ABCs Of Smarter Breath Delivery

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ABCs Of Smarter Breath Delivery

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Current Standard Breath Delivery Capabilities

• State-of-the-art gas delivery systems
• proportional solenoids
• revolutionary new exhalation valve technologies
• Flexible breath delivery
• flow triggering, volume ventilation, PCV and PS
• Advantages
• current breath types are accepted and well
  understood
• less education needed

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New Standard Breath Delivery Strategies

• Improved flexibility of accepted breath types
• broadened performance with pediatric and/or
  infant capabilities
• new pressure support and PCV capabilities
  allowing titration and improved vent / patient
  synchrony

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Work to Trigger

• Great strides have been made in recent years to
  decrease work to initiate breaths with flow
  triggering
• new data comparing ventilator trigger
  performance
• Leaks can cause triggering problems
• possible in infants, broncho-pleural fistulas,
  mask ventilation, and cuff problems
• these leaks result in loss of PEEP and
  autocycling
• Flow triggering and increasing flow sensitivity
  to a level above the leak will maintain PEEP,
  eliminate autocycling, and maintain sensitivity

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Effects Of Leaks With PEEP

• PEEP 10 cmH20
• No leak - no autocycling

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Effects Of Leaks With PEEP

• Leak develops - autocycling occurs
• Excessive ventilation and asynchrony results

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Effects Of Leaks With PEEP

• If pressure sensitivity is lowered - loss of PEEP
  develops

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Flow Triggering With Leaks

• Triggering will not occur until leak flow rate
  patient inspiratory flow exceeds flow sensitivity
  setting
• Autocycling is eliminated, PEEP is maintained,
  and patient sensitivity is enhanced

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740 and 840 Response Time Testing

• ALA / ATS conference in San Diego, April 1999 -
  Bob Kacmarek abstract presented publishing first
  comprehensive study comparing ventilator
  performance
• reported response time tests for 740, 840, Evita,
  Galileo, Bear 1000, and T-Bird
• looked at response time and negative pressure
  drop during CPAP, PS, and PCV

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What is PT and DTOT in Kacmarek Study?
Response Time or DTOT
Pressure
PT
Time

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Greater negative pressure or longer response time
Imposed WOB
Response Time or DTOT
Pressure
PTP(Imposed)
PT
Time

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Without Adjustment of Pressure Rise

• Many ventilators are sensitive to changes in
  impedance
• increasing resistance causes pressure to rise
  more quickly
• can result in discomfort, or premature
  termination of PS

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Rise to Pressure Adjustment

• Applicable in all pressure breaths
• Tailors inspiratory rise in pressure ventilation
  to match patient demand or reach MAP goals
• Should allow rise to be tailored from slow to fast

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• Not all clinicians want to adjust rate of rise
  (time, interest)
• Smarter rise settings should automatically adjust
  flow output as resistance or compliance varies
• maintains similar shape of curve through any
  patient size or impedance change which reduces
  the need for intervention and reducing pressure
  overshoot

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Optimal Rise to Pressure Adjustments

• Spontaneous breathing patients - easily set with
  regard to patient comfort and synchrony
• titrate while watching patient at bedside
• do as the old joke says...
• Generally set by watching patient breathing
  patterns
• if spontaneous flow demands are explosive -
  faster rise
• if spontaneous flow demands are relaxed - slower
  rise

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Breathing During PCV
C
D
B
A

• Patient efforts during the inspiratory phase of
  PCV can result in fighting and pressure spikes

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Active Exhalation Valve

• During inspiration, the valve is closed with the
  force of the insp pressure setting
• Allows coughing or spontaneous breathing at
  upper pressure level by venting excess pressure
  and flow (PCV or BiLevel)

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Expiratory Sensitivity

• Pressure support breaths terminate when patient
  flow decelerates to a selectable percentage of
  peak flow

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Expiratory Sensitivity

• Leaks can cause inability to terminate pressure
  support breaths, causing profound asynchrony
• I-times too long or too short can also cause
  asynchronous breathing

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Expiratory Sensitivity

• ESENS allows adjustment of the termination
  criteria for pressure supported breaths
• sets the percent of peak flow that cycles the
  pressure support breath into exhalation
• especially helpful to match the patients desired
  inspiratory time (with or w/o leaks)
• can improve synchrony between patient and
  ventilator

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Rise to Pressure and Esens Adjustments
C
D
B
A

• Easily set with regard to patient comfort and
  synchrony
• titrate while watching patient at bedside
• do as the old joke says...
• Set rate of rise first
• this helps with comfort early in the breath and
  determines peak flow
• Set Esens if longer or shorter inspiratory times
  are desired during PS

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Acute Care Ventilators and Non-invasive
Ventilation

• Significant interest in non-invasive ventilation
• avoiding intubation may reduce the risk for
  nosocomial infection
• Masks offer challenges to patient and clinicians
• patient comfort / acceptance is crucial
• leaks or aggressive rise to pressure can cause
  asynchronous support and lead to patient
  rejection
• Flow triggering, ESENS maximize trigger and
  termination sensitivities while rise to pressure
  adjustments improve subjective patient comfort

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Siemens 300, Drager Evita 4, and 840 ABCs Report
Card

• All vents were graded based on how well they
  accomplished smarter breath delivery
• 2 stars possible for each of the 4 categories
  (A-D)
• if they have a capability but dont do it as
  well, they might get 1/2 star
• A breath initiation
• 1 star if they have a very fast response time
  (R.T.),
• 2nd star if they have a flow sensitivity range
  allowing compensation for leaks of more than 3
  LPM
• B rise to pressure - 1 star if they can adjust
  from slow to fast, 1 star if they have a smart
  algorithm that automatically adjusts to changes
  in compliance, resistance, or patient size

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Siemens 300, Drager Evita4, and 840 ABCs Report
Card

• C active exhalation valve. This is so
  important to synchrony, BiLevel capability,
  patient safety allowing coughing etc. - If they
  have one they get 2 stars
• D expiratory sensitivity. They either have
  adjustable sensitivity or they dont. Again, 2
  stars if they have it

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Smarter Breath Delivery Report Grades

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Smarter Breath Delivery Report Grades

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Smarter Breath Delivery Report Grades

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