Transcript Weinmann Schulung Medumat Transport

Medical Training
- Ventilation Options For internal use only
© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Objective of Presentation
• This presentation on ventilation gives the reader an overview of the
available pressure and volume-controlled types of ventilation..
• The conventional processes, including setting options on the
ventilators, are explained.
• The reader will also learn about the use of Non Invasive Ventilation
(NIV) with MEDUMAT Transport.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Contents
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Functions and Physiological Goals of Ventilation
Ventilation Basics
Terminology
Assisted Ventilation Modes
Controlled Ventilation Modes
– Volume-controlled Ventilation
– Pressure-controlled Ventilation
• Non-Invasive Ventilation (NIV)
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Oxygen or Ventilation ?
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Ventilation Functions
• Influence gas exchange
• Take over the work of respiration
• The type of ventilation describes the changing relationship between
patient and ventilator:
– Controlled:
The device takes over the work of breathing.
– Augmented/ assisted/ supported:
The work of breathing is shared by the device and patient.
– Spontaneous:
The patient takes on the work of breathing.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Physiological Goals of Ventilation
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Alveolar ventilation
Arterial oxygenation
Increase of end-inspiratory and end-expiratory lung volume
Unloading respiratory musculature
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Clinical Goals of Ventilation
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Treatment of hypoxemia
Treatment of respiratory acidosis
Treatment of dyspnea
Prevention/treatment of atelectasis
Treatment of respiratory muscle fatigue
Allow analgesic sedation and muscle relaxation
Reduction of systemic and/or myocardial oxygen need
Reduction of intracranial pressure
Stabilization of thoracic wall
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
VS
CPAP
CPAP/ ASB
PSV
CPPV
SVV
SPV
NIV
VC
PC
PCV
ASB
BIPAP
IPPV
SIMV
BiLevel/ ASB
PEEP
PLV
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Spontaneous Breathing
• Inspiration: Negative pressure
• Expiration: Positive pressure
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Ventilation - Terminology
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Spontaneous Breathing vs. Ventilation
• Spontaneous breathing:
Passive volume expansion of lungs effected by pulling of rib
musculature and diaphragm
• Ventilation:
Active volume expansion by introducing volume
or ventilation pressure.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Ventilation Systems
•Terminology
•Assisted ventilation
•Controlled ventilation
•Volume-controlled
•Pressure-controlled
•Combinations
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
PEEP
• Definition:
– Positive End Expiratory Pressure
– In controlled ventilation PEEP corresponds to CPAP of
spontaneous breathing
– Advantages:
• Decline in atelectasis
• Higher volume per unit of pressure increase (predilation)
– Disadvantages:
• Increase of maximum ventilation pressure
• Impairment of venous blood backflow
• Application:
– With every type of ventilation at least PEEP 5
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Assisted Ventilation Modes
• CPAP mode increases respiratory pressure level to raise the
Functional Residual Capacity (FRC).
• This mode is used only on patients with sufficient spontaneous
breathing.
• Assisted Spontaneous Breathing (ASB) mode provides pressure
support in cases of insufficient spontaneous breathing. The patient
can breathe spontaneously without restriction, but gets support for
his respiratory work from MEDUMAT Transport.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Supporting Mode (CPAP)
• Continuous Positive Airway Pressure (CPAP)
• Supports the respiratory work of the patient
• Respiratory rate, pattern and tidal volume are determined by patient
• Respiratory work is made easier.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Assisted Spontaneous Breathing (ASB)
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Assisted spontaneous breathing
Pressure support of every breath of patient
Patient has to “trigger” the device
Can combine CPAP, BIPAP, SIMV
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Spontaneous breathing
CPAP / PEEP 10 cm
H2O
ASB 7 cm H2O
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Controlled Ventilation
• Takes over all respiratory work of patient
• Determines tidal volume by ventilation modes of
– pressure-controlled
– volume controlled
• Assisted modes (ASB/CPAP) can be combined
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Volume vs. Pressure-controlled Ventilation
• Volume-controlled modes ensure tidal and Respiratory Minute
Volume (RMV) with adherence to an upper pressure limit.
• Pressure-controlled modes maintain maximum ventilator pressures
and have a more physiological character. There is no volume
guarantee, which makes monitoring of tidal volume and RMV
necessary.
• Supporting modes combine the advantages of both systems.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Volume-controlled Ventilation
• The inspiratory gas flow is maintained until a certain volume is
reached.
• Airway pressure is passive (danger of barotrauma).
• Combination with pressure limit makes sense.
• Initially areas with high compliance and low resistance are ventilated
and then plateau pressure is reached.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Volume-controlled Ventilation
Advantage:
• Tidal volume is maintained
even when pulmonary
mechanics change.
Settings:
Respiratory Minute Volume
(rate x tidal volume)
Limit or control dimension:
maximum airway pressure
Disadvantage:
• Danger of pressure-caused
damage to lungs when
pulmonary mechanics
deteriorate
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Abbreviations in Volume-controlled
Ventilation
IPPV: Intermittent Positive Pressure Ventilation
PLV:
Pressure Limited Ventilation
CPPV: Continuous Positive Pressure Ventilation
(with set PEEP level)
VC:
Volume Control
SVV: Smart Volume Ventilation
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Volume-controlled Ventilation
• IPPV/CPPV
– Intermittent Positive Pressure Ventilation
– With PEEP = CPPV : Continuous Positive Pressure Ventilation
– Corresponds to completely controlled ventilation
– Time-controlled, constant volume, limited pressure
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
IPPV Settings
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Respiratory rate: Choice between 10 to 20 /minute
Tidal volume: 6 to 10 ml kg KG
I:E ratio: 1:1 or 1:1,7
Oxygen concentration: FiO2 0,3 – 1,0
Pressure limit: pMax 30 cm H2O
PEEP: 5 cm H2O
Inspiration segmentation (plateau)
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Special Emergency Mode
• IPPV ventilation
• Pre-set for
– Baby (10 kg)
– Child (20 kg)
– Adult (75 kg)
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Special Emergency Mode
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
SIMV
• Synchronized Intermittent Mandatory Ventilation
• Patient is given a pre-set minimum number of breaths with a defined
volume (see IPPV)
• Combination of controlled ventilation, synchronized mechanical
breaths triggered by the patient, and spontaneous breathing
• The patient may breathe independently (see CPAP-ASB) and direct
the device.
• Synchronized mechanical breaths are possible only within an
“anticipated breath window”.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
SIMV Settings
• Settings for IPPV/CPPV breaths
– Tidal volume 6 to 10ml kgKG
– Respiratory rate: 4 to 10
– I:E 1:1 – 1.7
• PEEP/CPAP 5 cm H2O
• Setting for SIMV
– Trigger threshold (l/min) of patient 3 l/min
• Oxygen concentration: FiO2 0.3 – 1,0
• Pressure limit: pMax 30 cm H2O
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
SVV
• Smart Volume Ventilation
• Weinmann‘s special mode of volume-controlled ventilation
• All pressure-controlled ventilation modes can be set
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Pressure-controlled Ventilation
• Application of gas flow until a pre-set airway pressure is reached.
• The pressure is maintained for a certain amount of time and then
reduced again during expiration.
• Tidal volume results from the ventilation pressure and the mechanical
characteristics of the lungs.
• Tidal volume and gas flow are dependent on the mechanical
characteristics of the lungs.
• Initially high and then decreased flow = decelerated flow
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Pressure-controlled Ventilation
Disadvantage:
Advantage:
• When respiratory mechanics
• The optimum pressure range
deteriorate, tidal volume
decreases and with it the
can be set individually for each
ventilation.
lung. The lung is protected and
• Tidal volume has to be measured
ventilator-induced lung
at end-expiratory point when
damage can be avoided.
pressure-controlled or nonvolume constant ventilation is
used.
Settings:
Airway pressure, respiratory rate
Limit or control dimension:
Tidal or respiratory minute volume
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Abbreviations in Pressure-controlled
Ventilation Modes
PCV:
Pressure Control Ventilation
allows no spontaneous breathing by patient.
BIPAP: Biphasic Positive Airway Pressure ®
BiLevel:Combination of timed change of two pressure levels
SPV: Smart Pressure Ventilation
Weinmann-specific platform for set up of pressurecontrolled ventilation mode.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
SPV
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Smart Pressure Ventilation
Weinmann’s special mode of pressure-controlled ventilation
All pressure-controlled ventilation modes can be set up
CPAP/ASB can be used only at the lower pressure level
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Bi-level Ventilation
• Biphasic Positive Airway Pressure
= ventilation with two pressure levels
(also known as BI-level Positive Airway Pressure)
• Pressure and time-controlled ventilation mode
• Volume is not constant !
• State-of-the-art ventilation mode in Intensive Care Unit (ICU)
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Bi-level
• Mode of Operation:
– Combination of CPAP and pressure-controlled ventilation
– Two (2) different pressure levels
– Spontaneous breathing at both levels is allowed at any time
during ventilation
– ASB support is possible
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Bi-Level: Settings
• Rate calculation:
– 60 sec. / targeted rate
– e.g., 10 rate = 6-second respiratory cycle
• Respiratory cycle:
– Set I:E via time selection
– e.g.: T1(Inspiration) 2 seconds / T2 (Expiration) 4 seconds
• Pressure level
– P1(high pressure/ inspiration)
– P2 (CPAP/PEEP/low pressure / expiration)
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Combinations and Special Modes
ASB:
BiLevel ASB:
Assisted Spontaneous Breathing
Each breath of the patient triggers a gas flow which
leads to the set inspiratory pressure level.
CPAP:
CPAP/ ASB
Continuous Positive Airway Pressure
Spontaneous breathing mode, maintains positive
pressure in airways during the entire spontaneous
breathing cycle + assisted spontaneous breathing
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Ventilation Parameters
• Rate
• Pinsp Pressure
• Ratio Inspiration:Expiration I:E
• Ramp
• PEEP
• Pmax
• Delta ASB
• FiO2
• Tidal volume
• Minute volume
•Trigger
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Non-Invasive Ventilation (NIV)
• For Non invasive Ventilation the patient is given a mask which,
depending on type, covers the nose and mouth or the entire face or
goes on the patient‘s head like a helmet.
• Basically all the ventilation modes used in invasive ventilation (via
tube or tracheostoma) can be used in non-invasive ventilation.
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Advantages of NIV
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Avoidance of intubation
Airways remain intact
Reduction in ventilator-induced pneumonia
Relaxation/sedation not required:
– Ø gastrointestinal atony
– Ø weaning symptom
Patient can communicate
Increase in mobility
Intermittent treatment as needed
Maintenance of glottal closure function
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Indications and Contraindications of NIV
Indications:
-Neuromuscular diseases (ALS,
polio)
-Mechanical disorders
(kyphoskoliosis, etc.)
-COPD
-Pulmonary edema
-Pneumonia
-Weaning
-ARDS
Contraindications:
–Coma or amentia
–Severe cooperation problems
–Acute life-threatening hypoxia
–Cardiac arrest
–Hemodynamic instability
–Increased risk of aspiration
• Swallowing disorders, ileus,
GI bleeding, abdominal
surgery (?)
–Obstruction in upper airways
–Secretion retention
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
NIV Operational Principle
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Unloading of respiratory pump
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Increase in intrathoracic pressure
- counteracts a pathological collapse of the alveolar sector
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Reduction in development of atelectasis and ventilation disorders
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Increase to FRC
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Decline in pulmonary shunt volume
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Improvement of pulmonary oxygen transfer
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Improvement in oxygenation
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Assessment of NIV in Clinical Use
• Criteria for success
– Improvement in alveolar
ventilation (PaCO2 falls)
– Improvement in pulmonary gas
exchange (SaO2 rises)
– Unloading of respiratory pump
– Decrease in cardiac rate
– Decrease in respiratory rate
– Reduces agitation, angst
– Reduction in dyspnea
• Cancellation criteria
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Hypercapnia during NIV
Hypoxemia with SaO2< 85%
Acidosis (pH < 7,2)
Rise in respiratory rate
• Dyspnea
– Loss of consciousness
– Circulatory instability
– Increasing agitation, angst
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© WEINMANN GERÄTE FÜR MEDIZIN GMBH+CO.KG, Author: S. El Diwany MEDUMAT Transport Product Presentation, June 2008
Summary
• Every existent respiratory activity of the patient should be utilized !
• The device should adjust to the patient – the patient should not
adjust to the device !
• Pressure and volume-controlled modes offer the best selection
options and adaptation to patient needs.
• Ventilation setup is one task; the monitoring of respiratory
parameters is the second.
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