Professional Documents
Culture Documents
1. INTRODUCTION
1.1 Anatomy Of Respiratory System..5
1.1.1 Function Of Respiratory System....5
1.1.2 Components Of Respiratory System..5
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3. MECHANICAL VENTILATOR
3.1 Mechanical Ventilator Definition...24
3.2 Mechanical Ventilator Classification..25
3.3 Pressure , Volume , Flow And Time Diagram...27
3.3.1 Pressure Time Diagram....27
3.3.2 Volume Time Diagram.27
3.3.3 Flow Time Diagram.28
3.3.4 Pressure Volume Diagram...28
3.4 Ventilator Mode ...29
3.4.1 Spontaneous....31
3.4.2 Positive End Expiratory Pressure (PEEP)...31
3.4.3 Continuous Positive Airway Pressure (CPAP)...34
3.4.4 Different Between PEEP and CPAP ..36
3.4.5 Controlled Mechanical Ventilation (CMV)36
3.4.6 Synchronized Intermittent Mandatory Ventilation (SIMV)38
3.4.7 Different Between CMV and SIMV41
4. THEORY OF OPERATION
4.1 Ventilator Block Diagram42
4.1.1 Gas Supply System..42
4.1.2 Microprocessor Electronic...44
4.1.3 Keyboard display panel...44
4.1.4 Patient Service System (Patient Circuit).44
4.1.5 Pneumatic System..45
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5. APPLICATION - DRAEGER-EVITA4
5.1 Introduction48
5.2 Basic principle.48
5.3 Block Diagram.49
5.3.1 Electronics System...50
5.3.2 Pneumatics System..52
5.3.2.1 Gas Connection Block....54
5.3.2.2 Parallel mixer or mixer block.55
5.3.2.3 Pressure sensor ....56
5.3.2.4 PEEP/PIP valve57
5.3.2.5 Inspiration block...58
5.3.2.6 patient system59
5.3.2.7 Air supply..59
5.3.2.8 O2 supply...60
5.3.2.9 Inspiration.61
5.3.2.10 Expiration62
5.3.2.11 Neubilizer62
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6.3.1 purpose...66
6.3.2 problems.67
REFERENCES .89
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1. INTRODUCTION
In this chapter will talk about general information in respirator system ,which plays an
important role in other biological systems.
We will talk about anatomy, physiology and associated disease of this system.
12 times a minute, the brain stem sends nerve impulses that tell the
diaphragms and thoracic cage muscles to contract. Contraction of these muscles expands the
rib cage, leading to the expansion of the lungs contained within. With each expansion of the
lungs we inhale a breath of fresh air containing 21% oxygen and almost no carbon dioxide.
After full expansion the brain command to inhale ceases and the thoracic cage passively
returns to its resting position, at the same time allowing the lungs to return to their resting
size. As the lungs return to their resting position we exhale a breath of stale air, containing
about 16% oxygen and 6% carbon dioxide. In health this breathing cycle is silent, automatic,
and effortless.
-5-
-6-
There is
almost no CO2 in air (about 0.03%); the carbon dioxide humans and animals exhale is a
negligible part of the entire atmosphere. The nitrogen is inert and does not take part in gas
exchange.
To accomplish gas exchange the air, we inhale is delivered to tiny sacs (alveoli) which
are the terminal or end units of the airways. During breathing, a volume of air is inhaled
through the airways (mouth and/or nose, pharynx, larynx, trachea, and bronchial tree)
into millions of tiny gas exchange sacs (the alveoli) deep within the lungs. There it
mixes with the carbon dioxide-rich gas coming from the blood. It is then exhaled back
through the same airways to the atmosphere. Normally this cyclic pattern repeats at a
breathing rate, or frequency, of about 12 breaths a minute (breaths/min) when we are at
-7-
rest (a higher resting rate for infants and children). The breathing rate increases when
we exercise or become excited.
Gas exchange is the function of the lungs that is required to supply oxygen to the blood for
distribution to the cells of the body, and to remove carbon dioxide from the blood that
the blood has collected from the cells of the body. Gas exchange in the lungs occurs
only in the smallest airways and the alveoli as (figure 1.2). It does not take place in the
airways (conducting airways) that carry the gas from the atmosphere to these terminal
regions. The size (volume) of these conducting airways is called the anatomical "dead
space" because it does not participate directly in gas exchange between the gas space in
the lungs and the blood. Gas is carried through the conducting airways by a process
called "convection". Gas is exchanged between the pulmonary gas space and the blood
by a process called "diffusion".
-8-
Therefore, if we were to develop a machine to help a person breathe, or to take over his or her
breathing altogether, it would have to be able to produce a tidal volume and a breathing rate
which, when multiplied together, produce enough ventilation, but not too much ventilation, to
supply the gas exchange needs of the body. During normal breathing the body selects a
combination of a tidal volume that is large enough to clear the dead space and add fresh gas to
the alveoli, and a breathing rate that assures the correct amount of ventilation is produced.
capillaries, which take up the oxygen and give off carbon dioxide.
Describes the procedure of inspiration and expiration and thus the inflow and
outflow of the gases we breathe between the alveolus and the atmosphere.
The diaphragm is a dome-shaped muscular plate consisting of a central beanshaped tendon that is attached to the thoracic cage, the spine, the ribs and the
sternum.
Contraction of the diaphragm pulls it down, causing it to flatten. The volume of
the thoracic cage increases and the pressure in the alveoli becomes negative
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-10-
The driving force for gas exchange between the alveoli and their surroundings,
that is for pulmonary ventilation, are the different pressures between the
alveoli at inspiration and expiration. During inspiration the pressure within the
alveoli must be lower than the atmospheric pressure of the surrounding air.
Conversely, the opposite pressure gradient must exist during expiration. If the
atmospheric pressure is assumed to be zero, the values of inspiration pressure
will be negative, whereas expiration will result in positive values (Fig. 1.4).
Fig. 1.4 Energy sources for inspiration and expiration and alveolar pressure changes
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-12-
dyspnea
paradoxical breathing
agitation, confusion
tachycardia, hypertension
possibly cyanosis
-13-
failure, PaO2 and PaCO2 are essential parameters for initiation and administration of
ventilator support.
Hypoventilation is defined as inadequate clearance of CO2 a phenomenon that can only
be confirmed by arterial blood gas analysis (arterial hypercapnia
The cardinal symptom of acute respiratory failure is a drop of the PaO2 below 6.7 kPa
during spontaneous breathing of room air in combination with tachypnea > 35/ min.
The indication for respiratory support is therefore based on two pathophysiological
mechanisms:
1.
Inadequate oxygenation
2.
Reduced CO2-elimination
There are two types of acute respiratory failure:
Pulmonary ventilator failure
with reduced
alveolar
ventilation and
reduced
pulmonary edema
ARDS
pneumonia
atelectasis
pulmonary fibrosis
-14-
Central causes
2.
Peripheral causes
a)
b)
injury of the chest wall (e.g. multiple rib fractures after thoracic trauma
kyphoscoliosis
-15-
pleural effusion
pneumothorax
Impediment of coughing
pain
central suppression (e.g. sedation!)
abdominal distension
tenacious bronchial secretions
Diseases:
Acute Obstructive Disease (e.g., acute severe asthma, airway mucosal edema)
dyspnea-related
anxiety,
apnea
of
prematurity,
intracranial
hemorrhage)
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0.6 L.
2.Inspiratory Reserve Volume (IRV): the volume that can be inhaled further
after quiet inhalation, that is, the difference between normal and maximal
ventilation.
Normal value: about 2.5 L
3.Expiratory Reserve Volume (ERV): the volume, that can be further exhaled
after quiet expiration, that is the difference between normal and maximal
expiration.
Normal value: about 1.5 L
4.Residual Volume (RV): the volume remaining after maximal expiration in the
lungs.
Normal value: about 1.5 to 2 L.
5.Functional Residual Capacity (FRC): the volume left in the lungs at the end
of quiet expiration.
Normal value: 3 to 3.5 L.
FRC = RV + ERV
The FRC is by definition the gas volume remaining in the lungs during
quiet breathing. It can be considered a measure for the gas exchange area.
It results from the balance between the opposite elastic forces exerted by the
lungs and chest.
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6.
Vital Capacity (VC): the volume difference between maximum inspiration and
maximum expiration. It is therefore a measure for the largest possible breathing
excursion.
Normal value: 3.5
7.
5.5 L
Total Lung Capacity (TLC): Maximal air capacity of the lung. It is calculated
from the sum of the VC and RV.
Normal value: approximately 6 L.
TLC = VC + RV
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4 mbar/l/sec.
In intubated patients with healthy lungs the inspiratory resistance lies between 4
mbar/l/sec.
In children, both the anatomical as well as the physiological features of the respiratory
organs cause considerably higher airflow resistance:
Normal values:
Newborn
30
50 mbar/l/sec
Infants
20
30 mbar/l/sec
Small children
20 mbar/l/sec
Adults
4 mbar/l/sec
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-20-
-21-
C=
Vml
p mbar
If additional volume is pressed into an elastic body such as a ballon, that has a certain
volume and is under a certain pressure, the volume changes by the value V and the pressure
increases by the value p. The volume change involves complete filling of the lungs from the
beginning to the end of a taken breath.
The larger the compliance the less the pressure increases at a certain filling volume.
Cstat =
The Cstat lies between 50 and 70 ml/mbar in the intubated patient without lung disease
A further requirement for correct measurement of the static compliance is a completely
relaxed respiratory musculature, that is a complete lack of muscular activity, which usually
can only be reached by deep sedation or relaxation.
-22-
Cdyn =
Cdyn is of very little clinical use, as it measures resistive components in addition to the
elastic forces.
Total Compliance :
1
c total
1
c lung
1
c thorax
Normal values:
Newborn:
ml/mbar
Infants:
10
20 ml/mbar
Small children
20
40 ml/mbar
Adults
70
100 ml/mbar
The compliance of the lungs depends on the elasticity of the pulmonary fiber structure,
the intrapulmonary fluid content and the surfactant activity.
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3. Mechanical Ventilator
A ventilator is an automatic mechanical device designed to provide all or part of the
work the body must produce to move gas into and out of the lungs. The act of moving air
into and out of the lungs is called breathing, or, more formally, ventilation.
Inhalation serves to
replenish alveolar gas. Prolonging the duration of the higher volume cycle enhances oxygen
uptake, while increasing intrathoracic pressure and reducing time available for CO2 removal.
The rate pattern and duration of gas flow control the interplay between volume and
pressure. In volume controlled modes, a desired tidal volume is delivered at a specific flow
(peak flow) rate, using constant decelerating or sinusoidal flow.
In pressure controlled
modes, flow occurs until a preset peak pressure is met over a specified inspiratory period, the
flow pattern is always decelerating.
Ventilator "cycling" refers to the mechanism by which the phase of the breath switches
from inspiration to expiration. Modes of ventilation are time cycled, volume cycled or flow
cycled. Time cycling refers to the application of a set "controlled" breath rate. In "controlled
ventilation" a number of mandatory breaths are delivered to the patient at a predetermined
interval.
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b)
c)
-25-
2.
Cycling: how the ventilator switches from inspiration to expiration: the flow has been
delivered to the volume or pressure target
a)
Time cycled
b)
Flow cycled
c)
Volume cycled
If an inspiratory
pause is added, then the breath is both volume and time cycled.
3.
Triggering: what causes the ventilator to cycle to inspiration. Ventilators may be time
triggered, pressure triggered or flow triggered.
a)
Time: the ventilator cycles at a set frequency as determined by the controlled rate.
b)
Pressure: the ventilator senses the patient's inspiratory effort by way of a decrease
in the baseline pressure.
c)
Flow: modern ventilators deliver a constant flow around the circuit throughout the
respiratory cycle. A deflection in this flow by patient inspiration, is monitored by the
ventilator and it delivers a breath. This mechanism requires less work by the patient
than pressure triggering.
4.
Breaths are either: what causes the ventilator to cycle from inspiration.
a)
Mandatory (controlled)
b)
c)
5.
Sinusoidal = this is the flow pattern seen in spontaneous breathing and CPAP.
b)
slows down as alveolar pressure increases (there is a high initial flow). Most intensives
and respiratory therapists use this pattern in volume targeted ventilation also, as it
results in a lower peak airway pressure than constant and accelerating flow, and better
distribution characteristics.
c)
Constant = flow continues at a constant rate until the set tidal volume is delivered.
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d)
6. Mode or Breath Pattern: there are only a few different modes of ventilation:
We will discuss it later in section 3.4 (ventilator mode).
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Flat lower portion of the curve: If the end expiratory lung volume (L vendexp.)
is too low end expiratory closure of the small airways (airway closure) and
collapse of the distal alveoli will occur. During every inspiration the so-called
alveolar opening pressure must be applied to that these collapsed lung areas can
open.
Alveolar opening pressure = pressure necessary to open collapsed alveoli
(recruitment)
The alveolar opening pressure is always higher than the alveolar closing pressure,
that is the pressure at which the alveoli collapse.
2.
Middle steep (linear) portion of the curve: In this portion of the curve the least
breathing work is necessary, the maximal steepness gives rise to the maximal
static compliance. The compliance thus varies with the lung volume. It is highest
in the area of the normal functional residual capacity (about 3 litres). A decrease
or an increase of the functional residual capacity from 2 or 5 litres respectively
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Flat upper portion of the curve: This part of the curve shows the maximal
alveolar elasticity.
increase in volume.
An
operating mode can be described by the way ventilator is triggered into inspiration and
cycled into exhalation.
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2.
What variables are limited during inspiration, and whether or not the mode allows only
mandatory breaths, spontaneous breaths, or both?
Many different functions are commonly available on modern ventilators regardless of
Spontaneous.
2.
3.
4.
5.
6.
7.
8.
9.
Spontaneous.
2.
Positive End-Expiratory(PEEP)
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3.
4.
5.
-31-
15 20
2.
1.
shunting. This condition may be caused by a reduction of the functional residual capacity
(FRC), atelectasis, or low Ventilation to Perfusion (V/Q) mismatch. Refractory hypoxemia is
defined as hypoxemia that responds poorly. To moderate to high levels of oxygen. A helpful
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clinical guideline for refractory hypoxemia is when the patient's PaO2 is 60 mm Hg or less at
an FIO2 of 50% or more.
2.
increasing the functional residual capacity (FRC) (increasing the gas-exchange area)
2.
Barotrauma.
3.
Increased intracranial pressure, and ICP increases due to impedance of venous return.
3.
-33-
PEEP should therefore only be reduced when there is adequate pulmonary gas exchange
at an FIO2 < 0.5. Abrupt termination of PEEP therapy can result in pleural effusions.
CPAP can be applied with an endotracheal tube or via a tight fitting face or nose mask.
CPAP breathing requires the patient to be awake and co-operative, to have adequate
spontaneous breathing, i.e. sufficient pulmonary pumping function.
-34-
Advantage of CPAP
Improved oxygenation (rise in PaO2) through increasing the functional residual capacity.
PaO2 FRC
with CPAP the breathing effort is reduced, because the inspiratory gas flow makes
breathing in easier
Indications
Pulmonary oedema
Pneumonias
RDS-Syndrome of new-borns
Failure to oxygenate is caused by reduced diffusing capacity and ventilation perfusion
mismatch.
pressure using CPAP. If the problem is atelectasis due, for example, to mucus plugging or
diaphragmatic splinting following abdominal surgery, or moderated amounts of pulmonary
edema, CPAP, as delivered by facemask or endotracheal tube, may sufficiently restore
pulmonary mechanics to avoid addition inspiratory support. CPAP is easy to apply: all that is
required is a PEEP valve and a flow generator.
-35-
Side-Effects
Are similar to PEEP ventilation because of the increased intra-thoracic pressure.
PEEP mode is not stand alone in ventilator machine. It comes as assistance mode in big
and complex ventilators.
2.
3- A. PEEP indicates:
a)
b)
B. CPAP indicates:
1)
2)
Pulmonary odema.
3)
Pneumonias
4)
Weaning
5)
In this mode, it introduce automatically and independently from any possibly existent
spontaneous breathing, that is no synchronization.
This mode is used when the patient in operation room or after operation when he still
unconscious, because all his muscles are in hebted (do not work).
-36-
.If
-37-
seconds long.
The mechanical breath is therefore triggered when the patient initiates an inspiratory
effort after the end of the spontaneous breathing phase and within the expectation window.
Apart from the number of mandatory breaths, with modern ventilators the ventilatory pattern
of the mandatory breath can also be varied via the adjustable variable VT, IPPV frequency,
inspiratory flow and I/E ratio, whereby IPPV frequency and I/E ratio determine the duration
of the mandatory breath
-38-
SIMV pressure-Controlled).
Because synchronization of the mandatory breath shortens the effective SIMV time and
would therefore undesirably increase the effective IMV frequency, modern ventilators
increase the following spontaneous breathing time by the missing time difference
T. An
increase in the frequency of SIMV is therefore avoided. The other factor (apart from VT)
responsible for the minimum ventilation, F IMA remains constant.
If the patient has inhaled a significantly larger volume at the beginning of the trigger
window, the ventilator reduces the following mandatory breath by reducing the time for the
inspiratory flow phase and the inspiration time. Thus, the other factor responsible for the
minimum ventilation, the tidal volume, VT, remains constant.
SIMV has proved successful for weaning patients after long periods of mechanical
ventilation. During weaning, the SIMV frequency of the ventilator is gradually reduced, and
therefore the break times are prolonged, until the required minute volume is achieved by
spontaneous breathing.
During spontaneous breathing the patient can be pressure supported with ASB (SIMV +
Pressure Support).
SIMV can also be used for long-term ventilation, because, through is reduced average
ventilation pressure, it causes less stress on the circulation. Furthermore, the spontaneous
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breathing rhythm of the patient remains largely intact, so that there is less risk of ventilator
dependency than with controlled ventilation. The basic idea of SIMV is that the patient
breathes largely spontaneously, and that the ventilator offers mechanical breaths with a very
low safety frequency, so that minimum ventilation is ensured.
*
This determines the minimum minute volume that the ventilator will provide.
When selecting the ventilator rate, the patient's spontaneous rate must be considered.
If the SIMV rate is set at a high rate, which lowers the PaCO2 below the patient resting
PaCO2, apnea will result, negating the benefit of SIMV. If the SIMV rate is set above the
patient's own respiratory rate, the result is complete mechanical ventilation or CMV. The
objective of SIMV is to provide a measure of ventilation back-up while permitting
spontaneous breathing to continue.
Unlike volume control ventilation, setting an I:E ratio is not required. In SIMV, the
inspiratory time is used to establish the timing of the breath. With spontaneously breathing
patients, the I:E ratios will be altered as the patient's respiratory rate and rhythm change.
Synchronization Window
The time interval just prior to time triggering in which the ventilator is responsive to the
patient's spontaneous inspiratory effort is commonly referred to as the "synchronization
window".
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coincide with the mechanical ventilation, the impact may be minimal. On the other hand,
when the mechanical ventilation interrupts a patient's own exhalation, the resulting abrupt and
unexpected rise in airway pressure may produce conditions where the patient 'fights' the
ventilator. This may also occur as the patient attempts to terminate a mechanical ventilation.
Either condition may produce unacceptable ventilation, requiring additional intervention.
Synchronising the patient's efforts with those of the ventilator provides a clinically significant
advantage.
SIMV allows the ventilator to sense a patient's own breathing and permit spontaneous
breathing between mechanical ventilations while ensuring sufficient mandatory breaths
should the patient's own rate fall below a preset value. This combination can maintain a more
appropriate minimum minute ventilation. Because of the synchronization provided in SIMV
mode, the ventilator will assist a patient's own breath when that breath falls within the
synchronization window as specified by the operator.
overcome difficulties experienced when patients attempt to compete with CMV mode
ventilations.
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4. THEORY OF OPERATION
4.1 Ventilator Block Diagram
Fig. 4.1 Functional Relationship of the operator, Patient, and the Ventilator
1.
2.
Microprocessor Electronic
3.
4.
5.
Pneumatic System.
Oxygen: blue
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In the UK
Oxygen: white
Vacuum: yellow
The supply points of central gas supplies are secured with check valves, which can only
be opened with special couplings. To avoid confusion, these connectors are gas specific.
Gases from cylinders are under high pressure:
Regulating valves reduce the gas pressure to 4 bar. The pressures at the supply points of
central gas supplies are also at 4 bar. If the pressure in the oxygen pipeline drops below a
value specified by the manufacturer, e.g. 1.5 bar, an O2 gas deficiency alarm sounds, which
cannot be turned off . Because oxygen in cylinders exists in gas form, the reseve in litres can
be calculated using the Boyle-Mariotte gas law (volume x pressure = const.) by multiplying
the volume of the cylinder with the pressure shown at the pressure gauge .
Boyle-Mariotte gas law: volume x pressure = constant
Example: Cylinder volume: 2.51
Cylinder pressure: 200 bar (1 bar = 10 5 Pa)
available oxygen reserve: 2.5 x 200 = 500 litres
With the following equation one can easily calculate, how long a patient can be
ventilated with an O2 cylinder.
Duration = V x P : (MV + 1)
The 2.5 litre cylinders used in emergency medicine contain 500 L oxygen at 200 bar. If
the patient is ventilated with a volume of, for example, 9 1/min with 100% O2 ( No AirMix ), the O2 supply will last 50 minutes. The equation allows for the gas demand of the
transport ventilator.
If the transport ventilator is switched over to the Air-Mix (60% oxygen) mode, the
supply duration is increased to about 100 minutes.
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Patient data such as breath type, pressure, volume, rate and I.E. rate are stored by
microprocessor and can be retrieved at any time.
The signals sent to the pneumatic system to control gas flow and pressure delivered to
the patient. Information sent to the displays indicates ventilator status and patient data.
The major components of the ventilator s microprocessor electronics are:
1.
The microprocessor,
2.
Memory,
3.
Keyboard control
4.
Display control
5.
Conversion circuitry
6.
Interface circuitry
The microprocessor receives information from keyboard, utility panel, DC power
supply, and memory as well as from pressure switches and temperature/flow sensors in the
pneumatic system.
-44-
parallel circuits one for oxygen and one for air. An important element of the pneumatic
-45-
system is the two proportional solenoid valves (PSOLS), which precisely control the flow
delivered to the patient.
Air and oxygen flow sensors provide feedback, which is used by the microprocessor to
control the PSOLS. As a result, the ventilator is able to supply air and oxygen to a patient
according to requirements pre-selected by an operator at the ventilator keyboard. The output
of mixed air and oxygen passes through a patient system external to the ventilator; this patient
system may be composed to tubing, filters, a nebulizer, water traps, and a humidifier
-46-
-47-
5. APPLICATION - DRAEGER-EVITA4
5.1 Introduction
In this chapter, we will discuss in detail one of the most used ventilator in most Ministry Of
Health hospitals in Kingdom of Saudi Arabia. This ventilator is the state of the art equipment
from draeger company. It is EVITA 4 ventilator.
The Evita 4 is a time-cycled, constant-volume long-term ventilator for adults and children.
The features and ventilation modes depend on the specific device and its optional features;
they are described in the instructions for use of the specific device. EVITA 4 has the
following characteristic :
1. Control Unit
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The control unit is the interface between the device and the operator. The control unit
serves to make adjustments, to display measured values and to generate alarms. In the control
unit the display, membrane keypad, touch screen and Graphics Controller PCB are
accommodated.
2. Electronics
The electronics is the central control unit of the Evita. It includes the CPU 68332
PCB, the CO2 Carrier PCB with the Processor Board PCB and Power Supply PCB and the
power Pack (Communication PCB, Paediatric Flow, IFCO PCB, and the optional SpO2 PCB).
3. Pneumatics
The pneumatics controls the pneumatic valves following preset ventilation parameters. It
includes an independent microprocessor system and the valve control. In the pneumatics the
Pneumatics Controller PCB, the HPSV Controller AIR/O2 PCB, the PEER valve, the mixer,
the pressure connection, the flow sensor and the O2 sensor are accommodated.
3.
pneumatics.
Figure5.2
Keys
13
-49-
Supply voltages
14
Power switch
Touchscreen
15
16
17
CAN bus
18
Inspiratory Paw
19
O2 sensor
Not applicable
20
21
10
22
Flow sensor
11
23
12
24
Expiratory Paw
1. EEPROm
The EEPROM is connected to the synchronized, serial interface 68832. The EEPROm
characterizes the Evita (enabled options, serial number, etc). When replacing the CPU 68332
PCB the EEPROM has to be transferred to the new printed circuit board.
2. Processor System
-50-
The processor system comprises a 68332 CPU, a 512 kBytes RAM and a 1 Mbyte flash
EPROM (electrically programmable and erasable read-only memory).
battery back-up. When the battery is being replaced a Goldcap capacitor ensures voltages
voltage supply of the RAMs. Programming of the flash EPROMS is only possible if the
system identified the SERVICE-Q signal.
3. RS232 interface
The CPU 68332 PCB provides an RS232 interface in the Evita. The interface is labeled
COM1. The interface is elecrtrically isolated from the Evita. Electrical isolation is made by
means of optocouplers.
4. ILV interface
The ILV interface is required for independent-lung ventilation with two Evita units.
The ILV interface is not electrically isolated. Pin 3 of the ILV interface is provided with a
filler plug. This filler plug prevents confusion with the RS232 interface.
5. Driver
The driver adjusts the access times between the 68332, the clock and the DUART.
6. Clock
The clock gives the current time. It has a battery back-up and continues to operate even
after the Evita has been switched off.
7. DUART
The DUART (Dual Universal Asynchronous Receiver / Transmitter) has two serial
interfaces and digital inputs and outputs. The serial interfaces are intended for connection of
the SpO2 and the CO2 module.
8. DC/DC converter
The DC/DC converter provides the voltage supply (+5 V ISO) required for the
interface. The input voltage of the DC/DC converter is +5 V.
9. CAN
The CAN interface is a fast, serial interface (Controller Area Network). The control
unit, the electronics and the pneumatics communicate via a CAN interface. The transmission
rate is 800 kbit/s.
-51-
The address bus, the data bus and the check-back signals are transferred by the bus
driver to the motherboard. The 68332 CPU communicates with the optional printed circuit
boards located on the motherboard via the bus driver. Currently, it is only the Pediatric Flow
PCB (Neoflow option).
figure5.3
-52-
AIR
Y3.1
O2
Y3.3
Inspiratory valve
Y4.1
PEEP/PIP valve
Y5.1
Expiratory valve
F1.1
Filter
-53-
F1.2
Filter
Y6.1
F3.2
Filter
Y6.2
D1.1
Non-return valve
S2.1
D1.2
Non-return valve
S2.2
D3.1
Non-return valve
S6.1
D3.2
S6.2
D3.3
S3.1
O2 Sensor
D5.1
Non-return valve
S5.1
Flow sensor
R1.1
R1.2
R1.3
R3.1
R4.1
Y1.1
Y1.2
Y1.3
Y1.4
Y2.1
Y2.2
The gas connection block comprises the O2 gas connection and the compressed
air connection.
The connections are fitted with filters F1.1 and F1.2 (metal fiber web).
-54-
The diodes or check valves D1.1 (AIR) and D1.2 (O2) prevent the gas from
flowing back into the central gas supply system.
The pressure regulators DR1.1 and DR1.2 are set to 2 bar. The control gas
flows past the DR1.1 to the 3/2-way valve Y1.1, from there to the emergency
valve Y1.3, to the PEEP/PIP valve Y4.1 and finally to the emergency valve
Y3.1.
The gas also flows to the expiratory prsessure sensor S6.2 (purge flow) via the
restrictor R1.1 (0.08 L/min).
Gas flows to the nebulizer via the 3/2-way valve Y1.4, if appropriately
adjusted.
In the event of AIR supply failure, the machine will switch over to O2 supply.
Switchover function .
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Sensitivity: 36.5mV/mbar
Offset voltage:1.74V
0.3mV/mbar.
0.04V
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R1.1 to flow to the expiratory pressure sensor S6.2 connecting line on the patient side. At this
point, expiratory humidity is prevented from reaching the pressure sensor S6.2.
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5.3.2.9 Inspiration
Depending on the setting (O2 concentration, inspiratory volume, frequency, T1,
inspiratory flow, inspiratory pressure) the HPSVs Y2.1 and Y2.2 open. The gas flows via the
inspiratory connector to the patient. At the same time, gas flows to the O2 sensor S3.1 and to
the safety valve D3.3; from there, it flows through the 3/2-way solenoid valve Y6.1 to the
inspiratory pressure sensor S6.1.
The safety valve D3.3 is fixed to 100 mbar and serve as an additional safety device in
the event of a complete failure of the electronic control.
When calibrating the O2 sensor S3.1 the sensor will be disconnected with valve Y3.3
from the inspiratory gas. The O2 sensor S3.1 is purged with calibration gas via the valve
Y1.2, the restrictor R1.3, the restrictor R3.1, and the valve Y3.2. The O2 concentration and
the inspiratory gas flow are not affected.
The pressure sensors S6.1 and S6.2 monitor the inspiratory pressure. During the entire
inspiratory time the PEEP/PIP valve Y4.1 provides pressure to the expiratory valve Y5.1.
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5.3.2.10 Expiration
At the start of expiration, the HPSV Y2.1 and Y2.2 are closed. No gas will be supplied to the
patient. The PEEP/PIP valve Y4.1 is switched to the set PEEP value. The expiration valve
Y5.1 will also be relieved and the patient can exhale via check valve D5.1 and the flow
sensor S5.1. The flow sensor S5.1 measures the expiratory volume.
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Figure 6.1
6.1.2 problems
The most common problem with intensive care ventilators is the risk of a patient
Acquiring ventilator associated pneumonia (VAP). It is generally accepted that prolonged
ventilation periods greatly increase a patient s risk of acquiring VAP. The link between
prolonged ventilation and VAP is unclear, but following proper infection control procedures
in maintaining the ventilator, the breathing circuit, and all associated
equipment can minimize patient risk.
Leaks, including those of the ventilator breathing circuit, are another problem that can
affect the ventilator s ability to maintain the PEEP level. This in turn may affect oxygen
saturation and can result in autocycling.
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Leaks may also prevent the ventilator from delivering a preset tidal volume or accurately
sensing flow and terminating a pressure-supported breath.
The friction-fit connector that attaches a ventilator to a patient s artificial airway can be
accidentally disconnected if it is not attached securely by the clinician.
6.2 Portable
6.2.1 Purpose
Portable ventilators provide long-term ventilatory support for patients who do not require
complex critical care ventilators. These portable units are commonly used in special extended
care facilities, in step-down respiratory care units, or in the home. They can also be used for
short-term transport or in emergencies.
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Figure 6.2
6.2.2 Problems
Most of the reported problems involving portable ventilators arise from user error, poorly
maintained exhalation valve assemblies, or the use of poor-quality
breathing circuits. Disconnection of the breathing circuit from the device is one of the most
commonly reported problems.
Caring for a patient receiving mechanically assisted ventilation in the home is potentially
dangerous due to the possibility of equipment failure, resulting in hypoxic brain damage or
death. Ventilator failures can be caused by improper equipment care, damage, tampering, or
incorrect use by caregivers.
Many reported incidents of a patient s inability to exhale are suspected to be caused
by jammed mushroom valves in the exhalation-valve.
6.3 Transport
6.3.1 Purpose
Transport ventilators are designed to take the place of manual bagging in emergency or
transport situations.Hand ventilation, even by nurses, respiratory therapists, emergency
medical technicians, and other trained professionals, tends to be at too fast a rate and at an
unstable tidal volume when performed for extended periods and can produce unintended acute
respiratory alkalosis and its sequelae (e.g., acute electrolyte imbalances and coronary
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vasoconstriction,which can lead to arrhythmias).Transport ventilators are well suited for both
prehospital and emergency department applications.
6.3.2 problems
Inherent in the use of transport ventilators are problems associated with both general
patient transport (e.g., disconnection of the breathing circuit, accidental extubation) and
emergency transport (e.g.,emergency vehicle noise interfering with monitors).Other problems
are associated with user error, poorly maintained units, and use of poor-quality breathing
circuits.
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to ventilate. Medical students were assigned to manually ventilate paralysis victims until
restoration of neuromuscular activity occurred. Iron lungs mimicked the chest cage's activity
in generating minute ventilation, but were of little value in diseases characterized by failure to
oxygenate. The machines were bulky, expensive and somewhat unhygienic.
The first positive pressure ventilators were pressure controlled. This made sense as the
chest is a negative pressure ventilator. Volume controlled ventilators became ubiquitous in
the 1960s as this mechanism was perceived to be more reliable at delivering minute
ventilation, and thus normalizing blood gases.
During the 1970s and 1980s ventilators were developed which allowed patients breathe
spontaneously, initially with assisted breaths (assist control ventilation) and subsequently with
spontaneous breathing limbs
The latter was the first mode to allow partial ventilatory support and thus gradual liberation
from the ventilator. Pressure support was initially developed as a method of lending partial
support to the patient's spontaneous breaths, and interactivity became a function of
microprocessor driven ventilators. Physicians rapidly discovered that this could be used as a
primary ventilation mode, with full patient interaction. Using the ventilator as an interactive
weaning device emerged at this time.
During the 1990s widespread concern developed about ventilator induced lung injury.
Accumulating evidence revealed that larger tidal volume, low PEEP, ventilation strategies
were damaging the lungs. This has led to the development of lung protective ventilator
strategies, using PEEP to maintain alveolar recruitment (the "open lung" approach), and lower
tidal volumes, leading to reduced end inspiratory volumes, to prevent stretch injury. There
was renewed interest in plateau pressure limitation and increasing mean airway pressures.
Various strategies have been developed to achieve this goal. Pressure controlled ventilation
has emerged as a viable alternative, although all strategies involve tidal volume targeting.
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Technology has played a large part in the development of modern ventilators. However,
the introduction of a multitude of new modes has not been accompanied by good quality
outcomes research. Dual modes, combing pressure limitation with tidal volume, have been
developed. Physicians are now demanding more control over gas flow than before
hence
the development of active exhalation valves, dynamic inspiration valves, rise time control,
automatic tube compensation and, of course, waveform analysis. Modern ventilators deliver
enhanced patients interactivity using better triggering sensors, and more comfortable
spontaneous breathing
arrival of high frequency oscillation into adult critical care units. Using this technique, the
physician sets the mean airway pressure, and there is minimal tidal gas movement.
It consisted of an airtight
cylinder that enclosed the patient up to his neck. A seal was formed with foam rubber around
the neck so that there was no leak. The cylinder made isolation of the patient's body
unavoidable, and even ports on the side made it difficult to provide adequate patient care. In
addition, the units had no assist mode, nor was there any means of regulating I/E ratios or
respiratory flow rates. The units were reasonably effective on patients who had relatively
normal airways, such as polio victims, but they inadequately ventilated patients with
significant respiratory disorders.
caused abdominal pooling of blood called tank shock. Because the abdominal wall is flaccid
and thus extremely subject to the negative pressure,1 abdominal pooling of blood can occur,
decreasing venous return and cardiac output. These units were difficult or impossible to
sterilize and were often noisy as well. Tracheotomy or intubation of the patient was usually
not necessary for long-term ventilation because maintaining an airway was not a crucial
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problem affecting volume delivery. This aspect reduced the chance of incurring pulmonary
infection or other problems associated with artificial airway. Iron lungs were also rugged and
dependable, with little maintenance or down time, and were easy to operate by personnel.
The newer isolate negative-pressure ventilators for newborns works basically as an iron.
Lung.
Figure 7.1
*
Iron lung. All but the head is enclosed in a sealed chamber. Slowly revolving wheel
imparts reciprocal motion to bellows assembly connected to chamber. When bellows expand,
subatmospheric pressure generated within chamber causes chest to rise and inspiration to
begin. During upward motion of bellow a one-way valve opens and returns pressure within
chamber to atmospheric. Chest recoils to normal position and exhalation begins. Amount of
positive and negative pressure can be controlled independently.
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Figure 7.2
Position of chest shell used for negative-pressure ventilation. Inspiration is initiated when
pump unit generates subatmospheric pressure in airtight shell. When subatmospheric pressure
is released, exhalation begins.
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Figure7.3
Cuirass shell used for negative pressure ventilation. Patient's is placed in supine position and
cuirass is stabilized with the use of straps and posts. Method of ventilation is identical to
chest shell unit.
An electric pump, similar in design to a vacuum cleaner, was used to generate negative
extrathoracic pressure.
Units a pump (Fig 7.4) reduce the pressure within the chamber to below atmospheric
level. This reduction causes the pressure surrounding the chest to drop below the pressure
within the lungs, and the chest rises. As the chest rises, the lungs expand and the pressure
within them becomes less than atmospheric. Atmospheric gases are thus drawn into the lungs
until equilibrium between lung pressure and surrounding pressure is reached. At that moment
inspiration ends.
To allow exhalation the subatmospheric pressure surrounding the chest is released. The
natural elastic recoil of the lungs and thoracic cage causes lung pressure to exceed
atmospheric pressure, and gas leaves the lungs until lung pressure and atmospheric pressure
are again equal.
Maximum pressure was less than that attainable with an iron lung and was dependent on
the tightness of the fit of the shell.
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Figure7.4
Schematic representation of pump unit used to provide negative pressure ventilation to shell
or garments. Pump unit consists of piston connected off center to a slowly revolving wheel.
The downward stroke of the piston releases the subatmospheric pressure and allows chest to
recoil to normal resting position and allow exhalation.
units also fell into disuse for some of the same reasons as did body-tank
respirators: (1) they were excessively noisy; (2) providing patient care was still hampered,
although improved over the body-respirator type; (3) regulation of I/E ratios was difficult, and
there was no consideration for the regulation of inspiratory flow rates; (4) the seal around the
chest was difficult to achieve, which often made the unit periodically undependable; and (5)
the negative pressure was not as great as in the iron lung, so it was impossible to totally
ventilate a patient who has no respiratory drive.1 These units, however, were used to augment
patients with weakened respiratory muscles to ventilate adequately through the night.
Because the negative pressure was primarily extrathoracic only, these devices provided for an
increased venous return compared with the tank units. In addition, the modification of adding
a flow sensor at the patient's nose for a triggering mechanism during an assist mode provided
easier synchronization of the ventilator and the patient than could be achieved with the iron
lung.
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included so that information on control settings, monitored variables, and alarm status can be
transferred to a bedside monitor, an information system, or some other interfaced device.
Power is supplied from either an electrical wall outlet or a battery; battery power is used for
short-term ventilation, such as during intra-hospital patient transport.
Some intensive care ventilators can receive gas (both air and oxygen) from a wall outlet
that generally provides gas at a pressure of approximately 50 pounds per square inch (psi) The
flow of gas to the patient can be regulated by a flow-control valve on the ventilator.
Alternately, some models regulate the 50 psi pressure source to a lower pressure and then
control the breath to the patient through venture or bellows components. To obtain the desired
FiO2 for delivery to the patient, most ventilators mix air and oxygen internally, although some
models require an external gas blender. During inspiratory gas delivery, an exhalation valve
is closed to maintain pressure in the breathing circuit and lungs.
The gas is delivered to the patient through the flexible breathing circuit. Most intensive
care ventilators use a double-limb breathing circuit made of corrugated plastic tubing to
transport the gas from the ventilator to the patient and return the exhaled gas to the ventilator
through one of the limbs (referred to as the expiratory limb). During inspiratory gas delivery,
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an external exhalation valve or one within the ventilator is closed to maintain pressure in the
breathing circuit and lungs. After the inspiratory phase, the gas is released to ambient air
through this valve. The breathing circuit also provides sites where the delivered gas may be
heated, humidified, monitored for proximal airway pressure, and conditioned with nebulized
medications and where condensation may be collected. Many model have sensors within the
ventilator or flow and provide feedback to the ventilator to automatically adjust its output.
The controls system are used to select breathing mode and ventilation pattern parameters
(e.g., tidal volume, breathing rate). For the ventilator to produce a prescribed breathing
pattern, several parameters can be independently set, such as length of the inspiratory or
expiratory phase, rate of mechanical breaths, ratio of inspiratory time to expiratory time (I:E
ratio), wave-form shape, tidal volume, minute volume (the volume inhaled during a minute),
peak inspiratory flow, peak pressure, and positive end-expiratory pressure (PEEP).
7.2.3 State of the art
7.2.3.1 High Frequency Ventilation (HFV)
High Frequency Ventilation is a collective description of all high frequency
ventilation techniques. Applied tidal volumes are some times smaller than anatomical dead
space (= 2ml/kg).
Three high frequency ventilatory modes depend on applied Ventilatory.
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The lack of an expiratory valve in this technique (open system) allows Venturi effect to occur
which enhances inspiration. Gas volumes are enhanced through entrainment .
Exhalation is passive between jet gas impulses, because of this there is a danger of "air
trapping" with consequent over-stretching and , barotrauma if expiratory times are too short.
HFJV can be combined with conventional ventilators modes (IPPV or IMV) with low tidal
volume.(Fig7.7)
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These sine pressure waves propagate down the bronchial system into the lungs. The active
expiratory flow avoids "air trapping". Fresh gas is supplied via a T piece lateral to the
direction of oscillation. This lateral respiratory gas flow is called "bias flow". The exhaust
arm of this lateral flow has a resistive tube ("impedance tube") to avoid excess oscillatory
volume loss at the "bias flow .
Inspiratory and expiratory times are equal and not adjustable.
Finally, High Frequency ventilatory techniques are not widely used clinically.
Principle of Operation
Because of the differing mechanical properties of the lung, tidal volumes are distributed
according to compliance. With conventional ventilation, PEEP in the healthy lung with the
better compliance results in a greater increase in lung volume than in the damaged lung with
lower compliance. This results in reduced ventilation of the diseased lung, and over-stretching
of the healthy lung with increased ventilation perfusion disturbance.
The mechanical effect of PEEP leads to compression of lung capillaries, with an increase in
pulmonary vascular resistance in the healthy parts of the lung. This results in increased
circulation in the damaged lung, with deteriorating oxygenation and increasing right-left
shunt.
Furthermore, ILV offers the opportunity to adjust the I: E ratios according ted
to the different compliance of each lung. If the lungs are ventilated with different I:E ratios,
the term asynchronous independent lung ventilation is used. If the I:E ratio is the same,
synchronous independent lung ventilation is used .
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The term inverse I:E ratio is used when the inspiration of the slave machine begins with the
expiration of the master machine and vice versa .
Usually, both lungs are ventilated with identical but reduced, tidal volumes. This ensures that,
in the event of inadvertent separation of the machines, the lungs are not ventilated at different
frequencies (safety measure).
With asymmetric lung diseases, independent lung ventilation offers
the opportunity to specifically treat ventilation/perfusion mismatches with SPEEP, and to
improve pulmonary gas exchange. Furthermore, general haemodynamics are less affected,
and oxygen availability is optimised for metabolic demand.
7.2.3.3 Applications
we will consider some models of draeger ventilators.
1.Savina
For adult and paediatric application with tidal volumes in volume controlled
ventilation starting from 50ml.
For use in recovery rooms, intensive care units, sub-acute care facilities, intra- and
inter-hospital transport.
Volume oriented ventilation with automatic adjustment of the flow rate: Option (Auto
Flow)
In case of failing electricity supply, Savina continues to work without any interruption
for one hour with internal battery (smart power management).
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up to seven hours with internal and external batteries (smart power management).
For inner clinical transport , you do not have to disconnect the patient from Savina
just take it along.
With Option AutoFlow Savina offers automatic adjustment of the flow rate to deliver
the set volume with the least possible pressure
Benefits:
1. Peak pressures are reduced.
2. The patient can breathe spontaneously during all phases of the ventilatory
cycle.
3. No nuisance alarms if patient coughs.
4. Improved gas distribution esp. in inhomogeneous lungs.
5. Flow rise can be adjusted to the patient by Flow Acceleration.
Trigger indicator
Alarm LEDs
AC / DC LED
Standby key
Flow sensor
Exhalation valve
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O2 inlet on
the right side
of the device
AC inlet
DC inlet
Main switch
Nurse call
(option)
Side rail
(option)
Serial port
Inlet for breathing air
Fig 7.11 Back phase of the savina ventila
Display
Mode
Mode
IPPV
Real-time
Real-time
curve
curve
Alarm
Alarm
message
message
Assist
Paw
mbar
30
20
10
0
-10
V Te
Measured
Measured
values
values
.520
12
10
MV
12
6.2
Advice
Advice
Fig 7.12
2. EVITA 2 dura.
This device have and will do the following function s
Select-Adjust-Confirm .
Start-up settings.
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Standby function.
Advisory Information.
Guided checklist.
Automated calibration .
Expiratory Valve
-
easy to sterilise.
no filters needed.
exchange in seconds.
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!
!!
Advisor
y
Caution
!!
Warning
Evita 2 dura offers exactly the right parameters for clinical routine.
Evita 2 dura is your tailor-made solution all times and in all situations.
Additional functions :
With AutoFlow in Evita 4 offers automatic adjustment of the flow rate to deliver the set
volume with the least possible pressure:
The patient can breathe spontaneously during all phases of the ventilatory cycle.
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7.2.4 Emerging
Evita XL from draeger.
Swivel mounted.
Easy to move.
2. User Interface
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Additional settings, alarms or diagnostic data readily available in the background and
easily configurable to the screen.
3. User Interface
Inspiration hold
Expiration hold
Suction Procedure
The most important function is to control weaning process (SMART CARE) 30, March,
2004
Protocol based weaning defines and organizes a process for ventilator adjustments, expected
outcomes, patient monitoring and patient care during weaning. Several studies have shown
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that implementation of protocols to aid the weaning process results in a significant reduction
in ventilation days. Due to shortened ventilation, possible complications may be reduced,
which could lead to a significant decrease in costs.
Smart Care, knowledge based weaning system, contains automated clinical guidelines based
on recognized medical expertise. by this ventilator; we are freeing the clinician for the "art of
medicine . The complete weaning process is continuously monitored by the EvitaXL,
provided that the patient is hemodynamically stabile, tracheotomized or intubated and has an
adequate oxygenation.
SmartCare divides the control process
into three steps:
Step 1: Stabilizing the patient within a respiratory comfort zone by regulating the level of
pressure support based on the three parameters breathing rate, tidal volume and end tidal CO2.
Step 2: Reducing invasiveness by testing if the patient can tolerate a lower pressure support
level without leaving the comfort zone.
Step 3: Testing readiness for extubation by maintaining the patient at the lowest limit of
support.
Smart Care continuously takes data and uses the mean parameter values to take decisions in
two- or five-minute intervals on whether to adapt pressure support. A knowledge-based
system has clear advantages over one based on a preset minute ventilation (MV). Infections or
fever may induce a higher metabolic rate, which has to be counterbalanced by an increase in
MV, and temporary situations such as increased
secretion or suction stress may lead to a higher MV demand. Preset MV systems cannot
automatically adjust to such changes. A knowledge-based approach to therapy can.
Smarter device
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Patient Information
Patient weight
Type of intubation
Type of humidification
Medical history of neurologic disorder or COPD
SmartStim mounting
1) Place the SmartStim at the device side rail. (see # 1)
2) Connect SmartStim to the power supply.
3) Connect with the provided hose (see # 2) the SmartStim with the Filter (see # 3).
4) Regulate the desire virtual frequency using the rotary knob on the SmartStim.
(see # 4)
5) Place the CO2 sensor on the reference cell (provided with the CO2 Sensor) (see # 5)
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7.2.5 Visionary
1.Future ventilators will use fresh air and do not need to O2 and air containers.
2.It will be portable and very small in size (hand size) , flexible tube is connected to it and it
uses regular battery.
3. When connected to a patient, it will be very smart and sensitive to detect diseases and lung
damage, it will directly select the appropriate mode.
4.some models will use solar cells to provide power instead of electricity .
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8. REFERENCE
1. Breathing and mechanical support (version1993)
4. ECRI
This report talk about one of the most important life support medical device which can
be used in many area as(e.g. critical care units, patient room, emergency and house).
It talk 3 months of hard work and we face many complication, but we pass it.
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We ask god to benefit all student and Muslims from this report
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