The evolution of Ventilator

Three problems of ventilation

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 ?

Applied Physics
What can we manipulate ?

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

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

Inspiratory pause

Tidal volume.

Cst =

Cc

Static pressure end expiratory pressure

Flow

Pressure

Cst : static compliance

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

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 ?

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

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.

Conditional variables
Pressure
Volume
Flow
Time

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.

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

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

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

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

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

Pressure

End of inspiration

Peak pressure
Plateau pressure

Resistance
Compliance

Pressure control
Volume

Flow

Pressure

End of insp. flow

What does not change .

1) Volume curve
2) Exp. Flow curve

Volume control

Pressure control
Volume

Flow

Volume
End of insp. 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

A normal lung

B decreased compliance

F
L
O
w

V
O
L
U
M
e

C increased resistance

SIMV
Patient triggered ventilation
Synchronized to patient breath
if the threshold is met .

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

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

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

Flow
Trigger

PaW

Volume

A .Controlled and time triggered

B .Spontaneous
C .Synchronized and assisted

Pressure

Trigger
Spontaneous
breath
Spontaneous
breath
Volume

Spontaneous
volume

Assisted breath
Back up ventilation period

Controlled breath

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

Pressure

Flow

Termination sens. on

10 %

Inspiratory cycle off

5%

Proper Inspiratory cycle termination

avoids lung hyperinflation and

1%

Increased work of breathing

40 %
10 %

Pressure limited
COMPLIANCE LINE

In
sp

Ex
p.

Vt.

PEEP
Over distension

PIP

Pressure Volume loops

Volume limited

Pressure limited
COMPLIANCE LINE

COMPLIANCE LINE

In
sp

In
sp
.

Ex
p.

Low
compliance

Ex
p.

Vt.

Vt.

PEEP

PIP

PEEP

PIP

Normal resistance
B

C
D

Volume

A
B

Pressure in CM
C
Increased resistance
D

Volume

Pressure in CM

volume

ork
w
tic
s
a
El

ork
w
ive
t
s
i
s
Re

Pressure

Triggering

Triggering
Neuro Ventilatory coupling .
Ideal technology

Central Nervous System

Phrenic Nerve

EA di
Waveform

Neurally Adjusted
Ventilatory Assist

Diaphragmatic contraction

NAVA

Ventilator

Chest Wall and Lung expansion

Air way pressure , flow and volume

Current
Technology

Tidal volume P plat PEEP Tidal volume PIP PEEP

Static compliance

Dynamic
characteristics

Elastic and resistive

property of respiratory
System

PIP P plat Flow rate

Maximum resistance
index

Time constant

PIP- P2 Flow rate

Minimum resistance
index

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

Mechanical Ventilation is a blend

science and art .