2) Various ventilator modes.ppt

7/22/2019 2) Various ventilator modes.ppt

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Introduction to various modes of

mechanical ventilation

Peter C. RimensbergerPediatric and Neonatal ICUDepartment of Pediatrics

University Hospital of Geneva

Geneva, Switzerland


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APRVAirway pressure release ventilation

ASBAssisted spontaneous breathing

ASVassisted spontaneous ventilation

ASVAdaptive support ventilation

ASV assisted spontaneous ventilation.

ATCAutomatic tube compensation

AutomodeAutomode

BIPAP Bilevel Positive Airway Pressure

CMV Continuous mandatory ventilation

CPAP Continuous positive airway pressureCPPV Continuous positive pressure ventilation

EPAP Expiratory positive airway pressure

HFV High frequency ventilation

HFFI High frequency flow interruption

HFJV High frequency jet ventilation

HFOV High frequency oscillatory ventilation

HFPPV High frequency positive pressure ventilation

ILV Independent lung ventilation

IPAP Inspiratory positive airway pressure

IPPV Intermittent positive pressure ventilationIRV Inversed ratio ventilation

LFPPV Low frequency positive pressure ventilation

MMV Mandatory minute volume

NAVA Neurally Adjusted Ventilatory Assist

NIF Negative inspiratory

NIV Non-invasive ventilation

PAP Positive airway pressure

PAV and PAV+ Proportional assist ventilation and proportional assist ventilation plus

PCMV (P-CMV) Pressure controlled mandatory ventilation

PCV Pressure controlled ventilation or

PC Pressure control

PEEP Positive end-expiratory pressure

PNPV Positive negative pressure ventilation

PPS Proportional pressure support

PRVC Pressure regulated volume controlledventilation

PSV Pressure Support Ventilation or PS

(S) IMV (Synchronized) intermittent mandatory ventilation

S-CPPV Synchronized continuous positive pressure ventilation

S-IPPV Synchronized intermittent positive pressure ventilation

TNI Therapy with nasal insufflation

VCMV (V-CMV) Volume controlled mandatory ventilation
http://en.wikipedia.org/wiki/Airway_pressure_release_ventilationhttp://en.wikipedia.org/w/index.php?title=Assisted_spontaneous_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Assisted_spontaneous_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Automatic_tube_compensation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Automode&action=edit&redlink=1http://en.wikipedia.org/wiki/Positive_airway_pressurehttp://en.wikipedia.org/w/index.php?title=Continuous_mandatory_ventilation&action=edit&redlink=1http://en.wikipedia.org/wiki/Continuous_positive_airway_pressurehttp://en.wikipedia.org/w/index.php?title=Continuous_positive_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Expiratory_positive_airway_pressure&action=edit&redlink=1http://en.wikipedia.org/wiki/High_frequency_ventilationhttp://en.wikipedia.org/w/index.php?title=Independent_lung_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Inspiratory_positive_airway_pressure&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Inversed_ratio_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Low_frequency_positive_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Mandatory_minute_volume&action=edit&redlink=1http://en.wikipedia.org/wiki/Neurally_Adjusted_Ventilatory_Assisthttp://en.wikipedia.org/w/index.php?title=Negative_inspiratory_force&action=edit&redlink=1http://en.wikipedia.org/wiki/Non-invasive_ventilationhttp://en.wikipedia.org/wiki/Positive_airway_pressurehttp://en.wikipedia.org/w/index.php?title=Proportional_assist_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Proportional_assist_ventilation_plus&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Pressure_controlled_mandatory_ventilation&action=edit&redlink=1http://en.wikipedia.org/wiki/Pressure_controlhttp://en.wikipedia.org/wiki/Positive_end-expiratory_pressurehttp://en.wikipedia.org/w/index.php?title=Positive_negative_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Proportional_pressure_support&action=edit&redlink=1http://en.wikipedia.org/wiki/Pressure_regulated_volume_controlhttp://en.wikipedia.org/wiki/Pressure_Support_Ventilationhttp://en.wikipedia.org/w/index.php?title=Intermittent_mandatory_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Synchronized_continuous_positive_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Synchronized_intermittent_positive_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Therapy_with_nasal_insufflation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Volume_controlled_mandatory_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Volume_Support&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Volume_controlled_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Volume_controlled_mandatory_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Therapy_with_nasal_insufflation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Synchronized_intermittent_positive_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Synchronized_continuous_positive_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Intermittent_mandatory_ventilation&action=edit&redlink=1http://en.wikipedia.org/wiki/Pressure_Support_Ventilationhttp://en.wikipedia.org/wiki/Pressure_regulated_volume_controlhttp://en.wikipedia.org/wiki/Pressure_regulated_volume_controlhttp://en.wikipedia.org/w/index.php?title=Proportional_pressure_support&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Positive_negative_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/wiki/Positive_end-expiratory_pressurehttp://en.wikipedia.org/wiki/Positive_end-expiratory_pressurehttp://en.wikipedia.org/wiki/Positive_end-expiratory_pressurehttp://en.wikipedia.org/wiki/Pressure_controlhttp://en.wikipedia.org/w/index.php?title=Pressure_controlled_mandatory_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Proportional_assist_ventilation_plus&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Proportional_assist_ventilation&action=edit&redlink=1http://en.wikipedia.org/wiki/Positive_airway_pressurehttp://en.wikipedia.org/wiki/Non-invasive_ventilationhttp://en.wikipedia.org/wiki/Non-invasive_ventilationhttp://en.wikipedia.org/wiki/Non-invasive_ventilationhttp://en.wikipedia.org/w/index.php?title=Negative_inspiratory_force&action=edit&redlink=1http://en.wikipedia.org/wiki/Neurally_Adjusted_Ventilatory_Assisthttp://en.wikipedia.org/w/index.php?title=Mandatory_minute_volume&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Low_frequency_positive_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Inversed_ratio_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Inspiratory_positive_airway_pressure&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Independent_lung_ventilation&action=edit&redlink=1http://en.wikipedia.org/wiki/High_frequency_ventilationhttp://en.wikipedia.org/w/index.php?title=Expiratory_positive_airway_pressure&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Continuous_positive_pressure_ventilation&action=edit&redlink=1http://en.wikipedia.org/wiki/Continuous_positive_airway_pressurehttp://en.wikipedia.org/w/index.php?title=Continuous_mandatory_ventilation&action=edit&redlink=1http://en.wikipedia.org/wiki/Positive_airway_pressurehttp://en.wikipedia.org/w/index.php?title=Automode&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Automatic_tube_compensation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Assisted_spontaneous_ventilation&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Assisted_spontaneous_ventilation&action=edit&redlink=1http://en.wikipedia.org/wiki/Airway_pressure_release_ventilation


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Spontaneous

Breathing

Mechanical

Ventilation

Pressure

Pressure

Pressure

Pressu

re

P

ressure

Time

Time

Time

Time

Time

CMV

SIMV

Bivent

APRV

CPAP

Concepts and Modes of Mechanical Ventilation


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Ventilation modes

Controlled: CMV

Fully or partially assisted: SIMV

SIPPVA/C / PTV

PSV

SIMV + PSV

SIPPV + PSV


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CMV


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Control Modes

every breath is fully supported by the

ventilator

in classic control modes, patients wereunable to breathe except at the

controlled set rate

in newer control modes, machines mayact in assist-control, with a minimum

set rate and all triggered breaths above

that rate also fully supported.


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IMV

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, &

Wood LDH(eds.): Principles of Critical Care


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SIPPV (or PTV or A/C) and SIMV

Terminology:

Triggered ventilation can be divided into patient triggered

(PTV), otherwise known as synchronous intermittent

positive pressure ventilation (SIPPV) or assist control(A/C), the infant being able to trigger a positive pressure

inflation with each breath,

and synchronized intermittent mandatory ventilation(SIMV), the infant being able to trigger only a pre-set

number of positive pressure inflations.


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Assist-control

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, &Wood LDH(eds.): Principles of Critical Care


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SIMV

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, &

Wood LDH(eds.): Principles of Critical Care


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IMV

IMV, SIMV, SIPPV (or A/C or PTV), PSV

SIMV

Assist/Control


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Does the mode make the difference?


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SIMV versus IMV in neonatal ventilation

Conclus ions:We found that SIMV was

at least as efficacious as conventional

IMV, and may have improved certain

outcomes in BW-specific groups.

Bernstein G et al. J PEDIATR 1996;128:453-63


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Baumer JH Arch Dis Child Fetal Neonatal Ed2000;82:F5F10

PTV with inspiratory times of between 0.2 and 0.25 seconds, the ventilator

set to trigger at each inspiratory effort, backup rate of 35 breaths a minute.

IMV with ventilator rates set initially at between 40 and 65 breaths a minute

and initial inspiratory times between 0.2 and 0.6 seconds.

PTV (A/C) versus IMV


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There was no observed benefit from the use of PTV, with a trend

towards a higher rate of pneumothorax under 28 weeks of gestation.

Although PTV has a similar outcome to IMV for treatment of RDS in

infants of 28 weeks or more gestation, within 72 hours of birth, it was

abandoned more often. It cannot be recommended for infants of less

than 28 weeks gestation with the ventilators used in this study.

PTV (A/C) versus IMV

Baumer JH Arch Dis Child Fetal Neonatal Ed2000;82:F5F10


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Greenough A et al. Cochrane Database of Systematic Reviews 2004, Issue 3. CD000456.


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IMV

IMV, SIMV, SIPPV (or A/C or PTV), PSV

SIMV

Assist/Control

FSVPSV


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Pressure Control vs. Pressure Support

Constant insp. pressure

Decelerating, variable

inspiratory flow rate

Time cycled: (A)

Pressure Control

Flow cycled: (B) Pressure Support

Pressure

Flow

A B

Time Cycled

Flow Cycled


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Termination Sensitivity = Cycle-off Criteria

Flow

Peak Flow (100%)

TS 5%

Tinsp. (eff.)Set (max)

Tinsp.

Leak

Time


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PSV improves respiratory function in VLBW

infants when compared to SIMV

Migliori C et al. Pediatr Pulmonol. 2003;35:364367


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minimal ventilator settings:

PIP 16 cm H2O

FIO2 0.30

PEEP 5 cmH2O

SIMV rate 15 breaths per minuteand remained on these settings

for 48 hours

Reyes ZC et al. Pediatrics 2006;118;1409-1417

SIMV versus SIMV + PSV


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Reyes ZC et al.

Pediatrics 2006;118;1409-1417

SIMV versus SIMV + PSV

CONCLUSIONS. The results of this

study suggest that the addition of PS as

a supplement to SIMV during the first 28

days may play a role in reducing the

duration of mechanical ventilation inextremely VLBW infants, and it may

lead to a reduced oxygen dependency


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Compliance Changes During Pressure

Controlled Ventilation

Volume

Pressure

Compl iance


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Volume Ventilation

Tidal volume, is not affected by therapidly changing pulmonary mechanics

Compl iancePressure Ventilation: Volume Ventilation:

Decreased Tidal Volume Increased Pressure

Volume

PressurePressure

Volume


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Combination Dual Control Modes

Combination or dual control modes combine

features of pressure and volume targeting to

accomplish ventilatory objectives which might

remain unmet by either used independently.

Combination modes are pressure targeted

Partial support is generally provided by pressuresupport

Full support is provided by Pressure Control


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Combination Dual Control Modes

Concept: Assured Volume Ventilation at the

lowest Pressure

- Pressure Regulated Volume Control

- Autoflow

- Volume Guarantee- Volume Targeted Ventilation


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PRVC, VG, Autoflow, VTV

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 the guided hand.


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Volume Guarantee: New Approaches in Volume Controlled Ventilation for Neonates.

Ahluwalia J, Morley C, Wahle HG. Drger Medizintechnik GmbH. ISBN 3-926762-42-X


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Pressure

Flow

Volume

Set tidal volume

Charles Gomersall 2003

Decelerating inspiratory flow pattern (square wave pressure

build up)

Pressure automatically adjusted according respiratorymechanics to deliver set tidal volume

PRVC


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VTV Automatically Adjusts To

Compliance Changes


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Compliance increaseTerm infant settings

0

10

20

30

40

50

1 6 11 16 21 26

number of breaths

Vt (ml)Draeger Babylog 8000+

Draeger Evita XL

Hamilton Galileo

Siemens Servo-i

Bird VipGold

set Vt = 28 ml

Resistance decrease (500 to 50 cmH2O/lt/s)Term infant settings

0

10

20

30

40

50

60

70

1 6 11 16 21 26

number of breaths

Vt (ml)

Draeger Babylog 8000+

Draeger Evita XL

Hamilton Galileo

Siemens Servo-i

Bird VipGold

set Vt = 28 ml

Is VTV safe?

Jaecklin T et al. ICM 2007


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Compliance increaseTerm infant settings

0

10

20

30

40

50

1 6 11 16 21 26

number of breaths

Vt (ml)Draeger Babylog 8000+

Draeger Evita XL

Hamilton Galileo

Siemens Servo-i

Bird VipGold

set Vt = 28 ml

Compliance increasePreterm infant settings

0

5

10

15

2025

30

35

40

1 6 11 16 21 26 31 36

number of breaths

Vt (ml)

Draeger Babylog 8000+

Draeger Evita XL

Hamilton Galileo

Siemens Servo-iBird VipGold

set Vt = 8 ml

Resistance decrease (500 to 50 cmH2O/lt/s)Preterm infant setting

0

2

4

6

8

10

12

14

16

18

20

1 6 11 16 21 26 31 36

number of breaths

Vt (ml) Draeger Babylog 8000+

Draeger Evita XL

Hamilton Galileo

Siemens Servo-i

Bird VipGold

set Vt = 8 ml

Is VTV safe?

Jaecklin T et al. ICM 2007


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Advantages of volume targeted ventilation

A significant increase in lung

compliance, such as following

exogenous surfactant administration

will lead to a proportional increase in

delivered VT unless the inflating

pressure is reduced

Volume Guarantee: New Approaches in Volume Controlled Ventilation for Neonates.

Ahluwalia J, Morley C, Wahle HG. Drger Medizintechnik GmbH. ISBN 3-926762-42-X

As the VT increases due to

improving compliance after

surfactant administration, the

ventilator automatically drops the

PIP.


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PRCV: Advantages

Decelerating inspiratory flow pattern

Pressure automatically adjusted for changes incompliance and resistance within a set range

Tidal volume guaranteed

Limits volutrauma

Prevents hypoventilation


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PRVC: Disadvantages

Pressure delivered is dependent on tidal volume

achieved on last breathIntermittent patient effort variable tidal volumes

Pressure

Flow

Volume

Set tidal volume



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Pressure

Flow

Volume

Set tidal volume

PRVC: Disadvantages

Pressure delivered is dependent on tidal volume

achieved on last breathIntermittent patient effort variable tidal volumes



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Volume Targeted

Ventilation

Concept: deliver the set Vt

at the lowest airway

pressure possible

Cheema IU Pediatr ics2001;107:13231328

p < 0.001

p < 0.001


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Volume Targeted Ventilation

Cheema IU Pediatr ics2001;107:13231328


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IL-8

IL-6

TNFa

IL-6

Lista G Pediatr Pulmonol. 2004; 37:510514


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Volume targeted ventilation: A Self Weaning Mode

PSV group: The weaning strategy consisted of

reducing the pressure support level progressively

over time, so that the work of breathing was shifted

from ventilator to the patient.

PSV-VG group: Weaning was a more automatic

process once appropriate levels of Vt had been

established.Similar blood gas goals (e.g., pH>7.25; pO2, 5075

mmHg; pCO2, 4065 mmHg) were achieved during

weaning from mechanical ventilation in both groups.

Methods:

?


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Outcome VTV: Death in Hospital

The Cochrane Library2007,


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Outcome VTV: Duration of mechanical ventilation

The Cochrane Library2007,

Issue 1

P R l t d V l C t l V til ti S h i d


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Pressure-Regulated Volume Control Ventilation vs. Synchronized

Intermittent Mandatory Ventilation for Very Low-Birth-Weight Infants

DAngio CT et al. Arch Pediatr Adolesc Med. 2005;159:868-875

P R l t d V l C t l V til ti S h i d


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Pressure-Regulated Volume Control Ventilation vs. Synchronized

Intermittent Mandatory Ventilation for Very Low-Birth-Weight Infants

Conclusion:

In mechanically ventilated

infants with birth weights of 500

to 1249 g, using PRVC

ventilation from birth did not

alter time to extubation.

DAngio CT et al. Arch Pediatr Adolesc Med. 2005;159:868-875


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A total of 24 RCTs and 3 systematic reviews comparing various

CMV modes and settings and 2 RCTs investigating permissive

hypercapnia reported no differences in mortality or

bronchopulmonary dysplasia.

2) Various ventilator modes.ppt

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