period of time following an output pulse or a sensed R-wave during
which the amplifier will not respond to outside signals.

• The sensing circuit detects a spontaneous R wave and resets the oscillator
timing capacitor.

• The reversion circuit allows the amplifier to detect a spontaneous R wave in

the presence of low-level continuous wave interference.

• In the absence of an R wave, this circuit allows the oscillator to pace at its
preset rate ± 1 beat per minute.
 DEFIBRILLATORS
• The rapid spread of action
potentials over the surface of the
atria causes two chambers of the
heart to contract together and
pump blood through the two
atrioventricular valves into the
ventricles.

• After a critical time delay, the

powerful ventricular muscles are
SYNCHRONOUSLY activated to
pump blood through the
pulmonary and systemic
circulatory systems.

• A condition in which this

necessary synchronism is LOST is
known as fibrillation.
• During fibrillation the normal rhythmic
contractions of either the atria or the
ventricles are replaced by rapid irregular
twitching of the muscular wall.
– Fibrillation of atrial muscles is called atrial
fibrillation;
– Fibrillation of the ventricles is known as
ventricular fibrillation.

• Fibrillation, once begun, is not self-correcting.

• The application of an electrical shock to resynchronize the heart is sometimes
called counter shock. If the patient does not respond, the burst is repeated
until defibrillation occurs.
• This method of counter shock was known as ac defibrillation.

• AC Defibrillation is done by applying a brief (0.25 to 1 sec) burst of 60-Hz AC at

an intensity of around 6 A to the chest of the patient through appropriate
electrodes.

• Drawback AC defibrillation:
– It cannot be successfully used to correct atrial defibrillation.
– attempts to correct atrial fibrillation by this method often result in the more serious
ventricular fibrillation.
– Thus, ac defibrillation is no longer used.
• DC defibrillation:
– In this method, a capacitor is charged to a high dc
voltage and then rapidly discharged through
electrodes across the chest of the patient.

• DC defibrillation is more successful in correcting

ventricular fibrillation, for correcting atrial
fibrillation and other types of arrhythmias.

• The DC method requires fewer repetitions and

is less likely to harm the patient.
• Amount of electrical energy discharged by the capacitor may range between 100 and 400 W-sec, or joules.

• Duration of the effective portion of the discharge is approximately 5 msec.

• Energy delivered is represented by the typical waveform shown in below Figure. (time plot of the current
forced to flow through the thoracic cavity).

• Area under the curve is proportional to the energy delivered.

• It can be seen that the peak value of current is nearly 20 A and monophasic.

• An inductor in the defibrillator is used to shape the wave in order to eliminate a sharp, undesirable current
spike.

Fig: Typical DC defibrillator circuit Fig: DC defibrillator discharge wave form

• Even with dc defibrillation, there is danger of damage to the myocardium and the
chest walls because peak voltages as high as 6000 V may be used.

• To reduce this risk, some defibrillators produce dual-peak waveforms of longer

duration (approximately 10 msec) at a much lower voltage.

• Effective defibrillation can be achieved in adults with lower levels of delivered

energy (between 50 and 200 W-sec).

• A typical dual-peak waveform is shown in Figure below

• Effective defibrillation at the desirable lower-voltage levels is also possible with the truncated
waveform shown in Figure below.

• The amplitude of this waveform is relatively constant, but its duration may be varied to obtain
the amount of energy required.

• To properly deliver a large current discharge applied through the skin large electrodes are used.
• These electrodes, called paddles, have metal disks that usually measure from 8 to 10 cm (3 to 4
in.) in diameter for external (transthoracic) use.

• Conductive jelly or a saline-soaked gauze pad (the latter is preferred) is applied between each
paddle surface and the skin to prevent burning.
• The two defibrillator electrodes applied to the thoracic walls are called either
anterior-anterior or anterior-posterior paddles.
– With anterior-anterior paddles, both paddles are applied to the chest.
– Anterior-posterior paddles are applied to both the patient's chest wall and back so that
the energy is delivered through the heart.

• Defibrillators are also used to convert other potentially dangerous arrhythmias

to one that is easily managed. This process is referred to as cardioversion.
– For this procedure, anterior-posterior paddles are generally used.
– For example, a defibrillator discharge may be used to convert a tachycardia (fast heart)
arrhythmia to a normal rhythm.
• To avoid the possibility of ventricular fibrillation resulting from the application
of the DC pulse in cardioversion, the discharge must be synchronized with the
ECG.

– The optimum time for discharge is during or immediately after the downward slope of
the R wave
(when the heart is in its absolute refractory period).

– This synchronization will ensure that the counter shock is not delivered during the
middle of the T wave, which is called the heart's vulnerable period.

– During this time, since it is partially refractory, the heart is susceptible to ventricular
fibrillation by the introduction of artificial stimuli.
 Shortwave diathermy
• Diathermy means ‘through heating’ or producing deep heating
directly in the tissues of the body.

• Advantages of diathermy technique:

– subject’s body becomes a part of the electrical circuit
– heat is produced within the body and not transferred through the skin
– treatment can be controlled precisely
– Careful placement of the electrodes permits localization of the heat to the
region that has to be treated
– amount of heat can be closely adjusted by means of circuit parameters

• Drawbacks of traditional systems:

– Externally applied sources of heat like hot towels, infrared lamps and
electric heating pads often produce discomfort and skin burns long before
adequate heat has penetrated to the deeper tissues
• Heating of the tissues is carried out by high frequency
alternating current (AC) which generally has a frequency
of 27.12 MHz and a wavelength of 11 m

• No discomfort is caused to the subject, because high

frequency currents do not stimulate motor or sensory
nerves and they do not produce any muscle contraction

• Method consists in applying the output of a radio

frequency (RF) oscillator to a pair of electrodes which are
positioned on the body over the region to be treated

• RF energy heats the tissues and promotes healing of

injured tissues and inflammations
• Circuit Description: The short wave diathermy machine consists of two
main circuits:
– an oscillating circuit, which produces a high frequency current and
– a patient circuit, which is connected to the oscillating circuit and through which the
electrical energy is transferred to the patient

• A typical example of which is shown in below Fig:

Fig: Simplified circuit diagram of a short-wave diathermy unit

• Transformer T1 is a step-up transformer for providing EHT (Extra High Tension) for
the anode of the triode valve.

• A second winding can provide heating current for the cathode of the triode valve.

• The tank (resonance) circuit is formed by the coil AB in parallel with the condenser
C1.

• Positive feedback is generated by coil CD.

• There is another coil EF and a variable condenser C2 which form the patient’s
resonator circuit due to its coupling with the oscillator coil AB.
• The anode supply of such a circuit is around 4000 V.

• The conduction in the triode takes place during the positive half-cycle and the high frequency is generated only during this period.

• The supply voltage is rectified before supplying to the anode of the oscillator valve. In such a case, the oscillations produced are
continuous and more power thus becomes available.

• In order to ensure that the oscillator circuit and the patient’s resonator circuit are tuned with each other, an ammeter is placed in series
with the circuit.

• The variable condenser C2 is adjusted to achieve a maximum reading on the meter, the needle swinging back on either side of the tuned
position.

• The maximum power delivered by these machines is 500 W.

• A thermal delay is normally incorporated in the anode supply which prevents the passage of current through this circuit until the
filament of the valve attains adequate temperature.

• The patient circuit is then switched on followed by a steady increase of current through the patient.

• A mains filter is incorporated in the primary circuit to suppress interference produced by the diathermy unit itself.
• There are several ways of regulating the intensity of current supplied
to the patient from a short-wave diathermy machine. This can be done
by either
– (i) controlling the anode voltage, or
– (ii) controlling the filament heating current, or
– (iii) adjusting the grid bias by change of grid leak resistanceR1, or
– (iv) adjusting the position of the resonator coil with respect to the oscillator
coil.

• However, the best way of finely regulating the current is by adjusting

the grid bias, by putting a variable resistance as the grid leak
resistance.
• Automatic Tuning in Short-wave Diathermy Machines:

– Tuning must be carefully carried out at the beginning of the treatment

and continuously monitored during the treatment.

– Tuning getting affected due to involuntary movements of the patients

and the resultant fall of dosage.

– In order to overcome the problem of making tuning adjustments during

the course of treatment, an additional circuit is fitted in the machine.

– The RF current in the patient circuit changes a capacitor to a voltage,

whose polarity and magnitude is a measure of the detuning of the
patient circuit.

– This voltage accordingly moves a servo-motor, adjusting the tuning

capacitor so that resonance is restored.
• Figure below shows a diathermy machine with automatic tuning in operation

Fig: Short-wave therapy unit with automatic tuning in use

Application Technique of Short-wave Therapy:

• Two most common forms of application include the capacitor plate

method and the inductive method shown in below figure:

Fig: Method of applying electrodes in short-wave diathermy treatment

(a) condenser method (b) inductive method
In the capacitor plate method,
• the output of the short-wave diathermy machine is connected to metal
electrodes which are positioned on the body over the region to be treated.

• These electrodes are called ‘PADS’ in the terminology of the diathermy.

• These pads or electrodes do not directly come into contact with the skin
– Usually layers of towels (sometimes air spaced also) are interposed between the
metal and the surface of the body.
– The pads are placed so that the portion of the body to be treated is sandwiched
between them.

• This arrangement is called the ‘Condenser Method’ wherein the metal pads
act as two plates while the body tissues between the pads as ‘dielectric’ of
the capacitor.

• When the radio frequency output is applied to the pads, the dielectric
losses of the capacitor manifest themselves as heat in the intervening
tissues.

• The dielectric losses may be due to vibration of ions and rotation of dipoles
in the tissue fluids (electrolytes) and molecular distortion in tissues which
are virtually insulators like fats.

• Figure shows the use of air-spaced condenser electrodes for short-wave

diathermy treatment.
In inductive method,
• output of the diathermy machine may be connected to a flexible cable instead of pads.

• This cable is coiled around the arm or knee or any other portion of the patient’s body where plate electrodes are
inconvenient to use.

• When RF current is passed through such a cable, an electrostatic field is set up between its ends and a magnetic field
around its centre

• Deep heating in the tissue results from electrostatic action whereas the heating of the superficial tissues is obtained by
eddy currents set up by a magnetic effect.

• This technique is known as ‘inductothermy’.

• Intensity of treatment is dependent on the subjective sensation of warmth felt by the patient.
 Haemodialysis machine
• General scheme for operation of Haemodialysis machine is shown below:

Figure:
• An Artificial kidney periodically connected to the circulatory system of uremic
patients to remove metabolic waste products from the blood.
(Metabolic wastes are substances left over from metabolic processes which cannot be used
by the organism. This includes nitrogen compounds, water, CO₂, phosphates, sulphates, etc.)

• There are two basic units of Haemodialysis system:

– Exchanger
– Dialysate delivery system

There are three basic types of exchangers:

• Coil dialyzer
• Parallel-plate dialyzer
• Hollow-fiber kidney
• Coil dialyzer:
• Parallel-plate dialyzer
• Hollow-fiber kidney
• Dialysate delivery system :
– Metering pumps mix the concentrated dialysate with water
– Another pump circulate the dialysate through an exchange chamber

• Electronic instruments & Precautions:

– Leakage in the semipermeable membrane causes immediate blood
loss
– Optical leakage detector (colorimetric or optical density change) is used
to detect leakage, because dialysate is a clear liquid and blood is red
– Instrument also monitors pressure change in the blood compartment
to detect Major leaks or clotting
– Any abnormality in gross concentration of electrolytes in dialysate
measure the conductivity of the dialysate in mixing chamber using
impedance technique
– Air bubble in the blood stream produces life-threatening air emboli.
When bubbles are detected, the blood pump is turned off until the
problem is solved.
• Respiratory Instrumentation
– Mechanism of respiration
– Spirometry
– Pneumotachograph
– Ventilators
Respiratory system
Negative pressure
 TESTS AND INSTRUMENTATION
FOR THE MECHANICS OF BREATHING

• The mechanics of breathing concern the

ability of a person to bring air into his lungs
from the outside atmosphere and to exhaust
air from the lungs.

• Basic pulmonary tests are those designed for

determination of lung volumes and capacities
 Lung volumes and capacities
• The tidal volume (TV), or normal depth of breathing,
– is the volume of gas inspired or expired during each normal, quiet, respiration cycle.

• Inspiratory reserve volume (IRV)

– is the extra volume of gas that a person can inspire with maximal effort after reaching the normal end inspiratory level.
– The end inspiratory level is the level reached at the end of a normal, quiet inspiration.

• The expiratory reserve volume (ERV)

– is that extra volume of gas that can be expired with maximum effort beyond the end expiratory level.
– The end expiratory level is the level reached at the end of a normal, quiet expiration.

• The residual volume (RV)

– is the volume of gas remaining in the lungs at the end of a maximal expiration.
• The vital capacity (VC)
– is the maximum volume of gas that can be expelled from the lungs by forceful effort after a
maximal inspiration.
– It is actually the difference between the level of maximum inspiration and the residual volume, and
it is measured without respect to time.
– The vital capacity is also the sum of the tidal volume, inspiratory reserve volume, and expiratory
reserve volume.

• The total lung capacity (TLC)

– is the amount of gas contained in the lungs at the end of a maximal inspiration.
– It is the sum of the vital capacity and residual volume.
– Total lung capacity is also the sum of the tidal volume, inspiratory reserve volume, expiratory
reserve volume, and residual volume.
• The inspiratory capacity (IC)
– is the maximum amount of gas that can be inspired after reaching the end
expiratory level.
– It is the sum of the tidal volume and the inspiratory reserve volume.

• The functional residual capacity (FRC)

– is the volume of gas remaining in the lungs at the end expiratory level.
– It is the sum of the residual volume and the expiratory reserve volume.
– The FRC can also be calculated as the total lung capacity minus the
inspiratory capacity
• Breathing is a dynamic process, and
– the rate at which gases can be exchanged with the blood
is a direct function of the rate at which air can be inspired
and expired.

• A measure of the overall output of the respiratory

system is the respiratory minute volume.

• Respiratory minute volume

– is a measure of the amount of air inspired during 1
minute at rest.
– It is obtained by multiplying the tidal volume by the
number of respiratory cycles per minute.
• A number of forced breathing tests are used to assess
– the muscle power associated with breathing and
– the resistance of the airway.

• Forced Vital Capacity (FVC)

– is the total amount of air that can forcibly be expired as quickly as
possible after taking the deepest possible breath.
– If the measurement is made with respect to the time, it is called a
timed vital capacity measurement.

• Forced Expiratory Volume (FEV)

– is a measure of the maximum amount of gas that can be expelled in a
given number of seconds
– For example, FEV1 indicates the amount of air that can be blown out in 1
second following a maximum inspiration
– FEV is sometimes given as a percentage of the FVC.
(FEV1 / FVC) x 100%
• Another useful measurement for assessing
the integrity of the breathing mechanism is
the maximal breathing capacity (MBC) or
maximal voluntary ventilation (MVV).
– This is a measure of the maximum amount of air
that can be breathed in and blown out over a
sustained interval, such as 15 or 20 seconds.
– A ratio of the maximal breathing capacity to the
vital capacity is also of clinical interest.
(MVV/VC)
• With each breath, most of the air enters the lungs to fill
the alveoli. However,
– a certain amount of air is required to fill the various cavities of
the air passages.
– This air is called the dead-space air, and the space it occupies is
called the dead space.

• The amount of air that actually reaches the alveolar

interface with the bloodstream with each breath is the
tidal volume minus the volume of the dead space.

• The respiratory minute volume can be broken down into

the alveolar ventilation per minute and the dead space
ventilation per minute.
 Instrumentation for Measuring the
Mechanics of Breathing
• The most widely used laboratory instrument
for respiratory volume measurements is the
recording spirometer.

• Using spirometer, we can obtain,

– all lung volumes and capacities that can be
determined by measuring the amount of gas
inspired or expired under a given set of
conditions or during a specified time interval
 Fig: Standard Spirometer

• The standard spirometer consists of a movable bell inverted over a chamber of water.

• Inside the bell, above the water line, is the gas that is to be breathed.

• The bell is counterbalanced by a weight to maintain the gas inside at atmospheric pressure
– so that its height above the water is proportional to the amount of gas in the bell.

• A breathing tube connects the mouth of the patient with the gas under the bell.
• Thus, as the patient breathes into the tube, the bell moves up and down with each
inspiration and expiration in proportion to the amount of air breathed in or out.

• Attached to the bell or the counterbalancing mechanism is a pen that writes on an

adjacent drum recorder, called a kymograph.

• As the kymograph rotates, the pen traces the breathing pattern of the patient.
• Several other types of Spirometers are available.
– For example, waterless spirometers (shown in Figure), which are also used clinically, operate on a principle similar to
that of the spirometer.

• Principle:
– In this instrument the air to be breathed is held in a chamber enclosed by two parallel metal pans hinged to each
other along one edge.

– The space between the two pans is enclosed by a flexible bellows (Like a fireplace bellows) to form the chamber.

– One of the pans, which contains an inlet tube, is fixed to a stand and the other swings freely with respect to it.

– The pan moves in response to very slight changes in volume.

– The instrument provides electrical outputs proportional to both volume and airflow, from which the required
determinations can be obtained.
 Spirogram
• In order to produce a spirogram,
– the patient is instructed to breathe through the mouth piece of the spirometer.
– His nose is blocked with a clip so that all breathing is through the mouth.

• The recorder is first set to a slow speed to measure vital capacity (typically, 32 mm/min).
– The patient breathed quietly for a short time at rest so as to provide a baseline.
– He was then instructed to exhale completely and then to inhale as much as he could.
– This process produced the vital capacity record at the extreme right of the figure.
• With his lungs at the maximal inspirational level,
– the patient held his breath a short time while the recorder was shifted to a higher
chart speed (e.g., 1920 mm/min).
– The patient was then instructed to blow out all the air he could as quickly as
possible to produce the FEV, curve on the record.
– To calculate the FEV1, a 1 -second interval was measured from the beginning of the
maximum slope.
• For the determination of maximal voluntary ventilation (MVV), the recorder is set at an intermediate speed.
– After a short rest, a few cycles of resting respiration were recorded.
– The patient was then instructed to breathe in and out as rapidly as possible for about 10 seconds, producing the MVV
record in the figure.

• Most spirometry tests are repeated two or three times

• Some instruments require that the height of the tracings be converted to Liters by use of a calibration factor
for the instrument, called the spirometer factor.
– This calibration factor can be obtained from a table or chart.

Vid - Spirometry Test for Lung Function

Vid - Spirometry
 Ventilators
Ventilators and Respirators

• The terms ventilator and respirator are used interchangeably

• Ventilator is used to continuously or intermittently

– to improve ventilation of the lungs and
– to supply humidity or aerosol medications to the pulmonary tree

• Most ventilators in clinical settings use positive pressure during inhalation to inflate the
lungs with various gases or mixtures of gases (air, oxygen, carbon dioxide, helium, etc.).

• Expiration is usually passive, although under certain conditions pressure may be

applied during the expiratory phase as well, in order to improve arterial oxygen tension.

• Most respirators can be operated in any one of the three different modes:
– Assist mode
– Controller mode
– assist-controller mode
• In the assist mode,

– inspiration is triggered by the patient.

– A pressure sensor responds to the slight negative pressure that

occurs each time the patient attempts to inhale and triggers the
apparatus to begin inflating the lungs.
– Thus, the respirator helps the patient inspire when he wants to
breathe.

– A sensitivity adjustment is provided to select the amount of patient

effort required to trigger the machine.

– The assist mode is used for patients who are able to control their
breathing but are unable to inhale a sufficient amount of air
without assistance.
• In the control mode,

– breathing is controlled by a timer set to provide the

desired respiration rate.

– Controlled ventilation is required for patients who

are unable to breathe on their own.

– In this mode the respirator has complete control

over the patient's respiration and does not respond
to any respiratory effort on the part of the patient.
• In the assist-control mode,

– the apparatus is normally triggered by the patient's

attempts to breathe, as in the assist mode.

– if the patient fails to breathe within a predetermined time,

a timer automatically triggers the device to inflate the
lungs.

– Thus, the patient controls his own breathing as long as he

can, but if he should fail to do so, the machine is able to
take over for him.

– This mode is most frequently used in critical care settings.

• Once inspiration has been triggered, inflation of the lungs
continues until one of the following conditions occurs:

– 1. The delivered gas reaches a predetermined PRESSURE in the

proximal or upper airways.
• A ventilator that operates primarily in this manner is said to be
pressure-cycled.

– 2. A predetermined VOLUME of gas has been delivered to the

patient.
• This is the primary mode of operation of volume cycled ventilators.

– 3. The air or oxygen has been applied for a predetermined

period of TIME.
• This is the characteristic mode of operation for time-cycled ventilators.
Pneumotachograph