Adjusting comfort settings on Newport HT70 Series Ventilators Narrated by Cyndy Miller, RRT

Comfort and Synchrony HT70 “Comfort” settings impact patient-ventilator synchrony. Synchrony impacts time to liberation for those patients who are weaning from the ventilator. Comfort impacts well being for those who are ventilator dependent. HT70-Adjusting Comfort Settings 0412

Dys-synchrony-Discomfort Patient looks uncomfortable or tells you they are uncomfortable. Patient doesn’t reliably trigger the ventilator when Trigger is set at a normal trigger setting. Unusually high or low respiratory rate. Double triggering. Tidal volume fluctuates a lot from breath to breath. HT70-Adjusting Comfort Settings 0412 3 3

Comfort Settings Condition Adjustment Volume Control breaths Flow & Flow Waveform Pressure Control breaths Slope Rise Pressure Support breaths Slope Rise, Expiratory Threshold, PS Max i Time HT70-Adjusting Comfort Settings 0412

Comfort Settings: Volume Control Flow and Flow Waveform Higher Flow Flow to Patient Lower Flow HT70-Adjusting Comfort Settings 0412

Volume Control Breaths Delivery End How does Volume Control work? Flow delivery is determined by user settings Flow Airway Pressure Pressure is generated by the ventilator to push the set Tidal Volume into the patient PEEP Breath ends when the Inspiratory Time elapses/Tidal Volume has been delivered. HT70-Adjusting Comfort Settings 0412

Volume Control Breaths – Comfort Settings You select the Peak Flow. You select the Flow Pattern. The Peak Flow and Flow Pattern don’t change even if the patient inhales at a higher or lower flow. HT70-Adjusting Comfort Settings 0412

Volume Control Breaths – (Peak) Flow (Peak) Flow is set on the Main Screen HT70-Adjusting Comfort Settings 0412

Volume Control Breaths – (Peak) Flow Patients who are spontaneously breathing will already be inhaling at a particular flowrate. If ventilator Flow is set too low, the patient will work harder to breathe. The (Peak) Flow you set must be at or above the patient’s spontaneous flowrate in order for the ventilator to take the workload away from the patient. Increase the (Peak) Flow setting until you see pressure rise smoothly when the patient inhales and you see the breath end in time to allow full exhalation (avoid auto-PEEP). HT70-Adjusting Comfort Settings 0412

Volume Control Breaths – (Peak) Flow Typical flowrates in Volume Control: Adults 40-60 L/min Pediatrics: 15-40 L/min HT70-Adjusting Comfort Settings 0412

Volume Control Breaths – (Peak) Flow Setting (Peak) Flow for patients who are not spontaneously breathing should be focused on achieving appropriate breath timing. Set Flow so that the patient has plenty of time to exhale in order to avoid auto-PEEP. HT70-Adjusting Comfort Settings 0412

Volume Control Breaths – (Peak) Flow Flow and Inspiratory Time are mathematically linked. Setting the Flow at a higher flowrate means making the breath shorter. And vise verse. If you increase the Flow to meet patient’s needs, it could make the Inspiratory Time too short. Flow Time HT70-Adjusting Comfort Settings 0412

Volume Control Breaths – (Peak) Flow Increasing the Flow setting (decreasing Inspiratory Time) to meet the flow demands of an actively breathing patient can cause double triggering and dys-synchrony if patient effort continues past when the breath ends. . V S L/min 1 2 3 4 5 6 The need for higher flow may be remedied by changing from a Square to Descending Ramp Flow Waveform first, then adjusting Flow. When you change to a Descending Ramp, the flowrate is automatically increased without shortening inspiratory time. HT70-Adjusting Comfort Settings 0412

Volume Control Breaths - Flow Waveform Flow Waveform is set on the More Screen (along with other “comfort settings”) HT70-Adjusting Comfort Settings 0412

Volume Control Breaths - Flow Waveform There are two selections: Square Descending Ramp HT70-Adjusting Comfort Settings 0412

Volume Control Breaths - Flow Waveform Challenge Situation: VT 350 mL Square Wave - Flow 30 L/min. Insp Time 0.7 s Patient is stressed and needs more flow. HT70-Adjusting Comfort Settings 0412

Volume Control Breaths - Flow Waveform Challenge Situation: VT 350 mL Square Wave - Flow increased to 50 L/min. Caused Insp Time to decrease to 0.4 s Inspiratory Time too short, double triggering occurs. Pt-ventilator dys-synchrony and fatigue follow. This did not solve the problem. HT70-Adjusting Comfort Settings 0412

Volume Control Breaths - Flow Waveform Challenge Situation: VT 350 mL Change to Descending Ramp Flow Wave – Set Flow to 50 L/min. Insp Time is now 0.6 s! Adequate for the patient. Patient is now comfortable. Flow needs are met without the breath being too short! HT70-Adjusting Comfort Settings 0412

Comfort Settings: Pressure Control Slope/Rise Faster (set closer to 1) Slope Rise Slower (set closer to 10) Slope Rise Target Pressure PEEP HT70-Adjusting Comfort Settings 0412

Pressure Control Breaths Delivery How does Pressure Control work? Flow delivery is a result of: Pressure change needed, Slope Rise setting, patient effort and patient pulmonary mechanics. Flow Airway Pressure Pressure delivery is determined by pressure change needed (difference between PC setting and PEEP). PEEP The actual target pressure is the PC setting above room pressure, (not above PEEP) HT70-Adjusting Comfort Settings 0412

Pressure Control Breaths End How does a Pressure Control breath end? Flow Breath ends when the Inspiratory Time elapses. Airway Pressure PEEP The user set Inspiratory Time determines the duration of the breath HT70-Adjusting Comfort Settings 0412

Pressure Control Breaths – Slope Rise The Slope Rise setting determines the rate of pressure rise to the Pressure Control level. Airway Pressure PC setting PEEP HT70-Adjusting Comfort Settings 0412

Pressure Control Breaths – Slope Rise Slope Rise is set on the More Screen (along with other “comfort settings”) HT70-Adjusting Comfort Settings 0412

Pressure Control Breaths – Slope Rise Range= 1-10 HT70 Plus = 1 fastest HT70 = 10 fastest HT70-Adjusting Comfort Settings 0412

Pressure Control Breaths – Slope Rise Work of Breathing A faster Slope-Rise with a squared pressure waveform delivers a higher peak-flow and higher machine assistance for the patient at the onset of the breath. A slower Slope-Rise with a slanted pressure waveform delivers a lower peak-flow and less machine assistance for the patient at the onset of the breath. Target Pressure Airway Pressure PEEP HT70-Adjusting Comfort Settings 0412

Pressure Control Breaths – Slope Rise Volume Delivery A faster Slope Rise can provide the opportunity for earlier volume delivery into the alveoli. Remember that alveolar pressure always lags behind airway pressure. When airway pressure rises slowly, alveolar pressure rises even more slowly. If it rises too slowly, alveolar pressure may not even reach the target peak pressure before the breath ends. Target Pressure PEEP If the user does not change Inspiratory Time, a faster Slope Rise setting may deliver a higher tidal volume. HT70-Adjusting Comfort Settings 0412

Pressure Control Breaths – Slope Rise How can you tell if Slope Rise is set too fast? “Ringing” in the flow waveform Sounds like “ch ch ch ch ch” Flow Slow it down a little HT70 = Set it at lower number HT70 Plus = Set it at higher number HT70-Adjusting Comfort Settings 0412

Comfort Settings: Pressure Support HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths Delivery How does Pressure Support work? Flow delivery is a result of the pressure change that must happen, the Slope Rise setting, the Expiratory Threshold setting, the PS Max i Time setting, patient effort and patient pulmonary mechanics. Flow Airway Pressure Pressure delivery is determined by pressure change needed (the actual PS setting). PEEP The Pressure Support setting IS the pressure change (above PEEP). HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths End How does a Pressure Support breath end? It ends by one of three mechanisms: Flow delivery drops to a user-set percent of the peak flow. Pressure rises 3 cmH2O/mbar above the target pressure. The breath duration reaches the user-set PS Max i Time setting. 100% of Peak Flow Flow Set from 5-85% of Peak Flow Target Pressure + 3 cmH2O Target Pressure PS setting + PEEP PAW PEEP PS Max i time = Maximum inspiratory time for pressure support breaths set from 0.1 to 3 seconds. HT70-Adjusting Comfort Settings 0412

Comfort Settings: Pressure Support Slope/Rise Faster (set closer to 1) Slope Rise Slower (set closer to 10) Slope Rise Target Pressure PEEP HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise Pressure Support breaths and Pressure Control breaths use the same Slope Rise setting and it works the same for both breath types. Airway Pressure Target Pressure PEEP HT70 = 10 fastest HT70 Plus = 1 fastest HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise So we don’t need to cover it again, right? HT70-Adjusting Comfort Settings 0412

Comfort Settings: Pressure Support Expiratory Threshold & PS Max i Time 5% = longest setting, 85% = shortest setting Flow Expiratory Threshold Set from 5-85% of Peak Flow PS Max I Time Set from 0.1-3 seconds HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths End User sets Expiratory Threshold and PS Max i Time 100% of Peak Flow Flow User does not set the pressure cycling off value. It is preset and not user adjustable. The pressure cycling off mechanism is intended to end the breath automatically if the patient exhales and pressure rises. Expiratory Threshold Set from 5-85% of Peak Flow Pressure rises 3 cmH2O above target pressure (not adjustable) PAW Target Pressure PEEP PS Max i time Set from 0.1 to 3 seconds. HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold Expiratory Threshold is set on the More Screen (along with other “comfort settings”) HT70-Adjusting Comfort Settings 0412 36 36

Pressure Support Breaths – Expiratory Threshold During a pressure support breath, flow starts out at a higher level and decelerates (declines) to a lower level. How many of you know why the flow rate decelerates? Flow Time HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold If flow keeps going at a preset rate, pressure keeps climbing. . V Paw cmH2O/ mbar In order to keep pressure at the airway from rising above the target pressure, flow delivery from the ventilator must decline in direct proportion to the rate that the lungs fill. HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold The maximum flow delivered during the breath is called the “Peak Flow” Peak Flow Expiratory Threshold = a % of Peak Flow Inspiration Exhalation Flow When flow drops from the peak flow to the % of peak flow set as the Expiratory Threshold, the breath cycles from inspiration to exhalation Time HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold Example If the Peak Flow is 100 L/min Peak Flow = 100 L/min Expiratory Threshold = 33% Flow = 33 L/min And Expiratory Threshold is set at 33% Inspiration Exhalation Flow The breath will change from the inspiratory phase to the expiratory phase when flow delivery to the patient drops from 100 L/min down to 33 L/min Time HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold Causes Pressure Support to cycle to exhalation when the patient stops inhaling Expiratory Threshold is an indirect setting for inspiratory time. The relationship between Expiratory Threshold and inspiratory time is a bit complex…………….. An ideal expiratory threshold setting = HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold Some people’s lungs fill/empty slowly Some people’s lungs fill/empty quickly Flow This is called a long time constant. This is called a short time constant Time Time Constant is the product of compliance and resistance. HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold To end up with a normal inspiratory time, the patient on the left (long time constant) needs a much higher Exp Threshold (% of peak flow) setting than the patient on the right (short time constant). Flow Insp Time = ~1 sec Time HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold If Expiratory Threshold Too Low Flow Target Pressure Airway Pressure PEEP Time (s) HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold The breath may cycle-off too late Flow Target Pressure Airway Pressure PEEP Time (s) HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold This can cause the patient to exhale against continuing support Flow Target Pressure Airway Pressure PEEP HT70-Adjusting Comfort Settings 0412

Late cycling off can cause an increase in work, fatigue and delayed liberation (delayed weaning) from mechanical ventilatory support. And also cause the ventilator to miss triggering a breath in response to the patient’s next breathing effort Flow Missed Triggers are one of the most common causes of weaning delay Target Pressure Airway Pressure PEEP HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Expiratory Threshold If Expiratory Threshold Too High Flow Early cycling off may occur and this commonly causes double triggering, followed by a “missed trigger”. Target Pressure Airway Pressure PEEP Time (s) Both early and late cycling off can cause missed triggers and discomfort/delayed liberation from mechanical ventilation. HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity Setting for Slope Rise and setting for Expiratory Threshold are interrelated Flow Time HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity If you have a patient who can benefit from extra assistance at the beginning of the breath, you need make the Slope Rise faster, right? Flow Time HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity Be careful. Making the Slope Rise faster will cause the Expiratory Threshold setting to be reached sooner, so the breath will get shorter if you don’t lower the Expiratory Threshold setting at the same time. Flow Time HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity Watch this example! Flow Target Pressure Airway Pressure PEEP Time (s) HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity Flow Target Pressure Airway Pressure PEEP Time (s) HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity Flow Target Pressure Airway Pressure PEEP Time (s) HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity Flow Target Pressure Airway Pressure PEEP Time (s) HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity Flow Target Pressure Airway Pressure PEEP Time (s) HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity Flow Target Pressure Airway Pressure PEEP Time (s) HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – Slope Rise & Expiratory Threshold Interactivity Flow If you make Slope Rise faster and that change results in double triggering, it means that you need to lower the Expiratory Threshold setting. Target Pressure Airway Pressure PEEP Time (s) HT70-Adjusting Comfort Settings 0412

Early cycling off Late cycling off Ch ch ch ch ch ch That’s the sound of double triggering!! Early cycling off Ch ch ch ch ch ch Late cycling off Tidal volume fluctuate a lot. Rate is lower. That’s missed triggering and auto-PEEP! HT70-Adjusting Comfort Settings 0412

Pressure Support Breaths – PS Max i Time What happens if there is a leak in the system? Flow may not decline during Pressure Support because the ventilator is trying to keep pressure in the “Big Lung” at the target pressure. PS Max i Time to the rescue! PS Max i Time set at 1.2 seconds Flow Target Pressure PAW PEEP Hint: Big Lung is the room! HT70-Adjusting Comfort Settings 0412 60 60

Pressure Support Breaths – PS Max i Time PS Max i Time is set on the More Screen (along with other “comfort settings”) HT70-Adjusting Comfort Settings 0412 61 61

Pressure Support Breaths – PS Max i Time This setting determines the maximum time allowable for a Pressure Support Breath. Even if flow never declines and the Expiratory Threshold is never met, the breath will stop when this time setting elapses. HT70-Adjusting Comfort Settings 0412 62 62

Pressure Support Breaths – PS Max i Time versus Expiratory Threshold So which has the ultimate control? PS Max i Time or PS Expiratory Threshold? PS Max I Time Expiratory Threshold HT70-Adjusting Comfort Settings 0412 63 63

Pressure Support Breaths – PS Max i Time versus Expiratory Threshold Whichever is achieved first! HT70-Adjusting Comfort Settings 0412 64 64

How to fix early cycling off Review Decrease the Expiratory Threshold Setting to lengthen the breath Lengthen the PS Max i Time Setting to stop from cutting the breath short For mandatory breaths, lengthen the inspiratory time HT70-Adjusting Comfort Settings 0412

How to fix late cycling off Review Increase the Expiratory Threshold Setting to shorten the breath Shorten the PS Max i Time Setting to cut the breath off in case of a leak For mandatory breaths, shorten the inspiratory time HT70-Adjusting Comfort Settings 0412

Quick Comfort Summary Adjust Flow and Flow Waveform to ensure optimal flow support (ventilator does the work) and the most compatible inspiratory time during Volume Control breaths. Adjust Slope Rise to ensure optimal flow support (ventilator does the work) at the onset of every Pressure Support and Pressure Control breath. Adjust Expiratory Threshold to create a compatible inspiratory time for all Pressure Support breaths. Adjust PS Max i Time to create a failsafe back up cycling off mechanism in case a leak in the circuit or around the patient’s mask or artificial airway causes flow to remain high during Pressure Support breaths. HT70-Adjusting Comfort Settings 0412

Getting Help is Easy Urgent! NON-Urgent Clinical questions - Clinical@Ventilators.com Technical questions - TechService@Ventilators.com Call +1.714.427.5811 Cyndy Miller ext. 218 NON-Urgent Call +1.714.427.5811 Clinical Assistance 24/7 Hotline: Ext. 123 Technical Service 24/7 Hotline: Ext. 500 Urgent! HT70-Adjusting Comfort Settings 0412

cmiller@newportmedical.com HT70-Adjusting Comfort Settings 0412

End of the Presentation HT70-Adjusting Comfort Settings 0412