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Physiology of Ventilatory Modes. III (Lecture 4)

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17 views19 pages

Physiology of Ventilatory Modes. III (Lecture 4)

Uploaded by

a9d8y13
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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PRESSURE

CONTROLLED MODES

Presented by:
Ms. Maryam
Assistant Professor
Objectives:
At the end of the lecture, student will able to:
 Identify and discuss different types of pressure control Modes.
 Explain following pressure control modes:
 Adaptive Support Ventilation (ASV)
 Proportional Assist Ventilation(PAV)
 Automatic Tube Compensation(ATC)
 Identify and discuss dual control modes with a volume target
 Explain different types of dual control modes with a volume target
 Demonstrate patient positioning to optimize oxygenation and ventilation

Adaptive Support Ventilation
(ASV)

o A dual control mode that uses pressure ventilation (both PC and


PSV) to maintain a set minimum VE using the least required
settings for minimal WOB depending on the patient’s effort and
time constant.

o It automatically adapts to patient demand by increasing or


decreasing support, depending on the patient’s elastic and resistive
loads.

o Mode available on the Hamilton Galileo ventilator.

o Ventilator adjustments of tidal volume and rate are microprocessor


controlled.
ASV Cont….
o Input:
o IBW, high pressure alarm,
o PEEP,
o FIO2,
o Inspiratory rise time
o flow cycle %
o % Minute ventilation
ASV Cont….
 If no spontaneous effort occurs, the ventilator determines the
appropriate respiratory rate,VT, and pressure limit delivered for
the mandatory breaths.

 I:E ratio and TI of the mandatory breaths are continually being


“optimized” by the ventilator to prevent auto-PEEP.

 If the patient begins having spontaneous breaths, the number of


mandatory breaths decrease and the ventilator switches to PS at
the same pressure level.

 Pressure limits for both mandatory and spontaneous breaths are


always being automatically adjusted to meet the Minute ventilation
target.
ASV Cont….
Indications
 Full or partial ventilatory support
 Patients requiring a lowest possible PIP and a guaranteed
VT
 ALI/ARDS
 Patients not breathing spontaneously and not triggering
the ventilator
 Patient with the possibility of work land changes (CL and
Raw)
 Facilitates weaning
Proportional Assist Ventilation
(PAV)

 PAV is a spontaneous breathing mode that offers assistance to


the patient in proportion to the patient’s effort

 It needs to know how much effort the patient is making for


each breath.

7
PAV Cont…
Clinical Application

 Set the proportion of assistance (generally between 10 and 90%) that we


want the ventilator to provide, and the rest is up to the patient.

 i.e., if we set PAV at 80% assistance, that means that the ventilator will do
80% of the work of breathing, and the patient will do 20% of the work of
breathing

 In other words, the set PAV % = the work provided by the ventilator

%assist Patient contribution Proportionality

25 75 1:3
50 50 1:1
75 25 3:1
90 10 9:1
PAV Cont…
 PAV vary inspiratory pressure in proportion to Patient effort,
elastance, and resistance

 Ventilator determines: Paw, flow, VT, IT based on


 Patient effort, elastance, and resistance

 Patient affects everything, as only set parameter is that


ventilator will perform a fixed proportion of work

 There are no control variables with PAV.


PAV Cont…
 Muscles of ventilation are unloaded.
 Flow gain unloads the resistive load(which help overcome
airway resistance).
 Volume gain unloads elastance loads (alveolar stiffness)

 Problems:
◦ There is no volume guarantee.
◦ There is difficulty with the accuracy of measuring elastance and
resistance.
◦ Potential for runaway ventilation caused by
 Leaks
 Overestimation of elastance and resistance
Automatic Tube Compensation
(ATC)

A means by which that portion of the work of breathing associated


with the movement of gas through an endotracheal or
tracheostomy tube (connecting the breathing circuit to the
patient's airway) is reduced or eliminated by the ventilator with no,
or minimal, intervention by the operator (care giver).
ATC Cont…

◦ Continuously measures flow and calculate the amount of pressure


needed to overcome the resistance of the airway.
Pressure = Resistance * Flow
◦ Calculates Airway resistance (Raw) associated with the artificial
airway.
◦ Attempts to adjust Paw to keep tracheal pressure constant at
baseline pressure.
◦ Goal is to eliminate imposed WOB by the ETT.
◦ Therapist input; type and size of artificial airway (ETT and
Tracheostomy tube) and % compensation desired (10% to 100%).
◦ As ATC accounts for WOB imposed by ETT, some consider it
equivalent to “electronic extubation”

12
External and Tracheal Pressures Differ
Because of Tube Resistance

ATC offsets a fraction of tube resistance


Dual Control Modes With a Volume
Target
◦ Pressure-controlled breaths but target a volume.

Volume support ventilation (VSV)


◦ Set: target VT, FIO2, PEEP, high pressure alarm
◦ PSV with volume target
◦ IF PSV delivers an inaccurate VT
 It adjusts the pressure, over several breaths, to achieve the set
volume. If volume is too low, the pressure is increased, and if volume
is too high, the pressure is decreased.
 Following breaths PSV adjusted a maximum of 3 cm H 2O until
volume target reestablished

14
Dual Control Modes With a Volume
Target
PRVC (pressure-regulated volume control)

◦ PCV with a volume target – Dual control mode


◦ delivers patient- or time-triggered, pressure targeted, time-cycled
breaths.
◦ If volume target is not reached:
 Next breaths pressure will adjust in maximum of 3 cm H 2O
increments per breath until targeted volume is attained

15
Patient Positioning To Optimize
Oxygenation And Ventilation

◦ Frequent turns(usually at least


2hours) are required to avoid
atelectasis, hypoxemia, secretion
retention, pressure sores.
 Kinetic beds may help(constantly
turns patients side to side
through 270°).
◦ Unilateral lung disease, place good
lung down as much as possible,
improves V/Q and oxygenation.

16
Patient Positioning To Optimize
Oxygenation And Ventilation
◦ In a supine patient with ARDS, alveoli in the
bases and posterior segments become
atelectatic.
◦ ARDS patients most often improve
oxygenation in prone position,
 Blood flow is redistributed to areas that
are better ventilated.
 This improve V/Q ratio.
 Prone positioning removes the weight of
the heart from its position over the lungs
while the patient is supine
 Pleural pressure in the nondependent
collapsed lung become more negative
and recruits alveoli.
Patient Positioning To Optimize
Oxygenation And Ventilation

 Problems: Labor intensive, extubation, line displacements,


corneal abrasion

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