NeoMode Challenges And Solutions Color Keying For Easy

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NeoMode Challenges And Solutions
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Dual Screen Technology - - Bottom screen is
for settings only
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Dual Screen Technology - - Upper screen is for
data only
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Color Keying For Easy Breath Recognition

• The waveforms and breath timing bar are color
  coded
• inspiration or controlled breath type bar is
  green
• spontaneous waveforms and breath type bar is
  orange
• exhalation is yellow

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Software Controlled Screens

• Only current modes and settings are displayed
• Information appears as needed

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Software Controlled Screens

• Only current modes and settings are displayed
• Information can appear as needed

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Smart Alarms -

• Smart in that they have different sounds
  depending on how serious the problem
• Smart in that they indicate actual cause of
  problem

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Smart Alarms -

• Smart in how they tell you what the potential
  solutions are
• Smart in that they sometimes put you in a safer
  state of ventilation
• expiratory occlusion, apnea, procedural error,
  safety valve open, etc

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Specifics for Volume Delivery and Spirometry

• NeoMode offers accurate volume delivery down to 5
  ml in Volume Ventilation
• tubing compliance compensation maintains accurate
  and consistent volume delivery regardless of any
  changes in patient compliance or circuit pressure
• accurate monitoring of exhaled volumes in any
  mode or breath type
• this is done with no flow sensor at the patient
  wye

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PCV Then and Now with the 840 ventilator

• Inflation pressure adjustments with the 840
  ventilator
• Peak airway and End-Expiratory pressures have an
  additive effect.
• Ex. To deliver 10/5, the therapist will set
  PEEPHi to 5 cmH20 and PEEPLow to 5 cmH20.

PEEPHI
10
P
PEEPLO
5
0
T
2
3
1
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PCV Then and Now with the 840 ventilator

• PEEP adjustments with the 840 ventilator
• as you increase or decrease PEEP, peak airway
  pressure changes by an equal amount.
• delta P remains unchanged and theoretically gas
  exchange does not change.

Delta P 10/0 10
Delta P 15/5 10
15
PEEPHI
10
P
5
PEEPLO
0
T
2
3
1
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PCV Then and Now with the 840 ventilator

• PEEP adjustments with TCPCV results in
  non-changing delta P.
• In prior generation infant ventilators, e.g. VIP,
  Infant Star, as you increased PEEP peak airway
  pressure did not change - but you decreased
  delta P.

Delta P 10/0 10
Delta P 10/5 5
15
PEEPHI
10
5
P
PEEPLO
0
T
2
3
1
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BiLevel Synchronized Transitions

• BiLevel was designed to allow spontaneous
  breathing at upper pressure level
• PCV has a fixed I-time
• if patients are starting an inspiration as I-time
  ends, discomfort and asynchrony are likely

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BiLevel Synchronized Transitions

• BiLevel was designed to allow substantial
  improvements for spontaneous breathing at upper
  pressure level
• PCV has a fixed I-time
• if patients are starting an inspiration as I-time
  ends, discomfort and asynchrony are likely
• Detecting inspiratory efforts and lengthening
  I-time can profoundly improve patient comfort /
  synchrony

Spontaneous Breaths
PEEPHI
P
PEEPLO
T
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BiLevel Synchronized Transitions

• Generally synchronized transitions are more
  effective when I-times are long enough to allow
  spontaneous breathing at the upper level

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PCV With Controlled I-times

• PCV delivers a non changing set I-time
• active exhalation valve is still functional
• loss of synchronized transitions, PS at upper
  level, and monitoring of spont volumes are likely
  to have little effect
• PCV may be more efficient if I-times are short
  and are variable

PEEPHI
P
PEEPLO
T
2
3
1
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Volume Ventilation With The 840

• All delivered and exhaled tidal volumes are
  compliance and BTPS compensated
• As compliance changes ventilator output changes
  to assure constant volumes
• What you see is always what you get

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840 Patient Safety Capabilities Are Especially
Important In NICU

• Occlusion algorithm
• occlusion of the expiratory occlusion limb of the
  circuit activates - occlusion status cycling -
  ventilating in and out of the insp side of the
  circuit through the safety valve
• Procedural error (initiates of the Pt is
  connected to the circuit before settings are
  made)
• enters safety ventilation
• Compliance compensated tidal volumes with actual
  patient high and low alarms

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840 Neonatal Breath Delivery In PCV

• In PCV, as compliance improves, tidal volume also
  increases
• Tidal or minute volume alarms can be set to alert
  the clinician of changing patient condition
• impending over distention can be recognized
  early
• What happens with leaks if PCV or volume
  ventilation is chosen?
• disabling volume alarms while maintaining
  disconnect alarm works in PCV and VCV

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Leaks In Volume Ventilation

• Cuffless ET Tube leaks may be positional
• As patient head position changes, the degree of
  leak may change
• If the ventilator is delivering a constant volume
  and the leak becomes less, patient volume
  increases
• increased leak causes lower Vt delivery

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Leaks In PCV With The 840

• As leak changes, pressure remains constant
• Since compliance has not changed, tidal volume
  will remain more constant than with volume based
  ventilation
• Compliance compensated exhaled tidal volume will
  more accurately reflect this changing condition
• Most clinicians pressure ventilate in the
  smallest patients but desire volume monitoring

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840 Neonate (micro-preemie) Review

• Improved volume delivery
• Vt to 5 ml w/ total compensation
• delivered Vt and exhalationspirometry accuracy
• (disable all volume alarms)
• neonatal circuits w/o prox sensor
• low compliance exhalation bacteria filter
• Improved synchrony
• Flow Sens increased to 0.1 lpm - 20 lpm
• deals well with leaks
• very fast response times
• 2.0 ET-Tubes and up
• Esens to 80 (leaks and synchrony)

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840 Neonate (micro-preemie) Review

• Less nuisance alarm issues
• all volume alarms can be disabled while
  maintaining disconnect detection
• IBW from 0.5kg to 150 kg
• default settings appropriate to patient
• alarms scaled to patient size
• Set RR increased to 150 bpm

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Without Adjustment of Pressure Rise

• Many ventilators are sensitive to changes in
  impedance
• increasing resistance causes pressure to rise
  more quickly
• can result in discomfort, or premature
  termination of PS

RES 5 RES 20
RES 50 cmH20/L/SEC
cmH20/L/SEC
cmH20/L/SEC
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Rise to Pressure Adjustment

• Tailors inspiratory rise in pressure ventilation
  to match patient demand or reach MAP goals in PS
  or PCV
• Should allow rise to be tailored from slow to fast

PLOT SETUP
UNFREEZE
40
PCIRCcmH2O
30
20
10
0
Slow rise Moderate rise Fast rise
10
-20
0
4
8
12s
2
6
10
INSP
80
60
40
20
0
20
40
60
EXP
-80
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• Not all clinicians want to adjust rate of
  rise(time and/or interest)
• Smarter rise algorithms should automatically
  adjust flow output as resistance or compliance
  varies
• maintains similar shape of curve through any
  patient size or impedance change which reduces
  the need for intervention and reduces chance of
  pressure overshoot

PLOT SETUP
UNFREEZE
40
PCIRCcmH2O
30
20
10
0
RES 5 RES 20
RES 50 cmH20/L/SEC
cmH20/L/SEC

cmH20/L/SEC
10
-20
0
4
8
12s
2
6
10
INSP
80
60
40
20
0
20
40
60
EXP
-80
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PCV Pressure Overshoot
C
D
B

• During inspiration, the valve is closed with the
  force of the insp pressure setting

A
PCV W/O Active Valve
PCV with Active Valve
40
PCIRCcmH2O
30
20
10
0
Spontaneous Efforts
Spontaneous Efforts
10
-20
0
4
8
12s
2
6
10
INSP
80
60
40
20
0
20
40
60
EXP
-80
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Active Exhalation Valves

• During inspiration, the valve is closed with the
  force of the insp pressure setting
• Allow coughing or spont breathing at upper
  pressure level by venting excess pressure and
  flow

PCV W/O Active Valve
PCV with Active Valve
40
PCIRCcmH2O
30
20
10
0
Spontaneous Efforts
Spontaneous Efforts
10
-20
0
4
8
12s
2
6
10
INSP
80
60
40
20
0
20
40
60
EXP
-80
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Tubing Compliance Compensation
(Volume Ventilation)
Tubing Comp PIP Set VT
Displayed VT Lung VT
ml/cmH2O W/O tube comp 1 30
55 55 25 Patient
compliance increases from 0.83 to 1.75
ml/cmH2O W/O tube comp 1
20 55 55
35 W/ tube comp 1 30
25 25
25 Patient compliance increases from 0.83 to
1.75 ml/cmH20 W/ tube comp 1
20 25 25
25
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Infant Capabilities -

• Flow Triggering minimizes autocycling while
  maintaining PEEP
• Tubing compliance compensation can provide more
  accurate volume ventilation down to 25 ml
• volumes can vary widely as patient compliance and
  circuit pressures change
• exhaled spirometry can be misleading if not
  compensated
• Flow triggering, ESENS, rise to pressure can
  improve synchrony

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Expiratory Sensitivity
D
B

• Pressure support breaths terminate when patient
  flow decelerates to a percentage of peak flow
• I-times too long or too short can also cause
  asynchronous breathing

A
40
PCIRCcmH2O
30
20
10
0
10
-20
0
4
8
12s
2
6
10
INSP
80
60
40
20
0
20
40
60
EXP
PS Termination Criteria (25)
-80
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Expiratory Sensitivity
Increased ESENS setting to 40
Flow

• ESENS allows adjustment of the termination
  criteria for pressure supported breaths
• sets the percent of peak flow that cycles the
  pressure support breath into exhalation
• Especially helpful to match the patients desired
  inspiratory time or to compensate for leaks
• Can improve synchrony between patient and
  ventilator

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Breath Delivery In PCV

• Rise time percent can improve comfort
• In PCV, as compliance improves, tidal volume also
  increases in small patients
• Spirometry remains accurate to delivered tidal
  volumes if tubing compliance compensated or
  measured proximally
• Tidal or minute volume alarms can be set to alert
  the clinician of changing patient condition
• impending over distention can be recognized early

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NeoMode settings Initial Set -Up

• f - Respiratory Rate
• Pi - Peak Pressure total peak pressure (set
  above PEEP)
• Ti - Inspiratory Time
• Psupp - Pressure support usually set between 3
  and 10 cmH2O
• Vsens - Flow Trigger Sensitivity usually set
  between 0.3 and 1.0 lpm
• O2 - 21-100
• PEEP default is 3 cmH2O.

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NeoMode settings Initial Set -Up

• PPEAK High Circuit Pressure Limit
• Rise Time Percent (RT) Increase from default
  setting of 50 to 70 in order to help
  synchronize and reduce air hunger. (The higher
  the RT, the faster the rise to pressure from
  PEEP to PIP)
• Usually set around 75
• ESENS Spontaneous Expiratory Sensitivity
  Increase to about 50 from the default time of
  25 to start. This will reduce the spontaneous
  inspiratory time and reduce the message of
  Inspiration Time Too Long (the usual cause is
  airway leaks). The setting can be increased as
  high as 80 Usually set at around 45 to start.
• Press ACCEPT

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NeoMode settings Initial Set -Up

• ESENS Spontaneous Expiratory Sensitivity
  Increase to about 50 from the default time of
  25 to start.
• Usually start at 45. Increase or decrease based
  on leak and ability to synchronize vent. This
  will reduce the spontaneous inspiratory time and
  reduce the message of Inspiration Time Too Long
  (the usual cause is airway leaks). The setting
  can be increased as high as 80 Usually set at
  around 45 to start.
• Press ACCEPT

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NeoMode settings Initial Set -Up

• DSENS Set DSENS to 95 when using NeoMode
  (default is 75) adjust up to 95

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END