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Calibration of Seven ICU Ventilators for Mechanical Ventilation with Helium–

Oxygen Mixtures

Article in American Journal of Respiratory and Critical Care Medicine · July 1999
DOI: 10.1164/ajrccm.160.1.9807127 · Source: PubMed

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Calibration of Seven ICU Ventilators for Mechanical
Ventilation with Helium–Oxygen Mixtures
DIDIER TASSAUX, PHILIPPE JOLLIET, JEAN-MARC THOURET, JEAN ROESELER, RENÉ DORNE,
and JEAN-CLAUDE CHEVROLET
Medical Intensive Care Division, University Hospital, Geneva, Switzerland; Service de Réanimation Médicale et
Assistance Respiratoire, Hôpital de la Croix-Rousse, Lyon, France; Soins Intensifs, Clinique Universitaire St.-Luc,
Brussels, Belgium; and Département d’Anesthésie-Réanimation, Hôpital St.-Luc, Lyon, France

The study evaluated seven intensive care unit (ICU) ventilators (Veolar FT, Galileo, Evita 2, Evita 4,
Servo 900C, Servo 300, Nellcor Puritan Bennett 7200 Series) with helium–oxygen (HeO2), using a
lung model, to develop correction factors for the safe use of HeO2. A 70:28 helium–O2 mixture (he-
liox) replaced air and combined with O2 (HeO2). Theoretical impact of HeO2 on inspiratory valves and
gas mixing was computed. True fraction of inspired oxygen (FIO2del) was compared with fraction of
inspired oxygen (FIO2) set on the ventilator (FIO2set). True tidal volume (VTdel) was compared with VT
set on the ventilator (VTset) in volume control and with control VTdel at FIO2 1.0 in pressure control.
FIO2del minimally exceeded FIO2set (< 5%) except with the 7200 Series (FIO2del . FIO2set by 125%). In
volume control, with the Veolar FT, Galileo, Evita 2, and Servo 900C, VTdel . VTset, with the 7200 Se-
ries VTdel , VTset (linear relationship, magnitude of discrepancy inversely related to FIO2set). With
the Evita 4, VTdel . VTset (nonlinear relationship), whereas with the Servo 300 VTdel 5 VTset. In
pressure control, VTdel was identical to control measurements, except with the 7200 Series (ventila-
tor malfunction). Correction factors were developed that can be applied to most ventilators. Tas-
saux D, Jolliet P, Thouret J-M, Roeseler J, Dorne R, Chevrolet J-C. Calibration of seven ICU ven-
tilators for mechanical ventilation with helium–oxygen mixtures.
AM J RESPIR CRIT CARE MED 1999;160:22–32.

Reducing the density of inspired gas by using a mixture of he-
lium and O2 (HeO2) instead of air and O2 (airO2) can be bene-
ficial in spontaneously breathing patients with upper or lower
airway obstructive disease (1, 2). In acute severe asthma,
breathing HeO2 increases peak expiratory flow and PaO2, and
decreases pulsus paradoxus, PaCO2, and dyspnea (3–5). In pa-
tients with COPD, breathing HeO2 increases expiratory flow
and decreases airway resistance (6, 7). Moreover, evidence
suggests that these favorable effects can also be obtained dur-
ing mechanical ventilation in status asthmaticus (8) and in
patients with COPD (9, 10), even though the data are still
preliminary in the latter patient population, and await confir-
mation by prospective studies. However, the physical proper-
ties of helium could interfere with several key ventilator func-
tions such as gas mixing, inspiratory and expiratory valve
accuracy, flow measurement, triggering, positive end-expira-
tory pressure (PEEP), and automatic leakage compensation,
thus raising issues regarding the accuracy of ventilator perfor-
mance (11) and patient safety.
The present study was designed to test the performances of
seven standard intensive care unit (ICU) ventilators available
in Europe during HeO2 utilization, compared with theoretical
predictions based on the physical properties of helium, and to
develop correction factors (12) to ensure the safe use of HeO2
during mechanical ventilation.
METHODS
Ventilators and HeO2 Administration
The ventilators studied were the Veolar FT, Galileo (Hamilton Medi-
cal, Rhäzuns, Switzerland), Evita 2, Evita 4 (Drägerwerk, Lübeck,
Germany), Servo 900C, Servo 300 (Siemens-Elema, Solna, Sweden),
and 7200 Series (Nellcor Puritan Bennett, Pleasanton, CA). Helium
was contained as a fixed mixture of 78:22 helium and O2, respectively
(heretofore referred to as “heliox,” to differentiate it from the final
heliox and O2 mixture delivered by the ventilator, termed HeO2), in a
50-L canister pressurized at 150 bar (Pangas Swiss Calibration, Lu-
zern, Switzerland), and delivered through a pressure regulator at 2 to
8 bar, according to manufacturer specifications, into the ventilator in-
let normally used for air.

(Received in original form July 24, 1998 and in revised form December 14, 1998 )
Supported by Hamilton Medical (Rhäzuns, Switzerland).
Correspondence and requests for reprints should be addressed to Dr. P. Jolliet,
Division des Soins Intensifs de Médecine, Hôpital Cantonal Universitaire, 1211
Geneva 14, Switzerland. E-mail: jolliet@cmu.unige.ch
Am J Respir Crit Care Med Vol 160. pp 22–32, 1999
Internet address: www.atsjournals.org
Fraction of Inspired O2 (FIO2)
The FIO2 set on the ventilator (FIO2set) was compared with the FIO2 ac-
tually delivered by the ventilator (FIO2del), determined by a rapid
paramagnetic gas analyzer (Normocap Oxy; Datex, Helsinki, Fin-
land), as well as with the FIO2 indicated by the ventilator’s own O2 sen-
sor. The range of FIO2set was 0.21 to 1.0, with 0.05 increments.
Tassaux, Jolliet, Thouret, et al.: ICU Ventilators with Helium–Oxygen
Delivered Tidal Volume and Inspiratory
Flow Measurements
Ventilators were connected to a test lung model (PneuView AI 2601I
TTL; Michigan Instruments, Grand Rapids, MI, cross-calibrated inde-
pendently from the manufacturer, Metron AS, Trondheim, Norway).
Briefly, the test lung is built around a chamber whose compliance
(Crs) and “airway” resistance (Raw) are determined by precision
spring-loading and variable cross-section resistors. A transducer mea-
sures pressure (P) inside the chamber. Tidal volume (VT) is deter-
mined as VT 5 Crs 3 P (measured at zero flow rate). Calculated VT is
verified against a calibrated volume scale attached to the device. In-
·
spiratory flow rate (VI) is computed by derivation of VT. For all tests,
Crs and Raw were set at 0.05 L/mbar and 5 mbar ? L ? s21, respec-
tively, and conditions were those of room air temperature, barometric
pressure, and humidity (ATPS). Using this model, flow and volume
measurements are independent of the physical properties of the gas
mixure, as opposed to measurements performed with a pneumotach-
ograph or other flow measuring devices in which a resistive compo-
nent is present (13). VT indicated by the lung model VT was further
checked against VT measured with a precision density-independent
spirometer (5420 Volume Monitor; Ohmeda, Louisville, KY) placed on
the inspiratory limb. Pressure, volume, and flow signals were stored in
a laptop computer equipped with the PneuView software package.
The following parameters were compared: VT set on the ventilator
(VTset); inspired (VTi) and expired (VTe) VT determined by the venti-
lator’s measuring device (if present); effective VT delivered by the
ventilator, as measured by the lung model and spirometer (VTdel).
After a complete test to verify the absence of leaks, the protocol
detailed subsequently was conducted at an FIO2set of 0.21, 0.3, 0.35,
0.4, 0.45, 0.5, 0.6, and 1.0. More measurements were made at the lower
end of the FIO2set range because there is probably little benefit to be
obtained clinically through a reduction in density above an FIO2 of 0.6.
The tests were conducted in both volume-controlled and pressure-
controlled modes.
In volume-controlled mode, VTset was increased by 50-ml incre-
ments from 100 to 1,300 ml. For each VTset, 10 successive measure-
ments were performed and averaged. Other ventilator settings were:
ventilatory rate 10/min, constant flow pattern, inspiratory:expiratory
time ratio 1:2, no PEEP; these settings were maintained constant
throughout the volume-controlled protocol. In the pressure-con-
trolled mode, the pressure limit was varied by 5-cm H2O increments,
between 5 and 60 cm H2O, at each FIO2set. For each level of pressure
limit and FIO2, VTdel was compared with VTdel obtained with an FIO2
of 1.0 (i.e., without heliox), used as control. Ventilatory rate and
PEEP were the same as in volume-controlled tests.
PEEP
PEEP was determined as the end-expiratory pressure measured in the
lung model chamber by the pressure transducer after 10 mechanical
breaths, for PEEP values set on the ventilator ranging from 5 to 25 cm
H2O, at each various FIO2set.
Theoretical Predictions
This approach pursued the following goals: first, to determine if the
consequences of using HeO2 on FIO2del and VTdel could be predicted
from its physical properties, and thus if the latter alone could account
for the changes observed; second, to validate the observed modifica-
TABLE 1
PROPERTIES OF PURE GASES AND AIR
Thermal Conductivity (k) Viscosity (h) Density (r)
Gas (mcal ? cm ? s ? °K) (Micropoises) (g/L)
Helium (He) 352.0 188.7 0.1785
Nitrogen (N2) 58.0 167.4 1.251
Oxygen (O2) 58.5 192.6 1.429
Air 58.0 170.8 1.293
23
tions in VT and FIO2; third, to validate the correction factors to be ap-
plied to VT. For this purpose, standard equations on the physics of gas
flow were used, integrating the main operating conditions and design
of the inspiratory valves, gas mixing devices (technical information
obtained from the manufacturers), and the physical properties of O2,
helium, nitrogen, and air (Table 1).
RESULTS
Theoretical Predictions
Briefly, the following approach and principles were used:
Dynamics of gas flow. The density of HeO2 (He) is mark-
edly inferior to that of airO2 (Figure 1) (1), which should alter
the dynamics of flow through the ventilator’s tubing and in-
spiratory valves. Indeed, laminar or turbulent conditions may
prevail, the nature of flow being described by Reynold’s num-
ber (Re) according to the following equation (14, 15):
Re = 2V̇ρ ⁄ πrµ (1)
·
where V 5 flow (ml/s), r 5 density of the gas (g/ml), r 5 ra-
dius of the tube (cm), m 5 gas viscosity (g/[cm ? s]). Re > 4,000
predicts turbulent flow, Re < 2,000 laminar flow (14, 15).
In laminar conditions, the pressure difference (DP) neces-
sary to obtain a given flow is determined by Equation 2:
∆P = k1 ( V̇lam ) (2)
where k1 (coefficient of linear resistance) 5 8hl/pr (from the
4
Hagen-Poiseuille equation), h 5 gas ·
viscosity (g/[cm ? s]), l 5
length of tube, r 5 radius of tube, Vlam 5 laminar flow (ml/s).
In turbulent conditions:
2
∆P = k ( V̇turb ) (3)
where k (coefficient of nonlinear resistance) 5 fl/4p2r5, where
f 5 a friction factor dependent on the Reynolds number and
the roughness of the tubing wall. In smooth
·
tubing f 5 0.316/
Re1/4, r 5 radius of the tube (cm), and Vturb 5 turbulent flow
(ml/s).
As can be seen, under laminar conditions, DP is uninflu-
enced by the density of the inhaled gas mixture, whereas in
turbulent conditions DP depends on density (the lower the
density, the lower Re and thus the lower k2). Hence, for a
given DP under turbulent conditions, which are those prevail-
ing in ventilatory tubing and valves, the lower the density of
the inhaled gas, the higher the flow.
Figure 1. Ratio of densities of airO2 and HeO2 to density of air, at
various values of FIO2.
24 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 160 1999

across the valve’s opening is described by the following equa-

tion (14):

∆P
V̇ = --------------------------------- (4)
ρ 1 1
---------2  -----2 – ----- 
2C  S 2 S 1 
2

Figure 2. Schematic representation of an electromagnetic propor-
tional inspiratory valve. Arrows indicate path through the valve fol-
lowed by the gas (heliox in this example).
Inspiratory valve design and theoretical consequences of us-
ing HeO2 on delivered VT and FIO2 in volume-controlled mode.
With the exception of the Servo 900C, all the ventilators
tested in this study are equipped with electromagnetic propor-
tional solenoid valves (16), consisting of two compartments
connected by an opening whose surface section is controlled
by a ball valve driven by a microprocessor-controlled electro-
magnetic motor magnetic motor (Figure 2). To minimize iner-
tia and valve response time (average 4 to 10 ms), the maximal
opening is small and varies within a tight range (1.2 to 14.4
mm2, depending on the ventilator). Thus, to obtain the high
inspiratory flow rates needed during mechanical ventilation in
the face of elevated resistance, these valves operate under tur-
bulent conditions. Two types of electrodynamic valves equip
most modern ventilators, categorized according to the magni-
tude of DP across the valve opening:
Low-pressure valves. The Veolar FT and Galileo are
equipped with one such valve, downstream from the airO2
mixing chamber (Figure 3). DP varies between 200 and 340
mbar, resulting in a flow of 250 to 3,000 ml/s depending on
the surface section of the opening (1.2 to 14.4 mm2). Flow
·
where V 5 flow (ml/s), DP 5 pressure difference across the
opening (dyn/cm2), r 5 density of the gas (g/ml), S1 5 cross-
section of cylindrical compartments (cm2), S2 5 cross section
of opening (cm2), and C 5 restriction coefficient (0.6 to 0.7,
depending on shape of opening and Reynolds number). Equa-
tion 4 predicts that for a given degree of valve opening and
DP, flow depends on gas density. Furthermore, as can be seen
from Figure 1, when air and O2 are used, there is very little
variation in overall gas density when FIO2 varies. However, re-
placing air with heliox results in density changing by a factor
of 8 as FIO2 increases between 0.22 and 1.0 (Figure 1). Hence,
if the terms of Equation 4, C, S1, S2, and DP remain constant
(K), Equation 4 can be simplified as follows:
1
V̇ ( air ) = K ( air ) --------------- (5)
ρ ( air )
and
1
V̇ ( HeO 2 ) = K ( HeO 2 ) ----------------------- (6)
ρ ( HeO 2 )
·
where V(HeO2) 5 flow of the HeO2 mixture leaving the ven-
tilator (ml/s), K(HeO2) 5 constant as defined above, and
r(HeO2) 5 density of the HeO2 mixture leaving the ventilator
(g/ml).
By definition, K(air) 5 K(HeO2), hence from Equations 5
and 6:
ρ ( air )
V̇ ( HeO 2 ) = V̇ ( air ) ----------------------- (7)
ρ ( HeO 2 )
finally,

Figure 3. Schematic representation of the inspiratory valve and gas mixing setup in the Veolar FT and
Galileo (right panel), and the Evita 2, 4, and Servo 300 (left panel). Arrows indicate path followed by the
gases.
Tassaux, Jolliet, Thouret, et al.: ICU Ventilators with Helium–Oxygen 25

TABLE 2
THEORETICAL VOLUME CORRECTION FACTORS

Volume Correction Factor* Volume Correction Factor* Volume Correction Factor*

FIO2set Single Low-pressure Valve† Dual Low-pressure Valve‡ Dual High-pressure Valve§

0.21 1.68 1.68 1.81

0.25 1.62 1.65 1.78
0.30 1.52 1.61 1.72
0.35 1.44 1.57 1.67
0.40 1.38 1.52 1.62
0.45 1.32 1.48 1.57
0.50 1.26 1.44 1.52
0.60 1.18 1.35 1.41
0.70 1.10 1.26 1.31
0.80 1.04 1.17 1.20
0.90 0.99 1.09 1.10
1 0.96 1 1
· ·
* Volume correction factor: in volume-controlled mode, V del 5 V set 3 volume correction factor.
†
Found in Veolar FT and Galileo.
‡
Found in 7200 Series.
§
Found in Evita 2, 4, and Servo 300.

ρ ( air ) volume correction factor for an FIO2 of 0.22 obtained from

V̇ ( HeO 2 ) = V̇ ( air ) ----------------------- (8)
ρ ( HeO 2 ) Equation 9, Equation 10 becomes
Thus, flow through the valve should increase when density is V̇del = V̇set ( 1.87 – 0.87 × Fi O set ) (11)
2
lower. From these equations, a theoretical volume correction
Thus:
factor for a given FIO2 can be determined that can be applied
to VTset: Volume Correction Factor = 1.87 – 0.87 × Fi O set (12)
2
ρ ( air ) Volume correction factors at different FIO2set are shown in
Volume Correction Factor = ----------------------- (9)
ρ ( HeO 2 ) Table 2.
The results are summarized in Table 2. Regarding FIO2, since in the Veolar and Galileo the mixing
The 7200 Series contains two such inspiratory valves (maxi- chamber is located upstream from the single inspiratory valve
· (Figure 3), density should not affect FIO2. Indeed, each gas is
mal DP is 687 mbar). Hence, total flow delivered ( Vdel) can
be computed as: admitted to the mixing chamber from its mural or canister
source through mechanical (Veolar FT) or electrodynamic
V̇del = V̇ O 2 + V̇air = V̇set ( F I O set – 0.22 ) ⁄ 0.78 + (10) (Galileo) valves until a total chamber pressure is reached. The
2

V̇set ( 1 – Fi O set ) ⁄ 0.78 latter is equal to the sum of partial pressures of both gases at
2 the desired combination of O2 and air (or heliox in this study)
· · determined by the FIO2 setting on the ventilator control panel.
where VO2 5 flow· through O2 valve (ml/s), Vair 5 flow through
air valve (ml/s), Vset 5 flow set on the ventilator (ml/s), and Thus, because this system is pressure- and not volume-con-
FIO2 5 inspired O2 fraction set on the ventilator. Applying the trolled, ideal gas laws apply (17). To simplify, pressure-control
consists of a transfer of a volume of gas from a first compart-
TABLE 3
ment (mural or canister) of a given volume (V1) and pressure
(P1) into a second compartment (mixing chamber) of a given
THEORETICAL FIO2 DELIVERED BY A DUAL HIGH-PRESSURE
volume (V2) at a given pressure (the target pressure P2). Ac-
(EVITA 2 AND 4, SERVO 300) AND LOW-PRESSURE
(7200 SERIES) INSPIRATORY VALVE SYSTEMS cording to Boyle’s law, at equilibrium P1 3 V1 5 P2 3 V2.
Hence, in the absence of flow and resistance, density exerts no
FIO2del† Corrected FIO2‡ influence, and the lower density of heliox should not influence
FIO2set* HP LP HP LP FIO2. With the 7200 Series, FIO2del should be determined by
the proportion of flow for each gas, and computed as follows:
0.21 0.22 0.22 0.21 0.21
0.25 0.24 0.24 0.27 0.27 V̇o 2 ( total ) V̇o 2 + 0.22V̇ ( HeO 2 )
0.3 0.27 0.27 0.35 0.35 Fi O del = -----------------------
- = ---------------------------------------------------
- (13)
2
0.35 0.30 0.30 0.43 0.42 V̇del V̇del
0.4 0.33 0.34 0.49 0.48
0.45 0.37 0.38 0.56 0.54 where:
0.5 0.40 0.41 0.61 0.6
0.60 0.49 0.5 0.71 0.7 V̇o 2 = V̇set ( Fi O set – 0.22 ) ⁄ 0.78 (14)
2
0.70 0.59 0.6 0.80 0.79
0.80 0.70 0.71 0.88 0.87 and
0.90 0.84 0.85 0.94 0.94
1 1 1 1 1 V̇ ( HeO 2 ) = V̇set ( 1 – Fi O set ) ⁄ 0.78 × 1.68 (15)
2

Definition of abbreviations: HP 5 dual high-pressure valve system; LP 5 dual low-pres- Finally:

sure valve system.
* Desired FIO2 set on the ventilator.
†
0.81Fi O set + 0.19
2
Actually delivered FIO2. Fi O del = --------------------------------------------
- (16)
‡
FIO2 to be set on the ventilator to obtain the desired FIO2. 2 1.87 – 0.87Fi O set
2
26 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 160 1999

TABLE 4 High-pressure valves. The Evita 2, 4, and Servo 300 are fit-
DELIVERED FIO2 DURING HeO2 UTILIZATION ted with two high-pressure valves, one for O2, the other for air
(or heliox in this study), upstream from the mixing chamber
FIO2set Veolar FT Galileo Evita 2 Evita 4 Servo 900C Servo 300 7200 Series
(Figure 3). A DP of 1 to 3 bar results in particular thermody-
0.21 0.22 0.22 0.22 0.22 0.22 0.22 0.22 namic conditions across the valve, known as “supercritical,”
0.25 0.25 0.25 0.24 0.24 0.25 0.26 0.56 the description of its complex nature being beyond the scope
0.3 0.31 0.31 0.28 0.27 0.33 0.33 0.73
of this study (18). Suffice it to say that under such conditions,
0.35 0.37 0.35 0.31 0.3 0.35 0.38 0.83
0.4 0.4 0.41 0.35 0.34 0.46 0.43 0.88
flow is described by Equation 18:
0.5 0.51 0.5 0.42 0.41 0.51 0.52 0.95
0.6 0.61 0.6 0.52 0.5 0.62 0.63 0.99 V̇ = a ⋅ P abs ⋅ c ⋅ x (18)
1 0.98 1 0.98 0.97 0.99 0.99 1
where a 5 constant independent of the nature of the gas; Pabs 5
absolute admission pressure (dyn/cm2); c 5 speed of sound in
Conversely, to obtain the desired FIO2, FIO2set should be cor- the particular gas (m/s), where c 5 √k/M , and where k 5 adia-
rected as follows: batic coefficient (N/m2) and M 5 molecular mass (kg/m3); x 5
position of the ball valve drive shaft (determines the surface of
the opening) in centimeters.
·
1.87Fi O del – 0.19 Total flow ( Vdel) delivered by both (O2 and air or heliox)
2
Fi O set = ---------------------------------------------
- (17)
2 0.81 + 0.87Fi O del
2
high-pressure valves can be determined by Equation 10. How-
ever, as seen from Equation 18, for a given DP and valve open-
Table 3 shows the predicted FIO2del obtained for a given ing, flow for each valve depends on the speed of sound c in
FIO2set, according to Equation 16, as well as corrected FIO2set this gas mixture, which in turn depends on √k/M . In turn,
obtained from Equation 17. these two variables depend on FIO2, ranging from 1.556 to 1.40
In the case of the Servo 900C, the inspiratory valve is of a for k and 9.94 to 31 for M, for O2:HeO2 mixtures of 78:22 to
different type. A scissors-type mechanism, controlled by a 0:100, respectively. If a 78:22 mixture of helium and O2 is ad-
stepper motor, regulates the cross-section by pinching a silicon ministered through a valve calibrated for air, as in our study,
tube. The peak inspiratory flow is determined by the pressure flow will be increased by a factor of 1.81, which· can be used to
entering the valve, while the scissors-type mechanism allows correct Equation 10 to determine total flow ( Vdel) delivered
an increase or decrease in flow by approximately 10% incre- by both high-pressure valves:
ments (16). Information from a pressure/flow monitoring de-
vice is fed back into the stepper motor controlling the scissors- V̇del = V̇o 2 + V̇ ( HeO 2 ) = V̇set ( Fi O set – 0.22 ) ⁄ 0.78 + (19)
2
type valve, thereby allowing constant regulation of inspiratory
V̇set ( 1 – Fi O set ) ⁄ 0.78 ⋅ 1.81
valve opening during inspiration. Due to the difficulty of mod- 2

eling flow across this type of valve, no mathematical predic- which can be further simplified to:
tions were made for the Servo 900C.
The gas mixing chamber is also upstream from the inspira-
V̇del = V̇o 2 + V̇ ( HeO 2 ) = V̇set ( 1.59 – 0.81 ⋅ (20)
tory valve, and thus FIO2 should not be influenced by the pres-
ence of heliox. Fi O set ) ⁄ 0.78
2

Figure 4. Relationship between VT set on the ventilator (VTset) and VT actually delivered by the ventilator
(VTdel), at various values of FIO2, with corresponding regression equations (panel), for the Veolar FT, Gali-
leo, and Evita 2.
Tassaux, Jolliet, Thouret, et al.: ICU Ventilators with Helium–Oxygen 27

TABLE 5
INSPIRATORY AND EXPIRATORY VOLUME FACTORS

Veolar FT Galileo Servo 900C Servo 300 Evita 2 Evita 4 7200 Series

FIO2set VFi VFe VFi VFe VFi VFe VFi VFe VFi VFe VFi VFe VFi VFe

0.21 1.68 1.70 1.68 1.70 1.38 1.34 1 1.34 1.83 Inop NL Inop 0.1 Inop
0.25 1.60 1.60 1.60 1.60 1.36 1.34 1 1.34 1.75 Inop NL Inop 0.14 Inop
0.30 1.51 1.50 1.51 1.50 1.35 1.33 1 1.33 1.73 Inop NL Inop 0.19 Inop
0.35 1.44 1.47 1.44 1.47 1.33 1.23 1 1.33 1.66 Inop NL Inop 0.25 Inop
0.40 1.37 1.40 1.37 1.40 1.31 1.22 1 1.22 1.60 Inop NL Inop 0.3 Inop
0.45 1.31 1.33 1.31 1.33 1.29 1.20 1 1.20 1.55 Inop NL Inop 0.35 Inop
0.50 1.28 1.30 1.28 1.30 1.26 1.17 1 1.17 1.48 Inop NL Inop 0.4 Inop
0.60 1.20 1.26 1.20 1.26 1.24 1.13 1 1.13 1.40 Inop NL Inop 0.5 Inop
1.0 0.97 1.01 0.97 1.01 0.97 1.09 0.99 1.09 0.986 1.093 0.99 1.093 1.05 1.05

Definition of abbreviations: Inop 5 inoperative; NL 5 nonlinear relationship; VFe 5 expiratory volume correction factor (VTe 5 VTe meas 3
VFe); VFi 5 inspiratory volume correction factor (VTdel 5 VTset 3 VFi).

Finally: Conversely, to obtain the desired FIO2, FIO2set should be cor-

rected as follows:
V̇del = V̇set ( 2.04 – 1.04Fi O set ) (21)
2

It is thus also possible to determine a “corrective volume 2.04Fi O del – 0.23

2
factor,” the true delivered volume being computed by the fol- Fi O set = ---------------------------------------------
- (24)
2 0.77 + 1.04Fi O del
lowing equation: 2

Results are shown in Table 3.

V̇del = V̇set ( 2.04 – 1.04Fi O set ) = V̇set ⋅ VolumeFactor (22)
2
FIO2
The volume factors for the various FIO2 used in this study are The results are outlined in Table 4. There was some degree of
shown in Table 2. discrepancy between FIO2set and FIO2del. The magnitude of
Regarding FIO2, the same equations (Equations 16 and 17) this discrepancy varied both between the ventilators tested
as for the 7200 Series apply, but with different constants ac- and as a function of FIO2set, being the greatest when FIO2set
counting for supercritical conditions. Hence, Equations 16 and was between 0.3 to 0.6. As can be seen, the Veolar FT, Gali-
17 become: leo, Servo 300, and Servo 900C were the most accurate,
whereas with the Evita 2 and Evita 4 FIO2del was lower than
0.77Fi O set – 0.23 FIO2set, by an average of 10%, reaching 18% at an FIO2set of
2
Fi O del = -----------------------------------------------
- (23) 0.5. With the 7200 Series, FIO2del was considerably higher than
2 2.04 – 1.047Fi O set
2

Figure 5. Relationship between VT set on the ventilator (VTset) and VT actually delivered by the ventilator
(VTdel), at various values of FIO2, with corresponding regression equations (panel), for the Evita 4.
28 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 160 1999

Figure 6. Relationship between VT set on the ventilator (VTset) and VT actually delivered by the ventilator
(VTdel), at various values of FIO2, with corresponding regression equations (panel), for the 7200 Series.

FIO2set. There was excellent agreement between these find-
ings and the theoretical predictions of FIO2del, except for the
7200 Series (Table 3). The FIO2 reported by the ventilator sen-
sor and that measured with the rapid paramagnetic gas ana-
lyzer were identical on all machines (data not shown).
Delivered VT in Volume-controlled Mode
There was variable congruency between VTset and VTdel.
With the Veolar FT, Galileo, and Evita 2, VTdel was consis-
tently higher than VTset, the magnitude of this discrepancy
being inversely related to FIO2, i.e., the lower the FIO2 (the
higher the heliox fraction), the more VTdel exceeded VTset, as
shown in Figure 4. Thus, VTdel exceeded VTset by 25% at an
FIO2 of 0.5 and by 60% at an FIO2 of 0.22. As can be seen in
Figure 4, for a given FIO2, there was a linear relationship be-
tween VTdel and VTset (the slopes of the regression lines for
each of the three ventilators being nearly identical, the set of
lines for only one ventilator is shown). From the regression
equations, a volume correction factor to be applied to VTset
to obtain a given VTdel for each FIO2 can be determined, as

Figure 7. Relationship between VT set on the ventilator (VTset) and VT actually delivered by the ventilator
(VTdel), according to FIO2 with corresponding regression equations (panel), for the Servo 300. Only the
FIO2 of 0.22 and 1.0 are shown to avoid excessive overlap, but the relationship was identical at all FIO2.
Tassaux, Jolliet, Thouret, et al.: ICU Ventilators with Helium–Oxygen
shown in Table 5. The Evita 4 followed the same pattern, but
for a VTset higher than 500 ml, the relationship between VTset
and VTdel became nonlinear, VTdel exceeding VTset by as
much as 100% when low FIO2 and high VTset were combined
(Figure 5). This problem could be solved by inactivation of
the leakage compensation mechanism, in which case the
machine’s performance was identical to the Evita 2. Further-
more, a high-priority alarm of inoperative flow measurement
was activated, which could not be silenced by recalibration of
the flow sensor, but required inactivating inspiratory flow
monitoring. With the Servo 900C VTdel also exceeded VTset,
but by more than 40% at an FIO2 of 0.22. With the 7200 Series,
VTdel was consistently lower than VTset, the magnitude of this
discrepancy being inversely related to FIO2, and being consid-
erable when FIO2 , 0.9 (Figure 6). Finally, the Servo 300 was
unaffected by the use of HeO2, whatever the FIO2, as shown by
the line of identity between VTset and VTdel (Figure 7).
Delivered VT in Pressure-controlled Mode
With the exception of the 7200 Series, in pressure-controlled
mode, VTdel was identical to control measurements at FIO2 of
1.0, at all pressure limits and FIO2 tested, with all ventilators.
However, VTi reported by the ventilator underestimated true
VTdel on all ventilators, by a magnitude equal to that between
VTset and VTdel in volume-controlled mode. With the 7200
Series, at all FIO2 , 0.5, repeated opening–closing of the heliox
inspiratory valve caused major vibrations within the ventila-
tor, prompting cessation of the test.
Expired VT
The findings apply to both volume- and pressure-controlled
modes.
There was considerable variation among the values of VTe
reported by the ventilators. With the Veolar FT, Galileo, Servo
900C, and Servo 300, indicated VTe was lower than VTdel. As
with VTset, this underestimation was linear and was a function
of FIO2, i.e., the lower the FIO2, the larger the disparity between
VTe and VTdel (Figure 8). Hence, even though there were
quantitative differences between the ventilators, correction
Figure 8. Relationship between expired V T reported by the ventilator (V Te) and actually expired VT (VT-
meas), at various values of F IO2, with corresponding regression equations (panel), for the Veolar FT and
Galileo.
29
factors could be determined. These factors are indicated in
Table 5. As can be seen, for the Veolar FT and Galileo the
factors were the same as for VTset. Correction factors for the
Servo 900C and Servo 300 were smaller than those of the Veo-
lar FT and Galileo.
With the Evita 2, Evita 4, and 7200 Series, reported VTe
was considerably higher than VTdel. This overestimation in-
creased nonlinearly as FIO2 decreased, VTe determination be-
coming inoperative below an FIO2 of 0.8. Concomitantly, a
high-priority alarm of expiratory flow monitoring malfunction
was activated. Recalibration of the flow sensor did not correct
this problem.
PEEP
Measured PEEP was in good agreement with set PEEP, the
maximal discrepancy being 6 0.5 cm H2O, independently of
FIO2.
DISCUSSION
In the seven nonmodified ICU ventilators tested, the use of
HeO2 led to alterations in ventilator function, whose nature
varied from one machine to another, as does the ease with
which these modifications can be corrected. Before discussing
these results, let us briefly summarize them:
1. The Veolar FT, Galileo, Servo 900C, and Servo 300 deliv-
ered an accurate FIO2 at all tested FIO2, whereas the Evita 2
and Evita 4 administered a lower than set FIO2, particularly
in the 0.35 to 0.6 range. The 7200 Series delivered a consid-
erably higher than set FIO2.
2. In volume-controlled mode, delivered VT was higher than
set VT on the Veolar FT, Galileo, Evita 2, and Servo 900C,
the magnitude of this discrepancy being inversely related to
FIO2. There was a linear correlation between VTset and
VTdel. The Evita 4 followed the same pattern up to a VTset
of 500 ml, but further VTset increases entailed considerable
discrepancy with VTdel, with a nonlinear relationship. The
7200 Series delivered a considerably lower than set VT
30 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
when FIO2 , 0.9. With the Servo 300, VTset and VTdel were
identical. Reported VTe was underestimated by all ventila-
tors, also as an inverse linear function of FIO2, except for
the Evita 2, Evita 4, and 7200 Series, which were unable to
monitor expired VT.
3. The observed results for FIO2 and VTdel were in agreement
with theoretical predictions based on the changes in density
and principles of ventilator design, except for the Servo 300
and 7200 Series.
4. In pressure-controlled mode, VTdel was identical to control
VT obtained at an FIO2 of 1.0 with all ventilators tested ex-
cept for the 7200 Series, which malfunctioned.
5. PEEP was adequately obtained with all ventilators at all
FIO2 tested.
Consequences on Delivered VT and FIO2 in
Volume-controlled Mode
The findings can be best understood by turning to the princi-
ples of valve design and gas flow discussed previously. The ef-
fects on FIO2 and VTdel are closely linked and will be discussed
together. As we have seen, the Veolar FT, Galileo, and Servo
900C are equipped with a single inspiratory valve, located
downstream from the gas mixer (Figure 3). Calibration of the
valve is performed for a single given FIO2. There is no built-in
system designed to adjust for changes in gas density. Hence, if
density decreases, flow should increase, and vice versa. This
is not a problem when airO2 mixtures are used, because the
densities of these two gases are quite close (Table 1 and Fig-
ure 1). Hence, whatever the FIO2, the overall density change of
the gas mixture is very small, and of no consequence on venti-
lator function. However, the considerably lower density of he-
liox (Table 1 and Figure 1) entails a marked increase in flow,
which is proportional to the fraction of heliox in the gas mix-
ture, and thus inversely proportional to FIO2. FIO2 itself is not
influenced by the reduction in density, however, because mix-
ing occurs upstream from the valve (Figure 3). This explains
why the Veolar FT, Galileo, and Servo 900C correctly admin-
istered the FIO2set (Table 4), whereas VTdel was higher than
VTset (Table 5), as predicted from theoretical calculations
(Tables 2 and 3).
The Evita 2 and Evita 4 are fitted with two proportional in-
spiratory valves, one for air, the other for O2, gas mixing oc-
curring downstream from these valves (Figure 3). Conse-
quently, replacing air with heliox should, for the reasons
outlined previously, increase flow through the valve normally
regulating air admission, whereas there will be no effect on the
O2 inspiratory valve. Because VTdel results from the outflow
from the mixing chamber, which in turn results from the com-
bined flows of both gases, total outflow will be increased, and
VTdel will be . VTset, proportionally to the fraction of heliox
present in the mixture, as predicted (Table 2) from Equations
21 and 22 and as confirmed by our tests (Figures 4 and 5).
However, contrarily to what occurs with the Veolar FT, Gali-
leo, and Servo 900C, FIO2 also changes. Indeed, the higher the
fraction of heliox, the more heliox flow through the valve will
exceed its set value, and as a result, FIO2del by the ventilator is
lower than FIO2set, as predicted (Table 3) by Equations 23 and
24 and as documented in our tests (Table 4).
Finally, an additional problem occurs with the Evita 4, with
which VTdel exceeds VTset in a nonlinear manner for any
FIO2 , 0.5 and VTset . 500 ml (Figure 5). This is due to the
automatic leakage compensation mechanism. Indeed, the ex-
piratory flow sensor malfunctions with HeO2, and the mecha-
nism erroneously interprets this as being caused by gas leaks
in the patient or ventilator circuit. Automatic compensation
triggers an increase in the degree of inspiratory valve opening,
VOL 160 1999
resulting in a major increase in VTdel. Volume correction fac-
tors can be computed for all FIO2 , 0.5, according to nonlinear
regression equations. Their general form would be y 5 aebx,
where y 5 volume factor, x 5 VTset, and b 5 correction factor
dependent on FIO2. However, using such factors might prove
impractical in the clinical setting. Another approach is to inac-
tivate the flow monitoring system through the control panel
menu, which corrects this problem but requires an indepen-
dent monitoring of VT.
The major discrepancies in both FIO2 and VT observed with
the 7200 Series, which differed from theoretical predictions,
can be explained by the design of the machine. Indeed, as pre-
viously stated, gas mixing occurs downstream from two inspira-
tory valves, one for O2, the other for air. Flow of gas coming out
of each valve is measured by a hot-wire pneumotachograph,
and this information is fed back to the valve to continuously
adjust the size of its opening, which thus regulates flow. Using
heliox instead of air has major consequences on the hot-wire
pneumotachograph of that particular valve for the following
reason. The device comprises two platinum wires located in
the mainstream flow, heated electrically and maintained at
4008 C. Cooling of the wires by convective heat loss is propor-
tional to gas flow. The intensity of electric current required to
maintain the wire at 4008 C can thus be translated into flow
units. Heat loss can be quantified by the following equation:
Ċ = Ac ⋅ h9c ⋅ V
2/3
⋅ Mv ⋅ Cm ( Ts – Ta ) (25)
·
where C 5 heat loss, Ac 5 surface of wire exposed to gas
(cm2), Ts 5 wire temperature (8K), h9c 5 coefficient of flow
geometry around wire, V 5 gas velocity (ml/s), Mv 5 volume
mass of gas (kg/m3), Cm 5 specific heat conductivity of gas
(mcal ? cm ? s ? 8K), and Ta 5 gas temperature (8K). The spe-
cific heat conductivity of helium is six times that of air (Table
1). Consequently, heat loss will increase markedly, and the de-
vice interprets this as being due to an increase in flow. How-
ever, because of the sixfold larger loss of heat the magnitude
of flow overestimation is also very large. Hence, the feedback
mechanism will markedly reduce valve opening, which in turn
will markedly reduce heliox flow. This explains the fact that
with this machine VTdel was lower than VTset, and also that
the magnitude of this discrepancy was substantial. Concomi-
tantly, the O2 valve function is unaltered by the use of heliox.
Thus, because gas mixing occurs downstream from these two
valves, and because, as we have seen, flow through the heliox
valve is considerably reduced, FIO2del will increase, as ob-
served (Table 4). At an FIO2set of 0.21, only the air (or in this
case heliox) valve is operative, which explains that FIO2del 5
FIO2set, since the FIO2 in the heliox tank is 0.22. Because of
these problems, the machine cannot be used safely with heliox.
Although resting on the same basic inspiratory gas delivery
design principles as the Evita 2 and 4 (Figure 3), the Servo 300
did not behave according to the theoretical predictions with
regard to FIO2 (Tables 3 and 4) and VTdel (Tables 2 and 5). In-
deed, the machine is also fitted with two high-pressure propor-
tional inspiratory valves, one for O2, the other for air (or he-
liox in this study), each valve being encased in a gas delivery
unit. A mixing chamber is located downstream from these two
units. Our understanding is that the reason for this lies in the
monitoring devices contained within the gas delivery systems,
because each of the latter is fitted with a temperature probe
and a differential pressure transducer. These devices are in-
tended to compensate for changes in density and temperature
caused by gas expansion within the ventilator. These changes
are negligible when standard wall inlet pressures (3 to 4 bar)
are used for O2 and air. However, the Servo 300 is designed to
operate with high-pressure sources, in which case the effects
Tassaux, Jolliet, Thouret, et al.: ICU Ventilators with Helium–Oxygen
of gas cooling on density during expansion are much greater.
Hence, in case of changes in the physical properties of the gas,
the temperature and pressure/flow sensors detect a discrep-
ancy between the set and actual flows, and correct the valve’s
opening through a feedback mechanism. The same mecha-
nisms are operative when density changes for reasons other
than temperature, e.g., when heliox is used instead of air, and
this probably explains why VTset and VTdel are identical with
this machine.
As for the Servo 900C, the actually observed difference be-
tween VTdel and VTset was smaller than that predicted (Table
2) from Equations 8 and 9. The reason for this is not quite
clear, but probably stems from the effect of HeO2 on the flow
derivation device. Briefly, this device consists of a main tube
with a wire mesh membrane across its lumen. The resistance
entailed by the latter forces a portion of the gas flow into a
small parallel tube, where pressure is measured by a differen-
tial transducer. The information is then fed back into the
mechanism controlling the inspiratory valve opening, any
drop in pressure entailing an increase in its opening and vice
versa. If air is replaced by heliox, resistance across the main
tube’s membrane will decrease, flow will pass through the
main tube, and thus decrease in the side tube. Hence, pressure
in the side tube will decrease, and the feedback mechanism
will compensate by further opening the inspiratory valve, in-
terpreting this as a true decrease in inspiratory flow. This
should result in VTdel being higher than VTset, but the magni-
tude of the difference cannot be precisely predicted by Equa-
tions 8 and 9, because more than one mechanism is involved in
the process.
A final series of factors should be considered in interpret-
ing our results. First, during inspiration, not all the VTset is de-
livered to the patient or the lung model, as a result of a vol-
ume of gas being trapped in the ventilator’s inspiratory circuit.
Two factors account for this occurrence: gas compressibility
and circuit compliance.
Gas compressibility. A portion of the VTset is trapped in
the inspiratory circuit, because of the compressibility of the
gas. In the clinical operating conditions of ICU ventilators, it
is estimated that this volume is equal to 1 ml/cm H2O/L (19).
In the conditions of our tests, mean inspiratory pressures were
< 10 and < 20 cm H2O for VTset of 500 ml and 1,000 ml, re-
spectively, which represents a volume of gas trapped within
the circuit due to compressibility alone of 5 to 10 ml.
Compliance of the circuit. Total compliance of the circuits
(including tubings, water traps, humidifiers, and filters) ranges
from 2.5 to 3 ml/cm H2O. During our tests, water traps, humidi-
fiers, and filters were removed. Thus, only the compliance of
the tubings (and pneumotachograph with the Hamilton ma-
chines) should be taken into consideration. Results are the
following: Hamilton Veolar FT and Galileo, 1.2 ml/cm H2O;
Nellcor Puritan Bennett 7200 Series, 1.6 ml/cm H2O; 0.8 ml/cm
H2O for the other machines tested. Hence, at the mean pres-
sure regimen documented in our tests, the trapped volume
would at most amount to 32 ml. Taking both these mechanisms
into account, the volume of gas trapped within the inspiratory
circuit should be < 42 ml in the conditions of our tests.
Considering the above, VTdel should be lower than mea-
sured expired tidal volume (VTmeas) in our study, and the
magnitude of this difference can be expressed by a factor that
includes the compressibility of the gas and the compliance of
the circuit. This factor can be determined at FIO2 1.0, because
then the difference between VTdel and VTmeas is due to com-
pressibility/compliance solely, and not to any confounding fac-
tor such as the effect of density on inspiratory valve function.
It should, however, be noted that, provided temperature is un-
31
changed, the compressibility of a volume of gas is a function of
neither its density nor its viscosity, and hence no difference in
the volume of trapped gas between airO2 or HeO2 should occur.
Second, the ventilators have various built-in corrections
designed to compensate for the aforementioned and other
mechanisms, to ease the clinician’s task.
Physical conditions. Ventilators deliver gas in ambient tem-
perature and pressure conditions (ATP), whereas expired gas is
in body temperature and pressure saturated (BTPS) conditions.
Most ventilators correct automatically the expiratory flow/vol-
ume signal to account for this difference. In the tests we per-
formed, both inspiration and expiration occur under ATP con-
ditions. Thus, the automatic correction should be disabled, or
a correction equation applied, to obtain true expiratory vol-
umes. The Evita 2 and 4, Servo 300 and 7200 Series feature an
automatic correction of expiratory flow, which takes into ac-
count the BTPS, whereas the Hamilton machines do not have
this function. However, during startup calibration of the prox-
imal pneumotachograph is performed under ATP conditions if
no air warmer is used, and under BTPS conditions if such a de-
vice is used.
Precision of the ventilators. Electromagnetic valves have a
degree of precision in the order of 5% compared with mea-
sured values (data from Hamilton Medical). Flow measure-
ments have a precision of , 10%. The volume values reported
by the ventilators can thus vary from 50 to 100 ml for a VTset
of 1,000 ml. Depending on the direction of this variation, this
error can mask or overestimate the value of trapped gas volume.
Special functions of some of the ventilators tested. The Evita
2 and 4, Servo 300 and 7200 Series all have a built-in function
for automatic compensation of circuit compliance. The latter
is measured during the startup procedure when the machine is
turned on. This procedure was performed before all our tests,
and hence VTdel already takes into account circuit compliance
correction on these ventilators.
To summarize, several factors can influence the exact value
of the various correction factors we determined: (1) during in-
spiration: gas compressibility (compression), circuit compli-
ance, precision of the inspiratory valve, presence or absence of
automatic compensation of circuit compliance; (2) during ex-
piration: gas compressibility (expansion), circuit compliance,
precision of flow sensors, presence or absence of automatic
BTPS correction. It must once again be stressed, however, that
none of these interferences with VT measurement will be in-
fluenced by density. Hence, these factors should not interfere
with the comparison of HeO2 and airO2.
Consequences on Delivered VT in
Pressure-controlled Mode
In pressure-controlled modes, VTdel depends on the mechani-
cal properties of the lung model and is mostly independent of
inspiratory valve function, the latter generating flow until a
preset target pressure level is attained. At equilibrium, i.e., at
the preset pressure level, the volume of gas that has been
transferred into the lung model is the same regardless of den-
sity, as predicted by Boyle’s law (17), and as outlined in METH-
ODS. Therefore, the density reduction associated with the use
of HeO2 should decrease the time needed to reach the target
pressure, but should not influence VTdel compared with VTdel
obtained in control conditions with the same target pressure
level but at an FIO2 of 1.0. However, the VTi reported by the
ventilator should underestimate VTdel. Our results confirm
this hypothesis.
The malfunction observed on the 7200 Series in this mode
is explained by the effect of heliox on the hot-wire pneumo-
tachograph flow sensor and its feedback mechanism on the in-
32 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
spiratory valve discussed previously. Indeed, in pressure-con-
trolled mode, the circuit is pressurized by a user-adjustable
peak inspiratory flow. However, because of the large overes-
timation of inspiratory flow entailed by heliox, the valve is
constantly cycling between open/closed positions, leading to
marked mechanical oscillations and dysfunction.
Expired VT Determination
VTe is determined by different systems in the ventilators tested,
with variable consequences on the accuracy of indicated VTe.
The Veolar FT and Galileo are equipped with a variable
orifice flowmeter (20) located proximally to the Y-piece of the
patient–ventilator circuit. In brief, the device consists of a
membrane with a flexible V-shaped membrane center portion,
placed across the mainstream flow. Pressure is measured on
both sides of this resistance, by a differential pressure trans-
ducer, whose output is proportional to flow. Because of the
center membrane’s flexibility, the cross-section of the opening
increases (and thus resistance decreases) as flow increases.
Thus, resistance remains constant over a flow range of 0.1 to
2.5 L/s (20), allowing a linear response of the device, which is
calibrated for a given gas density. Flow across the device’s ori-
fice being turbulent, if air is replaced by heliox, resistance will
decrease, and the pressure difference across the membrane
will drop. Thus, the device will underestimate true flow, as
confirmed by our experiments. Furthermore, because the
same device measures flow during both inspiration and expi-
ration, the same correction factor can be applied to inspired
and expired VT (Table 5).
The Servo 900C and Servo 300 are fitted with a flow deriva-
tion device, such as detailed in the previous paragraph, the
same discussion applying to VTe determination. The Evita 2,
Evita 4, and 7200 Series rely on a hot-wire technique flowme-
ter. Hence, for the reasons previously outlined, the magnitude
of expiratory flow and VTe will be considerably overestimated,
the difference being of such magnitude that the expiratory flow
monitoring malfunction alarm is activated, precluding any mon-
itoring of expiratory flow and VTe when FIO2 is , 0.8.
PEEP
The Veolar FT, Galileo, Evita 2, and Evita 4 are equipped with
diaphragm-type expiratory valves (16). An electromagnetic
(Veolar FT and Galileo) or pneumatic (Evita 2 and Evita 4)
motor applies a pressure on the diaphragm equal to the set
level of PEEP. During expiration, the diaphragm is either com-
pletely open (expiratory circuit pressure . PEEP) or closed
(expiratory circuit pressure , PEEP). Thus, there is virtually
no resistive component to this type of valve, and its perfor-
mance should be independent of gas density. Our results are
in accordance with this, showing no discrepancy between set
and measured PEEP.
The Servo 900C and Servo 300 use a scissors-type valve, of
the type used for inspiration. As seen previously, this valve is
based on variable compression of a segment of tubing. There
is thus a resistive component to maintaining a given PEEP.
Hence, reducing density should lead to an inability to keep the
desired PEEP level. However, as our results showed, this was
not the case. The reason for this lies in the feedback mecha-
nism incorporated into the expiratory valve, by which any
drop in pressure induces further compression of the tubing
segment to maintain the preset PEEP.
In conclusion, HeO2 interferes with several key ventilator
functions, especially in volume-controlled mode. The nature
and magnitude of these alterations vary between ventilators,
but all could lead to potentially hazardous management deci-
sions on the part of the ICU clinician, owing to the erroneous
View publication stats
VOL 160 1999
data provided by the machine. The ease with which these prob-
lems can be corrected varies from one ventilator to another,
and the 7200 Series cannot be used with heliox. Except for the
latter machine, most alterations stem from the known physical
properties of helium rather than from ventilator dysfunction, as
demonstrated by our study in which there was very good con-
cordance between theoretical predictions and measurements.
Consequently, correction factors and tables can be determined
(12), allowing for the safe use of HeO2 in the clinical setting.
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