bellavista avm

Adaptive Ventilation Mode

AVM Adaptive Ventilation Mode

bellavista’s Adaptive Ventilation Mode AVM is a closed-loop fully AVM is designed to ventilate patients all the way from intubation
automatic method of mechanical ventilation. It adjusts ventilation throughout weaning to spontaneous breathing and extubation. While be-
parameters according to patient weight and lung function as assessed by ing automatic and continuously adaptive to the patient it still gives full
the ventilator. control and clinical decision making to the caregiver.

Summary A) Setting Nominal Minute Volume C) Ideal Rate (Otis’ Equation)

Adaptive Ventilation Mode (AVM) provides posi- Before starting ventilation the caregiver enters the Minute volume can be achieved with any combina-
tive pressure ventilator support to adult and pedi- patient’s height and gender for AVM to propose tion of tidal volume and rate, allowing for rapid
atric patients ventilated invasively. and start ventilation with a nominal minute vol- shallow breathing as well as very slow sighing. To
It automatically adapts to the patient’s activity ume. prevent this, AVM proposes an explicit target rate
from mandatory ventilation to fully spontaneous RateTarget which, for a given target minute volume
pressure supported breathing, while providing results in a target tidal volume VtTarget. The target
safety backup ventilation at all times. 165 cm male  IBW 61 kg working point is continuously (breath-by-breath)
Ventilation: 0.1 L/min /kg Height and Gender
AVM gives full control to the caregiver to ventilate (Initially) adapted to every change in the patient’s lung me-
patients throughout the weaning phase from in- Nominal Target Minute Volume
chanics.
tubation to extubation, and in chronic ventilation Vt MVNominal 6.1 L/min AVM applies PRVC (pressure regulated volume
situations. controlled) algorithms to deliver VtTarget to the pa-
tient.
Adaptive Ventilation Mode (AVM) maintains an
Patient (165 cm)
operator-set minimal minute volume independent
Rate
1400 6.1 L/min
of the patient‘s activity. Based on the IBW ideal body the nominal target mi- 1200

The minute volume is proposed based on patient’s nute volume MVNominal is proposed which can be 1000

modified by the caregiver at any time, depending on

Vt [mL]

800
IBW (ideal body weight) set by the operator.
Ideal respiratory rate and tidal volume are calcu- the patient’s ventilatory status. 600 VtTarget

[A] 400
lated using Otis’ equation which is expected to
200
result in minimal work of breathing and in the least RateTarget
B) Three Test Breaths
0
amount of ventilator-applied inspiratory pressure. 0 10 20 30
Inspiratory pressure and machine rate are auto- AVM starts the ventilation with three PC-SIMV test Rate [bpm]

matically adjusted to meet the targets. breaths to determine the patient’s respiratory me-
AVM continuously adapts RateTarget to the patient’s
Continuously measuring the patient’s respiratory chanics.
[A]
respiratory mechanics using Otis’ Equation . Otis
mechanics breath by breath, AVM attempts to find
hypothesis was that mammals choose a breathing
a favorable breathing pattern and to avoid poten-
Pressure

pattern with a minimal work of breathing.

tially detrimental patterns like:
VtTarget is determined by dividing MVTarget through
 rapid shallow breathing
RateTarget.
 excessive dead space ventilation During the test breaths AVM evaluates the patient’s
This «ideal» working point is constantly adapted.
 breath stacking (inadvertent PEEP) expiratory time constant RCExp and prepares for the
 excessively large breaths. subsequent adaptive regulation of rate and tidal
volume.
Oxygenation remains under control of the user to
adjust FiO2, PEEP and if necessary other parame-
ters.
D) Taking Influence,
Clinical Decision Making
Question: Question: Question:
Depending on the patient’s ventilator status influ-
A) Dyspnea? B) Weaning? C) Patient stable for > 60 min?
ence can be taken on AVM’s automatic adaptation Rate > RateTarget + 10 %Spont = 0% or unstable %Spont1h = 100%
bpm AND AND
algorithms by adjusting the target minute volume. NO NO NO
OR paCO2 normal paCO2 normal
Ventilation with most patients will be started at paCO2 above normal
OR
100% of their nominal minute ventilation. In a later
P0.1 > 3 cmH2O
stage this percentage is changed by the caregiver
Yes YES YES
to react on the patient’s ventilatory status. Action: Question:
D) Oxigenation sufficient?
1400 Increase ventilation +10…20% FiO2 < 40% NO
100% = 6.1 L/min
AND
1200
PEEP < 8 cmH2O
1000
YES
Vt [mL]

800 120% Action: Question:

600 80% Increase minute volume Reduce ventilation -10% E) Weaning progressed?
NO
400 PInsp ≤ 10 cmH2O
Keep %MinVol above 70% Consider SBT
200
0 YES
Action:
0 10 20 30
Consider extubation!
Rate [bpm]
Clinical decision making: AVM does not relieve the caregiver from regularly evaluating the patient and
The target minute volume can be influenced by ad- taking decisions regarding ventilation. The questions are still the same: Is the patient dyspneic? How has
justing %MinVol to reflect the patient’s ventilatory weaning progressed? Is the patient stable and eventually ready for extubation?
requirement (see Clinical Decision Making).

I:E Timing Weaning / Spontaneous Breathing Lung Protective Rules

AVM controls rate and I:E timing by measuring the
expiratory time constant RCExp. The algorithms en-
sure a minimum exhalation time of 2RCExp to pre-
vent auto-PEEP.
AVM allows spontaneous breathing at any time.
This will naturally increase the rate while AVM will
maintain the tidal volume. Maintaining the tidal
volume prevents episodes of rapid shallow breath-
ing.
Not all combinations of Vt and Rate are safe for the
patient even though they might result in the cor-
rect minute volume. High tidal volumes would
over-distend the lungs whereas small tidal volumes
may not produce alveolar ventilation at all. Another
risk lies in inadequate respiratory rates.

1400 6.1 L/min

COPD: AVM reduces the rate, increases tidal volume
1200
and provides more expiration time.
1000
Vt [mL]

800
600 MVTarget

400 Spont MVActual

200
ARDS: AVM increases the rate and reduces tidal vol- 0
ume to keep peak pressure low, while maintaining 0 10 20 30
the minute volume. Rate [bpm]

Spontaneous breathing increases the actual minute Lung protective rules limit the adaptation into a safe
Changing Lung Mechanics ventilation. This effect is used during weaning by re- range of tidal volume (adjustable by the use via
1400 6.1 L/min
ducing the %MinVol setting to stimulate the patient PLimit), and rate, preventing breath stacking and
1200
to add some minute volume by additional sponta- auto-PEEP
1000
Target neous efforts.
Vt [mL]

800 New
600
Target Old
400
200
0 Literature, References
0 10 20 30 *) For detailed instructions see the current bellavista
Rate [bpm]
operating instructions and the separately available
After a change in the patient’s respiratory mechan- AVM manual.
ics, AVM adapts rate and tidal volume while main- [1] Otis, B. (1954). The Work of Breathing. Physiol
taining the target minute volume. Rev, (13), 449–458.

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