I. The outline
A. Outline of resuscitator
1. Concept
2. The purpose
3. The component
4. The feature
B. Classification of artificial respiration
1. Classification which depends as driving-unit
2. Classification by way of putting an active-ventilation
3. Classification by control form of ventilation in respiratory tract
C. Composition of trigger mechanism
1. The concept and the purpose
2. The component
3. The control system (The controlling mechanism and the operation theory)
4. The decorative element
A. The outline of the resuscitator
1. The concept
The equipment which does a ventilation substitution or ventilation help transitively is called resuscitator (Ventilator) in the lung of the patient who fell into the ventilatory-impairment with some cause. There are a thorax cunnus pressure type, a positive pressure type in the respiratory tract, a high-frequency-ventilation and so on. This book is current and handles only the artificial-ventilation equipment of the highest positive pressure type of the utility in the respiratory tract.
In the positive pressure type artificial respiration in the respiratory tract, the intake is actively done by the positive pressure, but expiration is passively emitted by the elasticity of the respiratory organs of the patient and doesn't help this actively. The mechanism which makes an expiratory-phase a negative pressure in the past, too, existed but at present, the PEEP mechanism which stops the emission of expiration gas is laid down. It is called CPPV(Contineous Positive Pressure Ventilation) when adding PEEP to IPPV(Intermittent Positive Pressure Ventilation). In the premature baby business, an expiration suction mechanism is sometimes laid down in the meaning which does breathing circuit resistance in the compensation but the airway pressure doesn't become a negative pressure in the expiratory-phase. Therefore, all general resuscitators which are marketed at present are a positive pressure type in the respiratory tract.
2. The purpose
At first, the artificial respiration could be begun in the purpose to improve a ventilatory-impairment but at present, it aims to improve gas exchange ability, too. In the future, the maintenance of the gas exchange ability which included an iron lung will become a final purpose.
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The reference ) ventilator? respirator?
In English, a resuscitator isn't called a respirator and at present, it uses a term, the ventilator. It is artificial-ventilation equipment if translating but in Japanese, it is as the resuscitator. It is a private view but that the resuscitator aims may be to be good in the respirator because aims is breathing of the wide sense.
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3. The component
A positive pressure Norito carpenter ventilator (making a resuscitator since then) is composed from the 1) intake gas plant, the 2) expiration control system, the 3) controlling mechanism, the 4) monitor (the alarm).
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1) The intake gas plant
(1) The bellows drive
It drives a bellows at the electric motor and in the compressed air and it gets intake gas. This law was used in the 1960s as the mechanism (Volume Generator) which gets the ventilation of the ]—Ê type. Today however, it is used for the machine for the anesthesia and the home medical treatment. However, it is difficult to follow a tachypn ea of "NADOKARA" with the physical inertia which is in the thing, the bellows drive-mechanism with the necessary journey to inhale in the bellows before doing a bellows at the novice. Also, the taking air quantity of ventilation above the bellows capacity can not be generated.
(2) The continuing intermittently valve
It wins intake gas in continuing intermittently in the high-pressure gas source. At the bellows drive-mechanism, because it is much less, comparing to that, the inertial mass of the continuing intermittently valve drive-mechanism can be a fast-operate. Also, there is not limitation on the air quantity of ventilation with once which was seen by the bellows drive system. The ]—Ê type, too, can support ]ˆ³ type, too. It often makes use with the new Mattick circuit which uses compressed gases for the controlling mechanism. It sometimes drives by Solenoid-controlled valve, too.
(3) The flow-control valve
Using the valve (the flow-control valve) which can adjust the opening degree of the intake valve according to the electronic signal, it controls the flow of the compressed gases and it gets intake gas. Most breathing mode can be supported. At the resuscitator in today, it is an indispensable mechanism.
(4) The others
It gets the ventilation of the ]ˆ³ type using the demand valve and Bennett valve (Benette PR-1,PR-2) (Pressure Generator). It is adopted as Pressure Support Ventilation(PSV) and the special mechanism which gets the ventilation of the PSV similarity. The ventilation law of the low invasiveness which helps breathing by the pressure ventilation under the mask which is recently represented by BiPAP is watched but this place is using a blower and a turbine as pressure generator (Pressure Generator). In T-Bird (the Bird Inc.), the technique to create quantity ventilation and a pressure ventilation mode, controlling the number of rotations of the turbine minutely straight, too, is practicalized.
2) The expiration control system
The continuing intermittently of the (1) expiration and (2)PEEP feature are demanded from the expiration control.
(1) The continuing intermittently of the expiration
The drive of the expiration continuing intermittently valve often uses a new Mattick circuit. Solenoid-controlled valve's drive, too, is used.
(2) The PEEP feature
Generally, PEEP valve is composed of the one to have used spring pressure and a magnet, air pressure, water pressure. Specifically, because the balloon valve which used air pressure had expiration continuing intermittently and PEEP feature, while long, it was used for an exhalation-valve. However, the mechanism which measures the maintenance of the PEEP pressure recently by the electric processing using the flow-control valve was developed. It is to avoid the change of the PEEP pressure by the change of the expiration gas flow rate. Also, this made BIPAP and time cycle, pressure relief ventilation mode for the premature baby possible.
3) The controlling mechanism
(1) The mechanical type
It applies mechanical mechanisms such as the cogwheel and the cam, the spring. At present, it is used by of the transfer —p and of the first aid —p, of the home therapy —p, of the anesthesia apparatus —p, the simple equipment of equal "NO". The simpler mechanism it is, highly reliable it is more.
(2) The new Mattick type
It composes a controlling mechanism with the circuit which used the flow of air. A frequently-used was done from the old days because it doesn't consume electricity, being small and being light-weight and it is possible to make the early mechanism of the response. However, with superior performance of breathing mode, structure was complicated. Therefore, the reliability declined and also the gas consumption, too, increased. At present, it is only used for the simple machine.
(3) The electronically controlled type
It composes using the tube and Semiconductor element. In the analog control times, the new Mattick type could not be surpassed but it got to do the can which is controlled, being advanced the digital circuit technology develops with where. A ligical decision is fixed by the wiring structure among the devices (The hardware processing). Servo-900 of the Siemens-Elema Inc. is a pioneer machine.
(4) The microprocessor type
Using the microprocessor, it processes by the software. Complicated judgement however, because it is possible to do easily in the description of the software, at present, it is used for most equipment. However, the problem of the crash of the microprocessor isn't fully solved.
4) The monitor, the alarm
It watches over the following three and it warns of them at the extraordinary time.
(1) The operation status of the resuscitator
The power, the oxygen plumbing pressure, the air pressure, the operation of the microprocessor, the oxygen concentration, the air charge temperature, the PEEP pressure upper limit, the PEEP draft limen, equal "GA" are watched over. There is much equipment which does these recently in the self-check to the environment operating.
(2) Breathing status of the patient condition
It watches over the intake gas flow rate, the intake capacity, the expiration gas flow rate, the volume-of-expired-gas, the expired volume per minute, the lung-compliance, equal "WO". The function to display these recently in graphical, too, is prepared.
(3) BASIC item
(1) (2) The monitoring system which is is more advanced as equipment is complicated but however, at present, as the handy and important item, 3 items of low peak airway pressure (low peak pressure alarm), high peak airway pressure (high peak pressure alarm), the air changes per hour are indispensable whatever equipment they are. The low peak airway pressure shows that the ventilation of the positive pressure type isn't successfully done and warns of the abnormal and improper setting of a breathing circuit leak and equipment. The high peak airway pressure warns of the abnormal and improper setting of breathing circuit, Fighting, the equipment abnormality. The air changes per hour shows whether the patient condition and the equipment operation are proper. Incidentally, the monitoring facilities of the expiration expired volume per minute tended to be omitted by the agreement on the price and the mechanism in the past. However, that the purpose of the artificial respiration was the sustenance of the ventilation was recognized and the monitoring facilities of the expiration expired volume per minute became indispensable approximately.
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4. The feature (Table 1)
Various breathing modes are practicalized by the resuscitator but the essential work which the resuscitator executes is summarized by the following 4 items. (It becomes 6 items when including the contingent work of the alarm and the monitor and so on.)
(1) The intake recognition
It recognizes, and it makes the beginning of the intake of the patient synchronize with this and it begins a mechanical ventilation. (This is called a trigger mechanism.) For its purpose, it measures an intake gas flow rate, an intake capacity, the change of the airway pressure, expiration time. It makes intake if these meet a constant condition.
(2) The intake gas control
It supplies intake gas from intake gas generator \. Meanwhile, it closes an exhalation-valve at the appropriate pressure. It adjusts the intake gas flow rate which the machine provides based on the degree (the airway pressure, the intake gas flow rate, the intake capacity) that the patient does intake. Also, it is used as the expiration gas flow rate and the volume-of-expired-gas, the "MO" control-information with preceding breathing.
(3) The expiration recognition
It recognizes that the expiration of the patient begins if measuring the change of the airway pressure and an intake gas flow rate, an intake capacity, intake time and these meet a constant condition, it ends mechanical intake and it begins expiration. However, it is difficult to recognize that the patient begins expiration without the delay in the positive pressure type artificial-ventilation. Therefore, it substitutes this in the end-of-suction end recognition, or it gives up expiration beginning recognition from "HANA" and the technique to end intake simply at the time is used. Incidentally, when adding an intake pose, the time of the condition which closed both of the intake valve and the exhalation-valve after the end-of-suction end is kept. Now, the lung of the patient is as intake and is maintained.
(4) The expiration gas control
The function to adjust the open condition of the exhalation-valve in the bias style or the continuous flow quantity by squeezing an intake gas flow rate to maintain proper PEEP which opens the exhalation-valve which applies into breathing circuit is included in this. When PEEP can not be maintained, it increases a bias style or a continuous flow from intake gas generator \.
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B. The classification of the artificial respiration mode
When classifying the various artificial respiration mode which is clinically applied at present, it boils three which are (1)Conteneous Mandatory Ventilation, (2)Intemittent Mandatory Ventilation(3) spontaneous-respiration mode (CPAP and BIPAP, APRV, equal) and it is possible to divide. Also, the difference of the operation form with 4 steps which are intake beginning recognition, an intake gas control, expiration beginning recognition, an expiration gas control more can divide these. On the other hand, in the new ventilation mode, it measures the air quantity of ventilation of the patient realtime and there is one which uses this for the timing-control of the active-ventilation and the index of the intake control. Of this viewpoint however, it is possible to classify. Incidentally, because the trigger mechanism which is intake beginning recognition is the problem to be common in each mode, it handles a trigger mechanism here specially independent. It handles the other 3 steps by "the specialized study, the artificial respiration mode" of the next chapter.
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1. The classification which depends as the driving-unit
The artificial respiration is the part of breathing work which the living body should do personally originally or the act of doing all transitively. There are following 2 ways with the driving-unit.
1) The type out of the body
Because the securing of the respiratory tract is unnecessary to the type out of the body drives a chest district and a diaphragm indirectly and to be ventilated by it, it is very useful for the emergency resuscitation. However, the certainty of the ventilation and it is a disadvantageous thing, an air quantity of ventilation and the point not to put on an airway pressure by the direct-control, the one of the response in the aspect of the efficiency. Comparatively, make a resuscitator "TENO" that the point, the equipment itself for which it is difficult to make a good system about whom become large-scale It is thought of as being unsuitable for the treatment in the point which clinical adaptation is limited to, being scarce about the accommodativeness, the point which is the ventilation law by which the usability of PEEP/CPAP is established but it can not apply these, "NADOKARA", at present. In the country, OKT-100 (the Kimura medical department instrument) which was developed based on the research expenses of the Ministry of Health and Welfare is marketed.
2) The respiratory tract ventilation type
It is construction being possible in the system with the quick and good response because there is a certainty of the ventilation in the way of ventilating the inside of the respiratory tract straight and the energy efficiencies is good. Also, there is an advantage to put these on by the direct-control because the air quantity of ventilation and the airway pressure can be directly monitored. Therefore, at present, the respiratory tract ventilation type is the mainstream of the artificial breathing and is average. However, in the securing of the respiratory tract, in the causa sine qua non, this becomes an agreed factor, being adaptable (The solution to this is the ventilation law of the low invasiveness which is represented by BiPAP). Two respiratory tract ventilation types of the high-frequency-ventilation law (above 60BPM) and the ventilation law to do, being a physiological air changes per hour resembles and being roughly divided into them At present, generally, the difference with pressure about the inspiratory-phase and the expiratory-phase, too, weights and it classifies into the following 4 methods.
Of ( reference ; however, become with now when only the positive pressure type ventilation law exists ) of to exclude a positive negative pressure type and to boil two of the (i) positive pressure type ventilation positive pressure ventilation method which gathered the concept of CPPV and IPPV and the special (ii) high-frequency-ventilation HFV method and to classify are clinical more.
(1) The positive negative pressure type (positive-negative pressure ventilation)
In case of intake, it applies positive pressure to the respiratory tract and it helps intake, and in case of the expiration, it adds a negative pressure and it helps expiration. It is active inhalation active exhalation method. There was a model that an expiration gas suction mechanism is provided for the resuscitator until the 1960s, too, but as the usability of following PEEP/CPAP was established, the positive negative pressure type resuscitator disappeared from the market from 1960 marriageabilities. At present, the term of the positive negative pressure type is a dead language. Incidentally, at the resuscitator for the newborn baby, in the expiration gas suction mechanism, it is organized but this is to offset patient circuit resistance and is not to make the respiratory tract a negative pressure.
(2) The intermittent positive pressure ventilation (IPPV, Intermittent Positive Pressure Ventilation)
It applies positive pressure in case of intake, but in case of the expiration, it releases pressure only and it emits expiration passively by the elasticity of the chest district and the lung. It is active inhalation, passive exhalation method. This is called intermittent positive pressure ventilation (IPPV) because it applies positive pressure intermittently. In other words, the term to the positive negative pressure type is IPPV. However, when this was proposed by the historic term about IPPV, there was a concept, ]ˆ³ type ventilation (volume limited), ]—Ê type ventilation (pressure limited), only and (and then PSV, too,) doesn't exist about IMV(intemittent mandatory ventilation) and PCV. Originally, IPPV is the term which is situated on the counter-electrode of the positive negative pressure type ventilation law. When doing this in the redeclaration from the modernistic meaning of a word, it is possible to be classified by IPPV when it is the general term of the positive pressure type ventilation law and it includes IMV, and CMV(continuous mandatory ventilation), CMV(Controlled Mechanical Ventilation), PCV, PSV, equal "WO" in IPPV. In other words, IPPV and CPPV are the ventilation concept to accomplish the root of the present ventilation law and these are the term which ended a historic mission together. However, because the Drager Inc. is still(, firmly maintaining historic interpretation) using IPPV at present, too, in both of CMV(continuous mandatory ventilation) and CMV(Controlled Mechanical Ventilation) concepts, it becomes the cause to make general user [ cause the confusion of the term.
It means the physical therapy of the lung which does the extension of the lung and a nebulizer therapy using the resuscitator of the ]ˆ³ type by the term that ( Note ; IPPB, Intemittent Positive Pressure Breathing, too, are historic. It is IPPV that, generally, it does continuously under the artificial respiratory tract, there is not a cannulation, and it adds a mouthpiece and it is IPPB that it does temporarily. )
(3) The continuous-positive-pressure-ventilation law (CPPV; continuous positive pressure ventilation)
PEEP(positive end-expiratory pressure) is the technique to be used for the respiratory failure treatment of the serious illness, improving the oxygenation ability of the lung, preventing the falling into a state of lethargy of the alveolus with the expiration end in applying constant pressure in case of the expiration. Ashbaugh called the ventilation law which added PEEP to IPPV CPPV(continuous positive pressure ventilation) in 1969 and it is the etymology of CPPV that released this usability. IPPV is an antithesis to the positive negative pressure type ventilation law but CPPV is more more than IPPV the ventilation law which stepped by one step and evaluated an advantage of positive pressure (PEEP) at the time of the expiration. That is, CPPV is the special type of IPPV but all present artificial respiration modes are in the category of the concept (that is, are the general term of the ventilation law which added PEEP) of CPPV. Way, the ventilation law which applies constant pressure to the spontaneous-respiration is called CPAP(continuous positive airway pressure) and the principle is the same as PEEP approximately. PEEP/CPAP is the feature which is indispensable to the present resuscitator, being evaluated high. Therefore, all resuscitators which are marketed at present are CPPV/IPPV machine. As for the past when the positive negative pressure type existed, at present, the meaning which distinguishes between the difference of CPPV and IPPV is anyway anyway the term that CPPV, too, ended a historic mission, not being.
(4) The high-frequency-ventilation (HFV; high frequency ventilation)
It is possible to classify into HFJV(high frequency jet ventilation) and HFO(high frequency oscillation) by the difference of the drive system. The former is the one of the neighborhood in Venturi effect, making a jet style in the compressed gases, continuing intermittently to the high frequency. In the method to amplify amplitude of vibration while dragging air, the latter is speaker drive, piston drive by the electromagnetic motor (linear or rotary), high frequency opening and shutting by the intake valve, high frequency opening and shutting by the exhalation-valve, the method which adds vibration to the patient circuit from "NADONI". Depending on the school, HFO and HFV aren't sometimes distinguished between, being clear, too. It is said to that it is equal to HFJV in HFO+PEEP. It becomes for HFV to have been able to be ventilated by the low airway pressure compared with usual ventilation but the certainty of the ventilation is bad. Therefore, it is realistic the conventional ventilation mode and to use HFV. However, HFV is a nonphysiologic ventilation law and at the developed adult of the respiratory center, it is strong in the sense of incongruity of the patient. Moreover, in the present situation to keep a spontaneous-respiration and for the advantage of the ventilation law by the improvement of the synchronism with the resuscitator to be evaluative high, application as the adult is limited. Because there is a laundering effect of the respiratory tract in ( Note ; HFJV ) of using for the management in the art such as the tracheoplasty because there is an advantage which can sustain ventilation by using for a nebulizer and breathing circuit's being open, too. On the other hand, the newborn baby is the one of the ‡B positive pressure ventilation where the ‡@ respiratory center can ignore the problem of the immature ‡A trigger. There is an equal "NO" characteristic which it is easy to make side with the mechanical ventilation often in ‡D HFV that the ventilation energy of ‡C HFV which it is easy for the evil to occur to it becomes practical use even if it is weak and HFV feature is often added to the resuscitator for the newborn baby in it because there is a depressant-action of the spontaneous-respiration. Logically, it is right in adding HFV to CPAP of the continuous flow method, but as for adding, the detection of the trigger becomes difficult very much when weighting an expiratory-phase and also in case of IMV(SIMV), in HFV, the consideration becomes necessary to the air trapping and so on, too. It is desirable to weight an expiratory-phase, too, if attending from the efficiency of the oxygenation but in the present situation, these contradiction is unsolved. Therefore, HFV in the form of the all kinds is proposed as the business of the resuscitator for the newborn baby.
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2. The classification by the way of putting an active-ventilation
When adaptable to the patient who has a spontaneous-respiration, the spontaneous-respiration and the mechanical ventilation don't suit successfully and the problem of Fighting of the clash of both causes the active-ventilation which was originally developed for the anesthesia. It is to solve it that the trigger mechanism to make the beginning and the active-ventilation of the intake effort of the patient synchronize with was practicalized. However, the beginning of the intake of the patient and the beginning of the mechanical active-ventilation synchronized but the fundamental contradiction exists in providing a mechanical controlled-respiration with approving the spontaneous-respiration of the patient freely. An epoch-making technique, IMV which the patient alternately provides the spontaneous-respiration aspect which can be freely breathed and the active-ventilation aspect which gives a mechanical active-ventilation for, dividing time to solve this, was developed. SIMV to make the beginning of the active-ventilation and the spontaneous-respiration synchronize with to reduce Fighting with the active-ventilation aspect more was developed.
(1) The continuous active-ventilation CMV(continuous mandatory ventilation)
All ventilation means the ventilation method which is done by the active-ventilation. It is the term which becomes a pair of IMV. Because IMV didn't become popular to 1970 marriageabilities, all artificial respirations were CMV (IPPV however, in other words, it was). It became the abbreviation that mechanical active-ventilation (CMV; controlled mechanical ventilation), too, is the same but in the past, these two CMV didn't have hinderance even if they meant the concept to be the same approximately and confused both. Because the various active-ventilation mode exists at present, these must be distinguished between, being clear. Regrettably, there are many books as it confused.
(2) The intermittent active-ventilation IMV(intermittent mandatory ventilation)
It is the ventilation law to divide by the temporal axes with and to make a spontaneous-respiration and a mechanical active-ventilation coexist with it. As for being general, the active-ventilation is SIMV(synchronized intemittent mandatory ventilation) which synchronizes with the beginning of the spontaneous-respiration. It is the mainstream that helps a spontaneous-respiration recently in PSV(pressure support ventilation). Tentatively, it is classified into the spontaneous-respiration mode but for example, PSV is entrusted with the character of the active-ventilation when setting PSV level high. In other words, all artificial respiration modes help a spontaneous-respiration and during the active-ventilation and voluntary ventilation, the clear distinction is impossible.
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Note ; CMV warns that it does the abbreviation of controlled mechanical ventilation by the abbreviation of continuous mandatory ventilation so as not to confuse.
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Reference ; The change and the history that artificial breathing by the ventilation law in the respiratory tract is established
1. The appearance of the automatic ventilator for the general anesthesia
The object of the surgery expanded into the thoracic cavity and the technology which performs an open-heart-surgery safely was variously made 1890-1900 marriageabilities by the trial and error. The positive pressure type ventilation by the endotracheal-intubation had been used (Tuffier&Hallion;1896 France, the R.Matas;1899 U.S., Kuhn;1900 Germany), too, but didn't become mainstream. It is because the technology which inserts a tube into the trachea safely and surely didn't become popular.
The usability of the general anesthesia by the inspired-gas opiate and the muscle-relaxant (Claret) was gradually established by 1950 marriageabilities. Because breathing of the patient has been strongly restrained, need which does some artificial respiration is caused by the general anesthesia. Therefore, the positive pressure type ventilation law which can swell the lung of the patient directly in applying positive pressure to the respiratory tract was used. At first, it was ventilating manually but a mechanical ventilator was developed to get the homeostasis and the certainty of the ventilation. The controlled-respiration equipment "Controller" which means "the machine which does ideal ventilation automatically" to the 1940-1950s was practicalized (In other words, a mechanical control ventilation controlled mechanical ventilation concept was made). These were called another name "Automatic ventilator". Spiropulsator (Sweden at 1940 pieces of the time), Blease Pulumoflator (UK at 1950 pieces of the time) and Jefferson ventilator (1950 marriageabilities, the U.S.) are a representative.
2. The artificial respiration except the anesthetic business
The establishment of the artificial breathing of the ventilation type in the respiratory tract for the treatment must be waited for to the big popularity of the poliomyelitis in Copenhagen in 1952. The fact that the hand skill of the safe endotracheal-intubation didn't become popular until then, being immature Because the hand skill of the safe positive pressure type ventilation law wasn't established and the negative aspect which accompanies positive pressure type ventilation was if anything emphasized, there was that few application of the positive pressure type artificial breathing in the respiratory tract was done to the respiratory therapy. The type resuscitator out of the body which is called an iron lung was more still predominant. However, with the big popularity of the poliomyelitis, too much, too, because a lot of patients occurred, it is possible to finish housing in the large-scale type resuscitator out of the body in the aspects of equipment and the simpler positive pressure type artificial breathing in the respiratory tract was applied. By the manually depending positive pressure type ventilation which depends on the airway management and the simple equipment by the tracheostomy, it got epoch-making lifesaving percentage. After that, the development of the positive pressure type resuscitator in the respiratory tract which raises a country was promoted. Engstrom(1954)¤Bang(1953)¤Blease(1956)¤ Beaver(1953)¤Barnet(1958)¤ Radcliffe(1953) , Drager(1955) , A lot of manufacturer such as Benett(1957) was born In these, the trigger mechanism to make the beginning and the active-ventilation of the intake effort of the patient synchronize with with the trigger mechanism was practicalized. It is because the spontaneous-respiration and the mechanical ventilation don't suit successfully and both solves clash Fighting's problem. These equipment was called "Assister" to "Controller". However, in the time until the second half of the 1950s, the equipment for the anesthesia and the treatment was not a fully divided translation and most were an also serving machine. Finally, the resuscitator evolves separately for the treatment and the anesthesia. The resuscitator for the treatment achieves leaping evolution transformation to solve the improvement of the synchronism and the ventilation efficiency with the spontaneous-respiration. Incidentally, for the treatment, it is called another name, a ward and long term management business. On the other hand, the resuscitator for the anesthesia seeks and simplifies the certainty of the mechanism and doesn't admit big improvement too much. At present, it converges on the method which drives a bellows with gas or the electric motor.
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3. The classification about the control form of the ventilation type (the positive pressure type artificial breathing) in the respiratory tract
; Pressure Ventilation (the pressure ventilation)-Volume Ventilation (The quantity ventilation)
a. The classic ventilation ; The comparison of ]—ÊŽ® (volume cycle) about the classic concept-]ˆ³ type (pressure cycle)
Artificial breathing is done to sustain the ventilation of the (i) lung and to improve (ii) oxygenation ability. As the respiratory tract ventilation type positive pressure type ventilation law to achieve this purpose, the advantages and disadvantages of pressure cycle (the ]ˆ³ type) and volume cycle (the ]—Ê type) was argued about to 1970 marriageabilities. The comparative chart of the ]—Ê type vs. the ]ˆ³ type ventilation to be often specified at the textbook of reflects this. The Pressure cycle method was more excellent about the synchronism and the ability with the patient to revise a leak, too, but then, because the monitor and the alarm mechanism of the air quantity of ventilation were immature, the sure ventilation could not be secured and was surpassed by (the suspected volume clcle method by) the volume cycle method (and constant flow, time cycle) after that.
(1) The quantity cycle ventilation (The mechanical active-ventilation) ; The classic ]—Ê type ventilation (Figure)
Because the patient could be ventilated at the taking air quantity of ventilation, the intake time, the intake gas flow rate, the intake pose time, the expiration time which the healer intends, this was called mechanical controlled-respiration (CMV;Controlled Mechanical Ventilation) and ]—Ê type ventilation (the volume cycle method) was evaluated with the ideal ventilation form. Among them, the beginning of the spontaneous-respiration, and synchronized CMV side with, assisted CMV to make side, triggered CMV and Assisted Volume Ventilation which is these variations, Volume Assisted Ventilation, Volume Control Ventilation, Volume Controlled Ventilation became the standard of the artificial respiration. If expressing in the strictness of ( Except the bellows drive system ) of most of the volume-cycled-respirators with actuality in it isn't possible to call volume cycle. are FALSE volume cycle which depends on constant flow, time cycle. Because however, aren't considering a synchronism with the patient about the concept of the mechanical control ventilation (the mechanical active-ventilation) For the patient who can crawl when there is a how much trigger mechanism and has a spontaneous-respiration, it brought about a pain of doing enduring difficulty being and it caused the evil of extraordinary rise of Fighting and the to that depending airway pressure, the pulmonary pressure damage, the self decannulation and so on.
(2) The pressure cycle ventilation (pressure cycle ventilation) ; The classic ]ˆ³ type ventilation
The way of ventilating to end intake when the inspiratory-pressure reaches a set value is called pressure cycle ventilation. It is a recently hardly used classic ventilation law. Incidentally, there is remarkable confusion in the concept in the place where the ]ˆ³ type ventilation means in Japanese because the translation of the Japanese ]ˆ³ type ventilation corresponds to this but has a different pressure ventilation mode at present.
(3) CPAP(Contineous Positive Airway Pressure) ; Classic voluntary ventilation
CPAP is not an artificial respiration mode if saying strictly and is one kind of the respiratory therapies. At the original text, it doesn't use a resuscitator and it does with the CPAP equipment, but at present, it is handy to do CPAP with the resuscitator and do is sure. But there was a discussion about the advantages and disadvantages of the continuous flow method and the demand method in the past The meaning to compare anyway passed away because the present first-class resuscitator was a high response in the same intake valve type in all continuous flow feature and demand feature and processed. For example, Flow-By of the Bennett Inc. and continuous flow setting + Flow Supplementation feature + PEEP compensator of the Bear Inc., Flow matching of the Bird Inc., BiPAP of the Respironics Inc., "NADONIYORU" CPAP handily provide the performance which surpassed the device of the classic CPAP equipment. Moreover, because to use here is rather mainstream recently in the use of PSV+PEEP than CPAP because the weaning is easier, it is more. However, that a lot of resuscitators with bad CPAP performance exist is a fact. Incidentally, a lot of resuscitators allot the position of CPAP in the meaning of the spontaneous-respiration mode but become the cause that this, too, causes the confusion of the term.
b. The new volume ventilation (Volume Ventilation)
(1) Volume Ventilation with Flow Wave Form Control (The quantity ventilation which was controlled in the intake corrugation)
The resuscitator which is made in the U.S. stepped forward from the concept of mechanical controlled-respiration CMV and by the category of the quantity ventilation, it pursued a synchronism with the spontaneous-respiration. It becomes for the inspiratory-pressure corrugation to have been able to be brought close to the square wave by using a dwindling wave for the flow pattern (constant. this the intake gas flow rate is called a square wave about the ordinariness) of the quantity ventilation. Because it is near the physiological spontaneous-respiration pattern in the positive draft, in addition to that a synchronism with the patient is improved, the dwindling wave can get the advantage of the pressure ventilation, too, compared with the square wave. In other words, pressure ventilation (PCV) can be copied, being FALSE while being a quantity ventilation mode. It puts on a peak airway pressure, too, in the lower place like PSV(pressure support ventilation) and PCV if being the same intake time. In the past, the dwindling wave still was option handling but in new T-Bird, the standard is a dwindling wave and gets to choose a square wave as the option. It is the mainstream that uses a dwindling wave recently in this way.
(2) Volume Ventilation with Flow Supplementation, Flow & Volume Augumentation (The quantity ventilation which was revised in the intake flow rate)
Another device is Flow supplementation, Flow & Volume Augumentation (the Bear Inc.). This is the mechanism to compensate for so as not to increase intake gas, that the intake demand by the patient who exceeds a setting flow rate in the active-ventilation is automatic in some cases and for the baseline pressure to become a negative pressure. It got to do can with the quantity the ventilation to have avoided the weir of CMV with Flow Supplementation. This develops into Pressure Augumentation(BEAR), VAPS(Bird) more and gets to control so as not to become below the PCV level in the active-ventilation. It brought this feature to the advantage, the "WO" quantity ventilation of the advantage and PCV which the intake quantity of the patient isn't mechanically limited to.
c. The new pressure ventilation (Pressure Ventilation)
(1) PCV(pressure control ventilation) (Figure 4)
The ventilation law to make make an inspiratory-pressure in the active-ventilation an index and constant-ize this by developing the idea which controls an intake gas flow rate as the technique to improve the fault of the mechanical active-ventilation was contrived. This is called PCV (pressure control ventilation, the pressure control ventilation). Because the excellent oxygenation ability has the equal "NO" advantage which becomes high to the extensity of the alveolus where few evils by the positive pressure of the respiratory tract occur compared with the mechanical active-ventilation because the average inspiratory-pressure and the peak airway pressure are the same in PCV, it is the mode to be recently loaded into most highly efficient resuscitator. However, the method which does PCV pressure in the self-regulation to improve this because PCV has a fault, that the air quantity of ventilation (which was made arguing in the past) is responsible, and creates ]—Ê type ventilation, too, was invented. It is PRVC(pressure regulated volume control) and Auto Flow (the auto flow) which this mentions later.
(2) PSV(pressure support ventilation)
PSV is the ventilation mode to have been contrived as a pair of PCV. The difference of both is in the difference of the intake condition-precedent. It is the time when the intake of the patient was ended in the former but the latter stops at time cycle. In the concept of IMV, the former is classified into the spontaneous-respiration mode because it sides with both of the intake expiration of the patient. It is thought of as the active-ventilation because the latter sides if there is intake but time cycle however, intake begins if not being. For example, it thinks that the active-ventilation is given in PCV in SIMV(PCV)+PSV and that it helps a spontaneous-respiration in PSV.
4) Pressure ventilation's and quantity ventilation's fusing
There is an advantage in the quantity ventilation, the pressure ventilation respectively. It adjusts the advantage of both in fusing in the developing combination and the ventilation mode to have decreased a fault can do these.
(1) It arranges quantity ventilation, pressure ventilation with the passage of time. .SIMV+PSV
SIMV(synchronized intermittent mandatory ventilation) (Figure 5)
SIMV consists of the active-ventilation aspect and the spontaneous-respiration aspect. With the spontaneous-respiration, to help PSV is general. If changing a viewpoint, SIMV+PSV is the epoch-making way of making both be compatible in dividing quantity ventilation and pressure ventilation by the temporal axes and arranging. Because it minimizes a utilization fault in each advantage, at present, it is evaluative as the standard ventilation law.
(2) It begins quantity ventilation, pressure ventilation at the same time. Pressure Augumentation,VAPS
Pressure Augumentation is the feature of Bear1000 and VAPS is Bird It is the feature of 8400, T-Bird. It is the function to provide the active-ventilation Volume Ventilation and PSV(Pressure Support Ventilation) again at the same time by the mode to have made quantity ventilation and pressure ventilation fuse. In the condition about which the spontaneous-respiration of the patient is weak, Volume Ventilation becomes predominant but if the spontaneous-respiration of the patient is strong, PSV is predominantly provided. When comparing with AutoFlow, the point that the pressure corrugation doesn't always become a square wave like PCV is a fault but the phenomenon where the inspiratory-pressure has risen steadily as the advantage doesn't happen. In AutoFlow, the intake quantity which exceeds a set value is permissible in the short run, in the long run, there is a fault which isn't permissible but it is permissible continuously in Pressure Augumentation, VAPS if being above the set value. Incidentally, Pressure Augumentation and VAPS are a mode of the ventilation of the similarity which does the original together but a few differences are in end-of-suction end condition (terminal flow rate).
(3) It does PCV pressure in the self-regulation and it makes ] quantity ventilation, being FALSE. AutoFlow,PRVC
AutoFlow can be used in Drager Evita4 and PRVC(Pressure Regulated Volume Control) is Siemens Servo It is possible to use at 300. Both is the function to provide quantity ventilation, being FALSE in the ventilation of the ironhand type in calculating PCV level based on the compliance which was measured in case of the preceding ventilation and doing automatic setting if expressing easily by the mode of the ventilation of the concept to be similar. This is fusing ventilation form in the advantage of PCV and the advantage of CMV. The principle about which there is a difference between AutoFlow, RPVC and the boiling young coming to an end in the data processing which fixes PCV level and the way of ventilating a test and so on but it becomes basic is the same. However, as for AutoFlow, the point which can be added by the mode of the ventilation of sCMV, SIMV, EMMV, equal "NOSUBETE" is a predominant point and the possibility of the clinical application is remarkably expanded into the point that PRVC is the variation of Assist/Control (Siemens calls VCV) only when comparing. For its purpose, AutoFlow combines another meaning, too.
(Meaning of reference AutoFlow : The integration of the U.S. type and the European type in case of quantity ventilation)
It adds intake pose time, being general in the concept of CMV (the mechanical active-ventilation), but this decreases an extension disproportion at the lung and can improve oxygenation ability. However, because it brings about a compulsory intake stop for the patient who has voluntary ventilation, it is possible to cause Fighting. Generally, as for European Plan's quantity ventilation, a concept, synchronized CMV to make a mechanical active-ventilation side with the spontaneous-respiration, is used. It thinks that it should always, in the intake pose time general added and there are FCS whose setting or is impossible which difficult many thing it saved an intake pose. On the other hand, the America type (isn't particular about the concept of CMV,) adds Wave Form and Flow supplementation feature and it thinks much of the successfully weighting ventilation in the volume in the spontaneous-respiration. Therefore, being general, there is not an intake pose and it chooses only at the necessary time by the option handling. Both walked as the incompatible ventilation mode while it was the same ]—Ê type ventilation. Because it becomes possible in AutoFlow to make all of the intake time of the active-ventilation, massaging with the intake pose, too, and also the intake time, in the intake pose time of the narrow sense, it passes away. The expiration of the patient is possible even if the exhalation-valve is an inspiratory-pressure, another advantage is (by the beneficence of the BIPAP system) a closed point and is during the intake time. Also, because flow supplementation feature, too, is theoretically included in AutoFlow, there is not an evil that the airway pressure becomes a negative pressure even if the patient does intake beyond the setting intake gas flow rate at the time of the active-ventilation. In other words, the concept of the quantity ventilation by the America type and the concept of European type sCMV, CPAP on it get to have fused here, being first.
(4) It does PSV pressure in the self-regulation and it makes quantity ventilation, being FALSE. .Hamilton MMV,VS
Minimum Minute Ventilation of the Hamilton style and Volume Support of Siemens differ in the data processing but in the ventilation mode which does PSV level in the self-regulation to become a constant air quantity of ventilation like AutoFlow and PRVC, it is the mode to realize quantity ventilation, being FALSE while these, too, are pressure ventilation. PSV mode however, it is made of the low invasiveness resuscitator of BiPAP "NADO" as intake begins with time cycle.
(5) It copies PCV by the quantity ventilation. Volume ventilation with Decelerating Wave Form
The decisive difference between the quantity ventilation and the pressure ventilation is in the flow corrugation. In the pressure ventilation, the dwindling wave is observed but if copying this with the flow corrugation of the quantity ventilation, while being quantity ventilation, it can realize pressure ventilation, being FALSE. Mainly, it is used for the quantity ventilation by the America type. Only present place + 50%--50% of straight change patterns are prepared but if getting to put on a various pattern by the auto selection in future, the problem that the air quantity of ventilation which AutoFlow and PRVC have is ambiguous is solved. Moreover, it becomes that it was possible to be permissible in the long run by the intake quantity above the set value if adding Flow Augumentation and Flow Supplementation feature, too.
(6) It cuts the peak pressure of the ]—Ê type ventilation. PLV(Pressure Limited Ventilation)
When the airway pressure rises in above the pressure which was set about the ]—Ê type active-ventilation by the feature which can be used about the model after Drager Evita, it does a peak shaving so as not to decrease an intake gas flow rate and to become above the set-pressure. In other words, it becomes PCV of volume cycle when becoming above the set-pressure (Because it changes in the intake time, the intake pose time changes only about the part). However, depending on the setting, the air quantity of ventilation sometimes can not be maintained, too.
(7) These combinations
By these, the mode which was literally made of permutation combination has a lot of discussions about the clinical meaning and the setting method at it.
(a) SIMV(Pressure Augumentation,VAPS)+PSV
(b) SIMV(AutoFlow)+PSV
(c) SIMV(PLV)+PSV
(8) The fusing of the different pressure ventilation mode
(7) It resembles the mode to be but these are the mode that it is possible to have combined only pressure ventilation.
(a) BIPAP+PSV
(b) SIMV(PCV)+PSV
5) The improvement of CPAP (Figure)
(1) BIPAP(Biphasic Positive Airway Pressure)
In CPAP, the oxygenation ability of the lung can be improved by the low airway pressure compared with the active-ventilation but the point which requires voluntary ventilation capacity which is certain degree of is a defect. It is BIPAP that added ability of the ventilation help to CPAP in changing two CPAP levels alternately (Narrow sense BIPAP). It is possible to use in Evita of the Drager Inc.. At first, it was defined as containing equal to or more than 2-3 spontaneous-respirations in one CPAP aspect. However, the ability of the ventilation help for this had a limit and clinical application, too, was limited. Recently, it is pretending to do BIPAP including PCV and the SIMV(PCV) mode by the BIPAP system (BIPAP of the wide sense). Therefore, BIPAP is the general term of the ventilation mode to be created, changing two CPAP levels alternately (It is possible to add PSV, too, to the low pressure aspect). Narrow sense BIPAP was the category of CPAP but BIPAP of the wide sense becomes the category of pressure ventilation Pressure Ventilation. For example, the ventilation mode which the Drager Inc. calls BIPAP+ASB means SIMV(Pressure Control)+PSV by the BIPAP system.
(2) APRV(Airway Pressure Reliese Ventilation)
In •Ï–@ of narrow sense BIPAP, the condition only of one piece of expiration is called APRV to the low pressure aspect.
(3) BiPAP
BiPAP is the registered trademark of the Respironics Inc. and Bi of BiPAP is the meaning of IPAP(Inspiratory Positive Airway Pressure) and EPAP(Expiratory Positive Airway Pressure), two PAP. The point which doesn't use an exhalation-valve mechanism for the bottom of the mask with the equipment which helps in the ventilation in "the positive pressure in case of intake" and "the positive pressure in case of the expiration", presupposing a leak and makes it to do can with ventilation help is revolutionary. It features maximum in the low invasiveness but if classifying only in the viewpoint as the ventilation mode, it is PCV and PSV, BIPAP, CPAP and similarity.
6) The mode of the ventilation of the new concept
It means concepts such as Volume Ventilation and Pressure Ventilation and the new ventilation mode which transcended a frame.
(1) PAV
PAV(Proportional Assist Ventilation) is a mode of the ventilation of the new concept that it isn't possible to classify by the pressure ventilation or the quantity ventilation. It is the ventilation mode to help this artificially at the constant rate to breathing work volume at some time which the lung is extending with intake. It wasn't readily practicalized because the parameter was complicated but it is BiPAP Vision of the Respironics Inc. and Drager Inc. Evita 4, Bennett It has begun to be loaded into 840.
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