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NEWERVENTILATORSWHATMAKESTHEMDIFFERENT?JohnNewhartCRTT.RCP.NEWERVENTILATORSWHATMAKESTH1PURITANBENNETTMA-1PURITANBENNETTMA-12PuritanBennettMA-1FirstreleasedAugust1967.SimpletouseBasicIMVsystem(non-sync).Bellowsspirometerforexhaledgasmeasurement.PuritanBennettMA-1Firstrele3SIEMENS900CSIEMENS900C4SIEMENS900B/C900BavailableintheUSAearly70’s..Timelimitedandminutevolumepreset.PatientortimecycledorSIMV.Expiratoryflowmonitoring.SIEMENS900B/C900Bavailable5BEARIBuiltinSIMV.Monitoringoftidalandminutevolume.Pneumaticallyandelectricallypowered,electricallycontrolledvolumelimited.Timeorpatientcycled,controlorassist/controlmodes.BEARIBuiltinSIMV.6PURITANBENNETT7200Released1983FirstwidelyacceptedmicroprocessorcontrolledventilatorinUSA.Softwareupgradable.PURITANBENNETT7200Released17NewerGenerationVentilatorsNewerGenerationVentilators8TRANSPORTVENTILATORS

EARLYMODELTRANSPORTVENTILATORS

EARLYMO9PULMONETICLTV1000PULMONETICLTV100010PULMONETICLTVCompactlightweight12.6lbs.Abilitytotransportmorecriticalpatients.Internalbattery.VolumeControl,PressureControlandPressureSupport.Volumeandpressurealarmsandmonitoring.PULMONETICLTVCompactlightwei11ChangesinVentilatorsInclude...Moresophisticatedhardware.Morecompactsize.Multiplehighspeedmicroprocessors.Backupbatterysystems. GraphicalUserInterface(GUI).Aneverexpandinglistofmodalities.ChangesinVentilatorsInclude12ModularDesignTouchScreenDisplaycanbemountedseparately

BreathDeliveryUnitweighsonly40lbs.canbemountedseparatelyfromcartModularDesignTouchScreenDis13NewHardwareProportionalcontrolvalvesActiveExhalationvalvesBatterybackupMiniatureblowerNewHardwareProportionalcontr14ProportionalControlValvesOneortwovalves(O2,Air,orboth)proportionallyopenorclosetocontroltheflowofgastothepatientcircuit.ResponsibleforFIO2,Flowrate,Flowwaveform.Microprocessorcontrolled.Eachvalveiscontrollablefrom1,000-4,000steps.ProportionalControlValvesOne15TwoProportionalValveSystem

NPB7200-840,DRAGERE2-4,SERVO300O2AIRToPatient50psig50psigEachgashasitsownsolenoid,flowsensorandpressureregulator.Bothvalvescontrolledbymicroprocessor.FLOWSENSORFLOWSENSORTwoProportionalValveSystem

16SingleProportionalSystem

HamiltonVeolar,Bird6400-8400st

O2AIRToPatient50psig50psigBLENDERRESERVOIR10-15PSIGAirandO2aremixedinablender,storedasamixedgasinareservoirthenpassthroughasingleproportionalvalve.PROPORTIONALVALVESingleProportionalSystem

Ham17PneumaticsChassis(PB840)PneumaticsChassis(PB840)18BlowerwithIntragralDigitalBlenderO2PulmoneticLTVTurbine/BlenderSystemBlendedgastopatientDeliveryControlValveBlowerwithIntragralDigital19ActiveExhalationValvesTheinspiratoryandexpiratoryvalvesareactiveduringinspirationtomaximizethereproducibilityofinspiratoryandexpiratoryevents.ThesevalvesarecriticalinnewermodessuchasAPRV,BiLevel,andATC.Withanactiveexhalationvalve,theventilatormovestheexhalationvalveoffofitsseatduringexhalation.Withanon-activevalvethepatientmustpushthevalveoffofits’seataddingtoexpiratoryresistanceandworkofbreathing.ActiveExhalationValvesThein20ActiveExhalationValveDuringinspiration,thevalveisclosedwiththeforceoftheinsppressuresetting

Allowscoughingorspontbreathingatupperpressurelevelbyventing

excesspressureandflow(PCVorBiLevel)

40PCIRC

cmH2OINSPLminEXP302010010-2080604020020-804060V.04812s2610SpontaneousEffortsSpontaneousEffortsPCVW/OActiveValvePCVwithActiveValveActiveExhalationValveDuring21TwoProportionalValveSystemWithActiveExhalationValve

O2AIR50psig50psigAirandO2solenoidscombinedwithactiveexhalationvalve.PATIENTEXHTwoProportionalValveSystem22MicroprocessorControlEachnewgenerationofventilatorincorporatesfasterprocessors.Multiplehighspeedprocessorsimprovetheventilatorsresponsetothepatientsneeds.Fasterprocessorsmakemoreinformationavailabletotheclinician.MicroprocessorControl23MICROPROCESSORFUNCTIONDuringeachbreath,theventilatorswitchesthroughmultiplealgorythims.Thesedeterminesensingofpatientbreath,riserateofbreath,criteriaforpatientterminationofbreathatvariouspointsduringthebreath,andventilatorinitiatedterminationofbreath.Monitoreddataaswellasdataneededforventilatorfunctionareconstantlybeingprocessedinthebackground.Mostcalculationsdonebytheventilatorareneverseenbytheuser.Mostmodesofventilationthathavecomeoutinthelast15yearswouldbeimpossiblewithoutcomputercontrol.MICROPROCESSORFUNCTIONDuring24UPGRADABILITYOlderventilatorsfrequentlyrequiredacompletefactoryoverhaultohaveonemodeadded.Upgradingnewerventilatorsisusuallyaccomplishedbysoftwareupgrade.ThismaybedonebychangingoutthechipsetoruploadingsoftwarefromaPC.Addingoptions/modestypicallyinvolveschangingachipthataccessesspecificoptionsincludedinthesoftware,orenteringacodenumberthroughakeypad.UPGRADABILITYOlderventilators25BatteryBack-UpIsnowstandardonmostICUventilators.EliminatesinterruptionsinventilatorfunctionduringflickersorshorttermfailureinA/Cpower.Aidspatientsafety.BatteryBack-UpIsnowstandard26GUI

GraphicalUserInterfaceTouchscreentechnology.BecomingthenormforICUventilators.Replacestraditionalknobs,buttonsetc.Blendsgraphicaldisplayswithcontrols.Easysoftwareupgrades.Givesadditionalinformationrelativetosettingchanges.GUI

GraphicalUserInterfaceTo27EaseofUse-SoftwareControlledScreensOnlycurrentmodesandsettingsaredisplayed(easeofuse)

Informationcanappearasneededtohelpmake

decisionseasierandsaferEaseofUse-SoftwareControl28AutomaticTubeCompensationOvercomestheresistancetoflowcreatedbyanendotrachealtubeortracheostomytube.Givesthepatientthesensationthattheyarenotintubated.Mostimportantduringspontaneousbreaths.Mayprovideacalculatedtrachealpressurecurveonthegraphicsdisplay(E4).Canbeusedto“train”therespiratorymuscles.AutomaticTubeCompensationOve29ET.TubeResistanceDuringBreathTypesMandatorybreathsfromtheventilatoreasilyovercometheresistanceofanET.tube.Spontaneousbreathsaremoredifficultasaresultofbreathingthrougharelativelysmallorifice.ET.TubeResistanceDuringBre30ATCFunctionDuringInspirationDuringinspiration,theventilatorincreasespressureatthetopoftheET.tubeproportionatetotheinspiratoryflowrate.ATCFunctionDuringInspiratio31FunctionofATCduringExhalationDuringexpirationthecircuitpressureisdecreasedbelowthePEEPlevel.ThetrachealpressureisheldconstantattheselectedPEEPlevel.Thisdecreasestheworkofexpiration.Thecircuitpressureiscalculatedfromtheexpiratoryflowrate.FunctionofATCduringExhalat32ATCwithPawandPtrachwaveformsdisplayedATCwithPawandPtrachwavefo33PressureCalculationUsingtheflowmeasuredbytheventilator,thedifferenceinpressureatanygiventimecanbecalculatedbythefollowingequation:Pressure=RtubeCoef.XFlow2,wheretuberesistanceRisitselfdependentontheflow.PressureCalculationUsingthe34DifferenceBetweenATCandPSPSisauserset,fixedpressurethatremainsconstantthroughouttheinspiratoryphaseirrespectiveofthepatientsflowrate.ATCisausersetlevelofcompensation(1-100%).ThedrivingpressurewillvaryaccordingtotheE.T.tubesizeset,compensationlevelandinspiratoryflowrate.DifferenceBetweenATCandPSP35CONCLUSION

VentilatorDesignThedesignofventilatorsdependsincreasinglyontheuseofmicroprocessorcontrolandsoftware.Thehardwareinventilatorsisbeingcontinuouslyminiaturized.Movetowardsventilatordesignsthatwillventilateinfantsthroughadults.CONCLUSION

VentilatorDesignTh36CONCLUSION

ModesofVentilationModesandhardwarethatminimizetheoverallworkofbreathing.Modesthatmake“decisions”basedonbothinputfromthetherapistandpatientmonitoring.Interfacesthatdisplaymoregraphicalandnumericalinformation.“SmartAlarms”thatlookforcombinationsandseverityofthresholds.Thealarmindicatesbysoundand/orgraphicstheseriousnessofthecondition.CONCLUSION

ModesofVentilatio37NEWERVENTILATORSWHATMAKESTHEMDIFFERENT?JohnNewhartCRTT.RCP.NEWERVENTILATORSWHATMAKESTH38PURITANBENNETTMA-1PURITANBENNETTMA-139PuritanBennettMA-1FirstreleasedAugust1967.SimpletouseBasicIMVsystem(non-sync).Bellowsspirometerforexhaledgasmeasurement.PuritanBennettMA-1Firstrele40SIEMENS900CSIEMENS900C41SIEMENS900B/C900BavailableintheUSAearly70’s..Timelimitedandminutevolumepreset.PatientortimecycledorSIMV.Expiratoryflowmonitoring.SIEMENS900B/C900Bavailable42BEARIBuiltinSIMV.Monitoringoftidalandminutevolume.Pneumaticallyandelectricallypowered,electricallycontrolledvolumelimited.Timeorpatientcycled,controlorassist/controlmodes.BEARIBuiltinSIMV.43PURITANBENNETT7200Released1983FirstwidelyacceptedmicroprocessorcontrolledventilatorinUSA.Softwareupgradable.PURITANBENNETT7200Released144NewerGenerationVentilatorsNewerGenerationVentilators45TRANSPORTVENTILATORS

EARLYMODELTRANSPORTVENTILATORS

EARLYMO46PULMONETICLTV1000PULMONETICLTV100047PULMONETICLTVCompactlightweight12.6lbs.Abilitytotransportmorecriticalpatients.Internalbattery.VolumeControl,PressureControlandPressureSupport.Volumeandpressurealarmsandmonitoring.PULMONETICLTVCompactlightwei48ChangesinVentilatorsInclude...Moresophisticatedhardware.Morecompactsize.Multiplehighspeedmicroprocessors.Backupbatterysystems. GraphicalUserInterface(GUI).Aneverexpandinglistofmodalities.ChangesinVentilatorsInclude49ModularDesignTouchScreenDisplaycanbemountedseparately

BreathDeliveryUnitweighsonly40lbs.canbemountedseparatelyfromcartModularDesignTouchScreenDis50NewHardwareProportionalcontrolvalvesActiveExhalationvalvesBatterybackupMiniatureblowerNewHardwareProportionalcontr51ProportionalControlValvesOneortwovalves(O2,Air,orboth)proportionallyopenorclosetocontroltheflowofgastothepatientcircuit.ResponsibleforFIO2,Flowrate,Flowwaveform.Microprocessorcontrolled.Eachvalveiscontrollablefrom1,000-4,000steps.ProportionalControlValvesOne52TwoProportionalValveSystem

NPB7200-840,DRAGERE2-4,SERVO300O2AIRToPatient50psig50psigEachgashasitsownsolenoid,flowsensorandpressureregulator.Bothvalvescontrolledbymicroprocessor.FLOWSENSORFLOWSENSORTwoProportionalValveSystem

53SingleProportionalSystem

HamiltonVeolar,Bird6400-8400st

O2AIRToPatient50psig50psigBLENDERRESERVOIR10-15PSIGAirandO2aremixedinablender,storedasamixedgasinareservoirthenpassthroughasingleproportionalvalve.PROPORTIONALVALVESingleProportionalSystem

Ham54PneumaticsChassis(PB840)PneumaticsChassis(PB840)55BlowerwithIntragralDigitalBlenderO2PulmoneticLTVTurbine/BlenderSystemBlendedgastopatientDeliveryControlValveBlowerwithIntragralDigital56ActiveExhalationValvesTheinspiratoryandexpiratoryvalvesareactiveduringinspirationtomaximizethereproducibilityofinspiratoryandexpiratoryevents.ThesevalvesarecriticalinnewermodessuchasAPRV,BiLevel,andATC.Withanactiveexhalationvalve,theventilatormovestheexhalationvalveoffofitsseatduringexhalation.Withanon-activevalvethepatientmustpushthevalveoffofits’seataddingtoexpiratoryresistanceandworkofbreathing.ActiveExhalationValvesThein57ActiveExhalationValveDuringinspiration,thevalveisclosedwiththeforceoftheinsppressuresetting

Allowscoughingorspontbreathingatupperpressurelevelbyventing

excesspressureandflow(PCVorBiLevel)

40PCIRC

cmH2OINSPLminEXP302010010-2080604020020-804060V.04812s2610SpontaneousEffortsSpontaneousEffortsPCVW/OActiveValvePCVwithActiveValveActiveExhalationValveDuring58TwoProportionalValveSystemWithActiveExhalationValve

O2AIR50psig50psigAirandO2solenoidscombinedwithactiveexhalationvalve.PATIENTEXHTwoProportionalValveSystem59MicroprocessorControlEachnewgenerationofventilatorincorporatesfasterprocessors.Multiplehighspeedprocessorsimprovetheventilatorsresponsetothepatientsneeds.Fasterprocessorsmakemoreinformationavailabletotheclinician.MicroprocessorControl60MICROPROCESSORFUNCTIONDuringeachbreath,theventilatorswitchesthroughmultiplealgorythims.Thesedeterminesensingofpatientbreath,riserateofbreath,criteriaforpatientterminationofbreathatvariouspointsduringthebreath,andventilatorinitiatedterminationofbreath.Monitoreddataaswellasdataneededforventilatorfunctionareconstantlybeingprocessedinthebackground.Mostcalculationsdonebytheventilatorareneverseenbytheuser.Mostmodesofventilationthathavecomeoutinthelast15yearswouldbeimpossiblewithoutcomputercontrol.MICROPROCESSORFUNCTIONDuring61UPGRADABILITYOlderventilatorsfrequentlyrequiredacompletefactoryoverhaultohaveonemodeadded.Upgradingnewerventilatorsisusuallyaccomplishedbysoftwareupgrade.ThismaybedonebychangingoutthechipsetoruploadingsoftwarefromaPC.Addingoptions/modestypicallyinvolveschangingachipthataccessesspecificoptionsincludedinthesoftware,orenteringacodenumberthroughakeypad.UPGRADABILITYOlderventilators62BatteryBack-UpIsnowstandardonmostICUventilators.EliminatesinterruptionsinventilatorfunctionduringflickersorshorttermfailureinA/Cpower.Aidspatientsafety.BatteryBack-UpIsnowstandard63GUI

GraphicalUserInterfaceTouchscreentechnology.BecomingthenormforICUventilators.Replacestraditionalknobs,buttonsetc.Blendsgraphicaldisplayswithcontrols.Easysoftwareupgrades.Givesadditionalinformationrelativetosettingchanges.GUI

GraphicalUserInterfaceTo64EaseofUse-SoftwareControlledScreensOnlycurrentmodesandsettingsaredisplayed(easeofuse)

Informationcanappearasneededtohelpmake

decisionseasierandsaferEaseofUse-SoftwareControl65AutomaticTubeCompensationOvercomestheresistancetoflowcreatedbyanendotrachealtubeortracheostomytube.Givesthepatientthesensationthattheyarenotintubated.Mostimportantduringspontaneousbreaths.Mayprovideacalculatedtrachealpressurecurveonthegraphicsdisplay(E4).Canbeusedto“train”therespiratorymuscles.AutomaticTubeCompensationOve66ET.TubeResistanceDuringBreathTypesMandatorybreathsfromtheventilatoreasilyovercometheresistanceofanET.tube.Spontaneousbreathsaremoredifficultasaresultofbreathingthrougharelativelysmallorifice.ET.TubeResistanceDuringBre67ATCFunctionDuringInspirationDuringinspiration,theventilatorincreasespressureatthetopoftheET.tubeproportionatetotheinspiratoryflowrate.ATCFunctionDuringInspiratio68FunctionofA

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