Dual modes ventilation for neonates
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This is a presentation covers the basics aspects of dual mode of mechanical ventilations. these modes that use the pressure control and volume control ventilation at the same time.
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Dual modes ventilation for neonates
- 1. Dual Modes of Ventilation Maher M. AlQuaimi, AEA, MsRC, RRT Lecturer at Dammam university Chairman of RC club in eastern province Education group board member SSRC
- 2. I declare any conflict of interest. I may present some modes or names that is only available in some companies.
- 3. Outline • Lung mechanics • volume control ventilation • Pressure control ventilation • Dual mode ventilation • Types of dual mode • Setup of modes • Evidences based practice • Conclusion
- 4. Outline • Lung mechanics • volume control ventilation • Pressure control ventilation • Dual mode ventilation • Types of dual mode • Setting of modes • Evidences • Conclusion
- 8. Ohm’s law V (volts) = I (amps) x R (Ω)
- 9. What is needed to inflate the lung? • Pvent + Pmus = VR+V/C .
- 10. Outline • Lung mechanics • volume control ventilation • Pressure control ventilation • Dual mode ventilation • Types of dual mode • Setup of modes • Evidences based practice • Conclusion
- 11. Quiz A B C
- 12. PCV vs VCV
- 13. PCV vs VCV PCV VCV Guarantee PIP = less risk of barotrauma Guarantee VT = better control of Co2 Variable flow, better synchrony Easier to identify lung mechanics PCV VCV Varying VT = vary CO2, volutrauma Fixed flow = asynchrony Both modes have MAJOR disadvantage. Being Passive
- 14. Outline • Lung mechanics • volume control ventilation • Pressure control ventilation • Dual mode ventilation • Types of dual mode • Setup of modes • Evidences based practice • Conclusion
- 15. Why Dual Modes?
- 16. • In theory, so as to combine the advantages of volume control and pressure-control ventilation, manufacturers developed “dual-modes,” which combine aspects of both volume-controlled and pressure-controlled ventilation. These dual- control modes, or adaptive pressure control modes (APC), use closed-loop feedback control systems that adapt the ventilator output based on the difference between the measured ventilation and a predefined target
- 17. • Pvent + Pmus = VR+V/C . closed-loop feedback • When compliance or resistance changes, P vent will change ..
- 18. Outline • Lung mechanics • volume control ventilation • Pressure control ventilation • Dual mode ventilation • Types of dual mode • Setup of modes • Evidences based practice • Conclusion
- 19. Volume Delivered Every Breath Volume Targeted Breath by Breath
- 20. Volume Delivered Every Breath • Volume-assured Pressure Support (VAPS) • Pressure Augmentation
- 21. Cont. • If volume is achieved it cycles to expiration when flow drops to 25% – Patients can get more than the determined volume • If volume not achieved, flow contentious until it is achieved • In both cases Volume is assured
- 22. Volume Targeted Breath by Breath • Pressure-Regulated Volume Control (PRVC) • Volume Targeted Pressure Control (VTPC) • Volume Control Plus (VC+) • Autoflow • Pressure Controlled Ventilation, Volume Guaranteed (PCV-VG) • VG
- 23. Pressure-Regulated Volume-control (PRVC) • Patient or time triggered, pressure limited, time-cycled breath • The desired tidal volume is presets, and the ventilator delivers a pressure (controlled) breaths until that preset tidal volume is achieved
- 24. Quiz 2 • Which type of dual mode measure the tidal volume within the breath • Is PRVC consider a PC or VC ?
- 25. Outline • Lung mechanics • volume control ventilation • Pressure control ventilation • Dual mode ventilation • Types of dual mode • Mode Settings • PAV • Evidences • Conclusion
- 26. Settings • Minimum respiratory rate • Target tidal volume ( 4 ml / kg ) • Upper pressure limit ( in some ventilators, it is defaulted at 5 cmH2o below the high peak pressure alarm) • FiO2 • Inspiratory time or I:E ratio • PEEP
- 27. Advantage of PRVC • Decelerating inspiratory flow pattern • Pressure automatically adjusted for changes in compliance and resistance within a set range • Tidal volume guaranteed • Limits volutrauma • Prevents hypoventilation • Automatic weaning of the pressure as the patient improves
- 28. Disadvantage of PRVC • Pressure delivered is dependent on tidal volume achieved on last breath – Intermittent patient effort → variable tidal volumes • Asynchrony with variable patient effort – Richard et al. Resp Care 2005Dec • Less suitable for patients with asthma or COPD
- 29. But still ..
- 30. BUT
- 32. PAV “PAV provides ventilatory assistance in terms of flow assist (FA, cm H2O/l/s) and volume assist (VA, cm H2O/l) which can specifically unload the resistive and elastic burden” “With PAV there is no target flow, volume, or pressure and the responsibility of guiding the ventilatory pattern is shifted completely from the caregiver to the patient with the purpose of improving the patient-ventilator interaction” Proportional assist ventilation (PAV): a significant advance or a futile struggle between logic and practice? (Thorax 2002)
- 33. PAV+ Only one setting Unloading percentage 100% Within the breath continues measurements of lung mechanics ( about 200 measurements in a second)
- 36. Added to the patient NAVA, PAV and PS were compared
- 37. Main results • 1) Compared to PSV, proportional modes favored a more variable VT. • (2) Load addition resulted in an increase in inspiratory effort which, when expressed as a percentage, was lower with PAV+ than that with NAVA and PSV
- 38. BMJ, 2015 12 infants with a median gestational age of 25 (range 24–26) median of 43 (range 8–86) days Comparison of PAV and ACV
- 39. Main results “Recruitment to the trial was stopped at 12 patients since it emerged at that point that the OI results were in favour of PAV for all 12 patients” • PAV group had significantly less MAP, PIP, RR, FiO2 and better Oxygen index • No significant difference was seen in Paco2 or desaturation episodes
- 40. Does it really worth it? Respiratory Care January 1, 2011 vol. 56 no. 1 61-72
- 41. Take home messages • Learn how to drive then drive safely • Use sharp clinical assessment and judgment • Treat the patient not the ventilator • Dual modes add up the advantages of both modes • PAV seems to be very promising mode and provide better synchrony
- 42. References • Essentials of Mechanical Ventilation (3rd ed) • Dr.Mazen Kerallah, online lecture http://goo.gl/jZOe4e • A presentation from Mrs.Shog Alhomod
- 43. @MaHeR_RT Scan the QR code and you can download the presentation
Editor's Notes
- Best of both worlds Deliver the VT with least possible pressure.. Like a bedside RT who monitors VT and adjust preset pressure
- Play the slide show to see how it will look.. So in column A, we assume the lung compliance is ok, the patient did good effort, and the volume is easily delivered. VAPS will exactly act as pressure support ventilation. See the square pressure waveform, expedential decay flow wave form, and the volume reaching above the target value. Expiration will begin when flow drops to 25% of initial flow as it does with PSV. Now reveal column B in slide show which represent the graph when the volume is not reached in a predetermined time criteria, the ventilator will automatically switch to volume controlled ventilation clearly shown by the change in flow waveform to square waveform and the preset VT will be delivered.
- All the names I know and there could be more
- Take home message: PRVC is a PRESSURE CONTROL MODE. It is commonly misperceived as VC mode from the miss leading name. It will deliver three 5 to 10 cmH2O test breaths to decide what pressure to start from then gives the pressure, monitor the exhaled VT, and adjust the pressure for next breath accordingly. (target VT reached maintain pressure, delivered VT less then expected increase the pressure, delivered VT more than expected decrease the pressure)