Ventilator Graphics (Japanese edition)

人工呼吸器グラフィック 患者の人工呼吸器外れを識別すると、設定を最適化します。

ARCHIVES

Pea Island Life Saving Station and Crew. Pea Island, NC Circa 1890

I have decided to stop posting public content and plan to keep this site up as an archives. However, new content available via subscription to the free newsletter. If interested sign up by selecting News letter tab or below. 

NEWS LETTER

Whats your mode? Episode ii (VC-CMVd)

Image 1. Pressure limitation associated with dual targeting may reduce the incidence of premature cycling.

Episode two of "Whats your mode" VC-CMV with dual targeting is now finished and available to my news letter subscribers. To receive access to this video please sign up for my news letter at this link: http://kscottrichey.blogspot.com/p/news-letter.html

You can also access the the news letter link from the tab on the top of the page labeled "News letter".

PRE-REQUISITE/RECOMMENDED VIDEOS

TARGETING SCHEMES

DUAL TARGETING

RELATED VIDEOS

EPISODE i

WHATS YOUR MODE

REFERENCE

A taxonomy for mechanical ventilation: 10 fundamental maxims.

A rational framework for selecting modes of ventilation.

Building a Ventilator Simulator with Power Point

I worked on this project for a mobile app wire-frame three years ago and recorded the process (over 70 short videos) thinking someone else might want to use this technique. This technique is for anyone that has ever wanted to build a simulator however does not have a computer programming background. These videos demonstrate how to build a interactive operator interface for an mechanical ventilator using MS Power Point. These lessons can be applied to create simulators for education, presentations, mobile app prototyping, etc.

VIDEO PLAYLIST

VENTILATOR SIMULATOR w MS PPT

Whats Your Mode? Episode i

Image 1. Settings within "Volume Control" a VC-CMVs modality on the FLOW-i anesthesia Delivery system. All highlighted settings may affect patient comfort.

My first episode of my new video series is now available to my news letter subscribers.
I posted a teaser video on YouTube (see below). 

Note- if you signed up to receive my news letter and do not have it in your "in-box" please check your spam folder.

VIDEOS to COME
(a * next to the name indicates this video is only available to news letter subscribers)

VC-CMVd*

VC-IMVs,s
VC-IMVds*
VC-IMVda,s*
VC-IMVd,a*
VC-IMVa,s*

PC-CMVs
PC-CMVa*

PC-IMVs,s
PC-IMVa,s*
PC-IMVa,a*
PC-IMVo,o*

PC-CSVs
PC-CSVr (PAV+)*
PC-CSVr (NAVA)*
PC-CSVa
PC-CSVi (Smart Care)*

To receive these extra videos please sign up for my free news letter by following the link on the page "News Letter". 

ATTRIBUTION
These videos have been conceived from the following two journal articles.  

Respir Care. 2014 Nov;59(11):1747-63. doi: 10.4187/respcare.03057.  A taxonomy for mechanical ventilation: 10 fundamental maxims. Chatburn RL, El-Khatib M, Mireles-Cabodevila E.

Respir Care. 2013 Feb;58(2):348-66. doi: 10.4187/respcare.01839. A rational framework for selecting modes of ventilation. Mireles-Cabodevila E, Hatipoğlu U, Chatburn RL.

I recommend reading both articles to obtain a deeper knowledge and appreciation for the different modes of mechanical ventilation. 


RECOMMENDED PREREQUISITE POSTS/VIDEOS

Targeting Scheme Intro

Targeting Scheme Post

Whats Your Mode?

What’s Your Mode?

Happy 2016! This post is to inform readers on two topics related to this blog.

First

This year I will begin transitioning this blog and my YouTube page to a FREE email subscription based newsletter. Throughout the year I will continue to post content on the blog and brief videos on my YouTube page, however subscribers to my newsletter will receive additional content on the topics of mechanical ventilation and respiratory therapy (e.g. extended more detailed videos, PDF files, etc.).

After December 2016 no additional content will be posted here, however the blog & YouTube page will remain open as an archive.

Image 1. Ventilator Screen shot of Adaptive Support Ventilation, patient safety and comfort targets. 

Second

I will be starting a new video series similar to ones I have already created (e.g. APRV, PC-CMV, Adaptive Pressure Control). The title of this series is “What’s your mode?”

This series will be comprised of approximately 18 videos providing operational transparency to the various modes of mechanical ventilation. I believe this is important because clinicians’ need to understand the boundaries of these modalities which is not always disclosed by the device manufacturer.

The video idea was conceived after reading I believe one of the most brilliant papers and theories on mechanical ventilation “A rational framework for selecting modes of mechanical ventilation” [1]. This paper questions why we use a specific ventilator mode and proposes selecting a mode based on the three central goals of mechanical ventilation; patient safety, patient comfort, and transitioning to liberation. The paper also introduces selecting a mode of mechanical ventilation based on mode capabilities and features to accomplish these goals.

Note- two evident things;

The mode has to be available on the ventilator in use.

The clinician has to be competent and know the capabilities and boundaries of a specific mode.  

If interested in receiving additional content please sign up for the News Letter below or on the page labeled “News Letter”.

CLICK LINK to Sign up

http://eepurl.com/bOs4IX

REFERENCE

[1]. Mireles-Cabodevila, E. Hatipoglu, U. and Chatburn, R. (2013). A rational framework for selecting modes of ventilation. Respiratory Care. 58 (2): 348-364. 

[2]. Respir Care. 2013 Feb;58(2):348-66. doi: 10.4187/respcare.01839. A rational framework for selecting modes of ventilation. Mireles-Cabodevila E, Hatipoğlu U, Chatburn RL.

   

   

Changing Flow Patterns vs. Changing Ventilator Modes

Figure 1: Various flow patterns within VC-CMVs on the Hamilton G5 Ventilator.

When a device operator thinks about changing the inspiratory flow pattern while administering a Volume-Controlled breathing pattern they do not assume it will change the mode of ventilation. 

However newer software in the Servo-i allows the operator to change the flow pattern 

from the traditional constant flow pattern, to either a fully decelerating  flow pattern (similar to PC-CMV) or to adaptive flow (Fig. 2).  The Adaptive Flow pattern was the default in older software which makes Volume Control a Dual Control mode [1].  The operator now has a choice of using Volume Control as a traditional VC-CMV mode by selecting the square waveform or providing a Dual Control breathing pattern by selecting the Adaptive Flow icon. 

Figure 2: Flow patterns available on the Servo-i, courtesy of Robert Chatburn. 

For more information on flow patterns and Dual Control see the below links.

DUAL CONTROL

Dual Targeting Schemes

FLOW PATTERNS

Flow Patterns & Flow Rates

RELATED POSTS

1. The Volume Control Ventilation Fallacy

    Targeting Schemes

HYPERCAPNEA & ATELECTRAUMA: MIMICKING APRV

In a previous post "APRV in the operating room is it practical?"  I argue that bringing a ICU ventilator into the operating room to utilize APRV is not practical and may lead to hypoventilation and hypoxia due to administration of anesthetic agents [1].

During surgical procedures the patient is maintained in stage 3 of anesthesia known as the "surgical stage". Stage 3 is broken down into four distinct planes, "from onset of automatic respiration to respiratory paralysis" [2]. The patient is usually maintained in Plane 3 (intercostal muscle paralysis) or Plane 4 (diaphragmatic paralysis) leading to the cessation of spontaneous breaths.

One key advantage of APRV is that the patient may breathe spontaneously contributing to the overall minute volume, with the termination of spontaneous efforts the patient will become severely hypercapnic.

Below is an image (fig 1) I captured from a "Pressure Control Ventilation Simulator" [3] demonstrating an ARDS patient on APRV.

Figure 1. Pressure Control Ventilation Simulator, notice patients PaCO2 at 100.7 mmHg.

Notice in figure 1 the outcome for a patient not contributing to the overall minute ventilation the PaCO2 would be 100.7 mmHg. 

Another example of how APRV maybe harmful in the operating room is when trying to mimic APRV with a anesthesia delivery system.

The Volume Control Ventilation Fallacy

Volume Control- Continuous Mandatory Ventilation with a “Set-point” targeting scheme (VC-CMV(s)) is likely the most utilized mode of mechanical ventilation in adult patients in North America. This is due to a few a reasons:

1.      VC-CMV is a standard mode on almost every intensive care ventilator and anesthesia delivery system.

2.      VC-CMV is one of the first modes of mechanical ventilation.

3.      VC-CMV is easy to understand in both theory and operation.

4.      VC-CMV is the standard of care when ventilating patients with Acute Respiratory Distress Syndrome (ARDS) and Acute Lung Injury (ALI).

5.      VC-CMV is the standard of care for adult patients intraoperatively.

The key advantage of VC-CMV(s) is the safety and simplicity of the set-point targeting scheme. The operator can manually set all parameters of the volume/flow waveform and adjust the minimum minute ventilation parameters (relating to frequency and tidal volume). “One can quickly trouble-shoot a patient’s situation, so during a change the operator can diagnose the problem and intervene rapidly”. [1]

When one sees a mode of ventilation labeled “Volume Control”, “VC”, “Volume A/C”, or “CMV” it affirms that the breathing pattern delivered to the patient will consist of a constant tidal volume and inspiratory flow waveform (fig. 1) 

Figure 1. Volume Control Ventilation Breath Pattern.

Figure 2. Volume and Flow waveform remains constant even-though compliance decreased to 25, compared to Figure 1.  

regardless of changes in a patient’s respiratory system mechanics and/or inspiratory drive (fig. 2) [2]. Conversely, due to no industry standard for ventilator mode taxonomy and medical device manufacturers marketing schemes the actual breath delivered to the patient does not resemble the predicted breath pattern and may result in a tidal volume much larger than the expected preset value.

How does this happen?

Ventilator Mode Map App

Ventilator Mode Map Mobile App

Due to no industry standard for ventilator mode taxonomy and over 170 unique names for modes of ventilation.  Learning and understanding ventilator mode classification can be problematic.   Ventilator Mode Map provides a easy to use handheld solution.   With this app one can choose from 12 different vendors,  37 different models (with pictures) and provides hundreds of definitions. One would have to review various text books and journal articles to compile this knowledge base.

This app is for android devices, I have a copy on my Samsung Galaxy tablet & Motorola phone, works fine on both devices. Available on Google Play see link below.

GOOGLE PLAY

Ventilator Mode Map

Free Virtual Mechanical Ventilator

OPENPediatrics website provides a free virtual mechanical ventilator that allows users to review mechanical ventilator knowledge, play scenarios, and test their skills with case simulations.

One just needs to register for free on their "Clinician Community Site" to utilize the simulator. 

LINKS

OPENPediatrics

OPENPediatrics simulator

OPENPediatrics Clinician Community  Site

RELATED POST

Creating Flow Mismatch with a Simulator

Intelligent Targeting Schemes

A Intelligent targeting scheme is "a ventilator control system that uses artificial intelligence programs such as fuzzy logic, rule based expert systems, & artificial neural networks" (Chatburn, 2012). Examples of modalities that use  Intelligent targeting are Smartcare & IntelliVent-ASV.

Please view the above video for more information on Intelligent targeting schemes.

RELATED POSTS

SmartCare Posts

Free Mechanical Ventilation Handouts

Reference

Chatburn, R. (2012). Standardized Vocabulary for Mechanical Ventilation. Mandu Press. 

*Note- this reference is available under the link free mechanical ventilation handouts.

Optimal Targeting Schemes

A Optimal targeting scheme is a "ventilator control system that automatically adjusts the targets of the ventilatory pattern to either minimize or maximize some overall performance characteristic" (Chatburn, 2002). 

Please view the above video for more information on Optimal targeting. 

RELATED VIDEOS

ASV Playlist

RELATED POSTS

Adaptive Support Ventilation Posts

Free Mechanical Ventilation Handouts

Reference

Chatburn, R. (2012). Standardized Vocabulary for Mechanical Ventilation. Mandu Press. 

*Note- this reference is available under the link free mechanical ventilation handouts.

Adaptive Targeting Schemes

Adaptive targeting schemes use "a control system that allows the ventilator to automatically set some (or all) of the targets between breaths to achieve other preset targets" (Chatburn, 2012). Adaptive Pressure Control is most likely the most recognized and most used modality that uses a adaptive targeting scheme.

 Please review the above video for a more detailed description. 

RELATED VIDEOS
Adaptive Pressure Control Playlist

RELATED POSTS

Adaptive Pressure Control List

Free Mechanical Ventilation Handouts

Reference

Chatburn, R. (2012). Standardized Vocabulary for Mechanical Ventilation. Mandu Press. 

*Note- this reference is available under the link free mechanical ventilation handouts.

Servo Targeting Schemes

Ventilator modes that use Servo targeting schemes are very responsive and provide the most comfort and synchrony in the spontaneous breathing patient. Servo targeting is "a control system for which the output of the ventilator automatically follows a varying input. This means that the inspiratory pressure is proportional to inspiratory effort" (Chatburn, R.). 

The below videos give a brief description of Servo targeting schemes and ventilator modes that use Servo targeting schemes. 

Automatic Tube Compensation

Automatic Tube Compensation is "a feature that allows the operator to enter the size of the patient's endotracheal tube & have the ventilator calculate the tubes resistance & then generate just enough pressure to compensate for the added resistive load" (Chatburn, R. 2012).

RELATED POST/LINKS
Free Mechanical Ventilation Handouts

Servo Targeting 

Reference

Chatburn, R. (2012). Standardized Vocabulary for Mechanical Ventilation. Mandu Press. 

*Note- this reference is available under the link free mechanical ventilation handouts.

Flow Patterns and Flow Rates

One corrective action in correcting flow mismatch is switching from a constant flow pattern to a decelerating flow pattern this provides a high initial peak flow. The above video overviews how different flow patterns effect inspiratory flow rates. 


RELATED POST/LINKS

Correcting flow mismatch by increasing ventilator flow rate

Creating Flow Mismatch with a Simulator

Oxylog 3000 Simulator

Why I do not use Draeger ventilator simulators

Flow mismatch: patient ventilator asynchrony associated with volume ventilation

Waveform of the week: Flow Mis-match

Decreasing Dyspnea During Mechanical Ventilation

Correcting flow mismatch by increasing ventilator flow rate

Flow mismatch is a common patient ventilatory asynchrony associated with volume ventilation, which may lead to cardiovascular instability, increased oxygen consumption, increased carbon dioxide production, increased patient discomfort and prolonged mechanical ventilation[iv]. Fortunately, flow mismatch can be simply identified with the proper assessment of the pressure waveform.

To correct flow mismatch titrate the flow rate to match the patient’s inspiratory demands. Another corrective action is switching from a constant flow pattern to a decelerating flow pattern this provides a high initial peak flow. One must consider that changes in ventilatory demand may result in unnecessary higher than average assist resulting in ventilator induced diaphragm dysfunction[ii], a lower PaCO2 set-point, and delay in liberation.


RELATED POST/LINKS

Creating Flow Mismatch with a Simulator

Oxylog 3000 Simulator

Why I do not use Draeger ventilator simulators

Flow mismatch: patient ventilator asynchrony associated with volume ventilation

Waveform of the week: Flow Mis-match

Decreasing Dyspnea During Mechanical Ventilation

Creating Flow Mismatch with a simulator

I know in the past I stated I did not use Draeger simulators. However this Oxylog simulator is responsive and I will be using it in a few videos. This video demonstrates that with this simulator, one can create "Flow Mismatch" a patient-ventilator asynchrony common in VC-CMV.

RELATED POST/LINKS

Oxylog 3000 Simulator

Why I do not use Draeger ventilator simulators

Flow mismatch: patient ventilator asynchrony associated with volume ventilation

Waveform of the week: Flow Mis-match

Decreasing Dyspnea During Mechanical Ventilation

Dual Targeting Schemes

Dual targeting schemes are a step above Set-point targeting in regards to engineering hierarchy. These modes can switch from volume-control to pressure-control during the inspiratory phase. 

The above video overviews dual targeting schemes and presents the advantages and disadvantages of these modalities. 

RELATED VIDEOS

Targeting Schemes

Free Mechanical Ventilation Handouts

Reference

Chatburn, R. (2012). Standardized Vocabulary for Mechanical Ventilation. Mandu Press. 

*Note- this reference is available under the link free mechanical ventilation handouts.

Targeting Schemes

A Targeting Scheme is "A model of the relationship between operator inputs and ventilator outputs to achieve a specific ventilatory pattern, usually in the form of a feedback control system" [1]. The targeting scheme describes the main functionality of a ventilator mode and helps one differentiate modes of mechanical ventilation. 

This is not only helpful when classifying a mode for academic purposes, but the knowledge of a targeting scheme is beneficial when selecting a ventilator mode to best match its capabilities to the clinical goals of mechanical ventilation. 

Arterial Waveform Analysis Devices

Image 1: From PiCCO @ Bedside, iOS Mobile app [1]. 

Due to the results of the March 2014 "ProCess Trial" indicating that early goal directed therapy in septic shock did not improve outcomes [2] , there has been less interest in using pulse contour analysis devices to optimize fluid management in the critically ill patient. 

The main reason for this is that these devices, even though less invasive then the pulmonary artery catheter still require at the minimum an arterial line and in addition (depending on device) a central venous catheter. 

However, before letting these devices collect dust on a shelf, I believe this tool can be still be very beneficial in two patient populations.

One, is the high risk surgical patient to optimize fluid management.

This strategy is currently termed "Goal directed Intra-operative fluid administration".

Fluid overload during surgery has been associated with [3]:

-Increased length of stay

-Bowel wall edema

-Edema organ dysfunction

-Adverse outcomes

Additionally, patients receiving fluid and hemodynamic optimization during surgery are at an decreased risk of renal impairment. 

The second type of patient that may benefit from minimally invasive cardiac output monitoring is the critically ill cardiovascular patient.

 With these patients the ICU physician is always questioning [4]:

-"Is the patient's pre-load sufficient to obtain adequate Cardiac output"?

-"Does the patient need volume (fluids) or forced diuresis"?

-"What is the patient's cardiac function"?

-"Does the patient need inotropes or pressors"?

In these patients'  not optimizing fluid management can be detrimental. 

TECHNOLOGY

All devices calculate cardiac output based on the traditional equation:

CO = SV X HR

CO = Cardiac Output

SV= Stroke volume

HR= Heart rate 

However, each device uses a proprietary method to calculate stroke volume or a modification of the Fick principle. Below is a table I created that compares and contrast three different pulse contour analysis devices.  

Image 2: Table comparing Pulse Contour Analysis Devices.

For more information on Arterial Waveform Analysis Devices one can visit the Society of Critical Care Medicine and take the online course "Less-Invasive Hemodynamic Monitoring" [5]. 

REFERENCE

1. PiCCO @ Beside, GE HealthCare iOS mobile app

2. Early Goal Directed Therapy Does Not Improve Outcomes in Septic Shock (ProCESS)

3. Optimization of the High Risk Surgical Patient. SCCM, lecture 2014

4. Transpulmonary Thermodilution. SCCM, lecture 2014. 

5. Less-Invasive Hemodynamic Monitoring.