Advances In Assisted Ventilation Engineering

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Advances in Assisted Ventilation Engineering

INTRODUCTION

Mechanical ventilation is a therapeutic procedure that aims to supply or help the patient’s ventilatory function, either invasively, through a orotracheal tube, or in an non -invasive way, allowing the upper airway to remain intact. The first VMNI respirator, using subathastic pressure, was made by Dalziel in 1838. The history of non -invasive mechanical assistance goes back 100 years ago in time, but it was not until 1987 when we enter what we can call modern non -invasive mechanical ventilation. The description of Delaubier and Rideau of a patient with a ventilated shower disease effectively through a nasal mask marked the beginning of a new era in the history of non -invasive mechanical ventilation. The generalization in the use of electricity caused this device, whose functioning was manual, its benefits improve. Drinker in 1928 designs the first steel lung prototype and later, Emerson modifies and generalizes its use. Brag, Nobel Prize in Medicine in 1930, designs a system that exerts intermittent pressure on the abdomen, known as Pneumobelt. On the other hand, the English Navy develops a type of respirator for non -invasive ventilation, which in this case uses a roller mechanism that exerts intermittent pressures on the thorax.

Patient safety is the most relevant of care quality and given the great importance acquired in recent years, it is of great interest to associate this to the fact that non -invasive mechanical ventilation is a rapid and easy application support that maintains the roadsintact air, avoids the risk of pneumonia associated with mechanical ventilation (NAVM) and therefore contributing to patient safety.

The increasingly frequent use in the critical care units (ICU) of this technique, makes us need nursing staff with expert knowledge and specialized in the management of the technique.

To start developing this knowledge, it is necessary.

Exhibition and description

At present, the VMNI has become the treatment of choice of many respiratory diseases, especially those that are with ventilatory pump failure, according to Castillo, and. G., Llano, m. C., Serrano, d. R., & Garcia, and. Z. “Estimated in our environment a prevalence of householder vmni of 29/100.000 inhabitants ”, and the expected thing is that this prevalence progressively increased in the coming years. In acute situations, VMNI provides significant advantages with respect to invasive ventilation avoiding the complications of the latter related to:

• the intubation process: trauma in teeth or pharynx, arrhythmias, hypotension or barotrauma;
• the loss of defense mechanisms: chronic bacterial colonization, fan associated with the fan;
• the withdrawal of the endotracheal tube: hemoptysis, dysfunction of vocal strings or tracheal stenosis, and
• maintenance of the level of consciousness and the relationship with the environment

VMNI equipment and techniques

The differential characteristic between VMNI and conventional mechanical ventilation is that in the first, the gas that reaches the lungs, is administered through a mask (or interface), while in the second one is done directly through an endotracheal tube.

“VMNI interfaces are the devices that make possible the adaptation between the patient and the mechanical fan. They seal the patient’s airway by communicating it with the mechanical fan, facilitating the entry of pressurized gas into the lungs ”(Rodrigo, A. 2004). In addition, choice can influence the development of complications, such as the appearance of skin lesions, claustrophobia, ocular irritation or possible leaks.

The mask that must be chosen must gather the following characteristics:

• Comfortable, light and low weight.
• Manufactured of stable, resistant and flexible material, preferable hypoallergenic and silicone.
• Transparent to visualize the appearance of secretions or vomiting and to minimize the sensation of claustrophobia.
• Simple installation that allows a quick and simple withdrawal
• Adaptable to different facial forms.
• That offers minimal resistance to air flow.
• That has an anti -family valve.
• That wash and maintenance can be performed in a simple way.

Some of the different teams are:

• Nasal mask: It is mainly used in cases of chronic respiratory failure and especially in the obstructive sleep apnea syndrome (SAOS). It has the disadvantage that they can produce pressure on the back of the nose with ulceration and skin necrosis. To be better tolerated there are different varieties that are coupled with the help of caps, or that add a fine plastic film that upon receiving the insufflated air swelled, acting like a shock absorber mattress. In addition, very small size masks have been developed that reduce the sensation of claustrophobia. There is an alternative to facial masks that are the so -called ‘butterflies or nasal tweezers’, which consist of a soft rubber that is inserted directly inside the nasal cavity.
• ORONASAL MASK: Cover nose and mouth. They are mostly used in patients with acute situations. They have the inconvenience that in case of failure or disconnection of the respirator, the mask does not allow the entry of the ambient air or the nose or mouth. It also hinders expectoration, speech and intake, producing greater degree of anxiety or aspiration of gastrointestinal content. These problems have been reduced in part, incorporating an anti -family valve that in case of a respirator failure allows gas exchange with the environment. They also incorporate a rapid extraction ’system that allows the immediate withdrawal of the mask to suffocation situations. They produce greater ventilation in the minute and lower CO2 retention, because with the first there is a large air leak through the mouth when presenting more dead space.
• Total or mask mask: presents similar characteristics to the oronasales. They are especially useful in emergency situations, as it avoids leaks more effectively than the previous ones. However, they produce a greater sensation of claustrophobia and prevent the patient from speaking and eating. .
• Helmet system: in an attempt to improve comfort and avoid complications derived from the use of the previous interfaces. The lower part of the ring has a transparent tongue and silicone lax connected that adheres to the neck perfectly avoiding leaks and skin lesions, gastric distension and ocular irritation, it is the contact zone. The Antonelli group has developed a helmet, a scanfandra type that decreases the need for intubation with greater efficiency than the facial mask, being better tolerated and with less side effects (skin necrosis,). It is recommended to use it with greater support pressure and higher flow rate than when used facial mask.
• MULTIPIENCES SYSTEM: The gas provided by the respirator is managed directly in the patient’s mouth through a small tube that incorporates a device to prevent air leakage around the lips. Although it has been used since 1960, it only enjoys relative popularity in cases of chronic respiratory failure.

Respirators used for VMNI

• VMNI with positive pressure: "The respirators with positive pressure (invasive or non -invasive) attend breathing by providing pressurized gas inside the airway, increasing transpulmonary pressure and insufflating the lungs" (Orejóna, R. NAJA, et al. 2005). Expiration is carried out passively by elastic pulmonary retraction, although sometimes it can be supplemented by the force exerted by the expiratory musculature.
• CPAP devices: They are continuous positive pressure devices of the respiratory tract that provides a light and stable pressure of the air on the respiratory tract to keep them open, however they have been successfully used both in acute and chronic respiratory failure. The CPAP is composed of a pressure generator, a filter that catches dust particles, a mask will work through the nose and a circuit that unites these three components, but in cases of nasal congestion or dryness, it is preferable to incorporate a humidifierof hot water. They provide constant pressure in inspiration and expiration, increasing residual functional capacity (CFR), and recruiting alveoli. In patients with (COPD) it has also demonstrated its efficiency, since it counteracts the inspiratory overload imposed by dynamic entrapment in the airway.
• Respirators with limited pressure: Includes two ventilation modes: ventilation with support pressure (PS) and pressure controlled ventilation (VCP). In the first, a certain inspiratory pressure is selected that attends spontaneous breathing, while the respiratory rate and I/E ratio are also selected in the VCP. On other occasions, rapid and shallow breath. In this modality, the inspiratory flow can change, therefore improving the compensation of leaks through the mask.
• Respirators with limited volume: they are more modern devices than the previous ones, adding a more exhaustive monitoring and also the possibility of cyclar by pressure, although they are also more expensive. In general, they are respirators that can be used for VMNI and for invasive ventilation. Keep in mind that these systems are not able to compensate for aerial leaks, so when used for VMNI it may require that current volumes be selected than for invasive ventilatory support.
• VMNI with negative pressure: "Ventilation with negative pressure (VPN) is characterized by the application of subatosis pressure on the chest surface during inspiration" describes Orejóna, R. NAJA, et al. This pressure will significantly increase the thorax and a decrease in pressure in the alveoli, originating in this way, a pressure gradient that makes the air move from the outside inside the lungs. During expiration, thorax pressure increases to equal to atmospheric, producing a decrease in lung volume and an increase in pressure on alveoli. The pressure gradient created makes the air move from the lungs to the alveoli.

INDICATIONS

It pursues beneficial effects derived from the positive pressure it exerts on the airway in the following sections:

• Gas exchange: oxygenation-ventilation.
• Symptom control: as dyspnea, sleep alterations.
• Respiratory musculature: improving fatigue, favoring the rest of the respiratory muscles.
• Improves quality of life.

In general, VMNI is indicated in:

• Severe, acute or chronic respiratory failure reacted.
• Hypoxemic respiratory failure.
• Patient with post-extubation failure.
• COPD exacerbation.
• Acute cardiogenic lung edema
• Asthma.
• Community-acquired pneumonia.
• Postoperated patient.
• Acute pulmonary lesion / acute respiratory distress syndrome
• Withdrawal of mechanical ventilation.
• Terminal patient.

CONCLUSION

VMNI has proven to be an effective and quite simple technique for the treatment of respiratory failure of different causes. In addition, it can be an alternative in some patients with difficulties in disconnection of conventional mechanical ventilation. However, for the success of this technique it is essential.

VMNI normalizes hypercapnia and improves hypoxemia, corrects respiratory alterations of sleep, improves drowsiness for the day and other symptoms of alveolar hypoventilation and improves the dyspnea of effort, with good result in the quality of life. A reduction in income and hospital stay has also been demonstrated.

BIBLIOGRAPHY

• Salvador Díaz Lobato, Sagrario Mayoralas Alises. Modern Non-Invasive Mechanical Ventilation Turns 25. Broncneumology archives, vol 49, no 11, November 2013, pages 475-479.
• Orejóna, r. NAJA, et al. Noninvasive mechanical ventilation. Rev. Esp. Anesthesiol. Resanim, 2005, Vol. 2 P. 88-100.
• UTSET, Josep Masip. Non -invasive mechanical ventilation in acute lung edema. 2001.
• Rodríguez, a. Noninvasive mechanical ventilation. Medicrit, 2004, Vol. 1, No 5, P. 186-93.
• Corners, a. M., et al. Non -invasive mechanical ventilation in the postoperative. Clinical review. Spanish Anesthesiology and Resuscitation Magazine, 2015, Vol. 62, no 9, P. 512-522.
• Granados Monroy, Rafael Andres, et al. Design of a biomedical engineering department for the CEHOCA clinic, specialized in maintenance of general medical equipment, imaging, equipment calibration, mechanical ventilation, and clinical laboratory. 2018. Doctoral thesis. Magdalena University.
• Jose Manuel Gallardo Romero, Teresa Gómez García, José Norberto Sancho Chust and Mónica González Martínez. Non -invasive ventilation. Bronchopneumonia files 2010;No 46 (Suppl 6): 14-21.
• Castillo, e. Garcia, et al. Non -invasive and invasive mechanical ventilation. Medicine-Proven Medical Training Program, 2014, Vol. 11, No 63, P. 3759-3767.
• More A, Masip J. Noninvasive Ventilation in Acute respiratory failure. Int j copd. 2014;9: 837-52.