Deep dive: Evita V600/ V800 the new era of adult ventilation6 Morawiec E, Kindler F, Schmidt M., Am...

Deep dive: Evita V600/ V800 – the new era of

adult ventilation

Dubai October 2nd 2019

Ambassador from Prosperous Luebeck – Katrin Mett

Treatment goals

Deep dive: Evita V600/ V800 – the new era of adult ventilation

Reduce

length of stay

Improve

patient comfort

Reduce

VALI / ARDS

Prevent

Prevent intubation as long as possible because …

• patients with mechanically-assisted ventilation could develop ventilator-associated-pneumonia (VAP).

• patients with VAP could have a significantly longer ICU and hospital length of stay.

• the treatment of VAP may account for almost half of all antibiotics administered in ICUs.


• Increase patient comfort

• Prevent intubation while at the same time assuring oxygenation and CO2-removal with minimal ventilatory support

• Prevent and avoid patient-ventilator asynchrony (double triggering and delayed cycling) during non-invasive ventilation

• Provide sufficient ventilatory support despite leakages and with changes in ventilatory demand of the patient

NIVAnti Air

Shower

O2-therapy

Clinical Strategy


Prevent

Supporting functionality


In the clinical routine this will …

… Reduce Complication

…Shorten stay in ICU

…Increase quality of life

NIV with automatic leak compensation

▪ Non-invasive ventilation (NIV) in all modes

▪ Automatic leak adaptation complements the

’ f h b h

▪ Adaptation for leakages related to trigger, cycling,

application of pressures and volumes

▪ Not applicable alarms not displayed during NIV

▪ Dedicated Draeger Accessories

1 Ferrer M, et al., Am. J. Respir. Crit. Care Med. 2003; (PubMed)2 Warren DK, et al., Crit Care Med. 2003; (PubMed)3 Nava S, et al., Intensive Care Med. 2006 (PubMed)4 Bülow HH, et al., Anaesthesiol Scand 2007 (PubMed)

https://www.ncbi.nlm.nih.gov/pubmed/12689847

http://www.ncbi.nlm.nih.gov/pubmed/12771596



Prevent


▪ Provision of high flow oxygen even with active

humidification

▪ Smooth and seamless transition from O2-

therapy through NIV to invasive ventilation and

back

▪ Dedicated Draeger Accessories

In the clinical routine this could …

… h f x h F O2 for

optimal oxygen therapy.

O2-therapy


Prevent




… f h

flush to the patient during e.g. mask fitting or

suctioning procedure.

▪ Anti Air Shower reduces flow during disconnect

and automatic resumption of ventilation

▪ Support of the patient when removing the mask

▪ Prevent of unnecessarily high flow through the

removed mask

Anti Air Shower

Stabilize

Stabilize the patient and protect the lung because …

• patients could develop ventilator-associated lung injury (VALI).

• VALI could turn into acute lung injury (ALI) or acute respiratory distress syndrome (ARDS).

• multiple organ failure and mortality rate may increase associated with ALI or ARDS.


Mechanical Ventilation in Intensive Care

Acute respiratory distress syndrome (ARDS) might be a consequence of ventilator associated lung injury (VALI) that should be prevented rather than treated.1

1) Villar and Slutsky, Crit Care, Feb. 20102) Bellani et al., JAMA, vol. 315, Feb. 2016.3) Kamdar et al., Am J Respir Crit Care Med., Oct. 2017.


• Find optimal ventilator settings

o Find compromise among collapse and hyperinflation

o Stabilize alveoli and reduce strain and stress, reducing stress due to cyclic opening and closing of alveoli

o Reduce driving pressure for comparable gas exchange

• Adapt ventilator settings to changed patient situations

• Assuring oxygenation and CO2-removal with minimal invasiveness

Clinical Strategy

Low Flow PV

Loop

QuickSet and

PressureLink

Recruitment

trends

APRV –

AutoRelease

Smart

Pulmonary View

PulmoVista 500

PC-AC

AutoFlowIntegrated CO2

monitoring


Stabilize



PROVEN FACTS with Low Flow PV Loop:

▪ The Low Flow PV Loop in the Evita can be used to

optimize ventilator settings.1

▪ The hysteresis of the PV curve can be used to assess

the recruitability of the lung.2

▪ The quasi-static measurement of the P-V curve is a

simple method, easy to interpret, for objective

adjustment of the ventilatory parameters in ARDS

patients as the lung injury evolves.3

1 Takeuchi M et al., Anesthesiology, V 97, No 3, 2002 Sep

2 Demory D et al.,, Intensive Care Med. 2008 Nov

3 Pestaña D et al., Acta Anaesthesiol Scand. 2003 Mar

Stabilize



▪ Breath-by-breath increase of Pinsp and/or

PEEP (QuickSet)

▪ Simultaneous increase of Pinsp and PEEP

(PressureLink)

▪ Conducting recruitment maneuvers

QuickSet and PressureLink


… h f h

application of any recruitment procedure.

Stabilize

Image Guided Lung Protection


See the previously unseen and truly personalise

ventilation with the combination of Evita and PulmoVista.

https://youtu.be/Jrus3-mbebI

Stabilize



Homogeneous gas distribution with the lowest

possible ventilation pressures and guaranteed

minute volumes.

▪ Delivers set volume at lowest possible pressure in

all volume modes

▪ Enables spontaneous breathing at anytime

▪ AutoFlow offers automatic flow and pressure

regulation in combination with the VC-AC, VC-

CMV, VC-SIMV and VC-MMV ventilation modes

Stabilize



▪ Non-invasive CO2 measurement

▪ Display of CO2 as etCO2 and continuous CO2 real-time

curves

▪ Volumetric measurement (Evita V-series):

CO2 production (VtCO2 ,VCO2), dead space (Vds) and

the pulmonary dead space fraction (Vds/Vte)

Integrated CO2 monitoring


… h f ff f

and of the gas exchange of the patient.

… f O2

serve as an early warning system with regard to

changes in the acuity level of critically ill patients.1

… b h ,

pulmonary perfusion and metabolism to support

optimization of ventilation settings.2

“

1 St. John RE, Crit Care Nurs Vol 23, No. 4, August 2003; 83-88

2 St. John RE,Crit Care Nurs Clin N Am. 1989; 20:363-374

4 AARC Guideline, Respiratory Care, May 2003 Vol. 48 No. 5

5 Behende et al.. Ann Erg Med 1992, 31:142-5

Prevent



▪ Trend and display of pressure related changes

to compliance and tidal volume

▪ Breath-by-breath resolution

▪ End-inspiratory pressure, PEEP, tidal volume

trends and dynamic compliance and can be

calculated with breath-to-breath resolution to

assess changes in compliance and volume.

Recruitment trends

In the clinical routine this will support …

… h f .

… h -up of lung protective ventilation

strategy.

Stabilize



Airway Pressure Release Ventilation:

▪ Spontaneous breathing under continuous

positive airway pressure with brief pressure

release times

▪ Sustained mean airway pressure

APRV ─ AutoRelease:

▪ Automatic adaptation of expiration time

APRV


… P V h f

the duration of mechanical ventilation as well

as days in ICU.2

… P V f

injury in high-risk trauma patients, reducing

trauma-related adult respiratory distress

syndrome mortality.3

Wean

Wean the patient quick and safe because ...▪ the incidence of acute lung injuries (ALI) or acute respiratory

distress syndrome (ARDS) could delay the induction of weaning

▪ the delayed induction of weaning may lead to weaning failure

▪ paid attention for early detection of risk factors may contribute to successful weaning to shorten ICU length of stay


Wean

The six phases of the weaning process


• Transfer work of breathing: avoid delay in transition to supported and spontaneous breathing and weaning

• Encourage spontaneous breathing while appropriately unloading the patient

• Establish and maintain a physiologic variability in patient’s spontaneous breathing

• Improve room to breathe, reduce sedation and encourage cognitive interaction

• Improve sleep quality

Clinical Strategy

VC-MMV/

AutoFlowATC

SmartCare/PS

Comprehensive

monitoring

PulmoVista 500

SPN-CPAP-VS

Variable PS

P0.1 measurement,

RSBi, NIF

SPN-PPS


Wean



Volume Control ─ Mandatory Minute Volume:

▪ Automatic adaptation the necessary pressure to

guarantee the set tidal volume

▪ Gradual reduction of time cycled strokes

VC-MMV/AutoFlow


… h f

assisted spontaneous breathing with a

minimum minute ventilation

… b h AutoFlow, the pressure

is reduced in accordance with the contribution

of the patient to the set tidal volume.

…VC-MMV with AutoFlow allows automatic

weaning by frequency and pressure.

Wean



P0.1 ─ Occlusion pressure:

▪ Determination of neural drive of breathing

Rapid Shallow Breathing index:

▪ D f ─

─

Negative Inspiratory Force:

▪ Determination of inspiratory strength

Automatic P0.1 measurement,

RSBi, NIF


… h f h

patients ability to breathe

spontaneously.

Wean



Automatic weaning from pressure

support:

▪ Decrease ventilatory support gradually

▪ Automated Spontaneous Breathing

Trial (SBT)

▪ Increase ventilatory support when

needed

SmartCare/PS


… S /PS h b h

to reduce weaning times by up to

40% and ventilation times by up to

33%.

F. Lellouche et al.; Am J Respir Crit Care Med. 2006 Oct 15; 174(8):894-900

Wean



Spontaneous ─ Proportional

Pressure Support:

… h

for elastic and/or resistive work of

breathing.

… h b

of proportional assisted ventilation.

SPN-PPS

Wean



Variable Pressure Support:

▪ Automatic variation of the pressure

support (PS) in SPN-CPAP/PS

▪ Generating random changes in

inspiratory pressure

Variable PS


… h ,

surfactant production and pulmonary

perfusion without negative hemodynamic

effects of elevated intrathoracic

pressures. 1, 2, 3, 4

More natural breathing with improved

patient ventilation synchrony. 5, 6, 7

1 Naik BI, Lynch C, Durbin CG. Respir Care. 20152 Mauri T, Lazzeri M, Bronco A, et al., Am J Respir Crit Care Med. 20173 Gama de Abreu M, Spieth PM, Pelosi P, et al.:Crit Care Med 20084 Arold SP, Suki B, Alencar AM et al., Am J Physiol Lung Cell Mol Physiol. 20035 Spieth PM, Güldner A, Huhle R, et al.:Crit Care 20136 Morawiec E, Kindler F, Schmidt M., Am J Respir Crit Care Med.. 20157 Vassilakopoulos T, Zakynthinos S.. Crit Care Med. 2008

Recover

Recover to secure the weaning success because …

• patients could develop acute respiratory failure after extubationand therefore could require reintubation.

• mortality rate could increase with weaning- and extubationfailure.

• extubation failure can be associated with prolonged patient care and significantly increased costs.


• Avoid re-intubation while at the same time assuring oxygenation and CO2 removal with minimal ventilatory support

• Prevent and avoid patient-ventilator asynchrony (double triggering and delayed cycling) during non-invasive ventilation

• Provide sufficient ventilatory support despite leakages and with changes in ventilatory demand of the patient

• Increase patient comfort

• Ventilatory support with minimal invasiveness

Clinical Strategy

NIVAnti Air

Shower

O2-therapy


Prevent




…

NIV reduces the number of possible complications by

62% and treatment errors by 50%.1

…Sh

NIV shortens stay on intensive care wards and reduces

the length of hospital stay by an average of 3 days.2

… f f

NIV increases the quality of life for patients.1,3,4

NIV with automatic leak compensation

▪ Non-invasive ventilation (NIV) in all modes

▪ Automatic leak compensation complements the

’ f h b h

▪ Adaptation for leakages related to trigger, cycling,

application of pressures and volumes

▪ Not applicable alarms not displayed during NIV

1 Ferrer M, et al., Am. J. Respir. Crit. Care Med. 2003; (PubMed)2 Warren DK, et al., Crit Care Med. 2003; (PubMed)3 Nava S, et al., Intensive Care Med. 2006 (PubMed)4 Bülow HH, et al., Anaesthesiol Scand 2007 (PubMed)


http://www.ncbi.nlm.nih.gov/pubmed/12771596



Prevent


▪ Provision of high flow oxygen even with active

humidification

▪ Smooth and seamless transition from O2-

therapy through NIV to invasive ventilation and

back


… h f x h F O2 for

optimal oxygen therapy.

O2-therapy


Prevent




… f h

flush to the patient during e.g. mask fitting or

suctioning procedure.

▪ Anti Air Shower reduces flow during disconnect

and automatic resumption of ventilation

▪ Support of the patient when removing the mask

▪ Prevent of unnecessarily high flow through the

removed mask

Anti Air Shower


https://www.draeger.com/en_uk/Hospital/Insights-to-Solutions/Respiratory-Care/Mechanical-Ventilation/Stabilize/APRV

https://www.draeger.com/en_uk/Hospital/Departments/Intensive-Care/mechanical-ventilation

https://www.draeger.com/en_uk/Hospital/Variable-PS


https://www.draeger.com/en_uk/Hospital/SmartCare-PS

https://www.draeger.com/en_uk/Hospital/High-Flow-Therapy

https://www.draeger.com/en_uk/Hospital/Insights-to-Solutions/Non-Invasive-Ventilation-in-ICU



https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2015.191.1_MeetingAbstracts.A3163











https://www.draeger.com/en_uk/Hospital/Insights-to-Solutions/Respiratory-Care/Mechanical-Ventilation/Stabilize/APRV


https://www.draeger.com/en_uk/Hospital/Variable-PS


https://www.draeger.com/en_uk/Hospital/SmartCare-PS

https://www.draeger.com/en_uk/Hospital/High-Flow-Therapy

https://www.draeger.com/en_uk/Hospital/Insights-to-Solutions/Non-Invasive-Ventilation-in-ICU

https://www.draeger.com/en_uk/Hospital/PulmoVista-500

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Deep dive: Evita V600/ V800 the new era of adult ventilation6 Morawiec E, Kindler F, Schmidt M., Am...

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