Pressure Augumentation,VAPS(Volume Assured Pressure Support)
1. The concept and the purpose (Figure ; Excerpting from user's manual of VAPS and PSV:Bear1000)
Pressure Augumentation is the development type of the Flow supplementation feature of Bear-5. Flow Supplenmentation increases an intake gas flow rate automatically so as not for the airway pressure to decline than baseline(=the PEEP level) when the intake demand by the patient exceeds a setting flow rate at the time of quantity ventilation (Volume Assisted Breath,CMV,VCV). Pressure Augumentation, VAPS self-adjust an intake gas flow rate so as not to become more actively below the set-pressure (setting with the control with PCV pressure). This feature can be added to the quantity ventilation by all the modes. If changing a viewpoint, this feature is the mode to have fused in the pressure ventilation and the quantity ventilation in the form to begin quantity ventilation and PSV at the same time. Incidentally, Pressure Augumentation is the name of the Bear Inc. and VAPS is the name of the Bird Inc.. Both does the original together and is the same almost but a few differences are in the end-of-suction end condition.
2. The component
1) The mode to use
It is possible to use by the mode of all ventilation to ventilate quantity. AMV and SIMV, the A/C(Volume) mode can use.
2) The trigger formula
The flow rate trigger in addition to the conventional pressure trigger, too, can be chosen.
3) Pressure Augumentation, the VAPS level
Pressure Augumentation, best Pressure Augumentation, the VAPS level in VAPS are unclear but when comparing with the PSV level, high Pressure Augumentation, the VAPS level, too, can be adaptable clinically. In PSV, because the ending of intake is flow cycle, in the high PSV level, it is difficult for it to reflect the will of the patient and the evil which has had a compulsory character comes out. On the other hand, because Pressure Augumentation, VAPS end in volume cycle (at the normal condition), such an evil can be evaded. Actually, in the version in the early stages, the setting of PSV level and the setting of PCV level were an identical control and this combined the setting of Pressure Augumentation, VAPS level, too. In the recent version, the setting of PSV level and PCV level is independent and the setting of PCV level becomes the set value of Pressure Augumentation, the VAPS level.
4) The condition setting of the quantity ventilation
The conditions such as the setting taking air quantity of ventilation, the intake gas flow rate, the corrugation, the air changes per hour (the SIMV number of times), too, are unclear therefore whether the conventional setting method is the optimal for Pressure Augumentation, VAPS.
5) The end-of-suction end recognition condition
In the present situation, in Pressure Augumentation, it is using an end-of-suction end recognition condition in PSV and VAPS is using the intake flow rate of the active-ventilation. In that which is best more, it is unclear.
6) The backup mode
Bear-1000 can use AMV(EMMV). Bird 8400STi and T Bird can use an anaerosis back-up.
3. The control system
1) The controlling mechanism
The controlling mechanism of the present place Pressure Augumentation, VAPS is only a microprocessor method.
2) The control-principle
When Pressure Augumentation, VAPS begin, an airway pressure is raised until (it sets) it (by) Pressure Augumentation, the VAPS level(=the PCV level) at a breath. The intake gas flow rate pattern in the early stages becomes the same as PCV, PSV if the set value of the PCV level is high or is strong in the intake effort of the patient. There is generally more this than setting flow rate (set CMV flow rate). (i) When passing until the last as the setting flow rate if not exceeding a setting flow rate from the beginning and a setting air quantity of ventilation is achieved, intake ends. In this case, it is completely done by quantity ventilation (CMV,VCV). When there are more peak rates of flow than the setting flow rates, there is a following change with 2 patterns. Finally, the intake flow rate declines to the level which is the same as the setting flow rate but if setting air quantity of ventilation (set Tidal volume) isn't achieved at this (ii) point, since then, intake is given to the elapse and Tomo in the time until an air quantity of ventilation is achieved at the setting flow rate (=volume cycle). In other words, in the first half, it is PCV(PSV) and in the second half, it becomes quantity ventilation. (iii) If a setting air quantity of ventilation is achieved at this point, in VAPS, intake ends here. In Pressure Augumentation, PCV(PSV) continues just as it is and the ventilation ends when meeting a condition like the end-of-suction end recognition condition (30% of peak flow rate) of PSV (=flow cycle). In this case, it becomes the ventilation of PSV completely.
4. The advantage and the fault
1) ] type ventilation's and ] type ventilation's fusing
Moreover, in two kinds of different ventilation laws, in the intermingled form, for the patient, there was a fault that the patient receives confusion and a sense of incongruity to be disorderedly provided in SIMV+PSV. When using, it is possible to make two kinds of ventilatory-patterns be similar and the synchronism of the patient can be improved in SIMV and AMV in Pressure Augumentation, VAPS.
2) The air quantity of ventilation back-up mechanism in PSV
A lot of advantages are pointed out but for an air quantity of ventilation not to be secured, some back-up mechanism is indispensable to PSV. Pressure Augumentation, VAPS can be applied as the air quantity of ventilation back-up mechanism of PSV, too. It operates as the back-up mechanism which included a minimum ventilatory-frequency if using Pressure Augumentation, VAPS by the A/C mode, setting Pressure Augumentation, VAPS level high and setting them to the minimum quantity to want to secure a compulsion taking air quantity of ventilation absolutely. If using in SIMV and the EMMV mode, it makes an air quantity of ventilation back-up possibility in the various ways which the operator intends.
3) The PSV end-of-suction end recognition condition ambiguousness solution
Generally, it is 12cmH.2When an enough air quantity of ventilation is won in the PSV level below the O, as for PSV, the spontaneous-respiration and the matching are good. However, when the spontaneous-respiration of the patient is weak about the degree which needs any more level, intake has ended unnecessarily early and can not always find an advantage compared with sCMV. The end-of-suction end recognition condition of PSV isn't appropriate and this is cause. There is an approach which sets intake time compulsorily in this case using PCV, too, but sometimes, it invites Fighting. On the other hand, because PSV can be ended in volume cycle when using Pressure Augumentation, VAPS, too, there is an advantage which maintains the advantage of PSV and can get "TATA" mom and moreover the effect which is equal to PCV in volume ventilation.
4) The prevention of double triggering
There is a case where twice of air quantities of ventilation are forced, making setting intake time equal to or more than again at the trigger in sCMV when the intake of the patient continues (double cycling). It isn't double triggeringed because Pressure Augumentation, VAPS become flow cycle in this case.
5) The comparison with VS/PRVC
It is possible to assume that VS/PRVC, too, is 1 form of the back-up mechanism of PSV but Pressure Augumentation, VAPS are smart in the sharpness of the theory, the simplicity of the algorithm as the technique that they solve "the security of the degree of freedom and the air quantity of ventilation of the ventilation" compared with VS/PRVC. However, in "the average airway pressure can be secured high by suppressing a peak airway pressure" ability, it is bad.
6) Termination criteria (The end-of-suction end condition)
Because of the difference of the end-of-suction end condition, intake sometimes ends VAPS compared with Pressure Augumentation, being early. The paradox with the intake time which draws in to the extent that the spontaneous-respiration is strong depending on the condition occurs. Specifically, this evil is more from Pressure Augumentation in VAPS and is cheap. ( general termination flow of PSV ) to become often a place around 10LPM and for this to be overwhelmingly little quantity compared with the intake gas flow rate to set by the quantity ventilation