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
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
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
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 ?
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
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)
34.
35.
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
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)