NEW 3.0 SOFTWARE FOR SERVO-i AND SERVO-s Servo-i Ventilator

SERVO-i VERSION 5.0 WEB CONFERENCE Overview of Servo-i SERVO-i version 5.0 updates SERVO-i VERSION 5.0 WEB CONFERENCE Overview of Servo-i WELCOME TO THE WEB CONFERENCE SERVO-i version 5.0 updates 2

User Interface – display 12.1 inch, Touch screen 3~4 waveform display 2 Loops, Reference and Overlay function Direct access knob Screen save and capture function Trends Special function key Auto brigtness

User Interface – display 3~4 waveform display. Pressure(yellow), Flow(green), Volume(blue), (EtCO2,Edi/option) 2 Loops. Volume/Pressure, Flow/Volume Reference and Overlay function. Compare patient’s status before and after Intervention Trigger indicator Pressure Flow Loop Volume Decrease the compliance

Touch pad – Ventilation mode Ventilation mode window

Touch pad – Admit patient Input the patient data

Touch pad – Nebulizer Nebulizer Setting the nebulizer

Touch pad – Status Status Information of the system

Touch pad – Additional settings Adjust the parameters during monitor the patient condition

Touch pad – Additional values Additional settings Measured & calculated values

Fixed keys – Alarm silence and Alarm profile Alarm silence – 2min. Alarm sound Apnea time in only Support mode Autoset in only CMV mode Bell symbol when occur alrams Alarm setting

Fixed keys – Save Cursor function Recorded waveform for 20 sec compare the settings Recorded waveform for 20 sec Capture the display

Fixed keys – Trend Zoom in/out function Display measured values and waveforms at the same time Event log display in green bar Recorded patient’s data for 24 hours

Copy the patient’s data Copy patient’s data by using memory card Can edit and display the time-based values and waveforms in MS excel

Fixed keys – Quick access Stabilize O2 saturation Comfortable patient : stop alarm & insp.flow Suction support

Fixed keys – Quick access Reference loop Overlay fuction Loop

Fixed keys – Quick access Auto scales Adjust channel : 2~4 Scales and Waveform configuration

Fixed keys – Menu Alarm

Fixed keys – Menu Review

Fixed keys – Menu Compensate circuit compliance

Fixed keys – Menu Copy data, Copy screen

Fixed keys – Menu O2 cell adatation : 장기간 사용중 O2 sensor가 소모되어 O2 alarm이 발생하는 경우 “Pre use check” 과정 없이 임시적으로 Calibration을 실행.

Fixed keys – Menu Press Main screen for unlock

Function key & Direct access knobs Start Ventilation Direct access knobs Special function key : Start breath, O2 breaths, Exp.hold, Insp.hold

SERVO-i VERSION 5.0 WEB CONFERENCE Workflow of Servo-i SERVO-i version 5.0 updates SERVO-i VERSION 5.0 WEB CONFERENCE Workflow of Servo-i WELCOME TO THE WEB CONFERENCE SERVO-i version 5.0 updates 25

Pre-use check & Patient circuit test Yes No

Pre-use check & Patient circuit test Do you wish to compensate for Compressible volume ? Yes or NO

Compensate for Compressible Volume Compensation “ON” Compensation “OFF”

Compensate for Compressible Volume Compensation “ON” Compensation “OFF”

Ventilation Mode selection & setting Ventilator setting 순서 호흡 모드 선택 해당 호흡 모드의 파라메터 셋팅

Set alams Alarm silence – 2min. Alarm sound Apnea time in only Support mode Autoset in only CMV mode Bell symbol when occur alrams

Start ventilation “ Start Ventilation”

Nebulizer patient unit Servo ultra nebulizer T-piece Patient circuit 과 연결 Medication cup Nebulizer patient unit Ventilator 와 연결 그림

Servo ultra nebulizer

Servo ultra nebulizer - Cleaning

Servo ventilator Cleaning – Expratory cassette 넣을때 소리!!!

Servo ventilator Cleaning – Expratory cassette 기본적으로 preusecheck 권하나 응급실처럼 갑자기 환자가 들어오는경우에 대안 제시 기타 : EO gas 소독 (manual에는 없는 내용이나 다른 병원에서 가장 많이 사용중)

Management– Servo duoguard 1 .HEPA Filter – 환자의 호기 가스가 통과되며,바이러스 및 박테리아를 걸러냄 2. Electrostatic Filter -네불라이저 약물을 집진 하여 HEPA Filter에 약물이 흡착되지 않음 네불라이저 사용중에도 호기저항 증가 거의 없음 (Test 6차례) 물이차는 경우 털어줄것 권장 Must Be Use in Nebulizing 2 ~3 days Use 권장 (nebulizer 자주 사용시) Reduce cleaning time for Exp. cassette Reduce Patient’s Expiratory Resistance ( Auto PEEP, WOB )

Management– Servo duoguard ** 저가 필터를 장시간 사용하는 경우 장비의 고장을 유발할 수 있습니다 . ** 교차감염 방지 및 Exp. Cassette 고장을 방지하기 위하여 제조사에서 공급하는 ServoDuoGuard를 사용 할 것을 권장함.

Management– Preventive Maintenance

Management– Preventive Maintenance

SERVO-i VERSION 5.0 WEB CONFERENCE Ventilation Mode and Parameters SERVO-i version 5.0 updates SERVO-i VERSION 5.0 WEB CONFERENCE Ventilation Mode and Parameters WELCOME TO THE WEB CONFERENCE SERVO-i version 5.0 updates 42

Controlled Mandatory Ventilation (CMV / ACMV) Ventilator setting 순서 호흡 모드 선택 해당 호흡 모드의 파라메터 셋팅

Volume Controlled Ventilation (VCV)

Volume Controlled Ventilation (VCV) X Y Z I : E ratio & T pause X : Inspiration time EX) Resp. rate : 20 b/min, I:E ration가 1:2 Y : Pause time (% of respiratory cycle) T pause : 10 % 인 경우 Z : Expiration time I : E = 1 sec : 2 sec = (0.7 sec + 0.3 sec) : 2 sec I : E = (X+Y) : Z I E

Volume Controlled Ventilation (VCV) T insp. rise (Inspiratory rise time) Time to peak inspiratory flow or pressure at the start of each breath as a percentage of respiratory cycle time or in second Support mode에서 의미 있슴 Shorter Insp. Rise time → Reduce WOB insp

Volume Controlled Ventilation (VCV) T Insp. rise time The change of the rise time in Volume Control Increase the airway peak pressure and peak flow

Volume Controlled Ventilation (VCV) Flow Adaptation Flow Adaptation : It is possible for the patient, by their own inspiratory efforts, to receive a higher inspiratory flow and Tidal Volume during an inspiration than pre-set. Without Flow Adaptation : Normal volume controlled ventilation. ARDSnet lung protective protocol with 6 ml/kg tidal volume 전통적인 VC는 정해진 insp. Time & exp. Time에 맞춰 설정한 tidal volume을 constant flow로 환자에게 넣어준다.

Volume Controlled Ventilation (VCV) Flow Adaptation Air starvation Adequate flow Inadequate flow Inadequate flow * Extra flow in servo 전통적인 VC는 정해진 insp. Time & exp. Time에 맞춰 설정한 tidal volume을 constant flow로 환자에게 넣어준다. Extra effort 후 flow가 계산된 flow rate으로 떨어질경우 flow는 set tidal을 맞추기위해 flow를 유지한다.

Volume Controlled Ventilation (VCV) Flow pattern The end inspiratory flow as % of Vpeak Decelerating Flow - lower the peak airway pressure Poor lung compliance can cause excessive airway pressure leading to barotrauma, volutrauma, and adverse hemodynamic effects. If the patient continues to inspire vigorously, added, unnecessary work is done. This can lead to fatigue.

Volume Controlled Ventilation (VCV) Trigger sensitivity (Pressure & Flow) Pressure triggering 보통 -1 ~ -2 cmH2O 정도로 설정. 환자의 흡기 노력에 의해 미리 정한 압력 수준까지 음압이 발생하는 경우 이를 감지하여 흡기가 시작됨 Flow triggering 호기시 2 l/min (소아, 0.5 l/min)의 bais flow가 환자의 흡기 노력에 의해 그 유량이 감소 될 때 호흡기가 이를 감지하여 흡기가 시작됨

Volume Controlled Ventilation (VCV) Trigger sensitivity (Pressure & Flow)

Volume Controlled Ventilation (VCV) Trigger sensitivity * Indicator Missed Effort More Sensitivity Decreased WOBp little trigger effort less trigger effort

Pressure Controlled Ventilation (PCV) 그림 좌우 같은그림으로

Pressure Controlled Ventilation (PCV) 그림 좌우 같은 그림 PC above PEEP Ppeak = PEEP + PC above PEEP

Pressure Controlled Ventilation (PCV) Active expiratory valve inspiration 동안 환자의 호기 노력으로 압력이 3cmH2O 상승하면 호기 밸브를 열어 설정한 압력을 유지 시킴

Pressure Controlled Ventilation (PCV) Collapsed airways and alveoli will fill like avalanches during insufflation of air. The filling is pressure and time dependant. Due to the tissue pressure this is more obviously expressed in the dependant parts of the lung. When a collapsed airway or alveoli starts to open this will result in a small pressure drop. If the continued filling of the alveoli is not immediately sensed and gas replenished, the alveoli will collapse again or depend on redistribution of air from other parts of the lung. If the response is exaggerated it will hyperinflate the area giving rise to barotrauma. The tight and exact regulation of the Servo-i will immediately sense even minute deviations in pressure and respond immediately. Late Inspiratory flow : 흡기말 alveoli open시 떨어지는 압력을 셋팅한 level로 유지하여 alveoli recuritment 효과 Ultrsonic flow sensor refresh rate 2,000 times/sec

Pressure Controlled Ventilation (PCV) Late Inspiratory flow : 흡기말 alveoli open시 떨어지는 압력을 셋팅한 level로 유지하여 alveoli recuritment 효과 Ultrsonic flow sensor refresh rate 2,000 times/sec

Pressure Controlled Ventilation (PCV) T Insp. rise time The change of the rise time in Pressure Control Avoid overshoot Affect MAP and tidal volume

Pressure Regulated Volume Control (PRVC) Prvc는 volume control mode 처럼 환자에게 설정한 볼륨을 전달하되 낮은 압력으로 공급하기위해 pc 와같은 decelerating flow로 환직를제공하는 모드 Tidal volume setting → Volume guarantee (VCV) Auto adjust Pressure level → Decelerating flow (PCV)

Upper pressure limit in PRVC & VC mode Pressure Regulated Volume Control (PRVC) Upper pressure limit in PRVC & VC mode VC PC PRVC Target Tidal volume Insp. pressure Flow pattern Constant Decelerating Assist Ventilation Yes

Supported Ventilation / Spontaneous Ventilation Ventilator setting 순서 호흡 모드 선택 해당 호흡 모드의 파라메터 셋팅

Pressure Supported Ventilation (PSV) Inspiratory cycle off(Insp. cycle off) Adjust the inspiration time PS above PEEP Ppeak = PEEP + PS above PEEP T insp. rise (set by second) Reduce WOBinsp Increase patient comfort

Pressure Supported Ventilation (PSV) Decreased insp. cycle off Longer inspiration time Reduce respiratory rate Increase tidal volume 70% 1%

Pressure Supported Ventilation (PSV) Increased insp. cycle off Fighting between patient and ventilator due to long inspiration time Shorter inspiration time Fighting 1% 50% 서로 셋팅이다름 그림교체

Pressure Supported Ventilation (PSV) Increased insp. cycle off Too long inspiration time due to leakage Ti 40% 30% Ti 50%

Continuous Positive Airway Pressure (CPAP) PS above PEEP = set to 0

Backup/Apnea Ventilation ‘Patient’s trigger’

Synchronized Intermittent Mandatory Ventilation(SIMV) Ventilator setting 순서 호흡 모드 선택 해당 호흡 모드의 파라메터 셋팅

Synchronized Intermittent Mandatory Ventilation PSV CMV

Synchronized Intermittent Mandatory Ventilation(SIMV) Example: SIMV rate ~ 6 b/min Breath cycle time ~ 3 sec Mandatory breath time을 결정

SERVO-i VERSION 5.0 WEB CONFERENCE Thank you for listening !!! SERVO-i version 5.0 updates SERVO-i VERSION 5.0 WEB CONFERENCE Thank you for listening !!! WELCOME TO THE WEB CONFERENCE SERVO-i version 5.0 updates 72