NeoMode Challenges And Solutions

1. NeoMode Challenges And Solutions

2. Dual Screen Technology - - Bottom screen is for settings only

3. Dual Screen Technology - - Upper screen is for data only

4. PLOT SETUP UNFREEZE 40 PCIRCcmH2O 30 20 10 0 10 -20 0 2 4 6 8 10 12s INSP 80 60 40 . 20 V 0 L min 20 40 60 EXP -80 Color Keying For Easy Breath Recognition • The waveforms and breath timing bar are color coded • inspiration or controlled breath type bar is green • spontaneous waveforms and breath type bar is orange • exhalation is yellow

5. Software Controlled Screens • Only current modes and settings are displayed • Information appears as needed *

6. Accept Software Controlled Screens • Only current modes and settings are displayed • Information can appear as needed *

7. !!! ! ! ! Smart Alarms - • Smart in that they have different sounds depending on how serious the problem • Smart in that they indicate actual cause of problem

8. Base Message Details Possible Remedy Smart Alarms - • Smart in how they tell you what the potential solutions are • Smart in that they sometimes put you in a safer state of ventilation • expiratory occlusion, apnea, procedural error, safety valve open, etc

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

10. PCV Then and Now with the 840 ventilator • Inflation pressure adjustments with the 840 ventilator • Peak airway and End-Expiratory pressures have an additive effect. • Ex. To deliver 10/5, the therapist will set PEEPHi to 5 cmH20 and PEEPLow to 5 cmH20. PEEPHI 10 P PEEPLO 5 0 T 2 3 1

11. PCV Then and Now with the 840 ventilator • PEEP adjustments with the 840 ventilator • as you increase or decrease PEEP, peak airway pressure changes by an equal amount. • delta P remains unchanged and “theoretically” gas exchange does not change. Delta P 10/0 = 10 Delta P 15/5 = 10 15 PEEPHI 10 P 5 PEEPLO 0 T 2 3 1

12. PCV Then and Now with the 840 ventilator • PEEP adjustments with TCPCV results in non-changing delta P. • In prior generation infant ventilators, e.g. VIP, Infant Star, as you increased PEEP peak airway pressure did not change - but you decreased delta P. Delta P 10/0 = 10 Delta P 10/5 = 5 15 PEEPHI 10 5 P 0 PEEPLO T 2 3 1

13. PEEPHI P PEEPLO T Spontaneous Breaths Spontaneous Breaths BiLevel Synchronized Transitions • BiLevel was designed to allow spontaneous breathing at upper pressure level • PCV has a fixed I-time • if patients are starting an inspiration as I-time ends, discomfort and asynchrony are likely

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

15. PEEPHI P PEEPLO T 2 3 1 BiLevel Synchronized Transitions • Generally synchronized transitions are more effective when I-times are long enough to allow spontaneous breathing at the upper level

16. PCV With Controlled I-times • PCV delivers a non changing set I-time • active exhalation valve is still functional • loss of synchronized transitions, PS at upper level, and monitoring of spont volumes are likely to have little effect • PCV may be more efficient if I-times are short and are variable PEEPHI P PEEPLO T 2 3 1

17. Volume Ventilation With The 840 • All delivered and exhaled tidal volumes are compliance and BTPS compensated • As compliance changes ventilator output changes to assure constant volumes • What you see is always what you get

18. 840 Patient Safety Capabilities Are Especially Important In NICU • Occlusion algorithm • occlusion of the expiratory occlusion limb of the circuit activates - occlusion status cycling - ventilating in and out of the insp side of the circuit through the safety valve • Procedural error (initiates of the Pt is connected to the circuit before settings are made) • enters safety ventilation • Compliance compensated tidal volumes with actual patient high and low alarms

19. 840 Neonatal Breath Delivery In PCV • In PCV, as compliance improves, tidal volume also increases • Tidal or minute volume alarms can be set to alert the clinician of changing patient condition • impending over distention can be recognized early • What happens with leaks if PCV or volume ventilation is chosen? • disabling volume alarms while maintaining disconnect alarm works in PCV and VCV

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

21. Leaks In PCV With The 840 • As leak changes, pressure remains constant • Since compliance has not changed, tidal volume will remain more constant than with volume based ventilation • Compliance compensated exhaled tidal volume will more accurately reflect this changing condition • Most clinicians pressure ventilate in the smallest patients but desire volume monitoring

22. 840 Neonate (micro-preemie) Review • Improved volume delivery • Vt to 5 ml w/ total compensation • delivered Vt and exhalationspirometry accuracy • (disable all volume alarms) • neonatal circuits w/o prox sensor • low compliance exhalation bacteria filter • Improved synchrony – • Flow Sens increased to 0.1 lpm - 20 lpm • deals well with leaks • very fast response times • 2.0 ET-Tubes and up • Esens to 80% (leaks and synchrony) *

23. 840 Neonate (micro-preemie) Review • Less nuisance alarm issues • all volume alarms can be disabled while maintaining disconnect detection • IBW from 0.5kg to 150 kg • default settings appropriate to patient • alarms scaled to patient size • Set RR increased to 150 bpm *

24. C B D A PLOT SETUP UNFREEZE 40 PCIRCcmH2O 30 20 10 0 10 -20 0 2 4 6 8 10 12s INSP 80 60 40 . 20 V 0 L min 20 40 60 EXP -80 Without Adjustment of Pressure Rise • Many ventilators are sensitive to changes in impedance • increasing resistance causes pressure to rise more quickly • can result in discomfort, or premature termination of PS RES = 5 RES = 20 RES = 50 cmH20/L/SEC cmH20/L/SEC cmH20/L/SEC

25. C B D A . V L min Rise to Pressure Adjustment • Tailors inspiratory rise in pressure ventilation to match patient demand or reach MAP goals in PS or PCV • Should allow rise to be tailored from slow to fast PLOT SETUP UNFREEZE 40 PCIRCcmH2O 30 20 10 0 Slow rise Moderate rise Fast rise 10 -20 0 2 4 6 8 10 12s INSP 80 60 40 20 0 20 40 60 EXP -80

26. . V L min • Not all clinicians want to adjust rate of rise(time and/or interest) • Smarter rise algorithms should automatically adjust flow output as resistance or compliance varies • maintains similar shape of curve through any patient size or impedance change which reduces the need for intervention and reduces chance of pressure overshoot PLOT SETUP UNFREEZE 40 PCIRCcmH2O 30 20 10 0 RES = 5 RES = 20 RES = 50 cmH20/L/SEC cmH20/L/SEC cmH20/L/SEC 10 -20 0 2 4 6 8 10 12s INSP 80 60 40 20 0 20 40 60 EXP -80

27. . V L min PCV Pressure Overshoot C D B A • During inspiration, the valve is closed with the force of the insp pressure setting PCV W/O Active Valve PCV with Active Valve 40 PCIRCcmH2O 30 20 10 0 Spontaneous Efforts Spontaneous Efforts 10 -20 0 2 4 6 8 10 12s INSP 80 60 40 20 0 20 40 60 EXP -80

28. . V L min Active Exhalation Valves • During inspiration, the valve is closed with the force of the insp pressure setting • Allow coughing or spont breathing at upper pressure level by venting excess pressure and flow PCV W/O Active Valve PCV with Active Valve 40 PCIRCcmH2O 30 20 10 0 Spontaneous Efforts Spontaneous Efforts 10 -20 0 2 4 6 8 10 12s INSP 80 60 40 20 0 20 40 60 EXP -80

29. Tubing Compliance Compensation (Volume Ventilation) Tubing CompPIPSet VTDisplayed VTLung VT ml/cmH2O W/O tube comp 1 30 55 55 25 Patient compliance increases from 0.83 to 1.75 ml/cmH2O W/O tube comp 1 20 55 55 35 W/ tube comp 1 30 25 2525 Patient compliance increases from 0.83 to 1.75 ml/cmH20 W/ tube comp 1 20 25 2525

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

31. . V L min Expiratory Sensitivity D B A • Pressure support breaths terminate when patient flow decelerates to a percentage of peak flow • I-times too long or too short can also cause asynchronous breathing 40 PCIRCcmH2O 30 20 10 0 10 -20 0 2 4 6 8 10 12s INSP 80 60 40 20 0 20 40 60 EXP PS Termination Criteria (25%) -80

32. Expiratory Sensitivity Increased ESENS setting to 40% • ESENS allows adjustment of the termination criteria for pressure supported breaths • sets the percent of peak flow that cycles the pressure support breath into exhalation • Especially helpful to match the patient’s desired inspiratory time or to compensate for leaks • Can improve synchrony between patient and ventilator Flow

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

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

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

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

37. NeoMode settings – Initial Set -Up • “DSENS”: Set DSENS to 95% when using NeoMode (default is 75%); adjust up to 95%

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