SCIENTIFIC REPORT

INTENSIVE CARE UNIT

VENTILATOR SYSTEMS

MAJOR: BIOMEDICAL ENGINEERING

LAB 1A- BIOMEDICAL INSTRUMENTATIONS

Teacher: Dr. Nguyen Thanh Qua

TA: Nguyen Hoang Phuc
Group 4:
Tran Phuong Anh-BEBEIU21002
Thai Nguyen Hao-BEBEIU21145
Le Nguyen Khai Hoan-BEBEIU21146
 CONTENTS
CHAPTER 1: INTRODUCTION.......................................................................... 3
1.1. Intensive Care Unit (ICU) Ventilator............................................................... 3
1.2. History and Revolution.....................................................................................4
CHAPTER 2: WORKING PRINCIPLE................................................................. 10
2.1. Block Diagrams.............................................................................................. 10
2.2. Components.................................................................................................... 11
2.2.1. Source of power.................................................................................... 11
2.2.2. Control of gas delivery..........................................................................11
2.2.3. Monitoring............................................................................................ 13
2.2.4. Safety Features......................................................................................14
2.3. Ventilator Settings.......................................................................................... 15
2.3.1. Input...................................................................................................... 15
2.3.2. Power conversion and transmission......................................................16
2.3.3. Output....................................................................................................18
2.3.4. Alarms ..................................................................................................19
2.3.5. Exhalation System.................................................................................19
2.3.6. PEEP System.........................................................................................20
2.3.7. Clinical Terms.......................................................................................20
2.4. Working Operation......................................................................................... 21
2.5. Nursing role.................................................................................................... 21
CHAPTER 3: CLINICAL APPLICATION......................................................22
3.1. Main Purposes of ICU Ventilator................................................................... 22
3.2. Medical treatments..........................................................................................22
3.3. Level of ICU Care…….................................................................................. 23
CHAPTER 4: DEVELOPMENT......................................................................... 24
REFERENCE........................................................................................................... 26

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The COVID-19 pandemic has brought attention to ventilators, but few people are familiar with
what they do or how they work. When a patient is unable to breathe adequately on their own, a
ventilator pumps air—usually with extra oxygen—into their airways. Patients who have had their
lung function severely impaired, such as by an injury or an illness like COVID-19, may require a
ventilator. It's also used to help people breathe while they're having surgery.

CHAPTER 1: INTRODUCTION

1.1. Intensive Care Unit (ICU) Ventilator

A ventilator is a machine that supports breathing. These machines mainly are
used in hospitals.Ventilators:
+ Get oxygen into the lungs
+ Remove carbon dioxide from the body
+ Help people breathe easier
+ Breathe for people who have lost all ability to breathe on their own.
The principal function of a ventilator is to pump or blow oxygen-rich air into the
lungs; this is referred to as “oxygenation”. Ventilators also assist in the removal of
carbon dioxide from the lungs, and this is referred to as “ventilation”.
Patients with conditions such as pneumonia, brain injury, and stroke are treated
with these machines.
Non-invasive ventilation
Non-invasive ventilation is the use of a face mask, nasal mask, or helmet to
provide breathing support. Positive pressure is used to deliver air, usually with added
oxygen, through the mask; the amount of pressure is usually alternated depending on
whether someone is breathing in or out.
The application of mechanical ventilatory support through a mask in place of
endotracheal intubation is becoming increasingly accepted and used in the emergency
department.
Non-invasive ventilation (NIV) is designed to avoid some of the risks associated
with invasive ventilation. Most modern 'intensive care' ventilators can administer NIV.
There are several different types of interfaces available, each with its own set of
advantages and disadvantages.
+ Total face masks (enclose mouth, nose eyes)
+ Full-face masks (enclose mouth and nose)
+ Nasal mask (covers nose but not mouth)
+ Mouthpieces (placed between lips and held in
place by lip seal)
+ Nasal pillows or plugs (inserted into nostrils)
+ Helmet (covers the whole head/all or part of the
neck e no contact with face)
NIV is a type of 'non-invasive' ventilation (NVC)
that can provide a variety of respiratory support modes.
Most modern 'intensive care' ventilators, as well as older
and more sophisticated 'non-invasive' models, can
deliver NIV.

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Invasive ventilation
Tracheal intubation is invasive ventilation that involves physically inserting a
tube into the patient's throat to take over respiratory function. This obstructs the
airway, so patients are sedated for this procedure.
The most common reason for admission to the ICU is invasive mechanical
ventilation, which requires access to the trachea, most commonly via an endotracheal
tube. The following are the most common indications for invasive ventilation,
according to large multinational surveys:
+ Coma 16%
+ COPD 13%
+ ARDS 11%
+ Heart failure 11%
+ Pneumonia 11%
+ Sepsis 11%
+ Trauma 11%
+ Postoperative Complications 11%
+ Neuromuscular Disorders 5%.
Many researchers are still unsure about COVID-19, but we do know that those
infected with the novel coronavirus experience symptoms such as fever, cough, and
sore throat, among other things.
If the body's immune system fails to fight the infection, it can spread to the lungs
and cause acute respiratory distress syndrome, which can be fatal (ARDS). The
alveoli (tiny air sacs that allow oxygen to reach the bloodstream and remove carbon
dioxide) fill with fluid in ARDS, reducing the ability of the lungs to provide enough
oxygen to vital organs.
"ARDS causes severe pulmonary inflammation, but the main issue is that it
renders portions of the lungs useless," Dr. Ferrante explains. "It can be life-
threatening, and many of these patients will require a ventilator."
1.2. History and Revolution
The history of mechanical ventilators, positive and negative pressure, invasive
and noninvasive ventilation will all be explored in this discussion. The goal will be to
figure out what developments in clinical medicine caused the mechanical ventilator to
be refined. The capabilities of today's ICU ventilators, as well as the evolution of
positive-pressure ICU ventilators, will be discussed. All of this will serve as a
backdrop for speculation about the future ICU ventilator.
Negative-pressure ventilators
During the nineteenth century and the first half of the twentieth
century.
The negative-pressure ventilator was the most common device
for providing ventilatory assistance.
A full-body type ventilator was the first description of a
negative-pressure ventilator.
In 1838
John Dalziel, a Scottish physician, was the first to describe this "tank ventilator" . It was
made up of an airtight box in which the patient was kept in a sitting position. Manually

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pumping air into and out of the box created negative pressure. Similar types of manually
operated negative-pressure ventilators were developed by a number of other groups.
In 1904
Sauerbrach also invented a negative-pressure operating
chamber.
With the development of the iron lung, originally designed and
built by Drinker and Shaw but manufactured and sold by Emerson,
negative-pressure ventilation became a much more clinical reality.
During the worldwide poliomyelitis epidemics from 1930 to
1960, this approach to ventilatory support reached its pinnacle.
The first intensive care units (ICUs) were established to care
for dozens of patients of all ages who required negative-pressure ventilation due to
poliomyelitis. The Boston Children's Hospital created a large negative-pressure chamber that
could hold four children at once and allow a nurse to care for them from within the chamber.

Other negative-pressure chambers, such as the "raincoat" and the "chest cuirass,"
were developed and used with varying degrees of success over time.

In the 1960s
However, due to a number of factors, there was a move away from negative-
pressure ventilation. The first volume-controlled ICU/anesthesia ventilators appeared.
At the end of WWII
The development of jet aviation led to the development
of small, portable intermittent positive-pressure breathing
(IPPB) devices, such as the Bennett and Bird IPPB machines.
Complications with the use of negative-pressure ventilation
made it impossible to continue using it in newly developed
ICUs. These devices were large, heavy, and cumbersome as a
group, and it was difficult to avoid excessive leaking (which
usually resulted in the patient's body cooling); they had
trouble maintaining effective ventilation, were unable to
maintain high airway pressure or establish PEEP, and access
to the patient was restricted.

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Positive-Pressure Noninvasive Ventilation

In 1780
Chaussier introduced the first mechanical apparatus used
to provide NIV, a bag and mask manual ventilator.This was a
sophisticated pneumatically operated positive-pressure device
that was credited with saving thousands of lives during its
lifetime.
In 1887
A more sophisticated bellow with a mask was introduced by Fell.
In 1910
Green and Janeway proposed a new method for delivering NIV. Their device
was dubbed a "rhythmic inflation apparatus." The patient's head was inserted into the
apparatus, and a seal was created around the patient's neck using positive pressure.
In 1911
Dräger's Pulmotor was first introduced.

The twentieth century

The Bennett TV and PR series of ventilators, as well as the Bird Mark series of
ventilators, were the most notable NIV devices.
In the 1960s and 1970s
These devices were primarily used for intermittent treatments rather than long-
term ventilation, but they were also commonly used for life support in both
noninvasive and invasive procedures.
In the late 1970s and early 1980s
Two events occurred that altered the concept of NIV.
- First, reports claimed that using the IPPB machine to deliver aerosolized medication
was no better than using a simple nebulizer, and that incentive spirometers and blow
bottles were just as effective in preventing and reversing postoperative atelectasis as
IPPB.
- The second event was a series of case studies showing that
NIV could be used to provide ventilatory support to patients
who are experiencing an exacerbation of chronic lung or
neuromuscular/neurologic disease, as well as to provide long-
term ventilator support to those same patients.
Pressure-targeted ventilation became the norm for NIV as

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newer, more sophisticated pressure-targeted ventilators designed specifically for NIV

entered the market. NIV modes are now available on the majority of new ventilators
on the market, and NIV has become the industry standard for initial ventilatory
support.
Positive-Pressure Invasive Ventilators
A. First-Generation ICU Ventilators
In the 1940s and 1950s
Positive-pressure invasive ventilation ventilators became
available.The fact that these early invasive ventilators only
provided volume-control ventilation was their defining feature.
With these first-generation ICU ventilators, patient-triggered
ventilation was not possible. However, these ventilators came
in a wide range of sophistication. It was a volume-controlled
ventilator that only provided machine-triggered inspiration but
had an adjustable inspiratory/expiratory ratio as well as
pressure and volume monitoring.
PEEP was not included in the first generation of ICU ventilators. PEEP did not
become a standard therapy in the ICU until after the landmark paper by Ashbaugh et
al. PEEP was applied to this generation of ventilators by submerging the expiratory
limb of the circuit to a depth equal to the desired PEEP.
In the early 1970s
With the introduction of the Puritan Bennett MA-1 ventilator,
this generation of ventilators came to an end.
B. Second-Generation ICU Ventilators
In several ways, the second generation of ICU ventilators
differed from the first. The ventilator itself was equipped with simple
patient monitors. The majority monitored tidal volume and respiratory
rate, but patient-triggered inspiration was the most distinguishing feature of this
generation of ventilators. However, volume ventilation was still the only option. Basic
alarms such as high pressure, high rate, and low tidal volume were also included in
this group of ventilators for the first time. Intermittent mandatory ventilation (IMV)
was introduced into adult ventilation shortly after this generation of ventilators was
introduced.
In 1973
Downs et al published the first case series based on IMV.
They used a ventilator circuit with an external secondary IMV
gas flow system. IMV became synchronized intermittent
mandatory ventilation as later ventilators of this generation
added demand values (SIMV). The Siemens Servo and Ohio
560 ventilators, in addition to the MA-1, were typical
ventilators of this generation.
Hewlett et al. published a paper in the late 1970s that gave a glimpse into the
future of ventilator modes. They were the first to demonstrate the concept of closed-
loop ventilation.
Despite the fact that their approach to mandatory minute ventilation was purely
mechanical, it served as a closed-loop controller and served as a model for many of
today's modes.

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Gas entered this system from the left and preferredentially entered a bellows
from which the patient could spontaneously breathe.
Gas was directed to a second bellows if the first bellows filled completely.
The gas from the bellows was delivered to the patient as a positive-pressure breath
once it was filled.
All breaths were either spontaneous or mandatory (if the patient became apneic)
or a mix of both depending on the flow of gas into the system, the setting of the
bellows capacity, and the patient's spontaneous minute volume.
The primary problem with this initial system was that the patient could breathe
the entire minute volume with a very rapid and shallow breathing pattern, but it did
provide the first form of closed-loop control.

C. Third-Generation ICU Ventilators

The Puritan Bennett 7200, Bear 1000, Servo 300, and Hamilton Veolar were
examples of third-generation ICU ventilators.
Microprocessor control was the single most important feature shared by all of
these ventilators. This was a watershed moment in the history of mechanical
ventilators because it opened the door to virtually any method of gas delivery and
monitoring. Furthermore, gas delivery mechanisms have been greatly improved.
Compared to previous generations of mechanical ventilators, these ventilators were
significantly more responsive to patient demand. Flow-triggering became a reality as
well, reducing the amount of effort required by patients to activate gas delivery.
Pressure support, pressure control, volume control, and SIMV were all included in
almost every ventilator of the time. SIMV could be used not only for volume
ventilation, but also for pressure ventilation and pressure support during spontaneous
breaths.

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D. Fourth-Generation ICU Ventilators

This is the current generation of ICU ventilators, which
are the most complex and versatile of any mechanical
ventilators ever manufactured. In this era there has clearly
been a marked increase in the number of ventilators, of all
possible types. Numerous ventilators classified as ICU
ventilator are available worldwide. There are a number of
what have been referred to as sub-acute ventilators, as well as transport/home-care
ventilators and ventilators designed specifically for NIV applications.
The single feature that distinguishes this generation is the plethora of ventilation
modes available. In addition, many of these new modes are based on closed-loop
control.
Adaptive support ventilation uses the Otis work-of-breathing model to try to
establish a ventilatory pattern. Another type of closed-loop pressure support for
weaning is SmartCare. The ventilator automatically performs a spontaneous breathing
trial when the pressure support level is reduced to a predetermined level (SBT). On
the fourth generation of ventilators, proportional assist ventilation and neurally
adjusted ventilatory assist are available, but they should be considered future modes.
Synchrony improves, tidal volume decreases, respiratory rate increases, and peak
airway pressure decreases when patients switch to either mode.
This generation of ICU ventilators is easily upgradeable, has waveforms as a
standard operating feature, and offers extensive monitoring. They each provide
monitoring data for 20 to 40 different variables. On the majority of these units,
trending data is also available. Some allow the clinician to program the pressure-
volume loop's performance.
The current generation of ICU ventilators is far ahead of the ICU ventilators we
used in the 1960s or 1970s. Considering how much change has occurred in ICU
ventilators over the last 50 years, one can speculate on the future of ICU ventilators.

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CHAPTER 2: WORKING PRINCIPLE

2.1. Block Diagrams

Figure 1. Basic block diagrams of ICU Ventilator

Figure 2. Simplified Mechanical Ventilation System

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2.2. Components
2.2.1. Source of power
Gas supply
- 1 bar = 100 kPa = 14.5 psi.
- 100% Oxygen or medical air ( 21% Oxygen and 79% Nitrogen).
- Either Wall or Bottled Gas.
- Air can be from a compressor.
- Colour Coded.
a. Wall Gas
- Wall gas = pressure of 350 - 400 kPa.
- Colour Coded.
- Indexed.
b. Bottled Gas
- Gas bottles 15MPa but has a
regulator that reduces it to
350 - 400kPa.
- Pin indexed.

Power Supplies
- Main power is regulated and reduced into set voltages.
+ ±5 Volts
+ ±12 Volts
+ ±24 Volts
- Loss of power Alarm for most ventilators.
- Battery power that is charging when on mains power and in use when power
failure.
Pressure Regulators
- From 350-400 kPa to 110-170 kPa (depending on the ventilator).
- Need to be calibrated if they are prone to drifting.
- Ventilator controls the trans-respiratory system pressure
- This trans-respiratory system gradient determines the depth or volume of respiration.
- Based on this a ventilator can be positive or negative pressure ventilator.
2.2.2. Control of gas delivery
Gas Blender
A gas blender is required to control the mixture of air, oxygen, anaesthetic gas or
whatever else you might be using the ventilate your patient. One may not need any
such gas blender if one is discussing some sort of stripped-down domiciliary model
which runs on room air alone, and which does not accept an exogenous oxygen source.
Gas Accumulator
A gas accumulator might be a component of a ventilator which requires a
precise control of gas mixtures and which cannot rely on proportioning valves to
produce this level of precision, eg. where the gas flows are very low. An example
of this is the accordionlike “bellows” of an anaesthetic machine; it is used to
maintain a reservoir of a stable gas mixture.

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Inspiratory flow regulator

Inspiratory flow regulator – basically, any device which ensures that the
respiratory circuit receives the prescribed gas flow. This is usually a solenoid
valve. This thing sits in front of the gas supply (either from the wall or from the
compressor turbine) and ensures that the patient is only exposed to carefully
measured amounts of that gas. Given that the wall gas in ICU piping outlets is
supplied at a standard pressure of 400kPa (approximately 4 atmospheres), it is
obviously an essential component.
Patient Circuit
The circuit, that wobbly mess of corrugated tubing, is often forgotten in
discussions of ventilator equipment, but it plays an important role (try to ventilate
the patient without one). Its characteristics, for example its compliance and
resistance to air flow, are important features.
Expiratory pressure regulator
Expiratory pressure regulator (i.e PEEP valve) is a means of maintaining and
controlling positive airway pressure. These are basically carefully controlled
expiratory flow obstructions, usually in the form of a solenoid valve (though crude
mechanical models also exist for old-school ventilators).
Humidification equipment
- Normally inspired air is warmed and humidified by the mouth and nose and then
passed into the lungs.
- Dry air can damage the lungs and cool air can reduce the patient's temperature.
- Heated humidifier is used to substitute the normal pathway.
- Patient is usually intubated via the nose or mouth.
- A heated humidifier is a hot plate with a water reservoir.
- Water is heated and the gas is passes over it.
- The gas becomes warm and moist and then enters that patient's lungs.
- The patient circuit is usually heated to reduce the amount of condensation or "rain-
out".
Connection to Patient
- Endotracheal tubing:
+ Connects patient to ventilator.
+ Inserted into nose or mouth and into the
trachea.
+ Balloon at the end that is inflated.
Intubation
- Process of inserting the tubing into the patient's airway.
- Once inserted, a balloon is inflated to create a seal.
- Tracheal intubation is invasive ventilation that involves physically inserting a tube
into the patient's throat to take over respiratory function. This obstructs the airway, so
patients are sedated for this procedure.

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Safety Valve System

- Provides a path to atmosphere for patient to breathe.
- If there is a power failure.
- Also limits the maximum pressure in the system.
- Spring keeps the safety valve closed normally.
- During power failure safety valve is released.
- Patient can breathe without restriction.
2.2.3. Monitoring
Oxygen Sensors
- Sensors know as Clark Type Sensors.
+ Organic material covering an electrolyte and 2
metal electrodes
+ Oxygen diffuses through the membrane and is
reduced, this creates a current which is measured.
- Life span of 1-2 years depending on use.
- Sensor is in line with the inspired gas.
- When calibrated it is taken out of line and 100%
oxygen and 21% oxygen are passed over the cell to compare with the expected
voltages.
- If the voltage is different to expected value to ventilator will alarm and the sensor
must be changed.
Retinopathy of Prematurity
- The oxygen levels of these babies must be closely checked.
- Most effective way to tell is by using the percent of oxygen saturation in blood
( SpO2 ).
+ If infant is at 100% saturation then the percentage of oxygen in the inspired gas is
reduced.
- Once infants are older then not a danger.
- Adults have no difficulty as the retina is firmly attached.
- Small birth weight babies can develop the condition.
-The Retina of the eye becomes detached when the blood vessels do not form properly.
- Can be due to high concentrations of oxygen when first born.
Flow Sensors
- Used to detect the flow rate to the patient.
+ Differential Pressure flowmeter.
+ Metal Gauze plate to reduce flow.
- Causes a pressure difference proportional to flow rate.
- Pressure measured and used to determine flow.
- Hot Wire Anemometer
+ Thin Platinum wire that is heated to constant temperature.
+ Fixed resistance.
+ As gas is passed over wire it cools down, increasing the
resistance. Current is increased to the wire to maintain
temperature.
- This determines flow but not direction.
- If 2 wires are in parallel then direction can be found.
- Once wire will cool before the other.

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- Flow is obstructed. When air passed through tubing opens the flap.
- Changed the pressure on the strain gage.
- Increase in flow is a reduction in resistance.
- Within the patient circuit so must be cleaned after each use.
- Can become brittle and break.
- Can be changed while the vent is in use ( but alarm will be triggered).
- Solenoids control the flow not the sensors so only an alarm will sound.
Gas concentration
Voltaic cells or spectrophotometers are commonly used to monitor gas
concentration. The oxygen supply sensor, for example, is typically an oxygen cell that
generates an output voltage proportional to the partial pressure of oxygen in the
inspiratory gas pipe.
Pressure
Historically, pressure in the circuit was measured using aneroid manometers,
which are pressure sensors that detect air pressure by the action of the air on the
elastic lid of an evacuated box. Integrated silicon wafer pressure transducers have
replaced these in current ventilators, at a tenth of the cost and with far greater
accuracy.
Volume
In current ventilators, volume is computed using flow data rather than being
measured directly. The major variable over which the intensivist had any control in
previous ventilator designs (e.g., the bellows and piston types) was a directly
measured volume.
Gas Mixing and Flow Control
- Solenoids control flow and mix of gases.
- Proportional: Changing current = changing flow.
- Solenoids work in unison to control flow.
- Control:
+ Tidal volumes.
+ Patient flow rates.
+ Respiratory rates.
+ I/E ratios and oxygen flow.
- Gases are either mixed in tubing or a separate chamber.
- Most ventilators have a separate chamber for the gas to be
inspired.
+ Used for mixing gas as well as reserve chamber for gas as well as reserve
chamber for gas to be inspired.
2.2.4. Safety Features
Filters
- Gas Supplies not always clean.
- Filters to protect the equipment as well as the patient.
- Water can also be present and so a water trap is also useful.
Water traps must be emptied.
- Filters and water traps on the inlet.
- Filters in the patient circuit.
- Bacterial filters to prevent infection to patients.

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Figure 3. Options of Filter placement

The safety features are some devices and measures which ensure that the
patient does not come to any additional harm from being ventilated (beyond the
already brutal effects which are integral to the process). These consist of filters and
alarms.
 Inspiratory filters of the ventilator promote purity of inspired gas (eg. by
removing airborne particles and bacteria from the inspired gas mixture).
 Expiratory filters keep the ICU workers safe. Expired gas is filtered to
keep the ventilator from constantly spitting out huge clouds of aerosolized
germs created in the patient's airways, which smell like a sewer. Expiratory
filters are also commonly used to protect ventilator components from the hot
and humid gases that must be exhaled, which would damage sensor
measurements and shorten the device's lifespan.
 Alarms are frequently built into the program to prevent unintended
modifications to the ventilator settings and strange ventilation
misapplications. In general, they are devices that alert you when the patient's
state or ventilator performance has exceeded the parameters that you have
determined to be safe. Non-software alarm-like features, such as mechanical
blow-off valves to relieve excess pressure when the patient coughs, are also
included into ventilators.
2.3. Ventilator Settings
2.3.1. Input
CPU

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- Controls regulation of all parameters.

- Checks alarm conditions.
- Keeps a record of all errors.
- Attached to the user interface (controls).
- Can interface with other equipment.
+ Monitor
+ Nurse Call Alarm
- Checks for leaks in the system.
2.3.2. Power conversion and transmission
Control circuit
- Its the system that governs the ventilator drive mechanism or output control valve.
- Classified as-
Open circuits
- Desired output is selected and venti. achieves it without any further input from
clinician.
Closed circuits
- Desired output is selected and venti.
- Measures a specific parameter (flow/vol/press) continuously and input is constantly
adjusted to match desired output.
Compressor
- Used if medical air is not available.
- If oxygen is not available in an emergencythen the compressor can be used to
supplement both gases.
- Usually seated underneath the ventilator.
- Suggested to have if the wall gas or bottled gas is not reliable.
Phase Variables
Trigger variable
- It's the variable that determines start of inspiration
- Triggering refers to the mechanism through which the ventilator senses inspiratory
effort and delivers gas flow or a machine breath in concert with the patient's
inspiratory effort.
- Can use pressure or volume or time or flow as a trigger.
- In modern ventilators the demand valve is triggered by either a fall in pressure
(pressure triggered) or a change in flow (flow triggered).
- With pressure triggered a preset pressure sensitivity has to be achieved before the
ventilator delivers fresh gas Into the inspiratory circuit. With flow triggered a preset
flow sensitivity is employed as the trigger mechanism.
Cycle variable
- Defined as the length of one complete breathing cycle.
- Inspiration ends when a specific cycle variable is reached.
- This variable is used as a feedback signal to end inspiratory flow delivery which
then allows exhalation to start.
- Most new ventilators measure flow and use it as a feedback signal.
- So volume becomes a function of flow and time.
- Volume= flow x inspiratory time.

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Baseline variable
- The variable controlled during expiration phase.
- Mostly its pressure.
Limit variable
- A variable(pressure,volume,flow) is 'limited' if it increases to to a preset before
inspiration cruds.
- Inspiration is NOT terminated when a variable has reached its limit.
Pressure controller
- Ventilator controls the trans-respiratory system pressure.
- This trans-respiratory system gradient determines the depth or volume of respiration.
- Based on this a ventilator can be positive or negative pressure ventilator.
Volume controller
• Volume cycled ventilation delivers a:
- Set volume;
- With a variable Pressure - determined by resistance, compliance and inspiratory
effort.
Time controller
- Measures and controls inspiratory and expiratory time.
- These ventilators are used in newborns and infants
Modes of Ventilation
MODE is a preprogramed settings that tells the ventilator how to oxygenate the
patient.
• Time cycled ventilators
• Volume cycled ventilators
• Pressure cycled ventilators
• High Frequency Ventilators
Time cycled ventilator
- Time delivery of gas flow; tidal volume = flow rate x inspiration time.
- Delivers relatively constant Tidal Volume.
- Allows precise control of gas delivery.
- Types: IMV-Bird, Foregger 210, Emerson.
Volume Cycled Ventilator
- Inspiratory gas flow terminated after preselected volume delivery.
- Pressure in circuit determined by tidal volume and Compliance.
- Delivered Tidal volume changes with changes in Compliance.
- Types: Bennett, Ohio 560, Bourns Bear 1, Monaghan, Siemons Servo.
Pressure cycled ventilators
- Gas flow continues until preset pressure develops.
- Tidal volume = flow rate x time until pressure is reached.
- Variable volume if circuit pressure varies change in compliance).
- Types: bird mark, bennett PR.

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High Frequency Ventilators

There are 5 types:
- High frequency positive pressure ventilation.
- Jet ventilation.
- Flow interruption.
- Oscillation.
- Percussive ventilation.
Control mode
- In control mode, the ventilator delivers the preset tidal volume once it is triggered
regardless of patient effort.
- If the patient is apneic or possesses limited respiratory drive, control mode can
ensure delivery of appropriate minute ventilation.
Support mode
- In support mode, the ventilator provides inspiratory assistance through the use of an
assist pressure.
- The ventilator detects inspiration by the patient and supplies an assist pressure
during inspiration.
- It terminates the assist pressure upon detecting onset of the expiratory phase.
- Support mode requires an adequate respiratory drive.
- The amount of assist pressure can be dialed in.
Other Modes of Ventilation
- IMV = Intermittent Mandatory Ventilation
- CMV = Continuous Mandatory Ventilation
+ Breath rate, pressure and volume of breaths set by user
+ Vent increases the pressure in the circuit to push air into the lungs
+ Pressure reduce for expiration .
- SIMV = Synchronised Intermittent Mandatory Ventilation
+ Vent detects the patient trying to breathe and delivers a gas to them
+ Used if trying to wean the patient off the ventilator
+ For patients that still require a little bit of ventilation
- IPPV = Intermittent Positive Pressure Ventilation
+ Similar to IMV and CMV but patient can take their own breaths (do not have to
fight the ventilator)
- CPAP = Continuous Positive Airway Pressure
+ For patients that can initiate their own breathing but cannot supple enough
oxygen for breathing.
+ Similar to PEEP.
+ Positive pressure keeps alveoli open.
+ Easier to breathe.
+ Constant flow of gas.
2.3.3. Output
Output waveforms
- Graphical representation of the control or phase variables in relation to time.
- Presented as : pressure, flow, volume, waveforms.
- The ventilator determines the shape of control variable whereas the other two
depend on the patient compliance and resistance.
- Conventionally flow above X-axis is inspiration.

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Flow Waveforms
• Inspiratory flow is controlled by setting the peak flow and flow waveform.
• The peak flow rate is the maximum amount of flow delivered to the patient during
inspiration, whereas the flow waveform determines the how quickly gas will
be delivered to the patient throughout various stages of the inspiratory cycle.
• There are four different types of flow waveforms available.
These include the square,
decelerating (ramp),
accelerating
sine/sinusoidal waveform
Pressure waveforms
- Rectangular
- Exponential rise
- Sine
• Can be used to monitor
+ Air trapping (auto-PEEP)
+ Airway Obstruction
+ Bronchodilator Response
+ Respiratory Mechanics (C/Raw)
+ Active Exhalation
+ Breath Type (Pressure vs Volume)
+ PIP, Pplat
+ CPAP. PEEP
+ Asynchrony
+ Triggering Effort
2.3.4. Alarms
Inspiratory time
- Inspiratory time is a combination of the inspiratory flow period and time taken for
inspiratory pause. The following diagram depicts how the addition of an inspiratory
pause extends total inspiratory time.
Expired Air
- Once the air has been expired by the patient:
+ No longer heated.
+ Water trap to remove moisture.
+ Enters expiratory block heated to stop rain out.
+ Filtered to stop infection from getting into the unit as well as contaminating the
environment.
+ Either enters room air or is scavenged.
2.3.5. Exhalation System
- Controls:
+ Timing of breaths.
+ Volume of the air delivered to the patient.
- During inhalation the exhalation valve closes to stop the flow of gas out of the.
system and into the patient this inflates the patient's lungs.

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- During exhalation the valve is opened to allow gas from the patient out through the
expired limb.
- Usually removable to allow for cleaning.
- Usually heated to stop condensation.
2.3.6. PEEP System
- Positive End Expired Pressure.
- Keeps lungs slightly inflated.
- Reduces damage to lungs.
- Maintained by closing the expiratory valve.
AutoPEEP
During expiration alveolar pressure is greater than circuit pressure until
expiratory flow ceases. If expiratory flow does not cease prior to the initiation of the
next breath gas trapping may occur. Gas trapping increases the pressure in the alveoli
at the end of expiration and has been termed: dynamic hyperinflation; autoPEEP;
inadvertent PEEP; intrinsic PEEP; and occult PEEP.
Dangers of PEEP
- High intrathoracic pressures can cause decreased venous return and decreased
cardiac output.
- May produce pulmonary barotrauma.
- May worsen air-trapping in obstructive pulmonary disease.
- Increases intracranial pressure.
- Alterations of renal functions and water metabolism.
Physiology of PEEP
- Reinflates collapsed alveoli and maintains alveolarinflation during exhalation
PEEP
↓
Decreases alveolar distending pressure
↓
Increases FRC by a veolar recruitment
↓
Improves ventilation
↓
Increases V/Q, improves oxygenation, decreases work of breathing
2.3.7. Clinical Terms
- PEEP = Positive End Expiratory Pressure: Pressure remaining in the circuit at the
end of expiration.
- PIP = Peak Inspiratory Pressure: Maximum pressure of inspiration.
- FiO2 = Fractional Inspired Oxygen: Displayed as a percentage.
- TE = Expiratory Time.
- I/E Ratio = ratio of time for inspiration and expiration.
- MAP = Mean Airway Pressure: The average pressure that the circuit has.

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2.4. Working Operation

A ventilator blows air into the airway through a breathing tube. This allows a
patient who has trouble breathing to receive the proper amount of oxygen. It also
helps the patient's body heal, since it eliminates the extra energy of labored breathing.
The machine works by bringing oxygen to the lungs and taking carbon dioxide out of
the lungs.
The ventilator pushes a mixture of air and oxygen into the patient's lungs to get
oxygen into the body. The ventilator can also hold a constant amount of low pressure,
called positive end-expiratory pressure (PEEP), in order to keep the air sacs in the
lung from collapsing.
During inspiration , the size of the thoracic cage increases overcoming the elastic
forces of the lungs and the thorax and resistance of the airways. As the volume of the
thoracic cage increases, intrapleural pressure becomes more negative, resulting in
lung expansion. Gas flows from the atmosphere into the lungs as a result of
transairway pressure gradient.
During expiration, the elastic forces of the lung and thorax cause the chest to
decrease in volume and exhalation occurs as a result of greater pressure at the
alveolus compared to atm. Press.
2.5. Nursing role
Patient on Ventilators
- Stay in collaboration with your Respiratory Therapist…..Learn to read CXR.
- Monitor SaO2, respiratory rate q1h. Observe how the patient is breathing.
- Follow vent changes. Respiratory Therapist will round on these patients q2hours and
give treatments q4h and PRN.
- Learn how to read where an OETT is taped, and how to listen for an “air leak”
- Get to know breathing medications and their side effects even if you aren’t
administering them. Some can cause tachycardia and tremors.
- Listen to BS at least q2h.
- Mouth care q2-4 hours
- Learn how to suction and perform q2h and PRN. Do not irrigate OETT with saline
prior to suctioning.
- Assess secretions (color, consistency, amount) and document. Monitor and
document for changes in these secretions.
- Turn patient q2h and learn if the patient’s bed has kinetic therapy.

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CHAPTER 3: CLINICAL APPLICATION

3.1. Main Purposes of ICU Ventilator

Indications of ventilators
+ Hypercapnic respiratory failure.
+ Hypoxemic respiratory failure.
+ Correction of life-threatening acidemia in the setting of salicylate intoxication
+ Intentional hyperventilation in the setting of major head injury with elevated
intracranial pressure.
+ Suspicion of clinical brain herniation from any cause.
+ Patient in critical condition with cyclic antidepressant toxicity.
3.2. Medical treatments
Because anesthesia drugs can interfere with your breathing, doctors sometimes
use ventilators during operations. Your doctor sedates you in order to place you on a
ventilator. Then they insert a tube into your windpipe and down your throat. This
makes getting air into and out of your lungs easier.

During COVID-19 disease

COVID-19 is a respiratory infection caused by the new coronavirus that is
causing the pandemic. The virus, known as SARS-CoV-2, enters your airways and
makes it difficult to breathe.
According to current estimates, about 6% of people infected with COVID-19
become critically ill. One in every four of them may require the use of a ventilator to
help them breathe. However, as the infection spreads around the world, the picture is
rapidly changing.
COVID-19 is spread by a virus that can enter your body through your nose,
mouth, or eyes. Once inside your body, it can make its way to your lungs, where
epithelial cells that line your airways are thought to be invaded.
The infection's inflammation can make it difficult for your lungs to clear fluid
and debris. Hypoxemia, or a lack of oxygen in the body, can result from this buildup.
The life-saving function of a ventilator is to support the lungs. These machines
can help you breathe by providing air with a higher oxygen content and creating
pressure in your lungs. They also aid in the removal of carbon dioxide and the
rebalancing of the pH levels in your blood.

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3.3. Level of ICU Care

Level 1: Provides monitoring, observation and short term ventilation.
Level 2: Monitoring, observation and long term ventilation with resident doctor.
Level 3: All above with invasive haemo-dynamic monitoring and dialysis.

Designing An ICU Team should include

+ Medical director
+ Nurse Administrator
+ Architect
+ Hospital Administrator
+ Engineering staff

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CHAPTER 4: DEVELOPMENT

The Future ICU Ventilator

The ICU ventilator of the future may not appear all that different from what we
have now, but it will have numerous qualities that set it apart from the current
generation of ventilators. Integration with other bedside technology will be possible. All
ICUs will have electronic charting within a few years, with data from all bedside
technology being transferred to electronic documentation systems. As a result,
ventilators must be able to communicate with every other bedside technologies via
electronic means.
Specialized ventilators for specific functions, such as newborn ventilation, adult
ventilation, NIV, and transportation, will be obsolete. All of these duties will be
performed as well as or better by the ICU ventilator of the future than by separate
ventilators of the past. According to the data, some ventilators can already provide
ventilation in a variety of settings and will be able to do so in the future.
Protocols will become an integral part of the ICU ventilator's basic operation.
Ventilators will be able to incorporate evidence-based algorithms into their basic
operational strategy as more data becomes available on how to offer lung-protective
ventilation and how to manage specific conditions. The tidal volume should be set
based on the patient's expected body weight. In addition to absolute volume, the
ventilator of the future will need us to input the patient's height and sex, and volumes
will be provided as mL/kg estimated body weight. Future ventilators will have the
Acute Respiratory Distress Syndrome Network protocol, as well as different techniques
to executing lung-recruitment exercises and controlling PEEP. These approaches will
still require the doctor to select fundamental parameters, but the ventilator will provide
guidance to ensure that breathing for a specific disease condition is performed
according to the most up-to-date evidence-based recommendations.
Alarms are responsible for a large portion of the noise pollution in the ICU. The
vast majority of the time, though, the alerts are false. As a result, employees have been
trained to disregard alarms ("alarm fatigue"). This will be corrected by the ventilator of
the future. Our current systems will be replaced by smart alarms. The high-pressure
warning, for example, does not have to sound every time the pressure exceeds the preset
level. The ventilator of the future will be able to recognize alarm patterns.
The following three instances would be interpreted differently by us, and there's no
reason why the ventilator couldn't do the same. First, a periodic increase in airway
pressure that occasionally surpasses the predetermined amount. Second, a gradually
increasing peak pressure over several hours with no change in tidal volume. Third,
airway pressure rises with each breath, and once the limit is reached, the delivered tidal
volume decreases with each breath. Each of these scenarios represents a possible
clinical issue with varying levels of urgency in response.
The first is most likely caused by secretions in the patient's airway or water in the
ventilator circuit, which causes the peak airway pressure to rise on a regular basis. This
isn't a life or death situation. The second scenario represents a shift in the patient's lung
mechanics, which necessitates the clinician determining the cause and maybe adjusting
the breathing strategy. But this isn't a life or death situation. The third situation, on the

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other hand, is a crisis. This could signify the development of a tension pneumothorax,
which necessitates rapid action. Clearly, the alert conditions in each of these three
circumstances should differ significantly. The ventilator of the future will be able to
comprehend these patterns, resulting in distinct alert circumstances.
The ventilators of the future will not display endless amounts of irrelevant data that
are useless to the practitioner. Only a limited number of separate pieces of data may be
processed by a single person. Information, not just lines of data, will be presented by the
next generation of ventilators. The clinician will be able to quickly determine if the
patient's status has altered using simple graphs or figures. At least one ventilator already
uses a figure to reflect a change in the patient's state. Important connected variables will
be presented so that the doctor can identify whether or not change has occurred quickly.
Tidal volume and airway pressure, for example, will be displayed in such a way that the
patterns in these variables may be easily discerned. In addition, information that has not
previously been available will be made available.
The number of breaths with missed triggers, double-triggers, or an unusually short
or long inspiratory or expiratory time will be calculated and shown, as well as the
asynchrony index. The presence of conditions linked to the emergence of auto-PEEP
will be recognized and shown.
The most significant function of this new generation of ventilators will be to assist
in decision-making. Following each alarm condition, a list of possible causes and
solutions will be provided. Changes in ventilator variables will be identified, and the
clinician will be advised of the change, as well as the possible causes and solutions.
From the ventilator's operation manual to the evidence that supports a recommended
action, the ventilator screen will provide access to a library of information.
On all ventilation modes, closed-loop ventilation control will be provided. These
new ventilators will be able to modify gas flow to increase synchronization between the
patient and the ventilator. They'll be able to understand the airway pressure and flow
waveform during both volume and pressure ventilation, and alter the flow waveform,
peak inspiratory flow, rising time, and termination criteria automatically to guarantee
gas supply is in sync with the patient's wishes. This is becoming a more relevant
element in ventilator operation as we learn that asynchrony can have a significant
impact on patient outcomes. On at least one ventilator, automatic termination criteria
change is already available.
All of these anticipated changes suggest that future users of mechanical ventilators
will need to be much more prepared than current users. They'll need to know everything
there is to know about the new features' operational difficulties. They'll have to be able
to tell when one characteristic is more important than the other. They'll have to ensure
that the ventilator is doing what it's supposed to be doing and that the patient is reacting
to the intervention as predicted. Clinicians in charge of these patient-ventilator systems
in the future will need to be far more capable than those in charge now.

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