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BP 200
Bourns LS104
Pressure Ventilation
- Controls the set pressure
- Cycles when set time or flow is
reached
- Volume depends on compliance
Pressure Ventilation
- Controls the set pressure
- Cycles when set time or flow is
reached
- Volume depends on compliance
Flow
Sensor
CT
Humid
Leak
CCRS
RS
Respiratory
System
Pressure-limited IMV
Continuous flow
PEEP
valve
Spont.
breath
Patient
Expiration
Continuous flow
Pressure
limit
Leak
Patient
Inflation
Why Volume-Targeted
Ventilation?
!!
VT
FRC
Qwl/BW
(mL/kg)
DLW/BW
(g/kg)
*
10
8
Albumin space
(%)
1.2
100
80
0.9
60
6
0.6
40
2
0
0.3
20
*P<0.01.
Dreyfuss D et al. Am Rev Respir Dis. 1988;137:1159-1164.
Volutrauma
Model
Modality
Maquet
PRVC, VC, VS
Viasys
VAPS, VC
Viasys
Volume Limit
Hamilton
Galileo
Carefusion
Avea
Adaptive Pressure
Ventilation, VC
VAPS + VL
VC, VG
P. Bennett
840
Volume Ventilation
Plus
Draeger
Babylog 8000 +,
Babylog VN 500
VG
VG, VC
Volume Guarantee
Principles of Operation
The PIP (working
pressure) is servoregulated within preset
limits (pressure limit)
to achieve VT that is
set by the user.
Regulation of PIP is in
response to exhaled VT
to minimize artifact
due to ETT leak.
Breath terminates if
130% of TVT reached.
Separate algorithm for
spontaneous and
machine breaths.
Pressure limit
Working
Pressure
VT = VT set by user
Pressure Limit
Working
Pressure
PRESSURE
VOLUME
Benefits of VG
Maintenance
Ventilated
Stable
Expiration
Ventilated
Unstable
Unventilated
Shear
forces
Inspiration
VT
CCP
FRC
COP
Patient-Ventilator Interactions
A/C
A/C+VG
50%
40%
30%
20%
10%
0%
VT>6/kg
p < 0.001
PaCO2<35
Keszler, et al. Ped Pulmonol 04
18
16
14
12
10
8
6
4
2
0
18
16
14
12
10
8
6
PIP
PIP limit
PEEP
VT
Set VT
4
2
0
1
9 10 11 12 13 14 15
Breath #
Note the large VT, generated by the infant, while the PIP
drops near the PEEP level as the ventilator in VG mode
responds appropriately to the large VT by reducing PIP.
A/C + VG
10
SIMV + VG
6
4
2
0
VT variance
* P < 0.001
SpO2 variance
A/C + VG
SIMV + VG
16
14
12
10
8
6
4
2
0
# P < 0.005
PIP
VT
MV (L/min x 10)
Tidal
Volume
Patients
Pleural
Pressure
Machine
Generated
Pressure
A/C + VG
SIMV + VG
140
120
100
80
60
40
20
0
* P < 0.001
HR
RR
SpO2
Normal Response of VG
PRESSURE
FLOW
Target tidal volume
VOLUME
Transpulmonary Pressure
Spontaneous
effort
Transpulmonary Pressure
Separate Algorithm
Working
Pressure
PRESSURE
FLOW
VOLUME
Systematic Review:
Severe IVH / PVL
Morley 2012
Summary of VG Studies
VT (ml/kg)
RLBW *
ELBW
5.5
5
4.5
4
3.5
3
0.3
0.4
0.5
0.6
Weight (kg)
0.7
0.8
0.9
Conventional Physiology
Anatomical dead-space = 2mL/kg. Instrumental dead-space is fixed.
Anatomical + Instrumental dead-space = 3mL in a typical 1 kg infant
Anatomical + Instrumental dead-space = 2.5mL in a typical 0.5 kg infant
Alveolar ventilation = tidal volume dead-space volume) x RR
Alveolar ventilation = X
VT = 5mL , DS=3mL
Alveolar ventilation
= 0.5 X
VT = 4mL , DS=3mL
Alveolar ventilation
=0
VT = 3mL , DS=3mL
500
450
400
350
300
250
200
150
100
50
0
DS + 2
DS+ 1
DS
DS -0.5
DS - 1
Volume
Volume above orTidal
below
dead (ml)
space (mL)
DS -1.5
Relationship of Post-Natal
Age and VT (mL/Kg)
VT (mL/kg)
Day 1-2
n = 251
Day 5-7
n = 185
5.15 + 0.6
5.24 + 0.7
6.07 + 1.4
53.9 + 6.2
VG-Clinical Caveats
VG should be implemented early.
Initial target VT is 4 - 5 mL/kg during the acute
phase of the illness.
Larger VT is needed in ELBW infants, those with
MAS and older infants with chronic lung disease!
PIP limit should be set 25% above the working PIP
and adjusted as needed.
PIP will default to the limit if sensor is out or when giving
a manual breath!
Mainstem bronchus intubation can result in volutrauma
If the low VT alarm sounds repeatedly, increase the
pressure limit AND INVESTIGATE THE CAUSE
Corrected VT
250
200
150
Total
Mech
100
Spont
50
0
SIMV
SIMV+VG4.5 SIMV+VG3
Whats Next?
Thank You
mkeszler@WIHRI.org
Troubleshooting
VG vs NAVA
Interrupted Exhalation
SIMV: Uneven VT
(Osorio, et al. J Perinat Apr 05)
7
6
ml/kg
5
4
3
2
1
0
SIMV
SIMV+PS3
VT SIMV
SIMV
VT spont
SIMV+PS6
5.0
4.0
Tracheal Width, mm
3.0
2.0
Ventilated
1.0
Non-ventilated
750
1,000
1,250
Study Weight, g
1,500