1. Patient Synchrony in bellavista Auto-Rise Pressure Rise Auto-Synch Expiration Trigger 1

2. Synchrony = Free Breathing 2 Mistakes can be made in the settings which influence free breathing. Trigger Expiratory Trigger Rise Time Auto-RiseAuto-Synch

3. Adaptive Rise Time, Auto-Rise From first breath  to fully adapted  in a few breaths. The rise time is reduced; as a result peak flow is optimized. Auto rise makes the rise time as fast as possible to optimize peak flow and ventilator response while at the same time minimizing overshoot

4. Auto-Rise Auto-Synch™ Auto-Rise combined with the Auto-Synch exhalation trigger is designed to facilitate and optimize invasive and non-invasive ventilation performance. Benefits: Simplified ventilation setup Optimal rise time at all times No false overpressure alarms Additional safety for neonates

5. Interactivity and Synchrony Robert Brink imtmedical 2013 Optimal Slope rise & Expiratory Threshold Adjustment Pressure Support cycles to exhalation when patient stops inhaling. Ideal expiratory threshold setting =

6. The Challenges Expiratory Threshold Exp Trigger The expiratory threshold setting determines the flowrate at which a Pressure Support breath will cycle-off. Slope Rise Slope rise setting impacts cycling off. Adjustment of slope rise may require re-adjustment of expiratory threshold. Interactivity and Synchrony

7. Time Flow Expiratory Threshold Expiratory Trigger Adjustment It is typically expressed as a percent of peak flow

8. Interactivity and Synchrony 30% of Peak Flow Time Flow Peak Flow Expiratory Threshold Adjustment And is based on the decay in flow during inspiration.

9. Interactivity and Synchrony Time Flow Pulmonary Time Constant Expiratory Threshold Adjustment The flow decay is the result of the patient’s pulmonary time constant.

10. Slope Rise Adjustment and Expiratory Threshold Adjustment Interactivity work together to bring synchrony back to Pressure Support and VTPS

11. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Electromyography Diaphragm Abdomen If Expiratory Threshold Too Low Optimal Expiratory Threshold Adjustment Challenge

12. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Electromyography Diaphragm Abdomen The breath may cycle-off too late Optimal Expiratory Threshold Adjustment Challenge

13. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Electromyography Diaphragm Abdomen This can cause the patient to exhale against continuing support Optimal Expiratory Threshold Adjustment Challenge

14. Interactivity and Synchrony And also cause the ventilator to miss triggering a breath the next time the patient attempts to breathe Airway Pressure Time (s) Target Pressure PEEP Flow Electromyography Diaphragm Abdomen Missed Trigger Optimal Expiratory Threshold Adjustment Challenge

15. Interactivity and Synchrony Time Flow Long Time Constant Optimal Expiratory Threshold Adjustment Challenge Obstructed patients’ long time constants cause delivered flow to decay more slowly. Obstructed patient

16. Interactivity and Synchrony Time Flow Peak Flow patient insp. effort ends (patient is ready to exhale) 50% Peak Flow Optimal Expiratory Threshold Adjustment Challenge Patient inspiratory efforts may end when inspiratory flow has decayed to about 50% of their peak-flow. At that point, the patient is ready to exhale but the ventilator prolongs the breath Obstructed patient

17. Interactivity and Synchrony Time Flow Peak Flow Obstructed patient Late cycling off Optimal Expiratory Threshold Adjustment Challenge It is common for the breath to cycle off too late on obstructed patients if the Expiratory Threshold setting is lower than 50%.

18. Interactivity and Synchrony Slope Rise and Expiratory Threshold Interactivity Challenge Late cycling off can also happen if slope rise is adjusted to a slower value after expiratory threshold has been set to an appropriate level.

19. Interactivity and Synchrony Time Flow 28% of Peak Flow Slope Rise and Expiratory Threshold Interactivity Challenge

20. Interactivity and Synchrony Time Flow 28% of Peak Flow Slope Rise and Expiratory Threshold Interactivity Challenge The slower slope rise will result in a lower flow at the onset of the breath.

21. Interactivity and Synchrony Time Flow 28% of Peak Flow Fast Slope Slow Slope Slope Rise and Expiratory Threshold Interactivity And that will prolong the time it takes for flow to drop to the % of flow required to cycle the breath off. (Since this is now a lower flow.)

22. Interactivity and Synchrony Time Flow 28% of Peak Flow Fast Slope Slow Slope Slope Rise and Expiratory Threshold Interactivity The longer the time constant, the more breath cycling off will be prolonged when Slope Rise is adjusted to a slower value.

23. Interactivity and Synchrony Problems related to late cycling-off (late termination) Late cycle-off Inadequate lung emptying time Auto-PEEP Missed Triggers Delayed cycling-off Airway Pressure Time (s) Flow Electro- myography Diaphragm Abdomen Missed Trigger Slope Rise and Expiratory Threshold Interactivity

24. Interactivity and Synchrony Slope Rise and Expiratory Threshold Interactivity Example: Exp Threshold = 30% Slope Rise setting results in a Peak flow = 100 L/min Cycling off flow = 30 L/min (30% of 100) Breath cycles off when inspiratory flow drops to 30 L/min Slope Rise Setting is lowered and it now results in a Peak flow = 50 L/min Cycling off flow = 15 L/min (30% of 50) Breath will not cycle off until flow drops to 15 L/min

25. Interactivity and Synchrony Slope Rise and Expiratory Threshold Interactivity Challenge Time Flow Short Time Constant Restrictive disorder Early cycling off may happen to patients with restrictive disorders, because they have short time constants and therefore their inspiratory flow decays more rapidly during pressure targeted breaths.

26. Interactivity and Synchrony Slope Rise and Expiratory Threshold Interactivity Challenge Flow drops to the cycling off threshold more quickly

27. Interactivity and Synchrony Slope Rise and Expiratory Threshold Interactivity Challenge Early cycling off can also happen with other patients if slope rise is adjusted to a faster value after the expiratory threshold has been set to an appropriate level.

28. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Slope Rise and Expiratory Threshold Interactivity Diaphragm Electromyography

29. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Diaphragm Electromyography Slope Rise and Expiratory Threshold Interactivity

30. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Diaphragm Electromyography Slope Rise and Expiratory Threshold Interactivity

31. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Diaphragm Electromyography Slope Rise and Expiratory Threshold Interactivity

32. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Diaphragm Electromyography Slope Rise and Expiratory Threshold Interactivity

33. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Diaphragm Electromyography Slope Rise and Expiratory Threshold Interactivity

34. Interactivity and Synchrony Airway Pressure Time (s) Target Pressure PEEP Flow Diaphragm Electromyography Slope Rise and Expiratory Threshold Interactivity Early cycling off commonly causes double triggering

35. Interactivity and Synchrony Then Missed Triggers Airway Pressure Time (s) Target Pressure PEEP Flow Electromyography Diaphragm Abdomen

36. Interactivity and Synchrony Effects of a rapid Slope/Rise on Triggering (if Exp Threshold too high) In Pressure Support, a rapid slope rise can cause early cycling off and double triggering if the Expiratory Threshold setting is set too high Flow high Reach Exp Threshold Too Early Early Cycle off Patient continues inhaling Double Trigger Decreased trigger reliability from auto PEEP Airway Pressure Flow Slope Rise and Expiratory Threshold Interactivity

37. Interactivity and Synchrony Slope Rise and Expiratory Threshold Interactivity Confusion Clinicians may avoid using higher pressure support levels or faster slope rise settings because they associate them with negative patient responses. In reality, higher pressure support levels and faster slope rise settings may be used successfully without missed triggers and dis-synchrony if the expiratory threshold is adjusted to a suitable level.

38. Interactivity and Synchrony Bibliography of Published Literature Relevant to Slope Rise Selection Chatmongkolchart S, Williams P, Hess D, Kacmarek RM, Evaluation of Inspiratory Rise Time and Inspiration Termination Criteria in New -Generation Mechanical Ventilators: A Lung Model Study. Respir Care. 2001 Jul;46(7):666-77. Chatburn, RL Primiano F, A New System for Understanding, Modes of Mechanical Ventilation, Respiratory Care. Respir Care. 2001 Jun;46(6):604-21 Kallet RH, Campbell AR, Alonso JA, Morabito DJ, Mackersie RC.. The effects of pressure control versus volume control assisted ventilation on patient work of breathing in acute lung injury and acute respiratory distress syndrome. Respir Care. 2000 Sep;45(9):1085-96. Kallet RHCampbell ARAlonso JAMorabito DJMackersie RC Bonmarchand G, Chevron V, Ménard JF, Girault C, Moritz-Berthelot F, Pasquis P, Leroy J. Effects of pressure ramp slope values on the work of breathing during pressure support ventilation in restrictive patients. Crit Care Med. 1999 Apr;27(4):715-22. Bonmarchand GChevron VMénard JFGirault CMoritz-Berthelot FPasquis PLeroy J Bunburaphong T, Imanaka H, Nishimura M, Hess D, Kacmarek RM. Performance characteristics of bilevel pressure ventilators: a lung model study. Chest. 1997 Apr;111(4):1050-60. Bunburaphong TImanaka HNishimura MHess DKacmarek RM Croci M, Pelosi P, Chiumello D, Gattinoni L. Regulation of Pressurization Rate Reduces Inspiratory Effort during Pressure Support Ventilation: A Bench Study. Respir Care 1996 Oct;41(10): 880-884.

39. Intelligent bellavista Control to the Rescue! Interactivity and Synchrony Auto-Rise Auto-Synch™