Physics of Ventilation
National Chairperson (Ex) Intensive Care Chapter I A P Founder Chairman..... National conference on pediatric critical care Professor of pediatrics ( Hon ) JNMC:Wardha Nagpur : INDIA
Dr Deopujari
The evolution of Ventilator
Three problems of ventilation
Applied Physics
What can we manipulate ?
Compliance Static compliance Dynamic compliance Resistance Work of breathing Flow Pressure Volume Surface area
Evolution of Ventilators
What can we manipulate ? 1)Minute ventilation 2)Pressure gradient 3)Surface are 4)Pulmonary vasculature 5)Solubility How can we do this ?
Compliance
Compliance is a quotient between volume and corresponding pressure change.
V
C=
Dynamic compliance
Static compliance
C O M P L I A N C E The compliance of any structure is the ease is with which the structure distends ( C= V / P)
c.c.p. = critical closing pressure c.o.p. = critical opening pressure
PEEP
V O L U M E
C.C.P. C.O.P.
PRESSURE
Volume
EX.
INS.
Optimal Benefit Of PEEP
Pressure
Static compliance
Time Tidal volume.
Inspiratory pause
Cst =
Static pressure end expiratory pressure
Cc
Flow
Cst : static compliance Cc : circuit compliance end expiratory pressure (Pend-ex) Pend-ex = Peep + P peep
Pressure
Peak pressure Plateau pressure
Resistance Compliance
Flow .
Flow indicates circulation of an element per unit of time through a given place Flow. Linear Turbulent
FLOW
Pmo
FLOW THROUGH A PIPE LIKE STRUCTURE REQUIRES A DRIVING PRESSURE (PalvPmo) TO OVERCOME THE FRICTIONAL RESISTANCE Palv FLOW DEPENDS ON Pressure Difference and Resistance V=P/R
Pressure .
Represents the force that a volume of gas exercises upon a unit area. Kinetic theory states that gas molecules bomb the walls of a container .
If volume remains constant , pressure varies in direct proportion to Temperature. If temperature remains constant , pressure varies in inverse relation to Volume .
Increase in pressure decreases volume
Resistance
Resistance is defined as the relationship between pressure (p) and flow ( 0 ) Therefore important when there is air flow. P R = ----------O Resistance depends upon Diameter of airway Length of airway Viscosity and density of air Resistance during inspiration Resistance during expiration
And how can we do this ?
Mechanical Ventilation Concept
Conditional variables Control variables Phase variables Trigger variables Limit variables Cycle variables Base line
CONDITIONAL VARIABLE
Conditional variables alone or in combination are analyzed by Ventilators control logic. The state of this variable determines as to which of two types of breath would be delivered. SIMV is based on timing window and accordingly the ventilator delivers . a pressure triggered ( patient ) or time triggered ( machine) breath. In this situation the patient effort and time are conditional variables for determining triggering.
Conditional variables Pressure Volume Flow Time
CONRTOL VARIALBE
Control variable manipulates the conditional to cause inspiration. Pressure , volume , flow and time are control variables.
The behavior of control Variable Ventilatory load.
remains constant in spite of changed
CONRTOL VARIALBE
Control variable manipulates the conditionals to cause inspiration. PRESSURE , VOLUME , FLOW and time are control variables.
The behavior of control Variable Ventilatory load.
remains constant in spite of changed
Pressure
Rectangular Exponential
CONRTOL VARIALBE
Control variable manipulates the conditional to cause inspiration. Pressure , VOLUME , FLOW and time are control variables.
The behavior of control Variable Ventilatory load.
remains constant in spite of changed
Volume
Ramp Sinusoidal
CONRTOL VARIALBE
Control variable manipulates the conditional to cause inspiration. PRESSURE , VOLUME , FLOW and time are control variables.
The behavior of control Variable Ventilatory load.
remains constant in spite of changed
Flow
rectangle sinusoidal ramp
ramp
exponential
LIMIT VARIBALE
During pressure support ventilation though one selects a level of support the Inspiration continues till predetermined flow rate or termination criteria is reached. During PSV patient determines the Rate .. Inspiratory time Flow..
Volume control
Volume
Flow
End of inspiration
Pressure
Peak pressure Plateau pressure
Resistance Compliance
Pressure control
Volume
Flow
End of insp. flow
What does not change . 1)Volume curve 2)Exp. Flow curve
Pressure
Pressure control
Volume Volume End of insp. flow
Volume control
Flow
End of insp. flow
Flow
Pressure Pressure
Peak p. Plateau p.
Resist.
Compliance
Volume limited and pressure limited ventilation .
Volume limited pressure limited
Advantages Tidal Volume guaranteed Precise control of Inspiratory flow Easy detection of changed respiratory impedance
Precise control pf pressure Decelerating flow reported to improve distribution of ventilation decrease dead space ventilation decrease PIP match Inspiratory flow
Disadvantages
PIP vary Inspiratory flow may not match the patients needs
Variable tidal volume Changes in impedance not easily detected
Modes of ventilation or moods of ventilation
Controlled Ventilation.
P R E S S U R e
F L O w
V O L U M e
A normal lung
B decreased compliance
C increased resistance
SIMV
Patient triggered ventilation Synchronized to patient breath if the threshold is met .
Patient controlled variables Respiratory rate Inspiratory time Clinician controlled variables PIP if pressure limited Tidal volume if volume cycled Inspiratory time if time cycled Flow SIMV rate
Flow cycling . Insp. Terminated at % of peak flow rather than time Synchronizes expiratory and Insp. flow thus total synchrony achieved.
When SIMV is used, the patient receives three different types of breath: The controlled (Mandatory) breath. Assisted (synchronized) breaths. Spontaneous breaths, which can be pressure supported.
A B
Flow
Trigger
PaW
Volume
A .Controlled and time triggered B .Spontaneous C .Synchronized and assisted
Pressure
Trigger
Spontaneous breath
Spontaneous breath Volume Assisted breath Back up ventilation period Controlled breath
Spontaneous volume
Pressure support
Pressure support ventilation is a spontaneous mode of ventilation. Inspiratory effort is assisted by the ventilator at an airway pressure that remains constant during the phase of inspiration. Inspiration is terminated when the peak Inspiratory flow reaches a preset level. (usually 25%)
Patient determines Rate Inspiratory time Airflow
PRVC A control mode, which delivers a set tidal volume with each breath at the lowest possible peak pressure. Delivers the breath with a decelerating flow pattern that is thought to be less injurious to the lung
Volume Support Equivalent to pressure support set a goal tidal volume the machine watches the delivered volumes and adjusts the pressure support to meet desired goal within limits set by you.
Airway Pressure Release Ventilation Can be thought of as giving a patient two different levels of CPAP Set high and low pressures with release time. Length of time at high pressure generally greater than length of time at low pressure. By releasing to lower pressure, lung volume is allowed to decrease to FRC
Certain other issues
Fixed insp. Time Termination sens. off
Termination sens. on
Pressure
Flow
Inspiratory cycle off
Proper Inspiratory cycle termination avoids lung hyperinflation and Increased work of breathing
10 % 5% 1%
40 % 10 %
Pressure limited
COMPLIANCE LINE
Vt.
PEEP Over distension
PIP
Pressure Volume loops
Pressure limited
COMPLIANCE LINE
Volume limited
COMPLIANCE LINE
Vt.
Low compliance
Vt.
PEEP
PIP
PEEP
PIP
Normal resistance B C D
Volume
A B C
Pressure in CM
Increased resistance D
Volume
Pressure in CM
volume Pressure
Triggering
Triggering
Neuro Ventilatory coupling .
Central Nervous System Ideal technology Neurally Adjusted Ventilatory Assist NAVA Ventilator
Phrenic Nerve
EA di Waveform
Diaphragmatic contraction
Chest Wall and Lung expansion
Air way pressure , flow and volume
Current Technology
Tidal volume P plat PEEP Tidal volume PIP PEEP
PIP P plat Flow rate
PIP- P2 Flow rate
Static compliance
Dynamic characteristics
Maximum resistance index
Minimum resistance index
Elastic and resistive property of respiratory System
Time constant
Resistive property
Conditional variables
Control variables
Pressure : Volume : Flow
Phase Variables Trigger : Limit : cycle : Base line
SLEEP even in difficult situation You can comfortably SLEEP if you know your physiology well
Thanks
