Sunday, April 24, 2011

Setting Ventilator Alarms Diagnostically

Many practitioners set alarm thresholds thoughtlessly due to the fact that many ventilators do a poor job of filtering alarm nuisances versus 'high-risk' alarms. Many times I see the high respiratory rate alarm set at threshold in which the patient would have severe air trapping and dynamic hyperinflation before the alarm threshold is met.

When using controlled modes of ventilation (VC-CMV & PC-CMV) it is extremely important to set the high respiratory rate alarm threshold appropriately.

During both machine and patient initiated breaths the inspiratory time is fixed, so any additional breaths takes away from the expiratory time which can quickly lead to a inverse inspiratory-to-expiratory (I: E) ratios.

How to set the High Respiratory Rate Alarm Diagnostically

In patients with obstructive airway disease I prefer to set my high
respiratory rate based on a 1:1, I: E ratio. 
That is when the patient sets off the high respiratory rate alarm I know that they are breathing at a 1:1 ratio and that any additional breaths will be an inverse I: E ratio, putting the patient at a increased risk for dynamic hyperinflation.

This is easy to calculate based on the patient's set inspiratory time.

Formula: x = 60/(I-time * 2)
X (high respiratory rate alarm)
60 (total cycle time)
I-time (machine set I-time)

A common I-time is 1.0 second this would equal a high respiratory rate alarm of 30 breaths/minute. This stays the same if the set rate is 8 or 25; the 1:1 threshold is at 30 breaths/min.

The 0.25 Second difference

If air trapping is a concern just decrease the I-time.
A 0.25 second change is significant. 

Decreasing the I-time from 1.0 second to 0.75 second increases the
alarm threshold to 40 bpm.