P/N: 2851-L1-V

Edition: June 2008

 Statement
TECME declares that this medical equipment is manufactured and
assembled according to the descriptions contained in this Manual.

• The information contained in this manual is subject to changes without prior notice.
• This manual contains TECME's proprietary information.
• The operating instructions should be read before using the NEUMOVENT Graph
Ventilator with particular attention given to warnings, cautions and notes.
NEUMOVENT Graph®

TECME
Authorized Representative:
Calle Pública s/n
GUIDO RAYOS X
La Voz del Interior al 5400 Salcedo 5-28034
X5008HJY - B° Los Boulevares Madrid – Spain
Córdoba-Argentina
Tel: +54 351 5691828/60/61/71
E-mail: tecnica@tecme.com.ar

Agency Requirements
Designed to meet applicable requirements of:
• A.N.M.A.T. AUTHORIZATION PM-1116-4.
• UNE-EN 794-1:1997. Lung Ventilators. Part 1: Particular requirements for critical care ventilators.
• UNE-EN 794-1/A1:2001. Lung Ventilators. Part 1: Particular requirements for critical care ventilators.
Amendment 1.
• IEC 60601-2-12:2001. Medical electrical equipment. Part 2-12: Particular requirements for the safety of
lung ventilators. Critical care ventilators.
• IEC 60601-1:2005 Medical electrical equipment. General requirements for safety.
• IEC 60601-1-2 Medical electrical equipment. Part 1-2: General requirements for safety. Collateral
standard: Electromagnetic Compatibility. Requirements and test.
• IEC 60601-1-2/A1:2004. Medical electrical equipment. Part 1-2: General requirements for safety.
Collateral standard: Electromagnetic Compatibility. Requirements and test. Amendment 1.
• UNE-EN 60601-1-8:2005 Medical electrical equipment Part 1-8: General requirements for safety.
Collateral standard - Alarm system - Requirements and test.
• UNE-EN 60601-1-8:20051/A1:2006 Medical electrical equipment Part 1-8: General requirements for
safety. Collateral standard - Alarm system - Requirements and test. Amendment 1.
• IEC 60601-1-4/A1:2000. Medical electric equipment. Part 1-4: General requirements for safety. Collateral
standard: Programmable electrical medial systems.
• IEC 60601-1-41/A1:2000. Medical electric equipment. Part 1-4: General requirements for safety. Collateral
standard: Programmable electrical medical systems. Amendment 1.
• UNE-EN 980:2004. Graphical symbols for use in the labeling of medical devices.
Chapter 1
Introduction ....................................................................................... 3
Intended use ................................................................................... 3
Definition of Terms .......................................................................... 4
Chapter 2
Technical Data and Specifications .................................................. 7
Chapter 3
Assembly and Installation Procedures ......................................... 13
Pedestal (Stand) Assembly ........................................................... 14
External Power Supply .................................................................. 15
Internal battery .............................................................................. 15
Connection of the Gas Supply ....................................................... 17
Connection between the ventilator and the supply source ............ 17
Pressure range at the Air and Oxygen supply ............................... 17
Breathing Circuit Assembly ........................................................... 18
Altitude compensation ................................................................... 22
Chapter 4
Features ........................................................................................... 23
Classification ................................................................................. 23
Variables for the Respiratory Phases ............................................ 23
Safety Mechanisms ....................................................................... 29
Chapter 5
Description ...................................................................................... 31
Sectors.......................................................................................... 31
1. Power Source ........................................................................... 32
2. Operative Modes ....................................................................... 32
3. Control Keys ............................................................................. 34
4. Complementary Keys ................................................................ 35
5. Selection sector ........................................................................ 36
6. Screen Values ........................................................................... 37
7. Alarm Settings ........................................................................... 39
8. Alarm Features ......................................................................... 41
9. Inspiratory Flow Waveform ....................................................... 48
10. Monitor .................................................................................... 48
11. Respiratory Mechanics ............................................................ 49
Chapter 6
Programming................................................................................... 51
Operative Modes ........................................................................... 55
Volume-Controlled Ventilation (VCV) ........................................ 56
Sigh ...................................................................................... 61
Inspiratory Pause .................................................................. 61
Pressure-Controlled Ventilation (PCV) ...................................... 62
Rise Time ............................................................................. 63
Pressure Support Ventilation (PSV) .......................................... 66
Table of Contents 1
 Continuous Positive Airway Pressure (CPAP ............................ 74
SIMV (VCV) + PSV ................................................................... 76
SIMV (PCV) + PSV ................................................................... 78
Non-Invasive Ventilation ........................................................... 79
MMV with PSV .......................................................................... 80
PSV with VT Assured ................................................................ 82
APRV ........................................................................................ 84
Backup Ventilation ........................................................................ 88
Watchdog ..................................................................................... 90
Chapter 7
Neonatal Category .......................................................................... 91
PCV (Pressure-Controlled Ventilation) .......................................... 92
Volume Compensated .............................................................. 93
Pressure Support/CPAP ............................................................... 94
SIMV (PCV) + PSV ....................................................................... 95
TCPL ............................................................................................ 96
Continuous Flow CPAP ................................................................. 97
Backup Ventilation ........................................................................ 99
Chapter 8
Ventilator Operational Test .......................................................... 101
Chapter 9
Lung Mechanics ............................................................................ 107
Auto-PEEP .................................................................................. 108
Static and Dynamic Compliance ................................................. 110
Inspiratory and Expiratory Resistance ......................................... 113
Slow vital Capacity ...................................................................... 114
P0.1 ............................................................................................ 116
P/Vflex ........................................................................................ 117
Pimax .......................................................................................... 119
Chapter 10
Graph Analysis .............................................................................. 121
Graph Characteristics ................................................................. 123
Normal Pressure Waveforms ...................................................... 124
Abnormal Pressure Waveforms .................................................. 126
Normal Volume Waveforms ........................................................ 130
Abnormal Volume Waveforms ..................................................... 130
Normal Flow Waveforms ............................................................. 131
Abnormal Flow Waveforms ......................................................... 133
Pressure/Volume Loop ................................................................ 136
Flow/Volume Loop ...................................................................... 139
Trend .......................................................................................... 140
Chapter 11
Care and Maintenance .................................................................. 141
Respiratory circuit ....................................................................... 141
Expiratory valve and flow sensor ................................................ 142
Diagram of the Respiratory Circuit .............................................. 143
Internal Battery ............................................................................ 144
Maintenance and revision every 5000 hours or once a year ....... 144
Warranty ........................................................................................ 145
Index .............................................................................................. 147
2 Table of Contents
 Chapter 1

The NEUMOVENT Graph is a microprocessor controlled ventilator incorporating

the most advanced ventilation modes.
Intended use: The device is intended for used in hospitals and hospital-type facilities that
provide respiratory care for patients requiring invasive and non-invasive respiratory sup-
port during short or long terms, and to cover a variety of clinical conditions.
Operation: It is based on the control of two proportional valves made up of high-quality
components, and related through an electronic circuit to a microcontroller.
Monitoring: It has an LCD color screen. It displays, in real time, pressure, volume and flow
waveforms, pressure/volume and flow/volume loops, oxygen concentration monitoring
with alarm, the data programmed according to the operative mode selected, and the
resulting data, as well as the up to 24 hour trend of expired volume, minute volume, airway
pressure, respiratory frequency, peak inspiratory flow and dynamic compliance.
Complementary studies: During ventilation, some respiratory mechanics tests can be
performed, and they include auto-PEEP, Dynamic and Static Compliance, Inspiratory and
Expiratory Resistance, Non-Forced Vital Capacity, P0.1, P/Vflex and Pimax.
Other characteristics: In spontaneous modes, the patient can breathe with minimum
respiratory effort. The pressure-triggered or flow-triggered system is highly efficient with the
possibility of satisfying an inspiratory flow demand of up to 180 L/min with the selected
oxygen concentration. The panel design and the direct interactive programming of the
selected operative mode, make this ventilator an easy-to-handle and easily-understood
device. The visual and audible alarm signals are accompanied by messages on the screen
indicating possible causes.
Alarms and safety features: All the alarms have visual and audible signals, and are accompa-
nied by a message on the screen. Besides the alarms, the device has a complete safety system
so as to guarantee its correct operation and to protect the patient from undue actions.
The NEUMOVENT Graph provides the following ventilation modes:
Adult and Pediatric
Volume-Controlled Ventilation (VCV), Assist/Control
Pressure-Controlled Ventilation (PCV), Assist/Control
Pressure Support Ventilation (PSV)
Continuous Positive Airway Pressure (CPAP)
Combined
• SIMV (VCV) + PSV
• SIMV (PCV) + PSV
• Non-Invasive Ventilation (NIV)
• Mandatory Minute Ventilation (MMV) + PSV
• PSV + VT Assured
• Airway Pressure Release Ventilation (APRV)
Neonate
Pressure-Controlled Ventilation (PCV), Assist/Control
Pressure Support (PSV)
Continuous Positive Airway Pressure (CPAP)
SIMV (PCV) + PSV
Time Cycle and Pressure Limited (TCPL)
Continuous Flow CPAP (NIV with leaks compensation)
Apnea Ventilation (Backup): Adult and Pediatric category by VCV or PCV mode.
Neonatology by PCV mode.

Introduction 3
Notices
In this Manual, you will frequently find the text highlighted and accompa-
nied by a sign indicating it is a NOTE, a WARNING or a PRECAUTION on
the topic being dealt with. They should be taken into account when using
this device.

Definition of Terms

WARNING: It means there is a possibility of personal injury to

oneself or others.

CAUTION: It means there is a possibility of damaging the

equipment or a neighboring device.

NOTE: Indicates specific points of interests to be taken into

account for a correct application.

WARNING
The indications relative to the application and regulation of
the controls mentioned in this manual are to be used as guidelines. The pro-
fessional in charge of its application, should, according to his knowledge
and experience, adapt this mechanical equipment to the patient’s needs.

WARNING
Do not use the ventilator in presence of flammable anesthetic
gases. It may result in an accident due to an explosion or fire.

WARNING:
The NEUMOVENT Graph is a life-sustaining device. Do not rely
solely on the ventilator performance. It is mandatory to perform frequent
and adequate clinical supervision of the patient. Also, an alternative way of
ventilation should be provided.

CAUTION:
The NEUMOVENT Graph is a restricted medical device to be
operated by qualified medical personnel under the direction of a qualified
medical practitioner.

4 Introduction
 WARNING
Every time a patient is connected to a ventilator, constant care
by specialized personnel is required. This is due to two reasons:
1) Some operation problems require immediate corrective action.
2) An alarm, or any combination of alarms, does not mean total safety in
case of any problem in the ventilatory system.

WARNING: Electromagnetic susceptibility

Ventilator malfunction may occur when operated in the close
vicinity of a device that emits high frequency (for example, cellular or wire-
less telephone, defibrillator) or of therapy devices with emission of short
waves.
Likewise, the devices of magnetic resonance produce emissions that can
damage to the ventilator in permanent form.

WARNING
Antistatic tubes neither electricity drivers won't be used so much in
the gas supply of the ventilator like in the breathing circuit.

WARNING
The ventilator cabinet should not be subjected to sterilization with
ethylene oxide gas. Irreparable damage of its components can take place.

NOTE
TECME SA has undertaken as part of its work methodology
the continuous improvement of its products and reserves the right to modify
the specifications without prior notice.

Introduction 5
6 Introduction
 Chapter 2

Application Pneumatic Requirements

Continuous ventilation of adult, pediatric and Oxygen supply: Pressure: 3.7 to 7 bar.
neonate patients. Connector: DISS(1) 9/16"-18.
Air supply: Pressure: 3.7 to 7 bar.
WARNING Connector: DISS(1) 3/4"-16.
Do not use this ventilator in presence of flam-
Within these limits, gases may have different
mable anesthetics. There may be danger of
pressures. The gases must supply a flow of up to
explosion or fire.
180 L/min.
Classification
Environment
Risk: Class IIb (Council Directive 93/42/EEC);
Class III (MERCOSUR/GMC/RES. N° 40/00) Storage Temperature: From -5°C to 70 °C.
Electric isolation: Class I, Type B Operating temperature: From 15 to 35 °C.
Protection: IP21 Relative Humidity: 0% to 95%, non-condensing.
Operation: Continuous ventilator
Operative Modes (According to Category)
Execution Characteristics
Software: Developed by TECME SA. Adult and Pediatric
TECME SA’s proprietary software. ❏ Volume Controlled (VCV), Assist/Control
Hardware: Microcontroller with watchdog system. ❏ Pressure-Controlled (PCV), Assist/Control
Memory: Total memory capacity: 512 Kb. ❏ Pressure Support (PSV)
❏ Continuous Positive Airway Pressure (CPAP)
Panel with Screen ❏ Combined:
Waterproof elastic sheet. Keys with microswitch. • SIMV (VCV) + PSV
• SIMV (PCV) + PSV
LCD Screen with 320 x 240 pixels resolution.
• Non-Invasive Ventilation (NIV)
• Mandatory Minute Ventilation (MMV) + PSV
Serial Output • PSV + Tidal Volume Assured
RS-232C Type with DB-9 connector. • APRV
Neonate
Power Requirements ❏ Pressure-Controlled (PCV), Assist/Control
Main current ❏ Pressure Support (PSV)
110 to 220 VAC 50-60 Hz. Automatically ❏ Continuous Positive Airway Pressure (CPAP)
switchable voltage. ❏ SIMV (PCV) + PSV
❏ Time Cycled, Pressure Limited (TCPL)
Internal battery ❏ Continuous Flow CPAP (Leak compensation)
12 VDC; 4.4 Ah.
Automatic recharge. Can supply 2 hours Backup Ventilation
30 minutes of power when fully charged. Adult and Pediatric applications: VCV or PCV
Charge level indicator. Neonate applications: PCV

(1) According to: Compressed Gas Association CGA V-5-2000,

Diameter-Index Safety System (USA).

Technical Data and Specifications 7

Parameter Selection Alarms
(Depending on the operative mode and All the alarms are visual and audible, and are
patient category: adult, pediatric, neonate) accompanied by a screen message.
Tidal Volume: 5 to 2500 mL High Priority Signals
Minute Volume: Up to 45 L/min High Inspiratory Pressure: 10 to 120 cm H2O
Inspiratory Time: 0.1 to 30 s Low Inspiratory Pressure: 1 to 99 cm H2O
I:E Ratio: 6:1 to 1:199
Low Inlet of both Gases: Below 3.5 bar (< 50 psi)
Machine Rate: 1 to 150 bpm
FIO2: 0.21 to 1.0 Low Inlet of one Gas: Below 3.5 bar (< 50 psi)
O2 100%: Begins oxygenation sequence for suction Battery depleted: Light and warn in the screen.
Sensitivity
• Flow-Triggered: 0.5, 2, 3, 4, 5 L/min High continuous pressure: Exceeded set
PEEP level +5 cm H2O for more than 15 seconds.
• Pressure-Triggered: –0.5 to –10 cm H2O below
PEEP Technical Failure: Electronic or software failure
PEEP/CPAP: 0 to 50 cm H2O
NIV mask disconnection: Audible and screen
Pressure-Controlled Ventilation (PCV):
message
2 to 70 cm H2O above PEEP
Pressure Support Ventilation (PSV): Oxygen not adequate: High priority signal when
0 to 70 cm H2O above PEEP the O2 % is 18% or less
Expiratory Sensitivity (PSV):
5, 10, 15, 20, 25, 30, 35, 40, 45 and 50% of Medium Priority Signals
delivered peak flow. High Tidal Volume: Up to 3.0 L
Inspiratory Pause (Volume mode): 0 to 2 s
Expiratory Pause Low Tidal Volume: From 0 L
To measure auto-PEEP: Automatic sequence of Power Loss: Light and audible signal
three 0.75 s pause. while the ON/OFF Switch is ON
Sigh (Volume mode)
• Rate: 5, 10, 15 or 20 per hour Oxygen Concentration: High limit: 25 to 100%
• Multiple sighs: 1, 2 or 3 Low limit: 19 to 90%
• Sigh volume: From 0.1 up to 2.0 L Apnea: Elapsed time: 5, 10, 15, 30, 60 s
• Maximum pressure limit
NIV Circuit Leak: Adult: > 50 L/min
Manual Inspiration: One inspiration
Ped: > 30 L/min
Flow Waveform Cont Flow CPAP: Neo: > 10 L/min
VCV: Rectangular, descending ramp,
sine, ascending ramp. Fan failure: Activate when a stop is detected
PCV and PSV: Descending ramp.
Low Priority Signals
Inspiratory Flow: From 2 to 180 L/min
fmax: According to the set limit (Default: 30 bpm)
Continuous flow (NEO): 2 - 40 L/min
PEEP Loss: 2, 4, 6 cm H2O and OFF
Limited Pressure (NEO): 2 - 70 cm H2O
High Exhaled Minute Volume: Up to 50 L/min
Maximum Limited Pressure (Plim, max)
Relief valve: 100 cm H2O Low Exhaled Minute Volume: From 1.0 L/min

Alarm Complement
Silence: 30 or 60 seconds by pressing the key
once or twice successively.

8 Technical Data and Specifications

 Menu
Other Controls When pressing this key a list of options opens up
Selection of Operative Mode to different functions and data:
Three keys for each group of operative modes: • Backup ventilation settings
• Ventilatory adjuncts
1) Volume ventilation
Get access to: Expiratory Sensitivity (PSV)
2) Pressure ventilation
Inspiratory Pause (VCV)
3) Ventilation with combined modes and options.
Sighs (VCV)
Enter Volume compensation (NEO)
To accept the programming values and to activate • Trends
functions, by itself or in combination with other keys. • Activated alarms
Reset Up to 660 saved events in 55 printable sheets
To go out, cancel or abort the current operation, • Tools
returning to the previous function. Get access to: Pressure units conversion
Ctrl Suction period
Time of use and software version
To activate functions in combination with other keys.
Sound volume
Nebulizer Oxygen sensor calibration
Flow to nebulizer during 30 minutes. It stopped Breathing circuit calibration
when the inspiratory flow is less than 20 L/min. Date and Time setting
Standby Help
To stop the ventilator. The programmed values and
mode are “in standby” (Standby + Enter). Respiratory Mechanics
Manual Trigger It selects from the screen menu:
To manually start an inspiration. • AutoPEEP (With automatic Expiratory Pause)
• Dynamic and Static compliance
Monitor • Inspiratory and Expiratory resistance
• Non-Forced Vital Capacity
Graphic • P0.1
To have access to the pressure, flow, volume wave- • P/Vflex
forms and pressure/volume and flow/volume loop • Pimax
graphs.
Freeze Internal Battery
To freeze the waveforms. However, neither the re-
sulting values nor the airway pressure bar of the Internal built-in battery that can supply 2 h 30 min of
airway are frozen. power depending on ventilator settings and battery
charge level. The charge level is shown perma-
Scale (Cursor) nently on the LCD screen as an icon.
To change the vertical and horizontal scale of the
The ventilator automatically switches to the internal
scalars or loops. When the screen is frozen, the
backup battery when electrical power supply failure
horizontal and vertical cursors may be moved.
is detected. The internal battery is charged if the
Print ventilator is attached to an AC power source.
To print the screen using VisualGraph software.

CAUTION Altitude Compensation

Connecting this medical device to a printer conform- To increase the accuracy of volume measurement,
ing the IEC 60601-1-1 is a sole responsibility of the the ventilator includes a correction table for altitude
user. adjustment. (See page 22).

Conversion of pressure units

Oxygen Monitoring Cell
Selection of units in cm H2O, mbar or hPa.
Connected in the first part of the respiratory circuit
to monitor the oxygen concentration of the gas sent To change the pressure unit go to Tools pressing
to the patient. The result is digitally displayed. the [Menu] key. The change will be kept in memory.

Technical Data and Specifications 9

 Controls Table

Precision
Parameter ● Limit (max–min)
(direct regulation or Increment Default setting Precision

%
● Steps of Limits Control
result) change

ADL: 0.050 – 2.5 Precalibrated screen

Tidal Volume ADL: 0.010 ADL: 0.400 pneumotach related
PED: 0.005 – 0.300 ± 10
(Liters) NEO: NA
PED: 0.001 PED: 0.200 with differential
transducer
ADL: 1 – 45 Precalibrated screen
Minute Volume ADL: 6.0 pneumotach related
PED: 1 – 20 0.100 ± 10 with differential
(Liters) PED: 4.0
NEO: NA transducer

Inspiratory Time 0.05 to 0.9 ADL: 1.0

0.1 – 30 (APRV) PED: 0.8 ≤5 Crystal quartz
(seconds) 0.1 to 1.0
NEO: 0.5
I:E Ratio
5:7.1 a 1:199 0.1:0.1 ≤5 Crystal quartz
(enabled in PCV)
ADL:Ptr 1.5 cmH2O–Flow 3 tr: Variable orifice
L/min pneumotach
Inspiratory Sensitivity Ptr: Pressure
Flow: 0.5, 1, 2, 3, 4, 5
Ptr: 0.5
PED:Ptr 1.5 cmH2O–Flow ± 10 transducer
( tr: L/min; Ptr: cm Pressure: 0.5 – 10 3L/min
H2O)
NEO:Ptr 1.5 cmH2O–Flow
1L/min

Mandatory Rate ADL: 12

1 – 150 1 PED: 14 ≤5 Crystal quartz
(bpm)
NEO: 18
Precalibrated screen
Inspiratory Flow pneumotach related
2 – 180 Automatic ± 10 with differential
(calculated; L/min)
transducer
Proportional valves
FIO2 0.21 – 1.0 0.1 0.50 ± 10 calibration
Pressure Controlled ADL: 15
(PCV) 2 – 70 1 PED: 8 ± 10 Pressure transducer
(cm H2O) NEO: 8
Pressure Support ADL: 15
(PSV) 0 – 70 1 PED: 8 ± 10 Pressure transducer
(cm H2O NEO: 8
5, 10, 15, 20, 25, 30, Precalibrated screen
Expiratory Sensitivity pneumotach related
35, 40, 45 and 50 % 25% ± 10
(enabled in PSV) of peak flow
with differential
transducer
PEEP / CPAP
0 – 50 1 ± 10 Pressure transducer
(cm H2O)
Inspiratory Pause
0, 0.25, 0.5, 0.75,
(enabled in VCV) 1.0, 1.5, 2.0
0 ≤5 Crystal quartz
(seconds)
Sigh: Volume (L) Precalibrated screen
(enabled in VCV : pneumotach related
0.1 – 2.0 0.050 0 ± 10 with differential
ADL and PED
transducer
Category)
5, 10, 15, 20
Sigh: Rate (per hour)
0 ≤5 Crystal quartz

Sigh: Events 1, 2, 3 0 ≤5 Crystal quartz

Sigh: Max Pressure 40 cm H2O ± 10 Pressure transducer
Alarm
Continuous Flow: Precalibrated screen
pneumotach related
NEO Category 2 – 40 L/min 1 L/min 8 L/min ± 10 with differential
(L/min) transducer
Pressure Limited: 2 – 70 cm H2O 1 cm H2O 8 cm H2O ± 10 Pressure transducer
NEO Category (cm H2O)

10 Technical Data and Specifications

 Monitored Parameters Table
Parameter Observations Exactitude
Pressure Peak, Plateau, Mean y Base ± 2 cm H2O

Expired Tidal Volume ± 10%

Inspiratory Flow ± 10%

Minute Volume ± 10%

Rate Programmed and Spontaneous ± 1%

Inspiratory Time ± 1%

Expiratory Time ± 1%

I:E Ratio ± 1%

O2 Percentage ± 3%

Alarms Table

Precision
Control Limit (max–min) Default Precision Limits
Increment

%
Event Steps of change setting Control

High Inspiratory ADL: 40

Pressure 10 (ó >min) – 120 1 PED: 35 ±10 Pressure transducer
(cm H2O) NEO: 25
Low Inspiratory
Pressure 3 (ó <max) – 99 1 5 ±10 Pressure transducer
(cm H2O)
High Tidal ADL: >VTmin – 3.0 ADL: 0.010 - 0.050 ADL: 0.600 Precalibrated screen
Volume PED: >VTmin – 1.0 PED: 0.005 - 0.010 PED: 0.300 ±10 pneumotach related with
(L) NEO: >VTmin – 0.1 NEO: 0.001 - 0.005 NEO: 0.050 differential transducer
Low Tidal ADL: 0.010– <VTmax ADL: 0.010 - 0.050 ADL: 0.200 Precalibrated screen
Volume PED: 0.001– <VTmax PED: 0.001 - 0.005 PED: 0.100 ±10 pneumotach related with
(L) NEO: 0.001– <VTmax NEO: 0.001 - 0.005 NEO: 0.005 differential transducer
High Expired ADL: >min – 50 ADL: 0.5 ADL: 9.5 Precalibrated screen
Minute Volume PED: >min – 50 PED: 0.5 PED: 6.0 ±10 pneumotach related with
(MMV only) (L) NEO: Unable differential transducer
Low Expired ADL: 1 – <max ADL: 0.5 ADL: 4.5
Variable orifice
Minute Volume PED: 1 – <max PED: 0.5 PED: 3.0 ±10
pneumotach
(MMV only) (L) NEO: Unable
High: 25 – 110 High: 60
Oxygen % 1% ±10 Oxygen sensor
Low: 18 – 95 Low:: 40
Oxygen
18% or less N/A N/A ±3 Oxygen sensor
not adequate
Precalibrated screen
NIV mask
N/A N/A N/A ±10 pneumotach related with
disconnection differential transducer
ADL: 50 L/min Precalibrated screen
NIV leak N/A N/A PED: 30 L/min ±10 pneumotach related with
NEO: 10 L/min differential transducer
Apnea 5, 10, 15, 30, 60 15 ≤ 5 Crystal quartz
(seconds)
Loss of PEEP 2, 4, 6, NO 4 ±10 Pressure transducer
(cm H2O)
High Breathing
3 – 160 1 30 ≤ 5 Crystal quartz
Rate (bpm)
While the ventilator is working, the interruption of the main electric power produces
Loss of Main
automatic commutation to operation for battery. The interruption can be made by the
Power operator for transfer of the equipment or to be a fortuitous fact.
Battery
Very low charge level. Replace for an alternative ventilation method.
Depleted
Technical
The operation is suspended. Replace for an alternative ventilation method.
Failure

End of
Chapter

Technical Data and Specifications 11

 This Page Intentionally Left Blank

12 Technical Data and Specifications

 Chapter 3

The NEUMOVENT Graph Ventilator and the associated patient circuit are shipped in a clean
but not sterile condition.
The complete assembly consists of the following components:

Quantity Description
1 NEUMOVENT Graph Ventilator
with watertrap for high pressure air inlet (located on the rear)
1 Four-wheel base
1 Support bar with set screw and washer
1 Tray with set screw and hex wrench
1 Extension arm with tubes holder
1 Expiratory valve with expiratory pneumotachograph
1 Oxygen sensor with cable
1 Test lung
1 Nebulizer with connector
1 Power supply cable
1 Oxygen supply high pressure hose (3 m)
with DISS connector
1 Air supply high pressure hose (3 m)
with DISS connector

NOTE: The following accessories are optional and

are not manufactured neither provided by
TECME
- Reusable or discarded breathing
circuit; adult, pediatric or neonate.
- Heater-humidifier.

WARNING
Do not use antistatic neither electrically conduc-
tive tubes in the breathing circuit and gas supply.

Assembly and Installation Procedures 13

 Pedestal (Stand) Assembly

It comprises three stages:

1) Fix the vertical bar in the rolling base with the Allen
screw adjusting with the hex tool.

Notice that the wheels with brake and the

heater-humidifier support should be placed forward.

2) Place the tray in the superior part of the bar making

coincide the metallic block in the neckline of the bar.
Adjust the fixation screw with the 5 mm hex tool.

3) Place the protection ring together with the hook-sup-

port, adjusting with the hex tool the four Allen screws
through the holes of the posterior part of the bar.

Securing the ventilator

Place the ventilator on the pedestal tray. Secure it with
the screw coming from below on the right of the tray, as
indicated in the next figure.

Support of the Breathing Tubes

The support end is placed on the lateral side of the pro-
tection ring. The support nut is tightened. The two ar-
ticulated segments are placed in the desired position and
the nuts are tightened.

14 Assembly and Installation Procedures

Connection of the Power Supply
The power inlet and the ON-OFF switch are on the back panel.

Use the 2.5 mm hex tool to fix the power cord. This way will prevent inad-
vertent disconnection.

External Power Supply

Connect the power cable to AC 220-110V.
Plug the other end in the corresponding three-pole socket (one to
earth). Do not disconnect the ground wire of the cable nor cancel the
ground connection.

WARNING
The ground connection is important to guarantee the correct operation
of the equipment.

External power failure

The interruption of the main line electric power supply usually is a result
of three events:

1) Lack of power of the main line.

2) Connection cable unplugged from the main line.

3) Burned entrance fuse.

Anyone of these factors produces the instantaneous change to electric

power of the battery. Simultaneously the corresponding alarm, with visual
and audible sign of high priority, is activated.

WARNING
The interruption of external electric power is an emergency. If the prob-
lem persists for some minutes an alternative ventilatory system should be
used.

Assembly and Installation Procedures 15

 Internal battery
The NEUMOVENT Graph contains an internal battery that can supply up to
2 hours 30 minutes of power depending on ventilator settings and battery
charge level. The ventilator automatically switches to the internal backup
battery when electrical power supply failure is detected. The internal battery
is charged during ventilator operation if attached to an AC power source. This
can be either in standby mode or when the ventilator is turned off.

CAUTION
Prior to operating the Ventilator for the first time, the battery must be
charged by connecting the ventilator to an external power source for a pe-
riod of at least eight (8) hours.

CAUTION
Do not try to replace a battery while the ventilator is "ON". Always
switch off the ventilator before replacing the battery.

CAUTION
In case of battery discard follow the institutional requirements. The
discarded unit should not be thrown to fire. Explosion may result.

CAUTION
If, when turning the ventilator on after being unplugged for an ex-
tended period of time the "Battery depleted" or "BAT INOP" signal appears,
the internal battery must be recharged by plugging the ventilator into a
power source for a minimum of eight (8) hours. Reappearance of the "Low
Battery" or "BAT INOP" signal after the battery has been recharged indi-
cates the need to replace the battery. Call an authorized service.

Battery charge condition

All the time, the Internal Battery indicator showing the state of the battery
charge appears on the bottom of the waveform area of the LCD screen.

WARNING
Never begin a ventilatory procedure when the equipment is turned ON
and the battery icon indicates very low load. DO NOT USE the ventilator
until the load is completed maintaining the connection to the main source of
electrical energy.
The operation of the ventilator in these conditions can produce serious de-
fects. Before this happens it should be provided an alternative way of venti-
lation.

16 Assembly and Installation Procedures

 Connection of the Gas Supply
Gas inlet connectors
AIR: Male DISS(1) 3/4"-16
OXYGEN: Male DISS(1) 9/16"-18
Pressure tubes connectors
AIR: Female DISS(1) 3/4"-16 (in each end)
OXYGEN: Female DISS(1) 9/16"-18 (in each end)
It is convenient for the wall gas installation to have the
corresponding male connectors.

Connection between the ventilator and the

supply source
Air Filter
➪ First, connect the air filter to the ventilator AIR inlet, tight-
Flow direction ening it by hand.
➪ In the exit of the filter drainage, connect a tube of suffi-
cient longitude in order to send the condensed water to a
From air container.
To ventilator
supply
➪ Then, connect the air pressure tube with the female 3/4"-
16 connector to the filter inlet, tightening it by hand. The
other end of the pressure tube is connected to the air
pressure supply (central supply or compressor).
➪ Connect the oxygen pressure tube end to the ventilator
OXYGEN inlet. The other end is connected to the oxygen
pressure supply.

WARNING
Automatic drain
system The responsibility to provide a correct and safe compressed
Oxygen and Air supply is exclusively of the user, and not of
the company TECME.

Pressure range at the Air and Oxygen supply

AIR: 3.5 to 7 bar (approximately 50-100 psi)
OXYGEN: 3.5 to 7 bar (approximately 50-100 psi)

CAUTION
The gas installation must be capable of providing flows of no less
than 120 L/min (compressor) and of up to 180 L/min.

NOTE
Within the above-mentioned pressure limits, it is not necessary for the
gases to have equal pressures. The internal system makes the necessary
adjustments for a correct working of the ventilator.

(1)
In accordance to: Compressed Gas Association CGA V-5-2000,
Diameter-Index Safety System (USA).

Assembly and Installation Procedures 17

 WARNING
Only clean, filtered and dry compressed air and oxygen must be used
to prevent any contamination of the ventilator or its malfunctioning(1).

WARNING
Do not use any device that could restrict the flow or the pressure, to
any extent, between the supply outlet and the pressure tubes. Therefore,
DO NOT USE pressure regulators with shutoff valve nor any rotameter or
ball positive displacement flowmeter/liter meter.

Breathing Circuit Assembly

WARNING
The breathing circuit tubes and the heater-humidifier are not provided by
TECME. The following instructions are only a guide to the user.
To maintenance and disinfection, refer to the manufacturer's instructions
and recommendations.

The Figure on page 13 shows the circuit’s components. The setup of the
circuit is the same for adults, children or neonate. The difference is
marked by the diameter of the tubes: 22 mm for adults, 15 mm for pedi-
atric, and 12 mm for neonates patients.

Patient’s Circuit and Complementary Parts

The patient’s circuit comprises the set of parts and tubes carrying the res-
piratory gas from the ventilator to the patient and from the patient to the
expiratory valve.

CAUTION
Some breathing circuits may have water traps in the middle of the
inspiratory and/or expiratory path. Make sure these devices are airtight.
Any leak may cause a volume loss in the circuit.

While the ventilator is being used, make sure the circuit is always con-
nected to the patient and free from any obstructions. However, the fact
that no monitoring can replace the need for a close clinical observation by
trained personnel must be taken into account.

CAUTION
When the oxygen sensor is used for the first time, it should be exposed
to ambient air at least 20 minutes before connecting it to the ventilator.

(1)
In accordance to: Compressed Gas Association CGA G-7-1990
Compressed Air for Human Respiration and CGA G-7.1-1997
Commodity Specification for Air.

18 Assembly and Installation Procedures

 For better understanding, the patient’s circuit is divided into:
✔ Inspiratory path with O2 % sensor and heater-humidifier.

✔ Fitting connecting to the patient

✔ Expiratory path

✔ Expiratory pneumotachograph (flow sensor) with expiratory valve

Inspiratory Path
The inspiratory path covers the section of the patient’s circuit
which begins in the ventilator and finishes in the fitting connect-
ing to the patient.
✔ Oxygen sensor. The cable is connected in the ventilator inlet
placed laterally.
✔ The section going to the humidifier.
✔ The section going from the humidifier up to the fitting connecting
to the patient. This section may have a device to accumulate con-
densed water.
The humidifier outlet is a 22 mm male connecting to a 22 mm L-
connector port. The other end is connected to the next section.

Y-Piece Connector to the Patient

The piece connecting to the patient is a Y-piece connector. The
intermediary of the tracheal tube is connected to the 15 mm
female port of the piece.

The figure shows the nebulizer connected immediately before

the Y-piece. The nebulizer must be taken out while it is not
being used.

Expiratory Path
The expiratory path begins at the Y-piece and may be constituted by two
tubes interconnected by a water trap. This section ends at the connection
with the expiratory flow sensor.

WARNING
Do not use antistatic neither electrically conductive tubes in the breath-
ing circuit and gas supply.

Expiratory Valve and Flow sensor

The expiratory flow sensor (pneumotachograph) is part of the expiratory
valve assembly. It has a free 22 mm male lower end where the last tube
of the patient’s breathing circuit is connected.

The small lateral tubes of the sensor are connected as follows; the lower
one to P1 and the upper tube to P2 on the cabinet bottom. This connec-

Assembly and Installation Procedures 19

 tion enables the transmission of the pressures to the internal differential
transducer for expiratory volume and flow integration. The upper tube
also transmits the airway pressure.

CAUTION
In the inner middle part of the flow sensor there is a transpar-
ent membrane, the integrity of which is essential for an adequate
reading of the expired volume.

The expiratory valve has a diaphragm inside. Once the valve is

completely assembled, it is screwed into the cabinet’s lower
connection.

CAUTION
It is important to position the diaphragm correctly for the
proper operation of the ventilator. The diaphragm must be fitted
into the valve body so that the ring is left on the outer part. Cover
it by screwing the cover tightly.

CAUTION
To replace diaphragm, always use original spare part. Similar
parts can produce valve malfunction.

NOTE
To discard the whole device or disused parts or elements pro-
vided by other suppliers, follow the requirements of the institutional
authority.

20 Assembly and Installation Procedures

RS-232C Connector
It is a serial outlet which accepts a DB9 9-pin connector. It is prepared to
send signals to other devices by means of an up to 15 meter long cable.

Use of the RS-232C

In order to connect it to a compatible personal computer and print the
data and graphics to a file using VisualGraph program. Request the corre-
sponding cable and software from TECME SA.

NOTE
The ventilator must be connected to the main power source to enable
the communications between the computer and the ventilator. When the venti-
lator operates with battery, there is no communication for the RS-232 outlet.

CAUTION
Connecting this medical device to a printer conforming the IEC 60601-1-
1 is a sole responsibility of the user.

Date and Time Setting

In order to set the date and the current time get the Date and Time
Setting screen through the [Menu] key.

Date: The change is made using the Selection [ ] keys for each portion of the
line dd/mm/yy. After the change (or not) press [Enter].

Time: Same as above using the hh/mm/ss format.

Assembly and Installation Procedures 21

 Flow and Volume Correction According to Ambient Pressure
(Altitude Compensation)
Flow and volume of the driving gas and that measured during expiration, will have
variation according to the atmospheric pressure (or altitude) of the place where the ven-
tilator is in operation.
Flows and volumes should have correction to keep reference to ambient pressure of the used
place. The correction is made introducing the average value of the local ambient pressure.

NOTE
The altitude adjustment need be accomplished only once, unless the ventilator is
moved and the new location varies by more than 150 m (500 feet) from the original location.

To make this operation, follow the below instructions:

➪ Turn the machine ON while pressing the [Volume](Tidal-Minute) key.
➪ The screen will show:

MEAN AMBIENT PRESSURE

965 mbar (724 torr)
➪ The change is made on the millibar value using the Selection sector keys and that of the
Rise Time. Simultaneously, will take place the corresponding variations in the torricelli units.

➪ With the Selection keys the increase or reduction of the value will take place every ten units.

up

Rise
➪ With the Rise Time Time
keys the change is every one unit.
down

➪ When the reached figure correspond to the mean one, press the [Menu] key . The value
is permanently memorized. Later on, it can be changed, if necessary, for a new value
following the same procedure.
➪ Turn the ventilator OFF.
➪ Each time the ventilator is turned ON, the Flow and the driving or exhaled Volume
will be corrected automatically.
It is not necessary to make new changes because the local fluctuations of the barometric
pressure won’t influence in significant form the results, unless the device has a different
location with important change in the altitude. As a guide, see the following table:

Standard Atmosphere
International Civil Aviation Organization (ICAO)
Atmospheric Pressure
Altitude (m)
mb mm Hg
0 1013 760
500 955 716
1000 899 674
1500 845 634
2000 795 596
2500 747 560
3000 702 525 End of
3500 658 493 Chapter
4000 616 462
4500 577 433

22 Assembly and Installation Procedures

 Chapter 4

Classification
To classify a ventilator it is necessary to know which it is the control vari-
able that puts on in action to make an inspiratory phase. The control
variables that can be used are: Pressure, Time, Volume and Flow. Gener-
ally, in each inspiration a single control variable is used, but the ventila-
tor can also control more than a variable in different times.

Criteria for determining the control variable

(1)
(modify from R.L.Chatburn )

The ventilator is a The ventilator is a The ventilator is a

Pressure Time Volume
Controller Controller Controller
no yes yes
Observation
and
Does pressure waveform
change when patient
yes Does volume waveform
change when patient no
Is volume measured directly
(by volumetric displacement
previous resistance and compliance resistance and compliance rather than by flow
knowledge change? change? transducer)?

no
The ventilator is a
Fow
NEUMOVENT Graph Controller

According to this concept, the NEUMOVENT Graph ventilator is a pressure or

flow controller. The inspiration is triggered by pressure, flow, time or
manually. It is pressure, volume or flow limited, and pressure, volume, flow
or time cycled.

In noninvasive ventilation has capacity of leak compensation up to 50 L/min

in ADL, 30 L/min in PED category, and up to 10 L/min in NEO.

Variables for the Respiratory Phases

They involve the events which take place during a ventilatory cycle, that
is: 1) change from expiration to inspiration, 2) inspiration, 3) change from
inspiration to expiration, and 4) expiration.

Change from Expiration to Inspiration

In the volume and pressure modes, the beginning of an inspiration may
be triggered by time - as a function of the respiratory frequency (adjust-
able between 1 and 150 cycles per minute) and by pressure or flow. In the
spontaneous modes, inspiration is triggered by pressure or by flow.

(1)
Chatburn RL: Classification of mechanical ventilators. In: Tobin MJ, editor:
Principles and practice of mechanical ventilation. New York: McGraw-Hill; 1994, p. 37-64

Features 23
 When triggered by pressure, inspiration begins when the patient’s effort
can produce a pressure decrease in the breathing circuit higher than the
one set with the sensitivity control. The decrease level may be adjusted
from 0.5 up to 10 cm H2O below the baseline pressure (compensated
PEEP).

When the flow-triggered mode is selected, a continuous flow is originated

in the ventilator during the expiratory phase. In this case, inspiration is
triggered when a difference between the flow sent by the ventilator and
the flow coming out of the expiratory pneumotachograph is detected. The
flow sensitivity may be set at 0.5, 1, 2, 3, 4, or 5 L/min. The continuous
flow is twice as much as the set value.

If inspiration is not triggered by the patient in the assist/control, SIMV

and backup ventilation modes, the ventilator will start the inspirations
triggered by time according to the selected baseline respiratory frequency.

Inspiration
During the Pressure-Controlled (PCV) and Pressure-Support (PSV and
combinations) ventilatory modes, inspiration is limited by pressure. In the
Mandatory Minute Volume mode, the pressure is variable depending on
the different working characteristics of this ventilatory mode. The inspira-
tory flow in the pressure-modes is automatically set in relation to the in-
spiratory time and the regulated pressure level, but it may be modified
with the Rise Time control.

Inspiration in the CPAP/Support Pressure mode may work in two ways.

One is the conventional way, where the inspiratory flow is generated by
means of a demand system which maintains the preset PEEP/CPAP level
(0 to 50 cm H2O). The other one adds PSV as a way of assisting the
patient’s inspiration. The pressure level may be set from 0 to 70 cm H2O)
above the PEEP/CPAP level.

In the volume mode, the flow is controlled by the inspiratory time, the
preset volume and the selected flow waveform. The tidal volume may be
set between 10 and 2500 mL with a flow availability of up to 180 L/min.
The inspiratory time can be set between 0.1 and 3 s (30 s in APRV).

Change from Inspiration to Expiration

Inspiration ends when one of the four variables (pressure, flow, time or
volume) reaches the set or calculated value.

Inspiration is cycled by pressure when the high pressure limit (alarm

limit) has been reached. The limit may be set between 10 and 120 cm
H2O. In Pressure Support, it is also cycled by pressure when the pressure
rises abruptly 5 cm H2O over the preset one (cough, sudden expiratory
effort).

When using the standard support pressure, inspiration is cycled by flow

when it falls to 25% of the peak flow value (default value), and it may be
changed to 50%, 45%, 40%, 35%, 30%, 20%, 15%, 10% or 5%. In Pres-
sure Support with VT Assured, the decelerating flow may change to con-
stant flow when the target volume has not been reached during
inspiration; this causes a pressure increase until the target volume is
completed and, consequently, inspiration is cycled by volume.

24 Features
 In the volume-controlled (VCV) or pressure-controlled (PCV) modes, inspi-
ration may be cycled by time. In the volume mode, the inspiratory time
may be extended between 0.25 and 2.0 seconds when the Inspiratory
Pause is used.

In the volume mode, one to three successive sighs may be programmed,

with volumes between 0.1 and 2.0 L, and 5, 10, 15 or 20 events per hour.
The preset sigh volume is added to the already set tidal volume.

Expiration
The baseline airway pressure may be set between 0 and 50 cm H2O by
adjusting the PEEP/CPAP control.

Inspiratory Waveforms
The inspiratory waves are those corresponding to pressure and flow.

Pressure Waveforms
The inspiratory pressure waveform has two types: ascending ramp wave-
form for the volume mode with constant flow and rectangular waveform
for the pressure modes. In the volume mode, when changing the rectan-
gular flow waveform, pressure waveforms are produced with a shape char-
acterized by the flow which generates them.

Flow Waveforms
There are four flow waveforms: rectangular, descending ramp, sine wave-
form, and ascending ramp.

The graphs shown below are obtained using the Print function of the ventilator.

Figure 4-1. Volume-Controlled operative mode. To the left, rectangular flow

waveform with a pressure waveform in ascending ramp. To the right, the flow
in descending ramp. VT = 0.7L; C = 0.05 L/cm H2O; Rp = 5 cm H2O/L/s.
VT: Set tidal volume
C: Compliance of the pulmonary model.
Rp: Parabolic resistance of the pulmonary model.

Features 25
 Figure 4-2. Volume-Controlled operative mode (VCV). On the left, sine
waveform flow. On the right, flow in ascending ramp. VT = 0.7L; C = 0.05
L/cm H2O; Rp = 5 cm H2O/L/s.

In the Volume-Controlled mode, any of the flow waves can be selected. In

the Pressure modes, the flow waveform is the descending ramp type and
cannot be changed.

Figure 4-3. Pressure-Controlled operative mode (PCV). Rectangular

pressure waveform with inspiratory flow in descending ramp. VT = 0.7 L;
C = 0.02 L/cm H2O; Rp = 20 cm H2O/L/s.

In all cases, depending on the operative mode used, the flow is calculated taking
into account the preset tidal volume, pressure and/or inspiratory time.

When the waveform is the rectangular type, the flow is relatively constant
and the peak flow is equivalent to the mean calculated flow. If the wave-
form is the descending ramp type, the inspiratory flow begins with the
maximum peak and decreases lineally. If it is a sine waveform, the flow
starts at zero, increases up to the calculated peak flow, and returns to
zero in a sine waveform. The ascending ramp waveform begins at zero,
and increases lineally until the calculated peak flow is reached.

26 Features
Modifications of the Inspiratory Flow
In the Volume controlled modes, the Inspiratory Pause may be pro-
grammed between 0.25 and 2 seconds. In the pressure controlled modes,
the pause function is not enabled.

Figure 4-4. Volume-Controlled Operative Mode (VCV) with a 0.5 second

inspiratory pause; VT = 0.7 L; C = 0.02 L/cm H2O; Rp = 20 cm H2O/L/s.

In the Pressure modes (PCV and PSV), the peak flow may be modified
with the Rise Time to adjust the flow to the patient’s demand. In the Vol-
ume-Controlled mode, the Rise Time is not enabled.

In the Pressure Support Ventilatory mode with VT Assured, the pressure

and flow control are combined during the inspiration.

Figure 4-5. Operative Mode: Pressure Support with VT Assured . Target

VT = 0.7 L; C = 0.02 L/cm H2O; Rp = 20 cm H2O/L/s. Note the change of
the descending ramp flow waveform to constant flow; simultaneously,
there is a pressure increase until the target tidal volume is reached.

Features 27
 Control Subsystems
Circuit Controls
The gas flow for the patient is regulated by two proportional valves (for air
and for oxygen), connected each one with a Silverman type pneumot-
achograph. The valves work simultaneously during each breath mixing
the gases to obtain the regulated FIO2.

The microprocessor receive signals from the inspiratory flow and airway
pressure, and control the orders for the adjusted variables and the output
signals. The airway pressure transducer is connected at the beginning of
the patient’s circuit. This transducer also handles the feedback signals
which are used for the pressure trigger, the cycling and the alarm levels,
and for the control of the pressure waveform in the Pressure-Controlled,
Pressure Support and Mandatory Minute ventilation modes.

The flow data is obtained by the differential transducers related to the

internal output pneumotachographs and to the expiratory pneumot-
achograph. The expiratory pneumotachograph is a variable hole type one.

Control Valves
The gas flow to the patient is regulated by the above-mentioned propor-
tional valves. The flow control is capable of sending flows of up to 180 L/
min when the gas supply is coming from a central installation, and of 120
L/min when the air is supplied by a semi-portable autonomous compres-
sor.
The expiratory valve is governed by two solenoid valves, one used for the
closing and opening (beginning and end of the inspiratory phase). The
other is a proportional low flow valve which regulates the partial closure
of the expiratory valve to produce positive end expiratory pressure. The
microprocessor coordinates the activities of these valves, timing their ac-
tions.
The valve system also has four solenoid valves which actuate synchro-
nously every 15 minutes to restore (atmospheric pressure) the differential
and pressure transducers. At the same time, another solenoid valve al-
lows the passage of the calibrated flow of the compressed air in order to
purge the expiratory pneumotachograph lines and to prevent any water or
humidity from entering into the transducers.

Control Panel
The control panel comprises the keys used to select different functions
and the screen where the results of both numerical data and graph repre-
sentations are displayed. Some keys have LED’s which indicate whether
the required function has been activated.

Screen
The screen displays graphs, numerical values and texts. The real time
graphs of pressure, flow, and of pressure/volume and flow/volume loops
and the oxygen concentration monitoring with alarm are displayed. The
airway pressure is dynamically displayed by an analog bar graph.
The numerical values displayed at the bottom and on the right of the
screen are programmed by the operator. The ones at the top and on the
left are the resulting values.

28 Features
 Some values have smaller characters such as the indication of the maxi-
mum and minimum VT alarm limit. Others are highlighted such as for
example the maximum and minimum pressure limit, which are sur-
rounded by a rectangle.
The mode being used is indicated by the characters highlighted in the re-
verse video mode. Above the mode in use, the indication of sigh and/or
inspiratory pause is displayed, when programmed.
Similarly, the screen displays messages indicating an alarm event or the
messages used to execute some action.
The sectors surrounding the screen include:
1) Power source
2) Operative modes
3) Ventilatory parameters
4) Flow waveform
5) Alarm limits.
6) Monitor
7) Selection keys
8) Alarms
Each sector will be considered under the chapter “Description”.

Safety Mechanisms
The ventilator’s safety mechanisms comprise the devices which constitute it
and the operative system which governs the microprocessor. Their function
is to preserve the integrity of the procedure, making it safe and reliable.

Ventilator Components
Safety valve: It is located at the beginning of the breathing circuit. It is
factory preset. It is opened when the pressure within the patient’s circuit
reaches, for any reason, 110 cm H2O. The gas enters into an internal gas
collector and is expelled to the outside.

Electronic circuit: When the microprocessor detects any failure in the elec-
tronic circuit, not only is the alarm for technical failure activated but also
the ventilator enters into inoperative mode and all solenoid valves are de-
activated.

Inspiratory relief valve (antiasphyxia): Located at the beginning of the

breathing circuit. It is opened when there is a power failure or an inopera-
tive state, thus enabling the aspiration of ambient air.

Operation gases exhaust: The operation gases which normally escape from
some of the internal mechanisms, are directed to a common collector from
where they are expelled to the outside.

Low supply pressure of the compressed air: The lack of pressure of the
compressed air (command gas) is compensated by the compressed oxygen
through a connecting valve. The corresponding alarm is triggered, through
another device, by the lack of pressure.

Low supply pressure of the compressed oxygen: The lack of pressure of

the oxygen is compensated by the compressed air. The corresponding
alarm is triggered, through another device, by the lack of pressure.

Features 29
 Monitoring of the airway pressure: There are two pressure transducers lo-
cated one at the beginning (proximal pressure) and the other at the end of
the patient’s service circuit (distal pressure).

The proximal transducer commands the pressure in the Pressure-Con-

trolled (PCV) and Pressure Support (PSV) Modes, the limits of the maxi-
mum and minimum airway pressure, and the positive end expiratory
pressure (PEEP). It also originates the values for the Peak, Plateau, Mean
and Baseline Airway Pressure. The distal transducer is involved in the
plotting of the pressure waveforms.

Voltage: The power source is self-regulated for alternate current from 110
to 220 volts.

Automatic Zero Reset: The pressure transducers are zeroed every 15 min-
utes or when the operator activates this function ([Ctrl] + [Ptr-Vtr]).

Line Purge: In order to avoid any obstruction of and/or humidity in the

internal transducers, air is injected through the tubes connecting the ex-
piratory pneumotachograph during the automatic zeroing.

Operative System
The operative system, which regulates the functions of the microproces-
sor, is designed with algorithms which prevent or avoid the execution of
any maneuver which may have unfavorable effects.

Memory test: Every time the equipment is turned on, a test of the RAM
and EPROM memories is run, thus ensuring the integrity of the operative
system.

PEEP and Flow Calibration: Every time the equipment is turned on, the
expiratory valve is electronically calibrated to regulate the positive end
expiratory pressure. There is also a calibration of the flows which go
through the expiratory pneumotachograph.

Parameter limits: Every parameter involved in the ventilation has mini-

mum and maximum limits that cannot be exceeded.

Values acceptance: All selected or changed values need to be accepted by

pressing [Enter], within a maximum time of 5 seconds.

Alarm limits: Each alarm has preset or programmed limits. When they are
exceeded, in some cases the action is instantaneously suppressed (e.g.:
maximum pressure limit) or in other cases, there is activation delay time
(e.g. PEEP loss), depending on the alarm hierarchy.

Alarm activation indicators: When an alarm is activated, there is not only a

light and auditory signal but also the screen shows a message indicating
the name of the activated alarm, the possible cause and suggestions for
the solution of the problem.

Watchdog: The watchdog is an independent system of surveillance of the

function of the electronic circuit. For details, see page 91.

End of
Chapter

30 Features
 Chapter 5

The control panel of the NEUMOVENT Graph ventilator has control keys
which regulate the different functions enabled, complementary keys and
the screen for plotting the different respiratory variables in real time. The
waveforms shown are originated by the changes produced in the ventila-
tor and in the patient.

Sectors
The panel is divided into sectors which include:
1. Power Source 7. Alarm Settings
2. Operative Modes 8. Alarm Features
3. Control Keys 9. Flow Waveform
4. Complementary Keys 10. Monitor
5. Values Selection 11. Respiratory Mechanics
6. Screen Values

Power Source
110-220 VAC
Alarms
Battery High insp. pressure
Charging Low inlet gas
Measured Values
. External power loss
Operative Modes Peak Flow TI I:E TE total VT VE
spont.
(L/min) (s) spont. (s) (bpm) (L) (L/min) Pressure Low battery
Volume Limits Continuous pressure
VCV Technical failure
Assist/Control
High Insp. Low insp. pressure
Pressure Category Pressure VT high-low
PCV
Assist/Control Paw Pressure O2% high-low
Control (PCV)
Pressure Support (PSV)
Peak (above PEEP) Apnea
CPAP f max
Plateau Pressure
Support (PSV) Low PEEP
Combined (above PEEP) .
Mean VE high-low

SIMV (VCV) + PSV Base PEEP/CPAP

(reference value) 30-60 s
SIMV (PCV) + PSV
Oxygen
Options Monitor Low Insp.
Pressure Lamp and
Alarm test: Ctrl + Reset
Respiratory
Mechanics
FIO2 Inspiratory I:E Machine Volume Sensitivity
Time Ratio Rate Tidal Minute Flow Pres.
Pressure Pressure
Support up Control
O2 PEEP Rise
. .
100% FIO2 TI I:E f VT VE Vtr Ptr CPAP
PSV Time PCV

down

Alarm Settings
Manual Reset
Stand by Nebulizer Trigger

Selection
Monitor
Graphics Scale Freeze Menu
(cursor) Enter
Flow Waveform
Vert Horz Print Ctrl

Description 31
 1. Power Source
• AC Wall Power
• Battery

The LED that is lit indicates the power source being used: Main AC Power
Supply, internal Battery.

2. Operative Modes
The followings operative modes that are described correspond to the Adult
(ADL) and Pediatric (PED) categories. The operative mode of the Neonatal
category (NEO) is described in Chapter 7.

The operative mode is selected by pressing one of the three keys in this
sector. This division into three parts is done to separate the groups ac-
cording to the predominant variable, i.e., volume, pressure or combined
modes. The combined modes include forms where both modalities are in-
volved and others where it is necessary to attain the target tidal volume or
the target minute volume.

Volume
Mode with specific regulation of the tidal volume.

• Assist/Control
Breaths are started by the ventilator or by the patient. The end of inspi-
ration depends on the values set by the operator.
The patient’s inspiratory effort may start the inspiratory phase. The trigger-
ing sensitivity may be pressure- or flow-regulated. A basic rate is also regu-
lated to ensure ventilation in case of a reduction in the inspiratory effort.

Pressure
It includes modes with specific regulation of the inspiratory pressure. It
has two submodes: 1) Pressure Controlled (PCV) Assist/Control, 2) Pres-
sure Support (PSV) and/or CPAP. In both submodes, the pressure rise
slope may be changed with the Rise Time control.

• PCV Assist/Control
A pressure mode where the breaths are started by the ventilator or by
the patient. Inspiration is controlled by pressure, triggered by time or
by the patient’s inspiratory effort (pressure or flow sensitivity), pressure
limited and time-cycled (given by the set inspiratory time or by the com-
bination of the rate and the I:E ratio). The end of inspiration depends
on the values set by the operator.
• Pressure Support/CPAP
A pressure-controlled spontaneous ventilatory mode, where the patient
starts the inspiratory phase (sensitivity by pressure or flow) and cycled
primarily by flow (50%, 45%, 40%, 35%, 30%, 25%, 20%, 15%, 10% or
5% of the peak flow). As a safety measure, the inspiratory phase also
ends by pressure or by time (see page 70).
In CPAP, the flow varies to keep the set continuous positive pressure
level. No mechanical positive-pressure breaths are delivered. The
patient's inspiratory effort is controlled with the sensitivity system. The
inspiratory flow demand can be regulated with the Rise Time control.

32 Description
Combined Modes
A group of modes in which the patient has spontaneous ventilation with
mandatory inspirations synchronously inserted. It also includes modes
with spontaneous ventilation and target tidal volume or target minute vol-
ume or double pressure level.
• SIMV (VCV) + PSV
Synchronized Intermittent Ventilation with Volume-Controlled manda-
tory inspiration, and with Pressure Support Spontaneous Inspiration.
• SIMV (PCV) + PSV
Synchronized Intermittent Ventilation with Pressure-Controlled manda-
tory inspiration, and with Pressure Support Spontaneous Inspiration.
• NIV
Non-invasive ventilation (NIV) is referred as ventilatory support
through the upper airway using a mask or a similar device. This tech-
nique is differentiated from the invasive one that uses a tracheal tube, a
laryngeal mask, or a tracheotomy. This ventilator perform non-invasive
ventilation with positive pressure and leaks compensation.
• MMV + PSV
Mandatory Minute Ventilation with Pressure Support Ventilation. The
Mandatory Minute Ventilation is a spontaneous ventilation mode with
pressure support. The difference in relation to the standard pressure
support is the automatic control of the pressure level. In MMV, the ini-
tial pressure support level is set by the operator. The target minute vol-
ume to be maintained is selected. If the patient becomes depressed, the
ventilator will gradually adjust the level of the inspiratory pressure of
each breath so as to reach the target minute volume.
• PSV + VT Assured
Pressure support with tidal volume assured. In this mode, the aim is to
comply with a preset tidal volume. The operator regulates the pressure
support level and the target tidal volume. During inspiration, if the tar-
get tidal volume is not attained when the flow has descended to the se-
lected % of the initial peak flow, the ventilator changes the descending
ramp flow wave to a rectangular wave (constant flow). As a conse-
quence, the inspiratory pressure increases until the volume is attained
and, at that moment, the inspiration ends.
• APRV
The Airway Pressure Release Ventilation is a mode which ventilates ap-
plying periodic switching between two adjustable levels (P-high and P-
lower) of continuous positive airway pressure (CPAP) during preset
periods of time. Spontaneous breathing is possible without restriction
at both levels. The two levels of positive pressure, alternating to inter-
vals of time selected by the operator, produce intermittent distension
and passive decompression of the lungs. At the same time, and so
much during the upper or lower level, the patient can breathe sponta-
neously with or without pressure support.

Backup Ventilation
Programmable mode to assure ventilation in case of inspiratory weakness
or apnea in the spontaneous ventilation modes such as Pressure Support,
SIMV in its two forms, MMV and PSV with VT Assured.

Description 33
 3. Control Keys
The control keys activate the variables enabled to change or to accept the
values depending on the selected operative mode.

FIO2 [FIO2]
It produces variations in the oxygen concentration of the outgoing gas
leaving the ventilator. It is enabled in all modes.

TI [TI] Inspiratory Time

It changes the inspiratory time at a rate of one tenth of a second in the
modes enabled. The I:E ratio is automatically modified.
The inspiratory time shown in the CPAP, Pressure Support, MMV and
PSV + VT Assured modes is the resulting time and is not subject to
changes.

I:E [I:E] I:E Ratio

It produces variations in the ratio of one tenth of the change unit. The
modifications change the inspiratory time automatically.
The inversion of the I:E Ratio may only be programmed in the PCV con-
trolled mode.

f [f ] Machine Rate - bpm

It establishes the rate of the mandatory inspirations. When the program-
ming includes the introduction of an inspiratory time, the modifications in
the rate produce automatic variations of the I:E Ratio; however, the in-
spiratory time does not vary.

[Sensitivity] Pressure-Flow
Ptr Vtr

It is enabled in all the modes.

There are two options: 1) Flow-triggered (Vtr) and 2) Pressure-triggered
(Ptr) Sensitivity. The initial default value is the flow-triggered option. By
pressing the key again, the pressure-triggered option is enabled. In both
cases, the values may be varied by using the keys in the Selection sector.

VT
.
VE
[VT] Tidal Volume
This key is enabled in the modes where volume is the main variable or
when it participates in a combined mode.
[ E] Minute Volume
It is only enabled in the Mandatory Minute Ventilation mode.
PEEP
CPAP
[PEEP/CPAP]
It is enabled in all modes. It programs a reference value for the positive
end expiratory pressure. The result obtained is checked in the Baseline
airway pressure reading.

PCV [PCV] Pressure-Controlled

It is enabled in the PCV Assist/Control mode and when it is combined
with other modes. It regulates the pressure level with values above PEEP.

PSV [PSV] Pressure Support

It is enabled in the PSV mode alone or when combined with another
mode. It regulates the pressure level with values above PEEP.

34 Description
 up
Rise
Time [Rise Time]
down

By pressing these keys, the pressurization is changed during pressure

support or pressure-controlled ventilation. The upper key accelerates the
rise time by tilting the inspiratory tracing towards the vertical axis. The
lower key tilts the inspiratory tracing towards the horizontal axis.

4. Complementary Keys
Reset [Reset]
It is a key with multiple functions, used alone or in combination with
other keys. To go out, cancel or abort the current operation, returning
to the previous function.
It is also used to:
• Test the alarms LED’s and sound [Ctrl + Reset]. The test lasts the
time during which the key is pressed. During the test, all the alarm
lights are lit intermittently and are accompanied by a characteristic
high pitch sound.
• Exit an open menu and to return to the graph mode.
• Cancel a maneuver.
• Restore all cursors to zero when the graph screen is frozen.
• Cancel a Print command.

Stand by [Standby]
In combination with [Enter], it stops the ventilator without modifying the
programmed mode and settings.
By pressing [Reset], the ventilator starts working again.
O2
100% [O2 100%]
In all modes, when pressing [O2 100%], the FIO2 value changes to 1.0
[oxygen 100%) and it is maintained for 150 seconds. The aim is to pro-
duce oxygenation prior and after tracheal aspiration.
Ctrl [Ctrl]
This function key is used in combination with others:
• [Ctrl] + [Reset] = Alarms Test.
• [FIO2] + [Ctrl] = Change of a value in steps of ten units.
• [Ctrl] + [VT] = Recalibration of the breathing circuit.
• [Ctrl] + [PEEP] = Change of the alarm limit.
• [Ctrl] + [Sensitivity] = Rest all sensors (zeroing).
• [Ctrl] + [PSV] = Change of the % of end of inspiration (expiratory sensitivity).
• [Ctrl] + [VCV] or [PCV] = Backup programming.
• [Ctrl] + [Graphic] = Screen clear.
• [Ctrl] + [Manual Trigger] = Programmed sigh in VCV.
• [Ctrl] + [Alarm Settings] = Screen message (if alarm signal is active)
• [Ctrl] + [Enter] = Accept the first default programming values.

Description 35
 Menu
[Menu]
When pressing this key a list of options opens up to different functions
and data:
• Backup ventilation settings
• Ventilatory adjuncts
Get access to: Expiratory Sensitivity (PSV)
Inspiratory Pause (VCV)
Sighs (VCV)
Volume compensation (NEO)
• Trends
• Activated alarms
Up to 660 saved events that can be partially printed.
• Tools
Get access to: Pressure units option (cm H2O, mbar, hPa)
Suction period
Time of use and software version
Sound volume
Oxygen sensor calibration
Breathing circuit calibration
Date and time setting
Help
Manual
Trigger [Manual Trigger]
While one mode is on, if this key is pressed, a manual inspiration is
started with the values of the selected mode. By pressing [Ctrl] first, a
sigh starts if it is programmed.

Nebulizer [Nebulizer]
It opens the gas outlet for the nebulizer for 30 minutes. The gas automa-
tically stops when the inspiratory peak flow is less than 20 L/min. In NEO
category the nebulizer function is deactivated, except in the TCPL mode.
With flow triggered sensitivity, automatically changed to pressure-triggered
ventilation while nebulization is on.

5. Selection sector
When a key corresponding to any variable is pressed, the value of the
variable changes in the screen to reverse video. With the double key of the
Selection sector (

) the value is increased or reduced. When pressing [En-
ter], the value is accepted and it returns to normal video.

If a key is pressed and the value is not changed within 5 seconds, the re-
verse video of that number returns to normal. This avoids any accidental
maneuver.
If during a change, that change is not accepted, when pressing the [Reset]
key, the number returns to the previous value. In all cases, the ventilator
continues with the prior programming until the [Enter] key is pressed.
Whenever an enabled key which changes a variable is pressed, the LED
begins to flash.
Once the value is accepted, or if after 5 seconds there was no modifica-
tion, it returns to permanent light.
Once a mode has been programmed and all enabled values have been ac-
cepted, the [Enter] key must be pressed to start or to change the ventila-
tion to the chosen mode.

36 Description
6. Screen Values
This description refers to the values and parameters which are displayed
on the screen, and are related to the names printed on the panel sheet
which surrounds it. In the chapter “Graph Analysis”, the details of the
waveforms are given.

The regulation parameters and the resulting data are distributed on the
four sides of the screen:

a) The Measured Values are on the upper part of the screen.

b) The Resulting Airway Pressure values are on the left.
c) The Set Pressure Limits are on the right.
d) The Programming values are on the lower part of the screen.
Measured Values
It shows the resulting values according to the selected operative mode.

Peak Flow - L/min-

The Peak Flow is expressed in liters per minute. In all modes, it indi-
cates the maximum gas flow delivered by the ventilator and measured
by the internal pneumotachograph.
Expiratory Time (TE -s-)
The Expiratory Time is expressed in seconds. It is the resulting value in
all modes. In the spontaneous modes, the resulting value of the inspira-
tory time [Ti] is displayed below this value and in smaller characters.
f total -bpm-
Total rate expressed in breaths per minute. The value appears in all
operative modes.
Expired Tidal Volume (VT - L)
Expired volume, breath by breath.
Expired Minute Volume ( E -L/min-)
Expired minute volume. It is displayed in all modes. It is updated with
every change of the tracings on the screen.

Description 37
 Airway Pressure (Paw -cm H2O)
Oxygen Monitor
Peak
It indicates the maximum pressure reached
breath by breath.
Plateau
It indicates the pressure maintained during
Category ADL 60 inspiration when an inspiratory pause has
Paw 50 been programmed.
Mean
Peak 25 40
It indicates the mean airway pressure of 10
Plateau 30 breaths.
Base
Mean 8 20
It indicates the end pressure of the expira-
10 tory phase with or without PEEP.
Base 0 0
Oxygen Monitor
Oxygen 51% Monitors the oxygen concentration in the de-
Monitor Hi 60
livered respiratory gases. The High and Low
Lo 40
alarms are set automatically 10% above and
below the set FIO2, but the values can be
changed through the Menu key.

Lung Icon
Activated in each spontaneous breath. Also,
during autocycling.

Pressure Limits -cm H2O-

These are pressure values set as ventilatory limits or alarm limits.

High Inspiratory Pressure

Pressure The screen indicates the programmed value
Limits which activates the alarm.
(cmHO)
2
Pressure Control (PCV) -above PEEP-
40 High Insp. The screen indicates the programmed value
Pressure
when the pressure control operative mode is
Pressure being used.
Control (PCV)
(abovePEEP)
Pressure Support (PSV) -above PEEP-
The screen indicates the programmed value
Pressure
Support (PSV)
when the pressure support mode is being
(abovePEEP) used.
PEEP/CPAP -reference value-
PEEP/CPAP
0 (reference value) The screen indicates the programmed value.
The result is indicated in the airway Baseline
5 Low Insp. pressure.
Pressure
Low Inspiratory Pressure
The screen indicates the programmed value
which activates the alarm.

38 Description
 Selected Values
They correspond to the main control keys.

0.50 1.0 1:3.0 15 0.500 3 L/min

FIO2 Inspiratory I:E Machine Volume Sensitivity
Time Ratio Rate Tidal Minute Flow Pres.
(sec) (bpm) (L) (L/min) (cmHO)
2

7. Alarm Settings
The key used to set the alarm limits is shown below:

Pressing the key, the following menu appears:

Inspiratory pressure
High
It sets the maximum alarm limit for the inspiratory pressure with limits
between 10 and 120 cm H2O. When the alarm is activated, inspiration
ends and the expiratory valve is opened instantaneously. When the alarm
is activated and the event has been overcome, the light signal and the
screen message remain on until the [Reset] key is pressed. It is the alarm
with highest priority, and must be programmed in all modes.

Low
When the inspiratory pressure does not reach the set value, the low in-
spiratory pressure alarm is activated. The set limits are from 1 to 60 cm
H2O. It is generally activated when one segment of the patient’s circuit is
disconnected. It has high priority, and must be programmed in all
modes. It is automatically restored.

Description 39
 Tidal volume
High
Low
It sets the high and low limits for the expired tidal volume. The values are
displayed below the expired tidal volume (on top of the screen). It has me-
dium priority and must be programmed in all modes. The initial default
values are 50% over, and 50% below the programmed tidal volume, re-
spectively. These values may be changed. The first time the key is
pressed, the change of the maximum limit is activated; the second time,
the change for the minimum limit is enabled.

Minute volume
It sets the maximum and minimum limits for the expired minute volume.
The values are displayed below the expired minute volume (on top of the
screen). The alarm is only enabled in the MMV (Mandatory Minute Venti-
lation) mode.

The initial default values are 50% over, and 50% below the programmed
volume, respectively. These values may be changed. The first time the key
is pressed, the high limit may be changed; the second time the low limit
may be changed.

Oxygen concentration
The High and Low alarm limits of the breathing gas oxygen concentration
delivered to the patient is automatically set 20% above and 20% below the
FIO2 setting. It has high priority and must be programmed in all modes.
The values can be changed pressing the [Menu] key and selecting the OXY-
GEN CONCENTRATION line.

Respiratory rate
It set the limit for the maximum allowed breathing frequency. The value is
displayed on the upper part of the screen. It is enabled in all modes with
a default value of 30 cycles per minute.

PEEP low
The PEEP low limit refers to the level of the positive expiratory pressure
fall expressed in cm H2O below the PEEP/CPAP set value.

Pressure alarms - Mode of operation

The data for the High and Low programmed pressure limits are analyzed
by the microprocessor in each respiratory cycle during the airway pres-
sure rise. For the PEEP limit (baseline PEEP], the programmed data are
analyzed during the drop in the airway pressure.

The alarm corresponding to the maximum pressure limit acts without any
delay when the airway pressure reaches the set limit value. It simulta-
neously produces the end of the inspiratory phase and the opening of the

40 Description
 expiratory valve. If the maximum limit is exceeded again, the alarm re-
mains on, and there is a audible and a flashing signal. If the airway pres-
sure returns to the preset levels, the alarm sound stops, but the light
indicator remains on until the [Reset] key is pressed.

90

50 High and
Low limits PEEP
40

Paw cmH2O
30

20

10

0
1s

Analysis of the airway pressure during the respiratory cycle. (See the text).

The low pressure alarm is activated 10 seconds after a pressure signal

higher than the set limit is not received. This alarm indicates mainly that
some sector of the breathing circuit has been disconnected or that there is
an important leak of the inspiratory gas.

The PEEP low alarm is activated ten seconds after a signal is received,
during the expiratory phase, indicating that the pressure is below the one
set as limit (2, 4 or 6 cm H2O below the PEEP value).

8. Alarm Features
All the alarms have visual and audible signals, and are accompanied by a
message on the screen indicating the name of the alarm activated, the
Alarms possible cause and some suggested solution. The alarms have activation
High insp. pressure priority and follow an order in accordance with that priority. This means
Low inlet gas that if there are two or more events taking place simultaneously, all the
External power loss LED’s corresponding to those alarms are lit, but the message on the
Low battery screen is that of the alarm with a higher hierarchy. In all cases, the High
Continuous pressure Inspiratory Pressure Alarm is considered the one with highest priority.
Technical failure
While the equipment remains on, all the events are recorded in permanent
Low insp. pressure
non erasable memory. The list of events appear in Alarm Activated trough
VT high-low the [Menu] key with date and time and can be printed.
O2% high-low
Apnea
When the Silence key is pressed once, the sound stops for 30 seconds; by
pressing it twice successively, there is a 60 second silence. The light indi-
f max
cator and the screen message are not stopped.
Low PEEP
.
VE high-low The light signal are grouped on the top right of the panel. Each alarm has
a LED which is lit when the alarm is activated. If the cause of the alarm
30-60 sec has been solved, the light signal continues to be lit until [Reset] is pressed
so as to know the origin of the problem.

Some alarms have programmable values (high and/or low limits of pres-
Lamp and
Alarm test: Ctrl + Reset sures, volumes, rate), other are automatically activated after an elapsed
time. While the device remains functioning, all the alarm events are re-
corded in memory and they appear in the screen of Activated Alarms with
date and hour in a maximum sequence of 660 events.

Description 41
 The signals of alarm are grouped in three categories:
1) High Priority
2) Medium Priority
3) Low Priority

High Priority Signals (warning)

They are those that require of an immediate action. They are character-
ized to be activated in instantaneous form. The alarms that are activated
with signals of High Priority are the following ones:
High inspiratory pressure (Adjustable by the user)
Definition: Maximum allowed airway pressure limit.
Selection: In all the ventilatory modes.
Ventilator action:
1) Immediately activated when the inspiratory pressure reaches the set limit.
2) Immediate opening of the expiratory valve with breathing circuit
decompression to PEEP level.

Signal type: Audible, visual and warn in the screen.

Silence: It can be silenced temporarily.
Setting limits: From 10 to 120 cm H2O
Default value: According to patient category:
ADL: 40 cm H2O
PED: 30 cm H2O
NEO: 25 cm H2O
Value change: With the [Alarm Settings] key
To know the cause, press [Ctrl] + [Alarm Settings] keys:
HIGH PRESSURE
CAUSES:
BREATHING CIRCUIT OR AIRWAY OBSTRUCTION
HIGH TIDAL VOLUME
LOW ALARM LIMIT
HIGH INSPIRATORY PEAK FLOW OR Ti LOW
PATIENT-VENTILATOR ASYNCHRONY

The audible alarm signal recovers automatically if the pressure returns to

an inferior value to the limit. The panel light signal does not disappear
until the [Reset] key is pressed.
Low inspiratory pressure (Adjustable by the user)
Definition: Minimum allowed airway pressure limit.
Selection: In all the modes.
Ventilator action: It is activated when the ventilator inspiratory phase
pressure stays more than 10 seconds below the set limit (5 seconds in
NEO category).
Signal type: Audible, light and warn in the screen.
Silence: It can be temporarily silenced.
Setting limits: From 1 to 99 cm H2O.
Default value: 5 cm H2O for all patient categories.
To know the cause, press [Ctrl] + [Alarm Settings] keys:
Screen message: LOW PRESSURE
CAUSES:
CIRCUIT LEAKS
LIMIT OF IT ALARMS ELEVATED
FLOW SENSOR HIGH HOSE DISCONNECTION

42 Description
 The audible alarm signal recovers automatically if the pressure returns to
a superior value of the set limit. The light signal does not disappear until
the [Reset] key is pressed.

Low inlet pressure of both gases (Nonadjustable by the user)

Definition: Warns an inappropriate or lack pressure of both feeding gases
(oxygen and air).
Ventilator action: It is activated immediately when the air and oxygen
supply pressure is reduced below 2.7 bar.
Signal type: Audible, visual and warn in the screen.
Silence: It cannot be silenced.
Screen message: LOW AIR AND OXYGEN PRESSURE
ACTION:
KEEP GAS PRESSURE BETWEEN 3.5 AND 7 bars
Automatic reposition if the pressure returns above the limit. The light sig-
nal does not disappear until the [Reset] key is pressed.
Low inlet pressure of one gas (Nonadjustable by the user)
Definition: Warns an inappropriate or lack pressure of one of the feeding
gas (oxygen or air).
Ventilator action: It is activated immediately when the air and oxygen
supply pressure is reduced below 2.7 bar. Simultaneously the gas with
morepressure passes to replace the lacking gas.
Signal type: Audible, visual and warn in the screen.
Silence: It cannot be silenced.
Screen message: LOW AIR OR OXYGEN PRESSURE
ACTION:
KEEP GAS PRESSURE BETWEEN 3.5 AND 7 bars
Automatic reposition if the pressure returns above the limit. The light sig-
nal does not disappear until the [Reset] key is pressed.
Depleted battery (Nonadjustable by the user)
Definition: It is an indication that the utility time of operation with bat-
tery could be very brief or null.
Ventilator action: There is not direct action.
Signal type: 1) Light and warn in the screen.
2) Icon indicating charge level.
Silence: It cannot be silenced.
Screen message: DEPLETED BATTERY

Continuous pressure (Nonadjustable by the user)

Definition: Maintenance of 5 cm H2O of pressure above PEEP/CPAP in
the ventilatory breathing circuit for more than 15 seconds.
Ventilator action: Decompression of the breathing circuit to the set baseline.
Signal type: Light and warn in the screen.
Silence: It cannot be silenced.
Screen message: CONTINUOUS PRESSURE
LOOK FOR BREATHING
TUBE OCCLUSION

Technical failure (Nonadjustable by the user)

Definition: Important alteration (electronic circuit or software) or burnt
fuse of the annex board.
Ventilator action: The ventilator stops to work. The screen fades. Con-
tinuous light and audible signal is activated.

Description 43
 Signal type: Audible and light.
The left Technical Failure LED lit when the alteration comprises the elec-
tronic circuit or the software.
The right LED lit when the annex board fuse burnt. No screen message.
Silence: It cannot be silenced.
Consequences: The alarm indicates to possible causes: 1) A serious alter-
ation of the hardware or software; 2) Burnt fuse of the annex board. The de-
vice should not be used. Attention of specialized Service should be requested.

WARNING
When the Technical Failure alarm is activated, do not intent to use the venti-
lator again. It should be sent to an authorized service.

Mask disconnection (Nonadjustable by the user)

Action: Screen message, audible signal 5 seconds after mask disconnection.

FIO2 18% or below

Definition: Oxygen source non-appropriate.
Signal type: Audible, visual and warn in the screen.
Screen message: STOP VENTILATION
CHECK OXYGEN SOURCE

Medium Priority Signals (caution)

They are activated with a time delay. In some the time is operator’s ad-
justable, in other the time is fixed. The alarms that are activated with
signals of Medium Priority are the following ones:

VT high (Adjustable by the user)

Definition: Maximum allowed limit of the tidal volume impelled by the
ventilator.
Selection: In all the modes.
Ventilator action: It is activated when the tidal volume of successive
breathing stays more than 10 seconds above the set limit.
Signal type: Audible, light and warn in the screen.
Silence: It can be silenced temporarily.
Setting limits: From 0.010 L up to 3.0 L.
Default value: According to the patient category:
ADL: 0.600 L; PED: 0.300 L; NEO: 0.050 L

Value Change: With the [Alarm Settings] key. The audible signal is sus-
pended when the pressure recovers accepted limits. The light signal does
not disappear until the [Reset] key is pressed.
Screen message: HIGH TIDAL VOLUME
CAUSES:
SET ALARM LIMIT LOW
CHANGES IN THE BREATHING SYSTEM IMPEDANCE (PRESSURE MODES)
SUPERIOR HOSE DISCONNECTION OF THE FLOW SENSOR
The audible signal of the alarm is suspended if the pressure returns to an
inferior value to the limit. The light signal of the alarms sector does not
disappear until the [Reset] key is pressed.

44 Description
VT low (Adjustable by the user)
Definition: Minimum allowed limit of the tidal volume impelled by the
ventilator.
Selection: In all the modes.
Ventilator action: It is activated when the tidal volume stays more than
10 seconds below the set limit. If, after 30 seconds, no action is taken by
the operator, the alarm status is changed to as a High Priority Signal.
Signal type: Audible, light and warn in the screen.
Silence: It can be silenced temporarily.
Setting limits: From 0.001 L up to the low value of the VT high.
Default value: According to the patient category:
ADL: 0.200 L; PED: 0.100 L; NEO: 0.005 L
Value change: With the [Alarm Settings] key.
Screen message: LOW TIDAL VOLUME
CAUSES:
DISCONNECTION
CIRCUIT LEAKS
HOSE DISCONNECTION OR OBSTRUCTION OF THE FLOW SENSOR
HIGH ALARM LIMIT
CHANGES IN THE BREATHING SYSTEM IMPEDANCE (PRESSURE MODES)
The audible signal of the alarm is suspended if the pressure returns to a
superior value to the limit. The light signal does not disappear until the
[Reset] key is pressed.

External power loss (Nonadjustable by the user)

Definition: Failure in the electric power of the main line. It is activated
when the current key of the device is in the ON position and the following
events happen:
1) Power loss of the main line.
2) Unplugged of connection cable from mains, and
3) Burned entrance fuse.
Ventilator action: Instantaneous commutation to internal battery source of
energy. The indicative LED of the panel lights.
Signal type: Audible, light and warn on the screen.
Silence: It cannot be silenced.
Screen message: POWER LOSS
ACTION:
RESTORE ELECTRIC POWER
USE AN ALTERNATIVE WAY OF VENTILATION
Automatic reposition if the electric power recovers. The light signal does
not disappear until the power returns.

O2 concentration high (Adjustable by the user)

Definition: Maximum allowed limit of the oxygen concentration supply by
the ventilator.
Selection: In all the modes.
Ventilator Action: It is activated when the oxygen concentration of suc-
cessive breathing stays more than 30 seconds above the set limit.
Signal type: Audible and warn in the screen.
Silence: It can be silenced temporarily.
Setting limits: 25 a 110%. Lower: 18 a 95%.
Default value: 60%
Value change: With the [Alarm Settings] key.
Screen message: HIGH OXYGEN CONCENTRATION

Description 45
 O2 concentration low (Adjustable by the user)
Definition: Minimum allowed limit of the oxygen concentration supply by
the ventilator.
Ventilator Action: It is activated when the oxygen concentration of suc-
cessive breathing stays more than 30 seconds below the set limit.
Signal type: Audible and warn in the screen.
Silence: It can be silenced temporarily.
Setting limits: 18 a 95%.
Default value: 40%
Value change: With the [Alarm Settings] key.
Screen message: LOW OXYGEN CONCENTRATION

Apnea (Adjustable by the user)

Definition: It is a condition where the ventilator considers a breathing stop
during spontaneous ventilation modes after an adjustable period of time.
Selection: In Pressure Support, Continuous Positive Airway Pressure and
Combined Modes (optional in SIMV).
Ventilator action: Change to the selected backup mode at 5, 10. 15, 30.
60 seconds according to the set time.
Signal type: Audible, light and warn in the screen.
Silence: It can be silenced temporarily.
Default value: 15 seconds in all the categories.
Value change: Pressing the [Menu] key.
Screen message: APNEA ALARM ACTIVATED
BACKUP VENTILATION IN USE
The alarm resets automatically if the patient returns to spontaneous venti-
lation. The light signal does not disappear until the [Reset] key is pressed.

NIV circuit leak (Nonadjustable by the user)

Definition: Non-compensated circuit leak
Action: Warns after 30 seconds.
Signal type: Audible and screen message.
Screen message: CIRCUIT LEAK
MORE THAN xx L/MIN
NONCOMPENSABLE

Fan Failure (Nonadjustable by the user)

Definition: Detention of the fan’s operation with possibilities of electronic
circuit overheating.
Signal type: Audible, and warn in the screen.
Silence: It cannot be silenced temporarily.
Screen message: FAN FAILURE
Operator Action: Check the fan correct functioning looking for foreign
materials obstructing the blades. If the failure persist, the ventilator
should be replaced.

Low Priority Signals (alert)

They are activated with a time delay, in some the time is adjustable for
the operator, in other the time is fixed. The alarms that are activated with
Low Priority Signals are the following ones:

46 Description
f max (Adjustable by the user)
Definition: It regulates the spontaneous maximum breathing frequency
limit. It is also activated if the breathing frequency is adjusted with a big-
ger value that the limit of the alarm.
Selection: In all the modes.
Ventilator action: The alarm is activated with light and audible signal
after 20 seconds of having been surpassed the set limit. If, after one
minute, no action is taken by the operator, the alarm status is changed to
as a Medium Priority Signal.
Signal type: Audible, light and I warn in the screen.
Silence: It can be silenced temporarily.
Default value: 30 bpm for all categories.
Value change: With the [Alarm Settings] key.
Screen message: MAXIMUM BREATHING RATE ALARM
CAUSES:
AUTOCYCLING
LOW ALARM LIMIT SETTING
CIRCUIT LEAKS
The alarm resets automatically if the frequency returns to an inferior
value to the limit. The light signal does not disappear until the [Reset] key
is pressed.

Low PEEP (Adjustable by the user)

Definition: Descent of the base pressure below the set value during venti-
lation with expiratory positive pressure or continuous positive pressure.
Selection: In all the modes.
Ventilator action: Light and audible signal and message in the screen after 15
seconds of persisting the alteration. If, after one minute, no action is taken by
the operator, the alarm status is changed to as a Medium Priority Signal.
Signal type: Audible, and warn in the screen.
Silence: It can be silenced temporarily.
Limits: 2, 4, 6 cm H2O below the PEEP limit. In OFF it is disabled.
Default value: 4 cm H2O.
Value change: With the [Alarm Settings] key or pressing Ctrl + PEEP keys.
Screen message: LOW PEEP
CAUSES:
CIRCUIT LEAKS
LOW ALARM LIMIT
Automatic reset if the pressure returns above the limit. The light signal
does not disappear until the [Reset] key is pressed.

VE high (Adjustable by the user)

Definition: Exhaled minute volume bigger that the selected in Mandatory
Minute Ventilation mode (MMV).
Ventilator action: Warn with light and audible signal with message in
the screen after 10 seconds of persisting the alteration. It generally indi-
cates loss for the breathing circuit or disconnection.
If, after one minute, no action is taken by the operator, the alarm status
is changed to as a Medium Priority Signal.
Signal type: Audible, light and warn in the screen.
Silence: It can be silenced temporarily.
Set limits: From 1 to 50 L/min.
Value change: With the [Alarm Settings] key.
Screen message: HIGH MINUTE VOLUME

Description 47
 CAUSES:
LOW ALARM LIMIT SETTING
CHANGE IN THE PATIENT RESPIRATORY MECHANICS
DISCONNECTION OF THE UPPER FLOW SENSOR TUBE

VE low (Adjustable by the user)

Definition: Exhaled minute volume smaller that the one selected in Man-
datory Minute Ventilation mode (MMV).
Ventilator action: Warns after 10 seconds. It generally indicates loss for
the breathing circuit or disconnection.
If, after one minute, no action is taken by the operator, the alarm status
is changed to as a Medium Priority Signal.
Signal type: Audible, light and warn in the screen.
Silence: It can be silenced temporarily.
Regulation limits: From 1.0 L/min.
Value change: With the [Alarm Settings] key.
Screen message: LOW MINUTE VOLUME
CAUSES:
HIGH ALARM LIMIT
CHANGES IN THE PATIENT RESPIRATORY MECHANICS
DISCONNECTION OF THE FLOW SENSOR LOWER TUBE
UPPER OR LOWER TUBE FLOW SENSOR OBSTRUCTION

9. Inspiratory Flow Waveform

In the volume mode, the flow waveform may be changed. By default, the
flow is descending ramp (decelerating flow).

Flow Waveform

In the modes where the main variable is the pressure (PCV or Pressure
Support), the flow is the descending ramp type and cannot be changed.

10. Monitor
The keys in this sector are used to operate the monitor.

Monitor
Graphics Scale Freeze Menu
(cursor)

Vert Horz

From left to right, the keys produce the following changes:

Graphic
It changes the types of waveforms. The representation starts with the si-
multaneous display of the pressure and flow waveforms. By pressing the
key successively, it goes from pressure to flow to pressure/volume and to
flow/volume loops.

48 Description
 Freeze
It only freezes the graph being shown, and enables the horizontal and ver-
tical cursors. The values and the airway pressure bars remain activated.
During this period, any change of value is disabled.
Scale (cursor)
While the graphics are active, [VERT] modifies the vertical scale in two
magnitudes depending on the graphic. The [HORZ] key modifies the time
from 6 to 12 seconds and vice versa in the pressure and flow waveforms;
in the case of loops, it modifies the volume scale.
The cursors are two dotted lines which may be moved horizontally or ver-
tically. The cursors are only activated when the graphs are frozen. They
disappear when they are unfrozen but are stored in the same position. In
order to move them, the screen is frozen, and the [VERT] key is pressed to
enable the vertical cursor and the [HORZ] key to enable the horizontal
one. Once one or the other cursor is activated, it may be moved to one
side or the other with the [↑↓] key in the Selection sector.
Menu (See page 36)

11. Respiratory Mechanics

This control is used to have access to a test menu of the respiratory mechanics
while the patient is being ventilated.
AutoPEEP
It determines the dynamic hyperinflation of the lung. The result is expressed in cm H2O.
Dynamic Compliance
It determines the ratio between the insufflated volume and the pressure necessary to
overcome the elastic and nonelastic resistance of the respiratory system, including the
tracheal tube. The result is expressed in mL/cm H2O.
Static Compliance
It determines the relationship between the insufflated volume and the necessary
pressure to overcome the elastic resistance of the respiratory system during a period
of zero flow. The result is expressed in mL/cm H2O.
Inspiratory and Expiratory Resistance
It determines the frictional resistance to a given inspiratory or expiratory flow put
up by the airways (the patient’s airway, artificial airway and of the ventilator’s cir-
cuit). The results are expressed in cm H2O/L/s.
Vital Capacity
To determine slow vital capacity.
P0.1
This measurement is used to predict the possibilities of weaning the patient from
the ventilator and to estimate the ventilatory reserve when the vital capacity mea-
surement cannot be obtained.
P/Vflex
It identify the lower an upper inflection in the Pressure/Volume curve using the
low flow infection method. Simultaneously it determines the compliance of the
middle portion of the curve.
Pimax
To measure the maximum negative inspiratory pressure.

End of
Chapter

Description 49
 This Page Intentionally Left Blank

50 Description
 Chapter 6

When the ventilator is started, a self-diagnosis test program is run, the

operating system of the ventilator makes a self-diagnosis of the program
and of the electronic circuit.

During this test there are a series of processes, some automatic ones and
others should be begun by the operator. These processes have the pur-
pose to check the operation of critical components, to calibrate the device
and to present a menu of options to make the choice of the different
modes that could be used. The verification includes four stages:

Stage 1
Comprises two steps:

a) Confirmation of the integrity of the RAM and EPROM memories of the

electronic circuit and of all the lights of the panel.
b) Test of operation of the proportional valves.

Stage 2
A menu appears on the screen, followed by this legend:

CATEGORY: ADULT
PEDIATRIC
NEONATE

PRESS ENTER TO ACCEPT

By pressing the [ ] key in the Selection sector, one of the categories is cho-
sen. The selection is accepted by pressing the [Enter] key.
CATEGORY: This selection causes the default values of the parameters to be
displayed and the values for the backup and the emergency ventilation to
be within the average range for each category.
The change of category is only made in this initial screen.
In this chapter will be explained the programming of Adult and Pediatric
category. The Neonate category will be seen in the next chapter.

Programming 51
 Stage 3
After accept the previous stage, the following diagram and message appears:

CALIBRATION

OUTLET
EXHALATION
VALVE
TUBES

PLUG
HEATER

Press ENTER to start

circuit calibration

Also it is possible to connect the Y in the conical metallic piece of the ped-
estal as one is seen in the following picture.

To make a correct calibration, a complete arrangement of the breathing cir-

cuit, including a heater (if used), should be connected between the ventilator
outlet and the exhalation valve. In this case, all the circuit will be checked.

Stage 4
Accepted the previous menu, in the screen the following message appears:

Calibration in process

xx%

The objective of this test is the calibration of the expiratory flow sensor
and of the expiratory valve. The bar indicates the progression of the test.

CAUTION
This calibration test should be made without the nebulizer connected
in the circuit.

52 Programming
Breathing circuit leaks
This test, besides the calibration, also checks the integrity of the patient’s
circuit. When a leak of gas exists for any part of the circuit less than 10
L/min, it is warned with the following message:
ATTENTION:
ATHE RESPIRATORY CIRCUIT HAS A LEAK OF xx L/MIN
THIS CAN GENERATE ERRORS IN:
EXPIRATORY VOLUME, PEEP AND TRIGGER
PRESS ENTER TO ACCEPT THE LEAK
PRESS RESET TO RESTART CALIBRATION

WARNING
With this situation, the ventilation procedure could be carrying
out but, if the leak is significant, it can produce danger in the control of the
ventilation. It is convenient to inspect the circuit carefully, to change the
damaged sector or to close the breach in convenient form.

If the leak is more than 10 L/min, as a safety measure, the ventilator be-
comes inoperative. Until the defect is not solved, the ventilator cannot be
programmed. In the screen the following message appears:

WARNING:
LEAK GREATER THAN 10 L/MIN
ADEQUATE VENTILATION IS NOT POSSIBLE.
CHECK PATIENT CIRCUIT.
PRESS RESET TO RESTART CALIBRATION

If during the course of the calibration there is an interrupted connection

of the breathing circuit (inadvertent disconnection) the calibration is not
completed. In this case, the screen shows the following message:

CALIBRATION FAILURE
KEEP THE CIRCUIT AIRTIGHT
THEN, REPEAT THE TEST
TO EXIT PRESS RESET

Recalibration
If during the ventilation of a patient it is necessary to change and to
recalibrate the breathing circuit, you can get the calibration screen
through the [Menu] key going to the TOOLS row.

This way they don't get lost the programming data that were using.

WARNING
This recalibration should be carried out with the breathing
circuit disconnected from the patient and closing the Y connector.

Programming 53
 Stage 5
Measured Values
.
Peak Flow TI I:E TE total VT VE
spont.
(L/min) (s) spont. (s) (bpm) (L) (L/min) Pressure
Limits

Category High Insp.

Pressure
Paw
Pressure
Peak Control (PCV)
(above PEEP)

Plateau
Pressure
Support (PSV)
Mean (above PEEP)

Base PEEP/CPAP
(reference value)

Oxygen
Monitor Low Insp.
Pressure

FIO2 Inspiratory I:E Machine Volume Sensitivity

Time Ratio Rate

After the previous stage, the screen is replaced by the outline for the sec-
tor of pressure and flow waveforms with an active zero line. The bar of
airway pressure also appears. The lights of all the lamps of the Operative
Modes sector blink, waiting for the selection of a Mode.

Operative Mode Key Selection

When a key is pressed in one of the Operative Mode sectors, the light of
the selected mode remains on. All the other lights are turned off. By
pressing the same key successively, it is possible to change to another
mode within the same sector. The possible option remains with the light
on; the other lights are turned off.

If before starting a ventilation mode, a key of another sector of the opera-

tive mode is pressed, a new sequence begins in that section. A given op-
erative mode may be completely programmed and stored in the temporary
memory. All the data remains stored as long as the equipment is not
turned off. To program any mode, there are certain mandatory controls, to
which the values must be assigned and accepted before they can begin to
operate.

Depending on the operative mode selected, the lights in the keys corre-
sponding to the controls that have been enabled begin to flash. Initially,
the controls that have been enabled have the default values, depending on
the patient category, to facilitate its programming. These initial values
may be accepted in all by pressing first the [Ctrl] key and then the [Enter]
key. All the lights of the keys that have been enabled stop flashing and a
green light is lit.

If any value is to be changed, the corresponding key is pressed, the value

of that parameter changes to inverse video. The change is made by press-
ing the [
] key in the Selection sector, and once it is accepted by pressing
[Enter], it returns to normal video and the light remains lit. If 5 seconds
after pressing a key, the value is not accepted (whether it is modified or
not), the value remains unchanged.

To change a value that has already been accepted, the corresponding key
is pressed. The light begins to flash. The new value will be accepted when
the [Enter] key is pressed; then the light will change to permanent light.
Until the value is not entered, the previous value remains active. If the
new value is not entered within 5 seconds, the previous value is not modi-
fied and the light returns to permanent light.

54 Programming
 Operative Modes
(Pediatric and Adult Category)

The operative modes that can be programmed with the

NEUMOVENT Graph are:

1) Volume mode: VCV

Operative Modes 2) Pressure modes: PCV, PSV/CPAP
Volume
VCV
3) Combined modes
Assist /Control • SIMV with Volume + Pressure Support
• SIMV with Pressure + Pressure Support
Pressure
• Options:
PCV
Assist /Control - Non-Invasive Ventilation
Pressure Support (PSV)
- Mandatory Minute Ventilation + Pressure Support
CPAP - Pressure Support with VT Assured
- Airway Pressure Release Ventilation
Combined
5) Backup ventilation
SIMV (VCV) + PSV

SIMV (PCV) + PSV

Figure 6-1. Each sector has a key. To get a particular mode the key
Options
should be pressed successively.

In the next part of this chapter will be described the programming for
ADULT and PEDIATRIC. The NEONATE category is described in Chapter 7.

To program an operative mode, there are specific command keys for those
mode and common keys that can be used for all the modes.

Within the commands, there are ones that are of obligatory use in all
modes, as well as other, also common but they are of non required use.

Required Use Commands

• High Inspiratory Pressure Alarm
• Low Inspiratory Pressure Alarm
• High and Low Tidal Volume Alarm
• Maximum Total Breathing Rate Alarm
• Fraction of Inspired Oxygen
• Sensitivity

Non Required Use Commands

Correspond to optional commands or of occasional use:
• PEEP
• Manual Trigger
• Nebulizer
• O2 100%

Programming 55
 Volume-Controlled Ventilation (VCV)
It includes the ventilatory mode with specific regulation of tidal volume.
The inspiratory pressure is variable, and it depends on the respiratory
impedance to regulated volume ratio.

During this mode, the ventilator works as a flow-controller where the se-
lected flow waveform is sustained during any variation of the lung compli-
ance/resistance.

In this mode, the ventilator is cycled by time, and the inspiratory flow is
automatically calculated and regulated. This means that for a given vol-
ume, the variations of the inspiratory flow are obtained by means of the
regulation of the inspiratory time. It also explains why the end of inspira-
tion is marked by a quick pressure drop without an inspiratory plateau,
unless it is specifically regulated.

In the volume mode, the way of generating the inspiratory flow may be
changed by means of the flow waveform change control.

Flow Waveform

The different flows are: constant, ascending ramp, sine and descending
ramp. Each of these flow waveforms also produce characteristic pressure
and volume waveforms.

Figure 6-2. The lower tracing corresponds to the four flow waves which
may be used in the volume-control mode. On the top, the pressure and
volume waves, corresponding to each flow waveform, are displayed.

56 Programming
Descending Ramp Flow Waveform
It is also called “decreasing” or “decelerating flow”. The descending ramp
flow waveform begins at the calculated peak value and decreases lineally
until zero is reached. In response to this decelerating flow, the pressure
and volume waveforms are quite similar to those of the pressure control
mode (PCV). However, in the VCV mode, the flow decrease is preset, while
in PCV it is entirely determined by the lung mechanics.

In this ventilator, when entering the mode selection, the descending ramp
flow is taken automatically by the program as the default flow waveform.
This decision was made considering that the NEUMOVENT Graph ventila-
tor is designed to make it easier for the patient to adapt him/herself to
the assist or spontaneous modes.

Figure 6-3. Simultaneous plotting of the airway pressure and flow using
the volume control operative mode with descending ramp flow waveform.

During volume assist ventilation, (inspiration triggered by the patient), the

initial high flow produced by the descending ramp flow meets the post-
trigger demand (post-trigger phase) better than the constant flow. It also
produces a lower pressure peak and higher mean pressure, thus produc-
ing an improvement of oxygenation.

Constant Flow Waveform

The constant flow produces a square waveform. During the inspiratory
phase, the pressure developed in the airway shows two sections. First
there is an initial fast increase due to a sudden pressurization of the cir-
cuit due to the continuous flow, which is considered to be a reflection of
the system resistive properties (resistance x flow). The second section has
a less sharp though progressive rise, and it depends on the flow derived
from the inspiratory time and the regulated volume, and represents the
system’s elastic properties. The pressure continues to rise until the end of
inspiration, a point which coincides with the stoppage of the flow (Maxi-
mum inspiratory pressure = [tidal volume/compliance] + [flow x resis-
tance]).

Programming 57
 Figure 6-4. Simultaneous plotting of the airway pressure and flow using
the volume control operative mode with constant flow waveform.

During assisted ventilation with constant flow, the observation of the pres-
sure waveform may help interpret any patient-ventilator asynchrony. The
next figure shows a concavity in the rising portion of the waveform as a
consequence of a flow demand higher than that generated by the ventilator.

Figure 6-5. The arrow indicates a concavity in the pressure waveform

during volume control ventilation with assist ventilation. The defect is
caused by a demand from the patient greater than the flow delivered by
the ventilator. Compare it to the profile of the normal tracing on the right.

Sine Flow Waveform

The flow waveform begins at zero, and reaches the maximum value in the
middle of the regulated inspiratory time, and begins to fall again until the
zero flow line. The flow waveform, as a whole, has a semi-circumference
shape. The pressure waveform profile is also of the sine type, but their
peak values have different times.

58 Programming
 Figure 6-6. Simultaneous plotting of
airway pressure and flow using the
volume-control operative mode with
sine flow waveform. Note that the
maximum pressure value is reached
after the maximum flow value.

Ascending Ramp Flow Waveform

It is also called “accelerating flow”. It begins at zero and increases lineally
and progressively until the peak flow is reached at the end of the set in-
spiratory time. In response to this type of waveform, the pressure and vol-
ume present an exponential tracing with a concavity upwards.

Figure 6-7. Simultaneous plotting of

airway pressure and flow using the
volume-control operative mode with
ascending ramp flow waveform.

Selection of the Flow Waveform

The selection of one or another flow waveform depends on the specific cir-
cumstances arising when trying to find the most appropriate way of ad-
justing the ventilator to the patient’s needs. The rectangular waveform is
the classic one, where the volume is attained with a comparatively low
flow, and with the lowest pressure peak. The decelerating (descending
ramp) flow waveform is appropriate in patients with respiratory assis-
tance, where the initial high flow may better satisfy the patient’s de-
mands; this waveform is the one producing the highest mean pressure.
The sine waveform is the one that simulates best normal breathing. The
accelerating (ascending ramp) flow waveform produces a higher pressure
peak and a lower mean pressure.

Programming 59
 VCV Programming

Required control keys with programming limits:

PEEP
CPAP
cm H2O

50
0

Other parameters
The alarm default values, which depend on whether the ADULT or
PEDIATRIC option was initially selected, will be displayed on the screen.
The change of any value is accomplished through the [Alarm Settings] key
(see Alarm Features page 41).

The programming of PEEP, sighs, inspiratory pause and nebulization is

optional. The 100% O2 procedure is available.

When beginning the programming, the descending ramp flow waveform

(decelerating flow) is active by default, but it may be changed at any mo-
ment. The descending ramp waveform produces the highest initial flow in
comparison to other waves, and may be more appropriate for patients
with assist ventilation.

WARNING
The volume control key [VT] regulates a drive reference value which will not
necessarily show the expired volume. This difference may be due to mul-
tiple factors: circuit compliance, system airtightness, positive end expiratory
pressure, etc.

In volume-control ventilation, the patient may start the inspiration with

its own effort, but if he presents with weak efforts or apnea, the ventilator
starts the inspiration according to the set baseline rate.

60 Programming
Sigh
The programming of sighs and inspiratory pause is only enabled in the
volume-control mode.

By pressing [Menu], selecting Ventilatory adjuncts and then the Sigh line, the
following menu appears on the screen:

By using the [

] key under Selection, the appropriate value is selected,
and each line is accepted with the [Enter] key. The notice of programmed
sigh is displayed over the name of the mode being used.

WARNING
The sigh volume is added to the already programmed tidal volume, so that:
total volume = tidal volume + sigh volume

To cancel the sigh function, select OFF under NUMBER.

Inspiratory Pause
By pressing [Menu], selecting Ventilatory adjuncts and then the Inspiratory
Pause line, the following appears on the screen:

INSPIRATORY PAUSE OFF

By pressing the [

] key, the inspiratory pause time is selected with varia-
tions every 0.25 seconds up to 2 seconds. The warning of programmed
pause is displayed on the left bottom of the screen. Simultaneously, the value
of the plateau pressure is displayed in the sector corresponding to airway
pressure (Paw).

Figure 6-8. Pressure and flow waveforms with 0.5 seconds of inspiratory
pause. During the pause, the flow drops to zero.

To cancel the inspiratory pause function, select OFF under TIME.

Programming 61
 Pressure-Controlled Ventilation (PCV)
In the Pressure-Controlled Ventilation mode (PCV), the NEUMOVENT
Graph ventilator works as a positive pressure controller because the pres-
sure waveform remains the same when the patient’s compliance or resis-
tance changes.

The switching from inspiration to expiration is normally regulated by time

(inspiratory cycling by time) or by pressure if the maximum safety pres-
sure limit is reached. As in all pressure controlled modes, during PCV, the
ventilatory volume is variable and depends on the lung size, the existent
pressure gradient at the beginning of inspiration between the upper air-
way and the alveoli, the respiratory system compliance and the available
inspiratory time.

The waveform of the pressure developed during inspiration is rectangular,

being the flow of the descending ramp type (decelerating flow). The typical
pressure plotting shows a quick lineal increase until the set pressure limit
is reached. Pressure is maintained constant during the set inspiratory time.

Figure 6-9. Pressure-Controlled Ventilation (PCV). Rectangular pressure

waveform with decelerating inspiratory flow. Inspiration is cycled by time.

In this mode, the initial flow is high and corresponds to the value of the
peak flow displayed on the screen.

The progressive fall of flow observed during inspiration is entirely deter-

mined by the lung mechanics. Therefore, in those conditions character-
ized by low resistance and low compliance, the flow may reach the zero
line far before the end of inspiration. On the contrary, when resistance is
normal and compliance is normal or high, the inspiratory flow may be
high at the end of inspiration, in particular if the inspiratory time is brief.

The advantage attributed to the PCV mode is the way in which the in-
spiratory pressure is controlled so that the regulated pressure is not ex-
ceeded. Depending on the regulated inspiratory time and on the lung
mechanics, the alveolar pressure will be closer or farther away from the
regulated pressure but it will never be higher.

62 Programming
Rise Time
The speed of the inspiratory pressurization may be varied by means of the
Rise Time keys, thus enabling a better adjustment of the ventilator to the
patient’s demand and lung mechanics.

Regulation
The Rise Time keys increase or decrease the pressurization speed, and the
height of the bar plotting the regulation level serves as a guide. Even
when each time the keys are pressed, there are 5 L/min changes in flow,
the regulation is empirical and the result depends on the characteristics
of the ventilated lung and on the regulated pressure. The simultaneous
visualization of the pressure waveform facilitates the achievement of an
appropriate setting.

A brief time will produce a quick pressurization, generating a rectangular

pressure waveform (characteristic of the pressure modes) and a deceler-
ated expiratory flow waveform.

Figure 6-10. PCV ventilatory mode: a) Slow rise time, the pressure
waveform looses its normal square configuration; b) Adequate rise time,
square pressure waveform and an evidently decelerated flow waveform.

Under certain circumstances, the rise up to a given pressure may be too

abrupt leaving a saw-tooth-like trace. These situations are solved by
modifying the rise time of the pressure waveform.

Figure 6-11. Example of an abrupt rise of the pressure waveform during

simulation of ventilation with a 20 cm H2O/L/sec resistance. The arrow
indicates that the RT (Rise Time) bar is too high.

Programming 63
 Figure 6-12. By maintaining the same resistance in the lung model, the
“rise time” was conveniently regulated.

NOTE
In the modes where PSV is combined with PCV, the rise time regulation in-
fluences both modes.

64 Programming
 PCV Programming

Required control keys with programming limits:

FIO2 Inspiratory I:E Machine Sensitivity Pressure

Time Ratio Rate Flow Pressure Control

. PEEP Rise
FIO2 TI I:E f Vtr Ptr CPAP Time
PCV
s bpm L/min cm H2O cm H2O cm H2O

1.0 3.0 1:99 150 5 10 50 70

0.21 0.1 5:1 1 0.5 0.5 2 2

WARNING
The set pressure value is always above the PEEP, i.e., the total pressure is
equal to the set one plus the PEEP value.

Other parameters
The alarm default values, which depend on whether the ADULT or
PEDIATRIC option was initially selected, will be displayed on the screen.
The change of any value is accomplished through the [Alarm Settings] key
(see Alarm Features page 41).

The programming of nebulization and PEEP is optional. The 100% O2 pro-

cedure is available.

The flow waveform is the descending ramp type and cannot be changed.

Sighs and inspiratory pause are not enabled.

The beginning of an inspiration may be triggered with the [Manual] key.

Programming 65
 Pressure Support Ventilation (PSV)
General Operation
One of the most outstanding characteristics of the NEUMOVENT Graph
Ventilator is the way the pressure support is programmed and operated.
This feature allows a greater efficiency in the adjustment of the ventilator
controls to the patient’s ventilatory needs.

Pressure support ventilation is a spontaneous ventilation mode where the

patient begins and ends the inspiratory phase; this means that he keeps
control of the frequency, the duration of the inspiration and of the tidal
volume. As in all modes limited by pressure, the tidal volume (VT) is vari-
able, depending on the regulated pressure in relation to the respiratory
system impedance, as well as to the patient’s demand.

In this ventilator, the pressure support is programmed directly, alone or

in combination with other modes.

The pressure support may be analyzed in three sectors of the respiratory

cycle: a) Beginning of Inspiration; 2) Inspiration and 3) End of Inspiration.

Figure 6-13. Pressure Support Ventilatory Mode. Pressure and flow

waveforms. The RT (Rise Time) bar is to the right.

66 Programming
1) Beginning of Inspiration
The inspiratory phase always begins (or is triggered) by the patient’s in-
spiratory effort. The trigger sensitivity control makes the patient’s effort be
greater or smaller. A good target is to try to achieve a greater sensitivity
without autocycling, so that the effort will be minimized.

The sensitivity is regulated by the flow variations (flow-triggered) or by the

pressure changes (pressure-triggered).

Vtr)
Flow Trigger Sensitivity (V
When flow sensitivity is selected, the ventilator makes a continuous flow
pass through the respiratory circuit during the expiratory phase. Inspira-
tion begins when the microprocessor detects a difference between the flow
coming into the respiratory circuit and the one leaving. The difference is
produced when the patients aspirates part of this continuous flow.

The difference between the flow entering the circuit and the one leaving
necessary to produce an inspiration may be set from 0.5 to 5 L/min. The
continuous flow is twice the selected difference. For example, for a flow
sensitivity of 3 L/min, a continuous flow of 6 L/min is produced in the
circuit; if in the connection to the patient 3 L/min or more are aspired, an
inspiratory cycle is triggered.

In all modes, the flow sensitivity is the default parameter. Even when the
flow sensitivity is selected, the beginning of an inspiratory phase may be
marked by a drop in the pressure waveform.

Pressure Trigger Sensitivity (Ptr)

In pressure-triggered sensitivity, the inspiration is triggered when a pressure
fall equal or greater than the selected one is detected in the respiratory circuit.

When pressure sensitivity is selected, and a PEEP value is set, a continu-

ous flow is also produced during the expiratory phase. This continuous
flow is intended to avoid a PEEP fall during prolonged expiratory periods
due to the patient’s circuit and/or to the expiratory valve, but it is not
directly involved in the sensitivity process.

2) Inspiration
This sector includes: a) pressurization period and b) set pressure holding
period.

a) Pressurization
The flow produced by the ventilator towards the respiratory circuit makes
the pressure begin to rise in the patient-ventilator system faster or slower.
The rise will be fast or slow depending on the initial flow. This initial flow
acts as a system pressurization factor.

Regulation of the pressurization speed (“Rise Time”)

The regulation of the pressurization speed, i.e., of the pressure rise time
allows a better adjustment of the inspiratory flow to the demand, and of
the patient’s post-trigger phase. This regulation is obtained by means of
the Rise Time control.

Programming 67
 A brief time will produce a quick pressurization, which will generate a
rectangular pressure waveform, characteristic of the mode, and a deceler-
ated expiratory flow waveform.

Figure 6-14. a) Slow rise time: the pressure waveform looses its normal
square configuration; b) Adequate rise time: square pressure waveform
and an evidently decelerated flow waveform.

If the peak flow is too high for the patient’s and/or circuit conditions,
there may be a failed inspiration, where the pressure is not maintained
and the tidal volume is very low.

Figure 6-15. Pressure Support with excessive regulation of the Rise

Time in relation to the circuit conditions and thus producing breathing
with little effectiveness.

68 Programming
When there is an increase of the airway resistance, the increase up to a
given pressure may be too abrupt causing a saw-tooth-like plotting.

Figure 6-16. Abrupt rise of the pressure waveform during a simulation of

ventilation with a 20 cm H2O/L/sec resistance. The arrow indicates that
the RT (Rise Time) bar is too high.

On the opposite end, a very low Rise Time in relation to the patient’s and/
or circuit conditions, does not let the pressure rise to the set value (with-
out producing the characteristic plateau) and also resulting in a ventila-
tory tidal volume lower than expected with a prolonged inspiratory time.
Between these two situations there is significant variability, and by han-
dling this variability, it is possible to adjust the peak flow to the patient’s
demands and conditions.

Figure 6-17. Pressure Support with low regulation of the Rise Time. The
pressure waveform looks similar to the one in the Volume mode with
rectangular flow waveform.

As it can be observed in the figures, the Rise Time is graphically repre-

sented by a vertical rectangle with a bar indicating the magnitude of the
peak flow. The bar does not have any values because the initial flow is
variable and depends on the system impedance, both of the ventilator and
of the patient. When there are no obstructions in the circuit, the gener-
ated flow may be varied up to 180 L/min according to patient's demand.

Programming 69
 The Rise Time may be regulated both in the Pressure Support mode alone
or in PSV of the combined modes. When the pressure support is com-
bined with Pressure-Controlled Ventilation (PCV), the regulated rise time
affects both modes.

b) Set Pressure Holding Period

Once the pressure value is achieved, the pressure is held stable while the
flow demand is greater than the one selected as end of inspiration. If the
rise time has been set higher than necessary, a brief pressure peak may
be observed at the beginning of the plateau and, as mentioned before, if
the change is excessive, a spiked pressure waveform is produced and
there is ineffective ventilation.

3) End of Inspiration
The inspiratory phase ends when during inspiration three types of
changes take place:

1) When the progressive decrease of the inspiratory flow reaches a given

percentage of the peak flow.
2) When the inspiration lasts more than 3 s in adult (ADL), 2 s in pediat-
ric (PED) and 1 second in neonatology (NEO) categories.
3) When the pressure rises abruptly more than 14% plus 5 cm H2O over
the set one in all categories.
The mechanism mentioned first is the usual one for the end of inspira-
tion. The other two are exceptional forms to protect the ventilation from
undesirable effects.

Regulation of the Expiratory Sensitivity (End of Inspiration)

During PSV, whether alone or in a combined mode, the percentage of the
peak flow may be regulated to produce the end of inspiration. Therefore,
by regulating this percentage, the expiratory sensitivity, that is the expira-
tory trigger, may be controlled.

By default, the program takes a 25% of the initial flow to end the inspira-
tion. This percentage may be changed by means of the [Menu] selecting
Ventilatory adjuncts and then the Expiratory sensitivity (PSV), or pressing:

Ctrl + PSV

to 50%
45%
40%
35%
30%
25% (default)
20%
15%
10%
5%
By changing the percentage, the flow waveform is modified, thus allowing
a better adjustment of this ventilatory mode to the patient’s demand.

70 Programming
 Figure 6-18. Flow waveforms with different expiratory sensitivity values.
The conditions of the lung model are equal in the three examples:
Breathing rate: 15 per minute, C50 and Rp5. The dotted line shows the
25% of the peak flow.

Note the significant difference between the two ends of the expiratory sen-
sitivity as regards tidal volume, minute volume and inspiratory time.

Figure 6-19. Overlapping of the flow tracings plotted in Figure 6-18. The
dotted line shows the 25% of the peak flow.

This regulation of the expiratory sensitivity, together with the rise time,
makes it possible for the NEUMOVENT Graph ventilator to handle the dif-
ferent conditions in patients ventilated with pressure support.

Programming 71
 PSV Programming
Since Pressure Support Ventilation is a spontaneous ventilation mode,
where the patient starts the inspiration with his own effort, it may happen
that, during ventilation, the effort decreases or stops. When there is lack
of stimulus, the ventilator does not cycle, therefore, in this mode, the
Backup Ventilation must be programmed. When the PSV mode is se-
lected, a message is displayed on the screen addressing the programming
of the backup ventilation first. The PSV can only be programmed once the
backup ventilation has been programmed.

Generally, PSV is used after a controlled or assist mode, when there is

already a reference as to the tidal volume and pressure used. These data
are important to set the initial ventilation values. In order to achieve a
tidal volume similar to the one used, an approximately equal pressure
must also be regulated.

With the first breaths, if necessary, the pressure will be varied looking for
the required volume. Also, by modifying the expiratory sensitivity, the re-
sulting volume is changed.

Required control keys with programming limits:

FIO2 Sensitivity Pressure

Flow Pressure Support

. PEEP PSV
Rise
FIO2 Vtr Ptr CPAP Time
L/min cm H2O cm H2O cm H2O

1.0 5 10 50 70
0.21 0.5 0.5 0 0

Other parameters
The alarm default values, which depend on whether the ADULT or
PEDIATRIC option was initially selected, will be displayed on the screen.
The change of any value is accomplished through the [Alarm Settings] key
(see Alarm Features page 41).

The programming of nebulization and PEEP is optional.

The 100% O2 procedure is available. The flow waveform is of the descend-

ing ramp type and cannot be changed. The expiratory sensitivity may be
varied between 5% and 50%. In order to have access to the change menu,
press the [Ctrl] + [PSV] keys successively.

Sighs and inspiratory pause are not enabled. The beginning of an inspira-
tion may be triggered with the [Manual] key. In the lung mechanics, only
Vital Capacity and P0.1 tests are enabled.

72 Programming
Pressure Support Monitoring
In the NEUMOVENT Graph ventilator, the PSV monitoring is continuous.
The measured and resulting values of these parameters are on the left
and at the top of the screen. Those on the left correspond to the airway
pressures. The figure below shows the simultaneous plotting of the airway
pressure and flow while the ventilator is connected to a lung model with a
Compliance of 0.050 L/cm H2O (C50) and a Resistance of
5 cm H2O/L/s (Rp5).

.
Peak Flow TI I:E TE total VT VE
spont.
(L/min) (sec) spont. (sec) (bpm) (L) (L/min) Pressure
Limits
(cmH2O)

High Insp.
Category BAT FULL
RT Pressure
Paw Pressure
(cmH2O) Control (PCV)
(above PEEP)
Peak

Plateau Pressure
Support (PSV)
(above PEEP)
Mean
PEEP/CPAP
Base (reference value)

Oxygen Low Insp.

Monitor Pressure

FIO2 Inspiratory I:E Machine Volume Sensitivity

Time Ratio Rate Tidal Minute Flow Pres.
(sec) (bpm) (L) (L/min) (L/min) (cmH2O)

The tracings observed in the figure have the typical aspect of this ventila-
tory mode. The pressure rises quickly keeping a plateau while the demand
lasts. Simultaneously, the flow drops progressively until the point corre-
sponding to the percentage of the peak flow which will mark the end of
the inspiratory phase. In this case, it is of 25%.

The pressure peak is 1 cm H2O higher than the set PS value. When Rise
Time is appropriately set, a pressure peak over 1 to 2 cm H2O over the set
one is accepted. Note the RT bar has a relative value of 1/3 of the total
flow availability.

Besides the expiratory time (TE), the inspiratory time (TI) is displayed im-
mediately below the first one. The position of the TI value means that it is
an inspiratory time with spontaneous breaths, and that in this mode it is
not programmed with the [TI] key. The monitoring of TI during spontane-
ous ventilation is very useful to adjust the ventilator.

The monitoring of the tidal volume and of the minute volume is the main
objective of the procedure. The tidal volume is updated breath by breath.
The minute volume is updated with each change of the graph cursor
screen.

Programming 73
 Continuous Positive Airway Pressure (CPAP)
It is a spontaneous breathing mode where the patient ventilates in a
continuous positive pressure system. There are no mechanical positive-
pressure breaths delivered, but the inspiration of the patient causes that the
ventilator generates a flow proportional to the demand. The patient’s effort
that open the flow valves is regulated by a sensitivity control.

The ventilator maintains an active pneumatic control of the continuous

positive pressure by means of the action of a proportional valve on the
diaphragm of the exhalation valve.

During the inspiration, the airway pressure graphic

shows a slight reduction in relation to the base line
of the continuous positive pressure and, during
the exhalation, an ascent of this pressure, that is
to say, an inverse waveform to the observed during
intermittent positive pressure.

The positive pressure level is regulated with the

PEEP/CPAP key. The others useful controls are
the Rise Time to regulate the available inspiratory
flow, and the Sensitivity to adapt the inspiratory
triggering to the effort of the patient. When the
ventilator does not sense airway pressure oscilla-
tions, it assumes an apnea state beginning to
ventilate with the Backup mode previously pro-
grammed. The response time or of the “apnea time”
is adjustable between 5 and 60 seconds; 15 sec-
onds is the default value.

Programming
The programming of CPAP is the same of the Pressure of Support with
PSV 0 (zero), and with PEEP set in an appropriate level.

Monitoring
The upper part of the screen exhibits, breath by breath, the resulting values
of: Inspiratory Peak Flow, Inspiratory Time, I:E Ratio, Breathing Frequency,
Exhaled Tidal Volume and Minute Volume.

The left part of the screen shows the resulting airway pressures: Peak, Mean
and Base (CPAP level). The lung icon is shown in each effective inspiration.

74 Programming
 Combined Modes
This group includes the ventilatory modes in which the patient has spon-
taneous ventilation with synchronized intermittent mandatory ventilation.
Mandatory inspiration means that the ventilator begins a programmed
inspiratory phase (VCV or PCV) at a preset rate per minute.

In some modes of this group, the patient’s breathing is monitored and

completed, if necessary, with target minute volume or target tidal volume.

As in all spontaneous modes, the Backup ventilation must be pro-

grammed first, since it will automatically replace the mode being used
when the ventilator detects a failure in the spontaneous breathing during
the set apnea time. However, in both SIMV, it is possible to choose to can-
cel the command used to enter into backup ventilation, since the rate of
mandatory inspiration remains as protective measure in case of apnea.

The combined modes that may be programmed are:

• SIMV (VCV) + PSV

Synchronized intermittent ventilation with volume-controlled manda-
tory inspiration and spontaneous inspirations with pressure support.

• SIMV (PCV) + PSV

Synchronized intermittent ventilation with pressure-controlled manda-
tory inspiration and spontaneous inspirations with pressure support.

• NIV
Non-invasive ventilation (NIV) is referred as ventilatory support
through the upper airway using a mask or a similar device. This tech-
nique is differentiated from the invasive one that uses tracheal tube,
laryngeal mask, or tracheotomy to provide ventilation.
This ventilator perform non-invasive ventilation with positive pressure
and leaks compensation.

• MMV + PSV
Mandatory minute ventilation with pressure support. The ventilator has
an automatic control of the pressure support level in order to guarantee
a minimum minute ventilation during an eventual decrease of the spon-
taneous breathing.

• PSV + VT Assured
Pressure support ventilation with assured tidal volume in case of an
eventual reduction of the breathing effort. In this mode the objective is
to guarantee a minimum tidal volume from a pressure regulated inspi-
ration.

• APRV
Is a mode which ventilates applying periodic switching between two ad-
justable levels of CPAP during preset periods of time. Spontaneous
breathing with or without PSV is possible at both levels.

Programming 75
 SIMV (VCV) + PSV
(SIMV [Volume-Control Ventilation] with Pressure Support)
In this synchronized ventilation mode, during mandatory breathing, the
patient receives a preset volume provided at a preset inspiratory time and
rate. During spontaneous breathing, the patients breathes with pressure
support.

The flow waveform of the mandatory inspirations may be changed during

ventilation.

Figure 6-20. Pressure (top) and flow (bottom) waveforms during SIMV
(VCV) + PSV. The arrow indicates a volume-controlled synchronized
mandatory breath with constant flow.

76 Programming
 SIMV (VCV) + PSV Programming
The programming is done by entering the values which correspond to the
volume-control ventilation mode on the one hand, and the spontaneous
mode (PSV) on the other.

Controls that are enabled and subject to mandatory programming:

For mandatory breathing (VCV) and spontaneous breathing (PCV)

FIO2 Inspiratory Machine Volume Sensitivity Pressure

Time Rate Tidal Minute Flow Pressure Support

. . PEEP Rise
PSV
FIO2 TI f VT VE Vtr Ptr CPAP Time
(s) (bpm) (mL) L/min cm H2O cm H2O cm H2O

1.0 3.0 150 2.500 5 10 50 70

0.21 0.3 1 5 0.5 0.5 0 0
Other parameters
The alarm default values, which depend on whether the ADULT or
PEDIATRIC option was initially selected, will be displayed on the screen.
The change of any value is accomplished through the [Alarm Settings] key
(see Alarm Features page 41).

The activation of PEEP, nebulization, 100% O2, inspiratory pause and

sighs for VCV are enabled. Manual pressing produces a mandatory inspi-
ration. In the respiratory mechanics, the Vital Capacity, P0.1 and Pimax
tests are enabled. Backup Ventilation, by default, is OFF, but it can be set
ON.

When programming the pressure support, the Rise Time may be varied.
To vary the expiratory sensitivity, press [Ctrl] + [PSV] successively to have
access to the change menu.

Programming 77
 SIMV (PCV) + PSV
(SIMV [Pressure-Controlled Ventilation] with Pressure Support)
In this synchronized ventilation mode, during mandatory breathing, the
patient receives pressure-controlled inspirations, with a decelerating flow,
provided at a preset inspiratory time and rate. During spontaneous
breathing, the patients breathes with pressure support.

Figure 6-21. Pressure (top) and flow (bot-

tom) waveforms during IMV (PCV) + PSV.
The arrow indicates a pressure synchro-
nized mandatory breath.

SIMV (PCV) + PSV Programming

Controls that are enabled and subject to programming:

FIO2 Inspiratory Machine Sensitivity Pressure Pressure

Time Rate Flow Pressure Support Control

. PEEP Rise
FIO2 TI f Vtr Ptr CPAP PSV Time
PCV
cm H2O cm H2O
(s) (bpm) L/min cm H2O cm H2O
1.0 3.0 150 5 10 50 70 70
0.21 0.3 1 0.5 0.5 0 0 2

Other parameters
The alarm default values, which depend on whether the ADULT or
PEDIATRIC option was initially selected, will be displayed on the screen.
The change of any value is accomplished through the [Alarm Settings] key
(see Alarm Features page 41).
The activation of PEEP, nebulization, and 100% O2 are enabled. Manual
pressing produces a mandatory inspiration. In the respiratory mechanics,
only the Vital Capacity and P0.1 tests are enabled. Backup Ventilation, by
default, is OFF, but it can be set ON. The changes in the Rise Time affect
both PCV and PSV. To vary the expiratory sensitivity of PSV, press [Ctrl] +
[PSV] successively to have access to the change menu.

78 Programming
 Non-Invasive Ventilation (NIV)
It is a mode controlled by pressure that combines characteristics of PCV
and PSV. The inspiratory pressure is adjustable up to 50 cm H2O, and it
is possible to add PEEP from 2 to 20 cm H2O.

The system can compensate leaks according to the patient's category. This
feature allows to stabilize the regulated pressure and trigger sensitivity
avoiding autocycling and thus improving patient-ventilator synchrony.
This mode has two ways to end of the inspiration: 1) The classic PSV cri-
teria, from 5% to 50% of the peak flow, and 2) Maximum inspiratory time
setting.

As a backup, a minimum respiratory frequency can be set in order to

guarantee the continuity of ventilation in case of reduction of the inspira-
tory effort.

The monitored expired tidal volume is an "estimated" of which the patient

receives, and its calculation considers eventual leaks.

NIV Programming
Operatives Modes Pressing the [Combined] key successively, Options is selected. The LED
Volume
blinks and the following menu is shown in the screen:
VCV
Assist/Control
Pressure NIV
PCV
Assist/Control Mode: MMV + PSV
Pressure Support (PSV)
CPAP PSV + VT ASS
Combined APRV
SIMV (VCV) + PSV Accept the mode pressing [Enter]. Simultaneously the following keys are
SIMV (PCV) + PSV
enabled:
Options

FIO2 Insp. Time Machine Sensitivity Pressure

Rate Flow Pressure Support

. PEEP Rise
FIO2 TI f Vtr Ptr CPAP
PSV
Time
(s) (bpm) L/min cmH2O cmH2O cmH2O
1.0 3.0 70 5 10 20 50
0.21 0.3 1 0.5 0.5 2 0

In this picture, the programming values range are seen below each key.
Other parameters
The alarms default values, those that depend on the patient's category,
are shown in the screen. The change of values is carried out by means of
the [Alarm Settings] key. This mode has, in addition, a non-compensated
leak alarm, and a mask disconnection alarm nonadjustable by the user.
Pressing the [Manual] key produces the beginning of an inspiration.
The respiratory mechanics is inactive. The 100% O2 control is inactive.

Programming 79
 MMV with PSV
(Mandatory Minute Ventilation with Pressure Support)
It is a totally spontaneous ventilatory mode where the patient breathes
with pressure support at a preset initial value, and there is regulation of a
minimum minute volume. During every minute, if the volume is not
reached, the pressure support level increases progressively until that vol-
ume is attained.

Figure 6-22. Pressure (top) and flow (bottom) waveforms during simula-
tion of breathing with Mandatory Minute Ventilation. The initial process
with a pressure support of 10 cm H2O is displayed, and the progressive
pressure increase may be observed.

Any reduction of the spontaneous breathing is automatically sensed by

the ventilator and the mechanical ventilatory support is increased without
the need of the operator being involved. On the other hand, an increase in
the spontaneous breathing will produce a decrease of the ventilator-driven
ventilation.

The pressure variations are of one or two centimeters of water to avoid

any abrupt rise or drop. Since the minute volume depends on the tidal
volume demanded by the patient and on the spontaneous breathing rate,
once the target minute volume is reached, there are usual variations
above or below the target.

The fact that the maximum and minimum alarm limits for the tidal vol-
ume and the minute volume and those of the airway pressure are en-
abled, ensures a protection against eventual undue increases either in the
pressure and/or in the volume.

80 Programming
 MMV with PSV Programming
Pressing the [Combined] key successively, it will be get the Options row.
The LED will lit and the following menu appears:

NIV
Mode: MMV + PSV
PSV + VT ASS
APRV

Accept the mode with the [Enter] key. Simultaneously the following keys
are enabled:

FIO2 Volume Sensitivity Pressure

Tidal Minute Flow Presure Support

. . PEEP PSV
Rise
FIO2 VT VE Vtr Ptr CPAP Time
L/min L/min cmH2O cm H2O cmH2O

1.0 45 5 10 50 70
0.21 1 0.5 0.5 0 0

Other parameters
The alarm default values, which depend on whether the ADULT or
PEDIATRIC option was initially selected, will be displayed on the screen.
The change of any value is accomplished through the [Alarm Settings] key
(see Alarm Features page 41).

The activation of PEEP, nebulization, and 100% O2 are enabled. Manual

pressing starts an inspiration. In the respiratory mechanics, only the Vital
Capacity and P0.1 tests are enabled.

When programming the pressure support, the Rise Time may be varied.
To vary the expiratory sensitivity, press [Ctrl] + [PSV] successively to have
access to the change menu.

Programming 81
 PSV with VT Assured
(Pressure Support Ventilation with Tidal Volume Assured)
It is a spontaneous ventilatory mode where the patient breathes with
pressure support at a given value combined with the regulation of the
minimum tidal volume. If during each breath, the set volume is not
reached, the descending ramp flow changes to continuous flow. This effect
produces a rise in the inspired volume until the target volume is reached
with a concomitant rise in the airway pressure.

Figure 6-23. Pressure Support Ventilation with Assured Tidal Volume.

Note the change in the descending ramp flow waveform to constant flow;
simultaneously, there is a progressive pressure increase until the target
tidal volume is reached.

In the following table, the operation of this mode is described by compar-

ing the volume attained by the patient with the volume set as target.

Condition

Variable Patient’s VT > Set VT Patient’s VT < Set VT

Control Pressure Pressure ® Volume

Trigger Patient (pressure or flow) Patient (pressure or flow)

Limit Pressure Pressure ® Flow

Cycling Flow Volume

Thus, when the volume inspired by patient reaches or exceeds the target
volume, the end of inspiration is cycled by flow as in an ordinary PSV. If
the inspired tidal volume is not reached when the flow reaches the set
percentage of the initial one, then the flow changes to constant flow and
completes the target volume with a pressure increase.

82 Programming
 PSV with VT Assured Programming
Pressing the [Combined] key successively, it will be get the Options row.
The LED will lit and the following menu appears:

NIV
Mode: MMV + PSV
PSV + VT ASS
APRV

With the Selection keys move down the highlighted band and accept the
mode with the [Enter] key. Simultaneously the following keys are enabled:
Controls that are enabled and subject to programming:

FIO2 Volume Sensitivity Pressure

Tidal Minute Flow Pressure Support

. . PEEP PSV
Rise
FIO2 VT VE Vtr Ptr CPAP Time
cm H2O
(mL) L/min cmH2O cmH2O

1.0 2.000 5 10 50 70
0.21 50 0.5 0.5 0 0

Other parameters
The alarm default values, which depend on whether the ADULT or
PEDIATRIC option was initially selected, will be displayed on the screen.
The change of any value is accomplished through the [Alarm Settings] key
(see Alarm Features page 41).

The activation of PEEP, nebulization, and 100% O2 are enabled. Manual

pressing produces a mandatory inspiration. Sighs are not enabled. In the
respiratory mechanics the Vital Capacity, P0.1 and Pimax tests are enabled.

WARNING
In this mode, the airway pressure may rise to undesirable values during the
inspiratory phase (inadequate combination of parameters); therefore, it is
convenient to set the maximum pressure alarm limit at a value close to the
selected pressure support level.

Rise Time and the percentage of the flow change from decelerated to con-
tinuous may be varied when programming the pressure support. The rise
time is regulated with the dedicated keys.
The flow change (decelerated to constant) in relation to the percentage of
the peak flow, may be adjusted at 50%, 45% 40%, 35%, 30%, 25%, 20%,
15%, 10% and 5%. Given the same conditions of lung compliance and
resistance, a high percentage produces a brief inspiration (less inspiratory
time), and a low percentage extends the inspiratory time.
When the mode has just been programmed, the default change percentage
is 25%. It is changed by pressing [Ctrl] + [PSV].

Programming 83
 Airway Pressure Release Ventilation (APRV)
The Airway Pressure Release Ventilation is a mode which ventilates apply-
ing periodic switching between two adjustable levels (P-high and P-low) of
continuous positive airway pressure (CPAP) during preset periods of time.
Spontaneous breathing is possible without restriction at both levels, with
or without pressure support (PSV).

In the NEUMOVENT Graph Ventilator this mode can be implemented in the

adult (ADL) and pediatric (PED) category.

The two levels of positive pressure, alternating to intervals of time selected

by the operator, produce intermittent distension and passive decompres-
sion of the lungs. At the same time, and so much during the upper or
lower level, the patient can breathe spontaneously with or without pres-
sure support. According to the regulation of the upper and the lower pres-
sure time, it can be administer ventilation with inverse I:E ratio.

Peak Flow


TI I:E TE total VT VE
spont.
(L/min) (sec) spont. (sec) (bpm) (L) (L/min) Pressure
Limits
(cmH2O)

High Insp.
BAT FULL
Category Pressure
Paw Pressure
(cmH2O) Control (PCV)
(above PEEP)
Peak

Plateau Pressure
Support (PSV)
(above PEEP)
Mean
PEEP/CPAP
Base (reference value)

Oxygen Low Insp.

Monitor Pressure

FIO2 Inspiratory I:E Machine Volume Sensitivity

Time Ratio Rate Tidal Minute Flow Pressure

Screen showing pressure curves during ventilation with Airway Pressure

Release Ventilation. In the periods of high and lower CPAP the waves
are that of the set pressure support.

The double function of the [Inspiratory Time] and of [PEEP/CPAP] keys

mark the difference with the other operative modes. In the sector of the
Inspiratory Time like in of PEEP/CPAP the values correspond, the supe-
rior, to the period of high CPAP and, the inferior, to that of lower CPAP.

The I:E and Rate keys are inactive but each result of the spontaneous
ventilation value is shown in the corresponding sector of the screen.

84 Programming
 APRV Programming
Pressing the [Combined] key successively, it will be get the Options row.
The LED will lit and the following menu appears:

NIV
Mode: MMV + PSV
PSV + VT ASS
APRV

With the Selection keys move down the highlighted band and accept the
mode with the [Enter] key. Simultaneously the following keys are enabled:

FIO2 Inspiratory Sensitivity Pressure

Time Flow Pressure Support

. PEEP PSV
Rise
FIO2 TI Vtr Ptr CPAP Time
seconds L/min cm H2O cm H2O cmH2O

1.0 CPAP high: 1 a 30 5 10 CPAP high: 0 a 50 70

0.21 CPAP low: 0.5 a 30 0.5 0.5 CPAP low: 0 a 50 0
Default values
5.0 s 5 cm H2O
0.50 3 L/min 5 cm H2O
1.5 s 0 cm H2O

PEEP
CPAP
[PEEP/CPAP]
The default values are of 5 and 0 cm H2O for P-high and P-lower CPAP,
respectively. In the screen, the first value appears in the normal place of
PEEP/CPAP. The second appears under the previous one.

To change the CPAP values the [PEEP/CPAP] key it is pressed once to

modify the high value or twice for the lower, with change of the number to
inverse video. With the key [

] of Selection sector it can be increased or
decreased the value, accepting with [Enter]. The low value can be same
but not bigger that the high.

TI [Ti]
This key completes a double function by means of which it can be ad-
justed the time value of the high and lower CPAP pressure period. The
values for default are 5 and 1.5 seconds respectively. In the screen, the
values appear one above the other one in the place that corresponds at
the Inspiratory Time.

To change the time values the [Ti] key should be pressed one or twice,
enabling the number of the high or low time respectively. With the key [

]
of Selection sector it can be increase or decrease the value, accepting with
[Enter].

[I:E] I:E Ratio

The key is inactive for programming, however, the value that corresponds
to the relationship between the high and the low CPAP time is shown in
the screen.

Programming 85
 up

[PSV] - [Rise Time]

PSV Rise
Time
down

During the period of high and low CPAP, the patient can have spontane-
ous ventilation with or without pressure support. As default there is 5 cm
H2O of pressure support but it can be changed from 0 to 50 cm H2O.

The pressurization of the beginning of the inspiration is regulated with

the Rise Time keys.

Ptr Vtr [Sensitivity]
Key enabled to regulate the trigger sensitivity during the spontaneous
breathing. For default, the sensitivity is for flow of 3 L/min.

f [f ] Machine Rate - bpm

The key is inactive for programming, however, the value of rate of the
high to low CPAP is shown as breathing frequency in the screen. If the
patient has spontaneous ventilation, the resulting frequency is shown in
f total screen sector.

Other keys
They are enabled for general programming:

FIO2 [FIO2]
With 0.50 as default value

O2
100% [O2 100%]
For pre and post tracheobronchial suction oxygenation.

Alarm Limits
The alarm default values, which depend on whether the ADULT or
PEDIATRIC option was initially selected, will be displayed on the screen.
The change of any value is accomplished through the [Alarm Settings] key
(see Alarm Features page 41).

As in the other modes, once accepted all the values the following message
appears:

ACCEPTED VALUES
PRESS [ENTER]

Backup Ventilation
In this mode, the Backup Ventilation, by default, is OFF, but it can be set
ON. To open the Backup Ventilation menu, it should be pressed the
[Ctrl] + [VCV] or [PCV] keys.

Lung Mechanics
In the lung mechanics, only Vital Capacity and P0.1 tests are enabled.

86 Programming
 Backup Ventilation
Backup ventilation is a mode intended to assure ventilation in patients
when there is a decrease in the breathing effort or episodes of apnea dur-
ing the spontaneous ventilation modes.

The modes in which it is necessary to program the backup ventilation are:

• Pressure Support Ventilation (PSV) and CPAP.

• Volume-controlled SIMV, with pressure support.
• Pressure-controlled SIMV, with pressure support.
• Mandatory minute ventilation with pressure support.
• Pressure support ventilation with assured volume.

When selecting one of this modes, and after accepting the values, the fol-
lowing message appears on the screen:

The apnea time default value is 15 seconds. It may be changed by press-

ing the [ ] key in the Selection sector. To accept the value, press [Enter].

In SIMV, either the activation of the backup ventilation with alarm (ON) or
no backup ventilation (OFF) may be chosen. The default option for both
SIMV and APRV modes is OFF (backup ventilation deactivated). By press-
ing the [ ] key in the Selection sector, one of the two options is chosen. In
order to accept the selected one, press [Enter].

Action: When there is no inspiratory effort or when it is weak, the apnea

alarm will be activated after the selected elapsed time (5, 10, 15, 30, 60
seconds). The ventilator will automatically enter into Backup Ventilation if
it has been programmed, and this is indicated by the following message:

APNEA ALARM ACTIVATED

BACKUP VENTILATION IN USE

The alarm sounds for 5 seconds while the message and light remains on.
If the cause persists, the sound is activated every 10 seconds for 5 sec-
onds, and this sequence continues until the cause disappears, or the op-
erative mode is changed.

If the patient recovers the inspiratory effort while the backup ventilation
is on, the ventilation in the programmed mode is resumed, the sound
stops but the light for Apnea continues on until the [Reset] key is pressed.

Programming 87
 Backup Ventilation Programming
The programming of the backup ventilation depends on the patient’s cat-
egory. It is in the VCV (Volume-control ventilation) or PCV (Pressure-con-
trolled ventilation) mode with ADULTS and PEDIATRIC patients, and in
the PCV (pressure-controlled ventilation) with NEONATAL patients.

Controls that are enabled and subject to programming:

PEDIATRIC AND ADULT: VOLUME-CONTROLLED MODE

FIO2 Inspiratory Machine Volume Sensitivity

Time Rate Tidal Minute Flow Pressure

. .
FIO2 TI f VT VE Vtr Ptr
Set value Set value or: Set value or: Set value or: Set value or:
or 0.50 ADL: 1.0 s ADL: 12 rpm ADL: 400 mL 2 L/min
PED: 0.7 s PED: 14 rpm PED: 200 mL

PEDIATRIC AND ADULT: PRESSURE-CONTROLLED MODE

FIO2 Inspiratory Machine Sensitivity Pressure

Time Control
Rate Flow Pressure
.

. Rise
FIO2 TI f Vtr Ptr Time PCV
Set value Set value or: Set value or: Set value or: Set value or:
or 0.50 ADL: 1.0 s ADL: 12 (rpm) 2 L/min 15 cm H2
PED: 0.7 s PED: 14 (rpm)

NEONATE: PRESSURE-CONTROLLED MODE

FIO2 Inspiratory Machine Sensitivity Pressure

Time Rate Flow Pressure Control

. Rise
FIO2 TI f Vtr Ptr Time PSV

Set value Set value Set value Set value Set value
or 0.50 or 0.50 s or 20 bpm or 2 L/min or 10 cm H2O

The PEEP level, the alarm limits for Tidal Volume (high and low) and the
spontaneous breathing rate are the same ones set in the mode being
used. Sighs and inspiratory pause are not enabled.

Nebulization and 100% O2 are enabled.

88 Programming
 Change in the response
• Mode
• Apnea time
• Alarm in SIMV: ON - OFF
Once the Backup mode is programmed, the ventilator response to an ap-
nea episode may be changed by pressing the [Ctrl] + [Backup] keys. The
menu for the apnea time is displayed on the screen with a + sign on the
line corresponding to the value which has been accepted.

By pressing the [ ] key in the Selection sector, the option or parameter of

each group is chosen, and it is accepted by pressing [Enter]. By pressing
[Reset], one can exit this at any moment.

Changes in the Ventilatory parameters of the Backup Mode

The changes may be made: 1) when the backup mode is being used and 2)
when the mode is not active or before it is required by the program.

1) The changes in the parameters while the Backup mode is actuating are
made directly by means of the keys that are enabled, as it is done in
any mode. The values displayed on the screen correspond to this mode.
2) When the Backup mode is not active but has already been programmed
or will be programmed before the program requires it, the [Backup] key
is pressed. The values may be changed individually. The LED corre-
sponding to the key blinks while the Backup mode is on the screen to
make the changes. Once one or several parameters have been checked
or changed, the [Enter] key is pressed to exit the backup programming
screen.
When the Backup key is pressed to change a parameter, the LED flashes
until the mode or the values are accepted.

If the patient recovers the inspiratory effort while the backup ventilation
is working, ventilation resumes in the mode initially programmed, the
sound stops but the Apnea led remains on until the [Reset] key is
pressed.

Programming 89
 Watchdog
The watchdog is an independent system used to supervise the electronic
circuit operation. It is not related to the Backup Ventilation, and it has a
factory preset pressure-controlled ventilatory mode that cannot be
changed.

It enters into operation:

1) 30 seconds after turning on the ventilator, if the first screen is not accepted.
2) When the microprocessor loses control of the program sequence regu-
lating the ventilation.
When it enters into operation, a signal which starts this emergency venti-
latory mode is activated.

Emergency Ventilation
The following ventilation mode is activated in the ventilator, for any cat-
egory (adult, pediatrics):

• Ventilatory Mode: Pressure-Controlled Ventilation (PCV). It cannot be changed.

• Inspiratory pressure (PCV): 15 cm H2O. This value may be changed.
• Rise Time: At 25% for all categories.
• Inspiratory time: 0.8 s. The value may be changed
• Rate: 15 bpm. The value may be changed.
• Pressure Sensitivity: -1.5 cm H2O
• FIO2: 100%. Change inactive.
• PEEP: 0 (zero). Inactive.
• Silence Control: Active.
• Maximum Pressure Alarm: 30 cm H2O. The value may be changed.
• Minimum Pressure Alarm: 5 cm H2O. The value may be changed.
• VT (high and low) and bE values and alarm: Inactive.

Message on Screen and Audible Signal

When Watchdog is activated, a continuous alarm sound may be heard
and the following message is displayed on the screen:
EMERGENCY VENTILATION
1) DISCONNECT THE VENTILATOR CONNECTION TO THE PATIENT
2) TURN THE VENTILATOR OFF
3) TURN THE VENTILATOR ON
4) PREPARE IT FOR CONNECTION

IF THE PROBLEM CONTINUES, DO NOT USE THE EQUIPMENT

AND SEND IT TO AN AUTHORIZED SERVICE CENTER.

End of
Chapter

90 Programming
 Chapter 7

The ventilatory modes in this category are:

• PCV (Pressure-Controlled Ventilation)

• PSV/CPAP (Pressure Support Ventilation/Continuous Positive Airway Pressure)
• SIMV with PCV + PSV (Synchronized Intermittent Mandatory Ventilation with
Pressure Controlled and spontaneous breathing with Pressure Support)
• Time Cycled, Pressure Limited (TCPL)
• Continuous Flow CPAP with leak compensation
• Backup Ventilation with Pressure-Controlled
In this category, these modes have some specific operational characteris-
tics, which are different to the Adult and Pediatric categories. These fea-
tures make it possible to adapt the ventilator controls to meet the
ventilatory needs of patients with a very low body weight.

When Category NEO is selected and the calibration of the breathing cir-
cuit is completed, in the Operative Modes sector of the panel, the lights of
PCV, PSV/CPAP, SIMV (PCV) + PSV and Options are blinking indicating
the enabled modes.

In PCV, PSV/CPAP and SIMV (PCV) + PSV, the ventilator works as a pres-
sure controller with descending ramp flow, regulation of the Rise Time
and expiratory sensitivity for PSV. In Options, the ventilator works with
continuous flow, time cycled and regulation of the inspiratory pressure
(TCPL), and continuous flow CPAP with leaks compensation.

NOTE
In the NEO category the following modes are inactive:
• Volume (VCV)
• SIMV (VCV) + PSV
• Options: MMV - PSV+VT Assured - APRV
Nebulizer: Is deactivated in NEO category, except in TCPL mode

Neonatal Category 91
 PCV (Pressure-Controlled Ventilation)
The limit of the inspiratory pressure is adjusted with the [PCV] key from 2
to 70 cm H2O. The pressurization it is adjusted with the [Rise Time] keys
from 2 to 30 L/min.

For further information on the form of acting and the effects in the mode PCV,
consult the ventilator’s Programming chapter of this Instructions Manual.

Figure 7-1. Parameters and pressure and flow curves during PCV mode
ventilation in neonatology category with VT Compensated.

Control Keys for PCV

The following figure shows the control keys that are enabled as well as the
programming limits.

FIO2 Inspiratory I:E Machine Sensitivity Pressure

Time Ratio Rate Flow Pressure Control

. PEEP Rise
FIO2 TI I:E f Vtr Ptr CPAP Time
PCV
s bpm L/min cm H2O cm H2O cm H2O

1.0 3.0 1:99 150 5 10 50 70

0.21 0.1 5:1 1 0.5 0.5 2 2

Pressure Control
With the [PCV] key, the inspiratory pressure limit is set from 2 to 70 cm
H2O. The default value is of 8 cm H2O.

FIO2
It may be changed at the rate of one unit. By pressing the [FIO2] and [Ctrl]
keys successively, variations of 10 units are obtained with the Selection
key. Initially, 0.50 is the default value.

92 Neonatal Category
Ti
It may be changed at rates of 0.1 s. The initial default value is 0.5 second.
When a value is changed, the set breathing rate is maintained while si-
multaneously the I:E ratio changes. Conversely, when the I:E ratio is
changed, variations depending on the set breathing rate are obtained.

I:E Ratio
Generally, this is a parameter which depends on the set inspiratory time
and rate. However, it may be directly programmed. By changing it, varia-
tions in the inspiratory time are obtained.

Rate
Adjustable from 1 to 150 breaths per minute. It is a fixed parameter that
is not influenced by changes of the inspiratory time neither of the I:E ra-
tio. The initial default value is 18 cycles per minute.

Sensitivity
It has two options, it may be triggered by flow or by a negative variation of
pressure in the breathing circuit.

The flow-triggered sensitivity is taken as initial default value set at 2 L/

min; the variations are at a rate of 1 L/min at a time. The pressure-trig-
gered Sensitivity may be varied from 0.5 cm H2O up to 10 cm H2O below
PEEP.

Volume Compensated
The value of the exhaled volume indicated in the upper line of the screen,
includes the compressed volume in the breathing circuit. When the
breathing circuit is calibrated, the calculation of the circuit compliance is
made. Keeping in mind this compressible volume, it is possible to sub-
tract it and to know the volume directed to the patient.

Through the [Menu] key, and in the corresponding row, it can be enabled
or disable the reading of the compensated tidal volume. The value appears
in the same place with the advice of VT Compensated or Not Comp.

This volume value is an orientation of the ventilatory tidal volume but it

also depends on other factors like leaks of the circuit or around the tra-
cheal tube.

Neonatal Category 93
 Pressure Support/CPAP
When in this mode and Pressure Support is programmed at “zero” Positive
End Expiratory Pressure (PEEP), the device is ready for CPAP (Continuous
Positive Airway Pressure). The patient inspires the set continuous flow
which must be sufficient to satisfy the patient’s demand.

When a Pressure Support value is set, an intermittent rise of the airway

pressure is observed until the set value is reached. The patient begins and
ends the inspiratory phase and, therefore, keeps control of the rate and
duration of the inspiratory time.

Figure 7-2. PSV/CPAP Mode. The spontaneous ventilatory parameters

are shown on the top of the screen. These are, from left to right, Inspira-
tory Flow, Inspiratory Time, Expiratory Time, Inspiratory Time/Total Time
Ratio and Total Breathing rate.

The control keys and limits of this mode are:

FIO2 Sensitivity Pressure

Flow Pres. Support

. PEEP Rise
FIO2 PSV
Vtr Ptr CPAP Time
L/min cmH2O cm H O
2
cmH2O

1.0 5 10 50 70
0.21 0.5 0.5 0 0

Since the ventilator’s cycling rate has not been set, these are modes with
completely spontaneous ventilation. Therefore, it is necessary to program
a backup mode which guarantees basic ventilation in case the ventilatory
inspiration cannot be triggered or if the inspiratory effort stops (apnea).

When [PSV/CPAP] key is pressed for the first time, it appears in the
screen the menu for programming the backup ventilation.

94 Neonatal Category
 SIMV (PCV) + PSV
(Synchronized Intermittent Mandatory Ventilation with Pressure Support)

In this form of synchronized ventilation, the patient receives pressure-

controlled inspirations, delivered at a preset inspiratory time and rate
during mandatory breathing. During spontaneous breathing, the patient
may be aided with pressure support.

Figure 7-3. Pressure curves during ventilation with SIMV (PCV) + PSV.
The higher curves correspond to pressure-synchronized mandatory
breathing. The lower ones represent spontaneous breathing with Pres-
sure Support.

The controls and limits of this mode are:

FIO2 Insp. Time Machine Sensitivity Pressure Pressure

Rate Flow Pres. Support Control

. Rise
FIO2
PEEP PSV PCV
TI Vtr Ptr CPAP Time
(s) (bpm) L/min cmH2O cm H2O cmH2O cmH2O

1.0 3.0 150 5 10 50 70 70

0.21 0.1 1 0.5 0.5 0 0 2

This mode can work with or without backup programming. When backup
ventilation is not programmed, in the event of apnea the ventilation is
guaranteed by the mandatory rate and the rest of the regulated param-
eters.

Neonatal Category 95
 Time Cycled-Pressure Limited (TCPL)
It is a mode that works with continuous flow, time cycled and with regula-
tion of the inspiratory pressure. It is programmed by means of Options of
the Combined Modes group. The regulation of parameters is made with
the same keys enabled for PCV.
In this mode there is reading of the exhaled VT.
Setting keys
Inspiratory pressure limit: It is set with the [PCV] key from 2 up to 70 cm H2O.
Continuous flow: It is regulated with the [Rise Time] keys. The actual flow
is shown aside of the column that represents a flowmeter. The variations
of the flow are from 2 up to 40 L/min.
The rest of the commands is regulated with the corresponding keys the
same as that described in PCV, including PEEP control.

FIO2
Ti
I:E ratio
Rate
Sensitivity
Alarms: All are active
Nebulizer: Activated in this mode

The following figure shows the active controls with the programming limits.

FIO2 Insp. Time I:E Ratio Machine Sensitivity Pressure

Control
Rate Flow Pressure
40 Rise
. PEEP
FIO2 TI I:E f Vtr Ptr CPAP
(Continuous
Flow)
Time
PCV
(s) (bpm) L/min cm H2O cmH2O

1:99 2 cm H2O
1.0 3.0 150 5 10 50 L/min 70
0.21 0.1 5:1 1 0.5 0.5 0
2

Figure 7-4. TCPL mode: time cycled, pressure limited, with flow
sensitivity and positive end expiratory pressure (PEEP).

96 Neonatal Category
 Continuous Flow CPAP (Nasal NIV)
It is a mode with spontaneous ventilation with adjustable continuous flow and positive pressure
in the respiratory circuit. There are no cycles with ventilatory support, but when the ventilator
does not sense inspiratory efforts begin to provide a programmed backup ventilation.
This procedure is applicable in invasive ventilation as well as in non invasive through nasal
prongs, having the aptitude to allow compensation of leaks (up to 10 L/min) to maintain the
regulated positive pressure.
It is programmed by means of Options of the Combined Modes group through the following menu:
TCPL
TCPL + SIMV
Continuous Flow CPAP
To accept the mode press the [Enter] key. Simultaneously the following keys are enabled:

FIO2
40
PEEP (Continuous Rise
FIO2 CPAP
Flow) Time
cm H2O
2
L/min
1.0 50
0.21 2

Continuous Flow Setting

It is regulated with the [Rise Time] key. The reading of the flow on the screen appears to
the left of the column that represents the flow. The range is from 2 to 40 L/min.
PEEP Setting
The numerical value of the PEEP is replaced by a symbol with radios having indicated
the increase or decrease of the positive pressure.
1. Press the [PEEP/CPAP] key. The symbol
is inverted.
2. The change is made with the Selection
key [↕↕ ].
3. Accept with the [Enter] key. Reversion
of the symbol.
The obtained value of PEEP is exhibited in
the Base pressure. Modification in the Base
pressure can also be obtained increasing or
decreasing the continuous flow.
In addition to the mentioned parameters, set
the FIO2 and Alarms. Except high and low
Tidal Volume, all the alarms are accessible
by the user.

Backup Ventilation
The backup mode works with pressure controlled (PCV) with leaks compensation up to
10 L/min and the following parameters:
PCV: 8 cm H2O; Ti: 0,5 s; Rate: 18 bpm; PEEP: the programmed one.
These values can be changed.

Neonatal Category 97
 Alarms in Neo Category
As in all other modes, there are general alarms which are automatically
activated, and alarms which are specifically regulated. The alarms that
are regulated are the following:

Breathing rate (f max)

It can be set from 3 to 160 bpm. It has a set delay time of 35 seconds. The
initial default value is 30 bpm.

High and Low Tidal Volume

To regulate in all the modes, but less in Continuous Flow. The high vol-
ume is regulated from 5 up to 100 mL, with changes of 10 mL. The low
volume from 1 up to 50 mL, with changes of 1 mL up to 10 and after to
10 mL.
The initial default values are 25 mL and 5 mL respectively .
This alarm is inactive in the mode "Continuous Flow."

High Inspiratory Pressure

It is immediately activated. It interrupts the inspiratory time and opens
the expiratory valve. It is regulated by steps of 1 cm H2O from 10 to 120.
The initial default value is 25 cm H2O.

Low Inspiratory Pressure

It generally gives the alert on a disconnection or important leak. The acti-
vation delay time is of 5 seconds. It is set at a steps of 1 cm H2O from 3
to 99. The initial default value is 5 cm H2O.

PEEP Loss
When a PEEP value is programmed, the default value is automatically set
at a pressure loss of 4 cm H2O for the alarm to be activated with a 10 sec-
ond delay. This value appears on the upper part of the curves box.

The value may be changed to 2 or 6 cm H2O, or the alarm may be deactivated

(OFF). In order to make these changes, the [Ctrl] and [PEEP/CPAP]
keys are pressed successively or thorough the [Menu] key.

98 Neonatal Category
 Backup Ventilation
To program Pressure Support/CPAP alone or combined with SIMV (with
the option SIMV ON), it is necessary first to program the backup mode.
This backup mode works with controlled pressure (PCV).

Initially, when selecting a mode with spontaneous ventilation, the follow-

ing menu appears in the screen:

The default values, or the already accepted ones, they appear in inverted
video. They can be changed with the key [ ] of the Selection sector. The
changes of each line are accepted with the [Enter] key. The accepted line
is marked in inverted video. To go out, with or without modification of a
parameter, should be pressed the [Reset] key. To make new changes press
the [Menu] key.

The operative mode for the backup in this category is Ventilation with
Controlled Pressure (PCV).

Figure 7-5. Screen indicating that the backup mode has been activated.
The values of the enabled controls may be changed during ventilation.

In SIMV it is possible to opt among activation of the backup ventilation

(ON) or without backup ventilation (OFF). In this last case, the rate of the
mandatory inspiration is as ventilatory guarantee. By default, is OFF.

Neonatal Category 99
 When it exists lack or weakness of the inspiratory effort, the apnea alarm
will be activated after the selected time (5, 10, 15, 30, 60 seconds). The
ventilator changes automatically to Backup Ventilation as it has been pro-
grammed, what is indicated by the following message in the screen:

APNEA ALARM ACTIVATED

BACKUP VENTILATION IN USE

The alarm sound during 5 seconds, while the message and the light stay.
If the cause persists, the sound is activated every 10 seconds during 5
seconds, following this sequence until the cause disappears or the opera-
tive mode is changed.

If the patient recovers the inspiratory effort while the backup ventilation
is working, the ventilation is renewed as programmed, the sound is sus-
pended but the luminous sign of Apnea continues until the [Reset] key is
pressed.

If the cause is overcome, the ventilation is renewed with the programmed

mode. The sound is suspended but the luminous sign of the sector
Alarms remains until the [Reset] key pressed.

End of
Chapter

100 Neonatal Category

 Chapter 8

This section covers a series of tests performed by the user, to verify proper
operation of the NEUMOVENT Graph Ventilator. They must be performed
the first time the ventilator is set up and prior to connecting the ventilator
to a patient.

CAUTION
If the ventilator does not pass any of the following tests do not apply it to a
patient.

Ventilator Preparation
The following equipment is needed:
1. Ventilator with appropriate breathing circuit
2. Test lung (1000 mL suggested)
3. Oxygen analyzer
4. Watch with second hand
When ready:
1. Connect the air and oxygen hose and electrical cord to the appropri-
ate sources.
2. Connect the external oxygen analyzer in line and attach the test
lung.
3. Turn the ventilator on and select ADULT category pressing [Enter].
4. Select the breathing circuit type and press [Enter].
5. Start the calibration breathing circuit as indicated.
6. When the programming screen appears, select VCV ventilation.
7. Start ventilation pressing [Ctrl] + [Enter].
The ventilator will begin to operate with the default parameters.
8. Allow the ventilator to run for at least two minutes with default pa-
rameters (see “Programming “ chapter).
9. Perform functional test as described in next section.

Ventilator Operational Tests 101

 General Tests
Oxygen System
Check the Oxygen concentration displayed on the analyzer after two min-
utes. The concentration should be between 45% and 55%. Press
the [O2 100%] key on the keypad. The oxygen analyzer should display
95% or higher after 10 breaths.

Rate
Using the watch, count the number of breaths delivered during one
minute. Observed rate on ventilator should match the timed rate.

Tidal Volume
Check the VT displayed on the screen and compares it with the set VT.
Change the VT to 500 and 250 mL and check again. Any difference
should be less than ± 10%.

PEEP
Set PEEP at 5 cm H2O. Observe if the base pressure waveform is kept
straight.

NOTE
Keep the set PEEP during the rest of the test. This maneuver will help
the test lung handling.

Trigger Sensitivity
Check patient triggering by squeezing the test lung and releasing. The
ventilator should deliver a breath. Reset flow sensitivity to 0.5 L/min.
This setting should not produce autocycling.
Change to pressure trigger to -0.5 cm H2O and verify there is not autocy-
cling.

Manual
Press the [Manual] breath key on the keypad. The ventilator should de-
liver a breath.

Flow Waveform
Press the key successively changing the waveform and verify the shape of
the flow curve.

Pressure Operative Mode

Press the [PCV Assist/Control] key.
Accept default settings pressing [Ctrl) + [Enter] key. Verify the function-
ing changing the rise time.

102 Ventilator Operational Tests

Alarm and Safety Tests
Patient Disconnect (Low Pressure)
Disconnect the test lung from the circuit. A patient disconnects warning,
activating the Low Pressure Alarm, will be displayed after 10 seconds and
the alarm will sound. Reconnect the test lung. The alarm will turn OFF
and the LED will remain lighting until the [Reset] key is pressed.

High Pressure
Set the alarm limit to 30 cm H2O. During inspiration squeeze the bag
strongly and quickly. A high-pressure warning will be displayed and the
alarm will sound immediately. At the same time, the expiratory valve will
open decompressing the circuit.
Release the test lung. The alarm will turn OFF and the LED will remain
lighting until the [Reset] key is pressed.

High and Low Tidal Volume

These alarms are active in all modes.
Start VCV with default parameters. Select High Tidal Volume alarm and
decrease the setting to 300. A High Tidal Volume warning will be dis-
played after 10 seconds and the alarm will sound. Press [Silence] on the
keypad and reset the high tidal volume alarm using the procedure de-
scribed above 400.
The Low Tidal Volume alarm is checked in the same manner as the High
Tidal Volume, except the Low Tidal Volume setting is selected and in-
creased to a level above 400. A Low Tidal Volume warning will be dis-
played after 10 seconds and the alarm will sound.
Press [Silence] on the keypad and reset the low tidal volume alarm to
200.

High Oxygen
Select in the oximeter the high O2 alarm to 30 %. In this case, a High
O2 % warning will be activated after several breaths and the oximeter
alarm will sound.
Reset the High O2 % alarm to 80%.

Low Oxygen
This alarm is checked in the same manner as the High O2 % alarm; how-
ever, the Low O2 % alarm should be set to 60%. In this case, a Low O2 %
warning will be activated after several breaths and the alarm will sound.
Reset the Low O2 % alarm to 30%.

High Rate
Set the alarm limit to 20 bpm. Simulate spontaneous breaths squeezing
the bag in such a manner to get more than 20 bpm. After 30 seconds, a
High Rate warning will be displayed and the alarm will sound.
Press [Silence] on the keypad and reset the High Rate alarm. Clear the
alarm LED by pressing the [Reset] key.

Ventilator Operational Tests 103

 Apnea Alarm for Spontaneous Ventilation
Select Pressure Support Ventilation (PSV) pressing twice the
[PCV Assist/Control] key.
Accept default settings pressing [Ctrl) + [Enter] key.
The Backup ventilation menu is displayed. Leave and accept default set-
ting pressing the [Reset] key.
Press [Enter]. The Pressure Support Ventilation is ready to start. Squeeze
the bag gently. The ventilation waveforms are displayed.
Stop squeezing. After 10 seconds the audible alarm should sound and in
the same time an Apnea warning will be displayed, and the ventilator will
switch to Apnea ventilation mode.
Start squeezing the bag. PSV will resume.
Pressing the [Backup Ventilation] key, the apnea parameters: mode, time
and SIMV with or without backup, can be changed.
Press [VCV] on the keypad and resume volume ventilation.

Silence
Push the [Silence] key to silence audible alarms. The alarm silence LED
will turn on. The light and sound OFF will remain 30 or 60 seconds ac-
cording to the press sequence: one for 30 s, twice for 60 s.

AC Disconnect
Disconnect the AC power cord from the outlet. The warning screen will
appear as the alarm sounds and the left LED of the Alarm row will light.
The signal will remain until the power supply is reconnect.
The battery icon on the screen shows the remain charge.

High and Low Minute Volume

These alarms are active in Mandatory Minute Ventilation mode only.
Start MMV + PSV with default parameters. Select High Minute Volume
alarm and decrease the setting to 5-6. Squeezing rapid the bag, the
minute exhaled volume will increase. A High Minute Volume warning will
be displayed after 10 seconds and the alarm will sound. Press [Silence]
on the keypad and reset the high minute volume alarm using the proce-
dure described above to 10-12.
The Low Minute Volume alarm is checked in the same manner as the
High Minute Volume, except the Low Minute Volume setting is selected
and increased to a level above 6 and the bag is squeezed slowly. A Low
Minute Volume warning will be displayed after 10 seconds and the alarm
will sound.
Press [Silence] on the keypad and reset the low minute volume alarm to
3-4.

The Functional Tests are now complete. If all tests were acceptable, the ven-
tilator is ready for use.

104 Ventilator Operational Tests

Operational Verification Test
In addition to the Ventilator Operation Tests performed by the user, the
ventilator performs an automated Operational Verification Test each time
the power is turned ON and during the breathing circuit calibration pro-
cess. To perform the Operational Verification Test the ventilator builds
pressure by applying constant pressure of ~ 40 cm H2O, and tests for a
patient circuit leaking.
When a leak of gas exists for any part of the circuit less than 10 L/min, it
is warned with the following message:
ATTENTION:
A LEAK OF xx L/MIN WAS DETECTED
IT CAN PRODUCE ERRORS IN:
EXPIRATORY VOLUME, PEEP AND SENSITIVITY
IF THE LEAK IS SOLVED: RECALIBRATE THE CIRCUIT

When a leak is less than 10 L/min, and you proceed to program and to
ventilate, it appears in permanent form, to the foot of the square of graph-
ics, the following message:
THERE IS A CIRCUIT LEAK OF xx L/MIN
If the leak is more than 10 L/min, as a safety measure, the ventilator be-
comes inoperative. Until the defect is not solved, the ventilator cannot be
programmed. In the screen the following message appears:
ATTENTION
ESCAPE ABOVE 10 L/MIN
IMPOSSIBILITY OF MAINTAINING SUITABLE VENTILATION
CAREFULLY INSPECT THE PATIENT’S CIRCUIT

End of
Chapter

Ventilator Operational Tests 105

 This Page Intentionally Left Blank

106 Ventilator Operational Tests

 Chapter 9

The lung mechanics program of the NEUMOVENT Graph ventilator in-

cludes the following measurements:

1) Auto-PEEP
2) Dynamic and static compliance
Inspiratory and expiratory resistance
3) Vital capacity
4) P0.1
5) P/Vflex
6) Pimax
Some tests are run breath by breath, such as dynamic compliance, the
value of which is displayed on the pressure/volume loop screen. In other
tests, the patient’s efforts must not be involved for the tests to be of value.

This chapter deals with general aspects applied to these determinations

as well as with the instructions for the tests procedures. When the Lung
Mechanics key is pressed, a menu with four options appears on the
screen:

• Auto-PEEP
• Dynamic and Static compliance
Inspiratory and Expiratory resistance
• Slow vital capacity
• P0.1
• P/Vflex
• Pimax

The second option is run as a whole because the calculations are made
during the same maneuver with volumetric breaths and inspiratory
pause.
As it will be seen when dealing with each specific option, the number of
tests that may be executed depends on the ventilatory mode being used.

NOTE
In Continuous Flow Mode of NEO category the Respiratory Mechanics
tests are not available.

WARNING
In the assisted and spontaneous modes (PSV-CPAP, SIMV, APRV,
MMV, PSV+VT Assured and VNI) the auto-PEEP, Dynamic and Static Compli-
ance, Inspiratory and Expiratory Resistance and P/Vflex tests are not accom-
plished.
If some of these tests are selected, appears in the screen the follow-
ing warning: Function nonallowed in this modality.

Lung Mechanics 107

 Auto-PEEP
General
Auto-PEEP, also referred to as intrinsic PEEP, is the dynamic unintended pulmo-
nary hyperinflation which occurs with mechanical ventilation when the time inter-
val between successive breaths is not enough to reestablish the balance of the
respiratory system.
Auto-PEEP is a phenomenon which may not be detected just by examining the
patient. It is possible to measure it through special maneuvers when its presence
is suspected. One way of assuming its presence is by analyzing the flow waveform
during mechanical ventilation. If during expiration, the flow tracing does not re-
turn to the baseline level before the next inspiration, it is very likely that auto-
PEEP may have developed.
This imbalance makes the intra-alveolar pressure remain positive continuously
during both phases of the respiratory cycle, so that the expiratory flow does not
stop at the end of expiration but continues almost unnoticed until the beginning
of the following inspiration, thus generating dynamic pulmonary hyperinflation.
Auto-PEEP may develop in ventilated patients with significant limitation of the expira-
tory flow (asthma, COPD) and in those without obstruction of the airway flow, but
with an increased ventilatory demand (high vE) accompanied by significant resistance
at the endotracheal tube and/or the ventilator’s circuit level. It may also develop dur-
ing mechanical ventilation with I:E ratio inversion, specially if one of the predisposing
causes is present.
Auto-PEEP produces unfavorable hemodynamic effects, alteration of the lung me-
chanics producing errors in the calculations which determine auto-PEEP, and it
also increases the work of breathing during assist or spontaneous ventilation.

Operation
Auto-PEEP is available in all categories but not functional during spontaneous
and assisted breaths.

NOTE
The assist and spontaneous mode are not studied. If the patient has spontaneous
breaths, auto-PEEP is not calculated.

Procedure
Auto-PEEP is measured through a static maneuver. The patient must remain under
controlled ventilation (by volume or pressure). The breathing efforts may alter the
measurement; therefore, if the patient is alert, it is important to instruct him in rela-
tion to the procedure so as to obtain maximum relaxation during the maneuver.

Expiratory pause
To make the auto-PEEP maneuver, the ventilator produces automatically, during
0.75 seconds three successive occlusions of the expiratory valve at the end of the
expiratory phase, thus producing an expiratory pause so as to measure the accu-
mulated transpulmonary pressure. The auto-PEEP value is calculated by averag-
ing three consecutive measurements.

108 Lung Mechanics

 Figure 9-1. Airway pressure tracing taken in
real time at end of the auto-PEEP test. The
result shows the total PEEP value as equal to
auto-PEEP because the test was performed
without positive end expiratory pressure.

Sequence
• Select Lung Mechanics with the panel key.
The screen will display an option menu.
• Select auto-PEEP by using the [

] key of the Selection sector.
• Press [Enter]

After this, the measurement begins taking three successive breaths. The
result is displayed on the screen as auto-PEEP and Total PEEP.

Figure 9-2. In this example, 5 cm H2O of PEEP were

applied. The total PEEP is 12 (PEEP + auto-PEEP).

End of auto-PEEP test

The measurement ends in two different ways:
• Automatically, after completing the 3 required maneuvers.
• Manually, at any moment by pressing the [Reset] key.

When the maneuver finishes, the ventilator continues the ventilation with
the originally programmed mode. The screen displays the auto-PEEP av-
erage value obtained from the three breaths studied.

Lung Mechanics 109

 Compliance and Resistance

Compliance
The compliance of the respiratory system is one of the variables most fre-
quently measured during mechanical ventilation. Through this maneuver,
static compliance and dynamic compliance are determined.

Static compliance is a measure of the lung-thorax compliance. It does not

represent lung elasticity, because for that determination, it is necessary to
measure the esophageal pressure as an equivalent of the pleural pressure.

Dynamic compliance is a measure of the respiratory system impedance as

a whole. It is determined by the sum of the frictional resistance of the air-
ways and the elastic resistance of the thoracic-pulmonary system.

General
The pressure applied through the respiratory system, measured at any
moment of the respiratory cycle, is called transpulmonary pressure (Ptp)
and it is equal to the sum of the elastic (Pel), resistive (Pr) and positive
end expiratory (PEEP) pressures.

Ptp = Pel + Pr + PEEP

During a ventilator passive inspiration, the pressure measured in the air-

way is used as a good estimate of the transpulmonary pressure.

The various pressures necessary for a calculation of the transpulmonary

pressure are obtained through passive insufflation of a known volume
with rectangular flow wave plus the addition of an inspiratory pause.

The inspiratory pause lasts 0.75 seconds so as to allow the balancing of

the alveolar pressure with the airway pressure, and thus obtaining a good
estimate of the transpulmonary pressure.

Through this maneuver, it is possible to obtain:

Pmax: Inspiratory pressure peak

Pplateau: pressure measured during the inspiratory pause

PEEP: positive end expiratory pressure or baseline

When the ventilator expands the thorax passively using constant flow
(rectangular wave), compliance is calculated by using the readings of
these pressures (Pmax, Pplateau and PEEP), and measuring simulta-
neously the tidal volume.

Operation
The measurement of compliance and resistance are available in all catego-
ries but not functional during spontaneous and assisted breaths.

110 Lung Mechanics

Static Compliance
Static compliance is equal to the change in pressure necessary to produce
a given change in the volume (dV/dP). This ventilator calculates it as fol-
lows:

VT
Static Compliance = ———————————— – Cc
Pplateau – PEEP

Where CC is the ventilator circuit compliance.

Both compliance and resistance are parameters of the lung mechanics

which are closely related to the pulmonary volume in relation to which
they were measured. The value obtained in this measurement is absolute
and is not expressed in relation to the specific pulmonary volume in rela-
tion to which it was measured, which is important at the moment of inter-
preting the results.

The measurement is made in three breaths with the tidal volume range
with which the patient is being ventilated, since both compliance and re-
sistance vary in relation to the tidal volume.

In adults, the normal value for static compliance varies between 0.06 and
0.10 L/cm H2O (60-100 mL every centimeter of water of insufflation pres-
sure).

Dynamic Compliance
Dynamic compliance is calculated on the basis of the pressure change
which takes place during the insufflation of a known volume according to
the following formula:

VT
Dynamic compliance = ———————————— – Cc
Pmax – PEEP

Dynamic compliance is a global index which makes reference to the

patient’s respiratory impedance in general, without making any distinc-
tions between its components (Pel and Pr).

In this ventilator, the dynamic compliance is shown in real time, breath

by breath, on the screen corresponding to the Pressure/Volume loop.

Lung Mechanics 111

 Procedure
The measurements of both compliance as well as of both resistance are
done altogether as requested by the Lung Mechanics menu.

Figure 9-3. Pressure waveform recorded at

the end of the measurement of Cdin, Cest,
Rins and Resp. The inspiratory pause is of
0.75 s. The result is shown simultaneously
after three successive maneuvers with val-
ues expressed in mL/cm H2O for dynamic
and static compliance and in cm H2O/L/s for
both resistance.

Compliance is measured through a static maneuver, this means the pa-

tient must be in controlled ventilation (by volume or pressure) that is why
it is important to instruct him/her in relation to the procedure so as to
obtain the maximum relaxation during the maneuver.

The modes which involve spontaneous respiration, SIMV, CPAP, MMV,

PSV + VT Assured are not studied.

In order to measure Compliance, the ventilator must be in volume-control

ventilation, with a rectangular flow wave. Automatically, an inspiratory
pause is produced by the occlusion of the expiratory valve at exactly the
end of inspiration. The pause lasts 0.75 seconds. During the pause, the
alveolar pressure (distal pressure) enters in equilibrium with the airway
pressure (proximal pressure).

This measurement can also be made during pressure-controlled ventilation,

although in this case, the flow wave will be of the descending ramp type,
something which should be taken into account when interpreting the data.
Sequence
• Press the [Lung Mechanics] key.
The screen will show an option menu.
• Select Compliance, Inspiratory Resistance, Expiratory Resistance using
the [

] key in the Selection sector.
• Press [Enter]. After this, the measurement starts.
End of measurement:
• Manually, at any moment by pressing the [Reset] key.

At the end of the maneuver, the ventilator returns to the original ventila-
tory mode.

112 Lung Mechanics

Resistance
Inspiratory and expiratory resistance is defined as the pressure difference
necessary to generate a given inspiratory or expiratory flow, and is the
expression of the airways resistance (of the patient, artificial and of the
ventilator’s circuit) to the flow.

Inspiratory Resistance
The inspiratory resistance is calculated by means of the following formula:

Pmax – Pplateau
Inspiratory resistance = —————————————
VT/Ti

Where VT/Ti is the mean inspiratory flow.

Similar to other lung mechanics measurements, the inspiratory resistance
needs the patient’s passive inflation with a known tidal volume, a rectan-
gular flow wave and an inspiratory pause. Those conditions are important
to validate the measurement.
The measurement of inspiratory resistance is omitted during the pressure-
controlled ventilation mode (PCV) because the changes in Pmax and Pmax –
Pplateau are not useful to assess the changes in the airways resistance.
The inspiratory resistance is measured during the inspiratory phase of a
ventilator passive inflation. During this inflation, the airways are dilated
by the effect of the positive pressure applied and by the increase in the
radial attraction on the bronchial tree; because of this, the inspiratory
resistance tends to be less than the expiratory one.
Expiratory Resistance
The measurement of the expiratory resistance is useful to assess the re-
sponse of bronchodilators in ventilated patients who suffer from obstruc-
tive respiratory diseases.
The formula used for its calculations is as follows:

Pplateau – PEEP
Expiratory resistance = —————————————
vexp

The expiratory resistance assesses the resistive characteristics of the air-

ways during expiration and that is why it is not affected by the type of
inspiratory flow wave used; this makes it possible to measure it during
the pressure modes. The expiratory resistance is almost always higher
than the inspiratory one since during its measurement several factors dif-
ferent from those participating in the inspiratory resistance are involved.
Procedure
Inspiratory and Expiratory resistance are measured together while deter-
mining static compliance through a pause at the end of inspiration which
lasts 0.75 seconds. The modes which involve spontaneous breathing
—SIMV, CPAP, MMV, PSV + VT Assured— are not studied. Inspiratory
resistance is not calculated in the PCV mode because the negative ramp
flow wave has a variable flow.

Lung Mechanics 113

 Slow Vital Capacity
Vital capacity is the amount of air which may be expired after a maximum
inspiration, and serves to assess the ventilatory reserve.

In the ventilated patient, vital capacity is used to monitor the improve-

ment in the ventilatory function and as one of the classical parameters for
weaning. A value of 10 mL/kg is considered adequate to begin an attempt
to wean the patient from the ventilator.

Operation
The measurement of Slow Vital Capacity is available in all categories ex-
cept in NEO category.

Procedure
The cooperation of the patient is important when measuring the vital ca-
pacity.

For this maneuver, the ventilator automatically selects the CPAP mode
with PSV 0 (zero)

Figure 9-4. When Vital Capacity is selected, the screen automatically

changes to the flow/volume loop. The result shows the value of the last
maneuver (Current) and the best volume obtained (Best).

The patient must be encouraged to make a maximum inspiration, and

then to exhale slowly up to the maximum possible expiration. The maneu-
ver must be slow given the resistive characteristics of the elements which
constitute the ventilator circuit and the tracheal tube; a forced expiration
may generate high intrapulmonary pressures.

As the patient makes the successive maneuvers for vital capacity, the
value obtained in each measurement is shown on the screen together with
the maximum value obtained until the last maneuver is performed.

114 Lung Mechanics

Sequence
• Press the [Lung Mechanics] key
• Select “Vital Capacity” in the menu
• Press [Enter] to accept it.

The ventilator changes the original ventilatory mode to CPAP + PSV = 0.

The flow/volume loop is displayed on the screen. After this, the measure-
ment begins.

As many measurements as desired will be made during a period of no

more than 90 seconds. After this time, the ventilator automatically re-
turns to the original ventilatory mode. If more measurements are re-
quired, another sequence should be started.

The value obtained in each maneuver appears on a screen together with

the maximum vital capacity obtained up to that moment.

The maneuver may finish in two ways:

• Automatically, after 90 seconds

• Manually, at any moment by pressing the [Reset] key

Lung Mechanics 115

 Occlusion Pressure
During the First 100 ms of Inspiration (P0.1)
Normal breathing is the result of a series of interrelated phenomena
which finally result in an adequate gas exchange. Patients with acute res-
piratory failure of any etiology who are ventilated, present an alteration in
the operation of the pump due to different causes. The assessment of the
function of the ventilatory pump in ventilated patients may be made by
measuring the inspiratory pressure during 100 milliseconds (P0.1).
The objective of this test is to help assess the patient’s capacity to resume
spontaneous ventilation. In this ventilator, the measurement of P0.1 is
available in ADL and PED categories.
The determination of P0.1 does not require the patient’s cooperation, fur-
thermore, it needs an unnoticed occlusion maneuver to take place.
It is often used as an index of success or failure in weaning the patient
from the ventilatory support. A P0.1 result greater than 6 cm H2O indi-
cates a high ventilatory demand level which the patient’s respiratory
muscles may not overcome, which will result in failure at weaning.
It is important to point out that P0.1 may also be affected by factors such
as the thoracic-abdominal configuration, the pulmonary volume and the
fiber length of the respiratory muscles.
Procedure
When selecting the test in the Lung Mechanics menu, the ventilator enters
the CPAP mode automatically with PSV = 0. At the beginning of the maneu-
ver, the ventilator analyzes the respiratory cycle during 2 breaths, identify-
ing inspiration and expiration. During the last expiration, there is occlusion
of the inspiratory valve, while the expiratory valve remains open.
The measurement of P0.1 begins when the ventilator detects a pressure
drop of –0.5 cm H2O in relation to the baseline pressure level. As from
this moment, the count of 100 ms begins and P0.1 is measured.
The result is expressed as absolute value, taking as reference the baseline
pressure level.
Sequence
• Select the Lung Mechanics mode
• Select P0.1 from the menu on the screen
• Press [Enter]
The ventilator changes the original ventilatory mode for CPAP + PSV = 0,
after this, the measurement begins as previously explained. During the
measurement, the screen will show negative deflections of the airway
pressure during the occlusion.
The measurement may finish in 2 ways:
• Automatically, 20 seconds after the occlusion
• Manually, at any moment, by pressing the [Reset] key.
At the end of the maneuver, the ventilator returns to the original ventila-
tory mode and the screen freezes showing the value obtained for P0.1. To
return to the Lung Mechanics menu or to the original screen, press [Re-
set] again.

116 Lung Mechanics

Inflexion Points of the P/V curve (P/Vflex)
The changes in the pulmonary mechanics that happen in the acute
respiratory failure can be monitored by means of a serial measurement of
the inflection points of the Pressure/Volume curve. The method used by
the NEUMOVENT Graph ventilator for this investigation, is the low
constant flow technique. With this approach, the lower inflection point
(Lip) and the upper inflection point (Uip) can be determined.

The data from the Lip has application in the setting of the optimal PEEP
level able to avoid alveolar collapse or lung injuries by the successive
collapse and opening of the alveoli (atelectrauma). The Uip represents the
transition towards the pulmonary overdistension, indicating the
maximum limit of pressure and volume that can be set during the
mechanical ventilation.
Like a complementary data, during this maneuver also the average value
of the compliance is obtained (Cmax).

Procedure
Measurement of P/Vflex is available in VCV and PCV modes of ADL and
PED categories. The patient must be intubated and ventilated with con-
trolled mode, that is to say, without spontaneous breathing.

After pressing [Respiratory Mechanics] key, select P/Vflex option. A grid

appears in the screen where the curve will be traced during the test.

On the left of the grid it can be seen the default values of the pressure
(Pmax) and the tidal volume (Vmax) allowed during the procedure. Both
values also compose the scales of the grid. These values can be modified
by the operator. Pressing the [Menu] key the line of Pmax changes to re-
verse video permitting the change. Once accepted one goes to the Vmax
line and a change can be made, if it is necessary.

Lung Mechanics 117

 The maneuver begins when the [Enter] key is pressed appearing the fol-
lowing events:

1) The ventilator makes a 3 seconds expiratory pause with zero PEEP.

2) The low flow insufflation starts with 100% O2.

3) The curve is drawn in progressive form.

4) The maneuver ends when the set volume or pressure is reached, any-
one is first. The test can be suspended pressing the [Reset] key.
5) At the end of the test, the ventilation of the patient is reassumed with
the mode and parameters programmed.
6) To the left of the grid, it is shown the following results:

Lip: xx cm H2O
Uip: xx cm H2O
Cmax: xx mL/cm H2O

To leave the program, press the [Reset] key.

Commentaries
It is possible that in some cases the test fail to show results of Lip. This is
because the program omits the calculation of the lower inflection point
when it is below 4 cm H2O.

As far as the value of the upper inflection point is, depends on the charac-
teristics of the ventilated lung in relation to the volume limit set for the
test.

118 Lung Mechanics

Maximum Inspiratory Pressure (Pimax)

Pimax is an index which assesses the maximum contractile capacity that

the inspiratory muscles, specially of the diaphragm, have. One of the
characteristics of the muscles, in general, is the relation existing between
the capacity to generate force and the degree of stretching of the fibers at
the beginning of the contraction. The longer the fiber, the greater the ca-
pacity to generate force. In the case of the respiratory muscles, the great-
est length is achieved with the patient at residual volume, i.e., in
maximum expiration.

Pimax not only reflects the function of the respiratory muscles in isolation
but it may also be affected by the alterations that may occur at any point
where the muscular contraction generates (central nervous system, con-
duction pathways, neuromuscular junction, mechanical situation of the
muscle, peripheral receptors, etc.)

Pimax is measured with a maximum inspiratory effort and an occluded

airway. For the maneuver, to be well assessed, the patient must cooperate
in its execution. However, the test can be performed in noncooperative
patients with the occlusion technique of the airways for 20 seconds, thus
values that are 30 per cent more negative than the standard mode are
obtained.

Procedure
As it has already been mentioned, Pimax measurement do not require the
patient’s cooperation.

When selecting the test in the Lung Mechanics menu, the ventilator en-
ters the CPAP mode automatically with PSV=5 and PEEP=0. At the begin-
ning of the maneuver, the ventilator analyzes the respiratory cycle during
2 breaths, identifying inspiration and expiration. During the last expira-
tion, there is occlusion of the inspiratory valve, while the expiratory valve
remains open.

The airway continues to be occluded for 20 seconds, during which Pimax

is measured.

Pimax is calculated as the greatest airway pressure fall which takes place
during occlusion. The result is expressed as absolute value, taking as ref-
erence the baseline pressure level.

Sequence
• Select Lung Mechanics tests
• Select Pimax from the menu on the screen
• Press [Enter]

The ventilator changes the original ventilatory mode for PSV=5 and
PEEP =0, after this, the measurement begins as previously explained.

Lung Mechanics 119

 During the measurement, the screen will show negative deflections of the
airway pressure during the occlusion.

The measurement may finish in 2 ways:

• Automatically, 20 seconds after the occlusion

• Manually, at any moment, by pressing the [Reset] key.

At the end of the maneuver, the ventilator returns to the original ventila-
tory mode and the screen freezes showing the value obtained for Pimax.

To return to the Lung Mechanics menu or to the original screen, press

[Reset] again.

End of
Chapter

120 Lung Mechanics

 Chapter 10

One of the outstanding characteristics of the NEUMOVENT Graph Ventila-

tor is the capacity to graphically plot in real time, the relationship be-
tween the ventilator and the ventilated patient. Thus, it is possible not
only to adjust the equipment to the patient’s needs, but also to optimize
the ventilatory strategy.

The graphs and numerical data complement each other in the analysis of
the ventilatory condition. The graphs have the capacity to show the pa-
tient-ventilator system at work.

The learning of the tracing of those situations considered to be normal is

relatively simple. The interpretation of the graphics is similar to diagnostic
imaging, such as the information given by an Rx. The experience acquired
allows a better understanding of the variations.

NEUMOVENT Graph shows pressure, volume, flow waveforms, pressure/

volume and flow/volume loops. By pressing the panel keys controlling the
screen, one can switch from one graph to the other whether in isolation or
in groups. Also, the scales may be changed, or frozen, the vertical or hori-
zontal cursors may be moved with memory of the position, or the screen
may be printed to a graph printer or to a file with BMP extension. The
latter has been used in the examples shown below.

Some of the graphs have been obtained during the patient’s ventilation,
and others while the ventilator is connected to the Bio-Tek test lung, VT-2
model (Bio-Tek Instruments Inc., Winooski, VT, USA) in adult mode. The
graphs shown here have been taken from the ventilator screen with the
Print function, assuming ventilation with a compliance of 50 mL/cmH2O
(C50) and an airway resistance of 5 cm H2O/L/sec (R5). To simulate other
alterations, one or both components have been varied. In all cases, the
compliance and resistance used in the lung model are indicated.

Figure 10-1. Bio-Tek VT-2 Test

Lung.

The simulations for this description, unless otherwise indicated, have been
made with the ventilator’s controls set for a tidal volume (VT) of 0.500 L, a
rate (f) of 20 bpm, and an I:E ratio of 1:2 or the closest possible.

Graph Analysis 121

 Description of the Screen

.
Peak Flow TI I:E TE total VT VE
spont.
(L/min) (sec) spont. (sec) (bpm) (L) (L/min) Pressure
Limits
(cmH2O)

High Insp.
Category BAT FULL
RT Pressure
Paw Pressure
(cmH2O) Control (PCV)
(above PEEP)
Peak

Plateau Pressure
Support (PSV)
(above PEEP)
Mean
PEEP/CPAP
Base (reference value)

Oxygen Low Insp.

Monitor Pressure

FIO2 Inspiratory I:E Machine Volume Sensitivity

Time Ratio Rate Tidal Minute Flow Pres.
(sec) (bpm) (L) (L/min) (L/min) (cmH2O)

Figure 10-2. Screen with two types of figures occupying all the area.
One is a graphic, and the other an alphanumeric representation.

The panel sheet around the screen has in print the designations corre-
sponding to the values on the screen. The lower horizontal line and the
right vertical one show the values selected by the operator. The upper
horizontal line and the left vertical one indicate the resulting or calculated
values.

The mode in use is indicated with characters in reverse video. Below the
mode in use, the screen shows sigh or pause, if programmed. When the
screen with the graphs is activated, the airway pressure scalar with the
bar following the airway pressure up and down remains on.

Some data are only displayed if the corresponding mode has been se-
lected. Other values have smaller characters, such as the indication of
maximum or minimum VT alarm limit, or highlighted such as the maxi-
mum and minimum pressure limit, which is surrounded by a rectangle.

When any alarm is activated, the screen displays a message with the
name of the activated alarm, the possible cause, and suggestions for its
solution.

122 Graph Analysis

 Graph Characteristics
The graphs displayed on the screen are classified by type in:
Scalars: to designate the open waveform in which one variable is ex-
pressed as a function of time, for example: Pressure/Time or Flow/Time.
Loops: are closed waveforms which combine two variables traced over an
x-y coordinate axis, being the most common ones Pressure/Volume and
Flow/Volume.

Figure 10-3. The figure shows the two types of graphs usually employed
in mechanical ventilation: Scalars and Loops.

In all graphs, the vertical axis corresponds to the measured variable. In

the pressure and flow waveforms, the horizontal axis traces time; the
positive deviations correspond to the inspiratory phase and the negative
ones to the expiratory phase.

Figure 10-4. Pressure and flow waveform during volume-controlled ventilation.

TI: Inspiratory Time. TE: Expiratory time. PIP: Peak Inspiratory Pressure.
Insp: Inspiratory flow derived from the ventilator. Exp: Expiratory flow de-
rived from the patient (lung model). The inspiratory flow is processed by the
internal or inspiratory pneumotachograph; the expiratory flow originates in
the expiratory pneumotachograph located at the end of the ventilator expira-
tory pathway.

Graph Analysis 123

 Another feature of the graphs presentation is the possibility of modifying
the sweep velocity thus allowing the visualization of the greatest possible
number of breaths per screen, also by zooming the display, the tracings
may be observed in greater detail; it is also possible to observe one, two or
three simultaneous waveforms.

Figure 10-5. The screen on the left shows a low sweep velocity (12 sec-
onds per screen), while the one in the middle has a 6 second sweep and
the one on the right a 3 second sweep per screen.

Normal Pressure Waveforms

The tracing of the pressure waveform is the variable providing more infor-
mation on the patient-ventilator interaction and on the mechanics of the
respiratory system as well as on certain aspects of the respiratory work of
the patient.

During volume-controlled ventilation with a patient totally relaxed, the

ventilator develops the pressure necessary to overcome the conditions of
resistance, elasticity or inertia of the respiratory system. In this case, the
tracing of the pressure waveform shows a slow increase during inspiration
and there are no significant differences between each breath.

In the volume-controlled mode, with rectangular flow waveform, the pres-

sure plotting shows two parts (Figure 10-5, on the right). The first, short
lasting, has a quick increase, and most of the flow remains in the circuit,
distending and compressing volume. In this case, the period is determined
by the circuit’s compliance. In the second part of the inspiration, the in-
crease in pressure is slower and depends on the flow derived from the in-
spiratory time and regulated volume.

Since the NEUMOVENT Graph ventilator has no direct regulation of the

inspiratory flow, the end of inspiration is well defined by the instant open-
ing of the expiratory valve once the regulated inspiratory time has
elapsed. If an inspiratory pause is added, it is possible to observe a brief
pressure drop followed by a horizontal tracing or plateau. The plateau has
a duration equal to the regulated pause. During this time, there is no
flow, and an equilibrium is generated between the proximal and the alveo-
lar airway. During the measurement of static compliance, an inspiratory
pause is automatically produced providing information on the transpul-
monary pressure.

124 Graph Analysis

 Figure 10-6. Pressure, volume and flow scalars with a 0.5 second regu-
lation of the inspiratory pause. Note that during the pause, the volume
waveform also forms a plateau, while the flow waveform drops to zero.

Differently from volume-controlled ventilation with rectangular flow, dur-

ing pressure-controlled ventilation (PCV) or pressure support ventilation
(PSP), the tracing shows a quick and lineal increase until the set pressure
limit is reached. The pressure remains constant during spontaneous or
regulated inspiratory time.

Figure 10-7. Pressure-controlled ventilation (PCV). Rectangular pressure

waveform with positive ramp inspiratory flow. Inspiration is time-cycled.
The profile of the PSV waveform is similar to the figure, but the end of
inspiration takes place when the inspiratory flow decreases to 25% that
of the peak flow (default value).

In this mode, the initial flow is high and corresponds to the peak flow
value shown on the screen.

The end of inspiration of PCV and PSV takes place differently. In PCV, the
end of inspiration is marked by the regulated inspiratory time. In PSV, it
takes place when the inspiratory flow decreases to 25% that of the peak
flow (default value) or to 50, 45, 40, 35, 30, 20, 15, 10 or 5%, depending
on the selection made. In PSV with assured Volume, inspiration ends
when the selected target tidal volume is reached.

Graph Analysis 125

 During expiration, the airway pressure is mainly determined by the
circuit’s expiratory resistance. To a lesser degree, there is also involve-
ment of the respiratory system compliance and resistance. When PEEP is
added, the pressure drops stops at the regulated level.

Figure 10-8. Pressure waveform during ventilation with 5 cm H2O of

PEEP.

Abnormal Pressure Waveforms

The analysis of the pressure waveforms may give information on any alter-
ation in the patient-ventilator interaction. These alterations may arise
from inadequate regulation of some parameters, or from selections made
in the ventilator itself, or from the underlying lung pathology. The defect
in the patient-ventilator interaction may result in asynchrony, augmented
inspiratory effort, unsatisfactory inspiratory flow, or it may arise from
leaks in the respiratory circuit.

During assist or spontaneous ventilation, the patient starts and continues

the inspiratory phase with his own effort which may result in irregulari-
ties in the tracing. This is almost always due to the lack of coordination
between the patient’s demand and the way the ventilator delivers volume.
When this happens, the ventilator controls must be changed until a cor-
rect adjustment is obtained. These changes include modification of the
flow waveform in volume-controlled ventilation (the descending ramp
waveform is better) or of Rise Time in ventilation by pressure. The inspira-
tory time, sensitivity and amount of volume or pressure also have an in-
fluence on them.

Asynchrony. It is one of the most frequent difficulties during assist venti-

lation of patients with an increased ventilatory demand or when there is
inadequate regulation of the ventilator trigger sensitivity.

In some cases, the patients try to exhale during the inspiratory phase or
inspire during the expiratory phase. In the first case, there is an increase
of the pressure peak and in the second, there are deflections of the pres-
sure tracing. Sometimes, during SIMV, there is an incorrect regulation of
trigger sensitivity, in which case some alterations are observed in the res-
piratory pace.

126 Graph Analysis

 Figure 10-9. Asynchrony during SIMV + PSV. a) Excessive demand dur-
ing the trigger phase; b) Spontaneous breaths which are not able to trig-
ger the ventilator (sensitivity inadequately regulated); c) Spontaneous
breath overlapping a mandatory breath.

Trigger Sensitivity. In the pressure-triggered mode (Ptr), the patient must

generate a negative inspiratory pressure for the ventilator to start the in-
spiratory phase. When the sensitivity is correctly regulated, a slight drop
of the pressure waveform baseline of no more than 1 or 2 cm H2O may be
observed. If the deflection is greater, it indicates that the sensitivity is in-
correctly regulated or that the patient’s flow demand is not satisfied. Ei-
ther case may produce an increase in the work of breathing.

Figure 10-10. Pressure-triggered mode. a) Significant negative deflection

produced by inadequate regulation of sensitivity. B) Normal deflection
during trigger.

When the flow-triggered mode (vtr) is selected, it is normal to observe

that the baseline rises around 2 cm H2O due to the continuous flow itself
generated during the expiratory time.

Figure 10-11. Flow-triggered mode. Sensitivity flow: 5 L/min, with base-

line flow of 10 L/min. A slight elevation of the baseline may be observed.

Graph Analysis 127

 Inspiratory Flow. During volume assist ventilation with rectangular flow
waveform, a concave tracing may be observed in the ascending slope of
the pressure waveform. This abnormality is seen when the patient’s de-
mand has increased, indicating unsatisfactory inspiratory flow. This alter-
ation may be corrected in two ways, by increasing the inspiratory flow
through the shortening of the inspiratory time, or by changing the flow
waveform to the descending ramp type. The initial high flow of the latter
may mitigate the patient’s inspiratory work.

Figure 10-12. The arrow indicates a concavity in the pressure waveform

during assist ventilation caused by a higher demand of inspiratory flow.
The patient’s flow demand is higher than the flow delivered by the ventila-
tor. Compare it to the profile of the normal slope on the right.

Regulation of Rise Time. In the pressure-limited modes (PCV, PSV), the

pressure waveform may be used to regulate the rise time. The regulation
of the pressure rise time enables a better adjustment of the inspiratory
flow to the patient’s demand.

A brief time will produce a quick pressurization, generating a rectangular

pressure waveform (characteristic of the pressure modes) and a decelerat-
ing expiratory flow waveform.

Figure 10-13. PCV. a) Slow rise time, the pressure waveform loses it
normal square configuration; b) Adequate rise time, square pressure
waveform and an evidently decelerating flow waveform.

128 Graph Analysis

Under some circumstances, the increase to a given pressure may be too
abrupt causing a saw-tooth-like tracing. These cases are solved by modi-
fying the pressure waveform rise time. This control enables a better ad-
justment of the ventilator to the patient’s needs.

Figure 10-14. Examples of an abrupt rise of the pressure waveform dur-

ing simulation of ventilation with a 20 cm H2O/L/sec resistance. The ar-
row indicates that the RT (rise time) bar is too high.

Figure 10-15. Given the same resistance in the lung model, rise time
was, in this case, conveniently regulated.

Assessment of circuit leaks. The leaks in the patient’s circuit or in the ex-
piratory valve may be detected in the pressure waveform when the in-
spiratory plateau level is not maintained (if programmed) or when the end
expiratory pressure is not maintained.

Graph Analysis 129

 Normal Volume Waveforms
During the inspiratory phase, the volume waveforms show an increase,
the shape of which depends on the flow generating them.

Figure 10-16. Volume waves (center) with different shapes depending on

the flow. From left to right: constant flow waveform, decelerating flow,
sine flow, and positive ramp flow waveform.

The expiratory phase is recognized by the simultaneous beginning and

progressive decrease of the pressure and volume waveform. Under normal
circumstances, the volume baseline tends to follow the flow waveform
rather than the pressure waveform.

Abnormal Volume Waveforms

The alterations of the volume waveform are mainly due to two causes,
leaks in the respiratory circuit and expiratory obstruction.

Figure 10-17. Left: Volume waveform with incomplete descent of the

baseline suggesting a volume leak in the respiratory circuit. Right: The
volume waveform shows a prolonged descent following the flow expira-
tory delay.

130 Graph Analysis

Normal Flow Waveforms
The flow waveform is constituted by two parts: 1) Inspiratory flow plotted
above the baseline and, 2) Expiratory flow plotted below the baseline. The
baseline corresponds to zero flow.

The inspiratory flow provides information on the ventilator’s work, and it

may be modified by a correct handling of the equipment.

The expiratory flow depends basically on the mechanical characteristics of

the patient‘s respiratory system (compliance and resistance) and on the
conditions of the ventilator circuit (tracheal tube, circuit tubes, expiratory
valve); therefore, it constitutes an important tool to monitor the patient.

Figure 10-18. Flow waveform with rectangular shape generated by the

volume-controlled mode. The upper part corresponds to the inspiration
and the lower one to the expiration.

In this ventilator, the composition of the flow waveform comes from the
integration made by the pneumotachographs. Thus, the internal pneumo-
tachograph provides information to plot the inspiratory flow, and the ex-
ternal one, located at the end of the patient’s circuit, plots the expiratory
flow.

The generation, and therefore, the shape of the flow waveform, depends
on the selected ventilatory mode. In the volume-controlled mode, the de-
fault flow waveform is of the descending ramp type, but it may be changed
to a rectangular, sine or positive ramp waveform. The changes in flow are
accompanied by changes in the pressure waves which adopt various
shapes.

Graph Analysis 131

 Figure 10-19. Pressure and flow waveforms obtained simultaneously
during volume-controlled ventilation. At the bottom, the four flow waves –
rectangular, descending ramp, sine and positive ramp waveform– are
observed. At the top, the pressure waves corresponding to each flow
waveform are shown.

The selection of one or another flow waveform depends on the specific cir-
cumstances that arise when trying to adjust the ventilator to the patient’s
needs. The rectangular waveform is the classical one, where the volume is
obtained with a relatively low flow. The descending ramp waveform is ad-
equate for patients with ventilatory assistance, where the initial high flow
may better satisfy the patient’s needs. The sine waveform simulates best
normal breathing. The positive ramp waveform produces the highest pres-
sure peak.

The pressure modes (PCV or PSV) are driven by a descending ramp flow
(decelerating flow) which keeps the regulated pressure constant. The gen-
eration of pressure is the same in all modes; they differ in the way the
inspiratory phase begins or ends.

Figure 10-20. Plotting of pressure (top) and flow (bottom) using pres-
sure-controlled ventilation mode (PCV). During inspiration the pressure is
constant and the flow is decelerated (descending ramp).

132 Graph Analysis

 Pressure Support Ventilation with Tidal Volume Assured (PSV + VT As-
sured) is the only mode that can generate two flow waves in the same in-
spiration. Thus, when the target volume is not obtained during the
patient’s demand, the flow changes from decelerated to continuous until
the regulated VT value is attained.

Figure 10-21. Operative mode: Pressure Support with Tidal Volume As-
sured. Note the change in the descending ramp flow waveform to con-
stant flow; simultaneously there is a pressure increase until the target
tidal volume is attained.

Abnormal Flow Waveforms

The analysis of the flow waveforms provides information on the alterations
of the ventilator, of the patient-ventilator relation or those produced in the
patient himself. Some situations will be described so as to guide the op-
erator in relation to the possible origin of a defect in the flow waveforms.

Operation of the Ventilator. When the defect is in the upper part of the flow
waveform, it is possible that the alteration may be generated by the sen-
sors of the internal pneumotachograph. However, the external pneumot-
achograph is the one most likely to cause problems due to its location.

Figure 10-22. Absence of expiratory flow indicating a defect in the sens-

ing of the expiratory pneumotachograph. In this case, the cause was the
disconnection of the P1 tube going into the ventilator.

Graph Analysis 133

 Optimization of flow during PCV or PSV. During these pressure modes, the
flow is usually descending ramp or decelerating waveform, and this can-
not be changed.

An incorrect regulation of the peak inspiratory flow may alter the shape of
the waveform making it lose its decelerating characteristic. The adequate
flow profile may be corrected by regulating rise time and observing at the
same time the flow waveform (Figure 6-12).

Optimization of VT during PCV. In the pressure-limited ventilatory modes,

VT depends on the set pressure level, the inspiratory time and the
patient’s respiratory impedance.

At times, even when the pressure levels are correctly set, it may be ob-
served that the expiratory portion of the flow waveform decreases to the
baseline in an abrupt step-like way instead of decreasing slowly. This in-
dicates that the inspiratory time is short for the lung which is in condition
to receive more volume. A regulation alternative in the above-mentioned
case may be the reduction of the pressure level and/or the increase of the
inspiratory time.

Figure 10-23. PCV. By prolonging the inspiratory time, VT may be in-

creased without modifying the set pressure level.

Evidence of Auto-PEEP. Auto-PEEP or dynamic hyperinflation is the unin-

tended residual positive pressure at the alveolar level, which takes place
at the end of expiration as a result of an incomplete emptying of the lung.
Auto-PEEP may cause barotraumas and hemodynamic alterations.

This ventilator has a program to assess the lung mechanics allowing a

measurement of auto-PEEP; however, during mechanical ventilation, this
alteration may be observed in the expiratory flow waveform.

During normal expiration, the expiratory flow waveform reaches the base-
line slowly and progressively. An abrupt step-like increase, before the next
inspiration, indicates that the expiratory time is insufficient and that part
of the inspired volume has been trapped in the lung suggesting dynamic
hyperinflation.

134 Graph Analysis

 Figure 10-24. Auto-PEEP; a) Normal return of the expiratory flow wave-
form to the baseline; b) Abrupt return in step-like form of the expiratory
flow to the baseline. There is no complete expiration of the lung before
beginning the next inspiration (dynamic hyperinflation).

Assessment of Patient and Treatment. A prolonged expiration may be

caused by the obstruction of the airways (bronchospasm or dynamic col-
lapse of the airways).

The appearance of vibrations tends to be produced by the presence of se-

cretions or excessive condensate in the expiratory circuit.

Figure 10-25. The vibration observed in the expiratory flow tracing may
be produced by secretions or condensed water in the circuit.

The conformation of the flow waveform and the expiratory time may also
be used to assess the patient’s response to a treatment with bronchodila-
tors, although the Flow/Volume loop tends to be more useful.

Graph Analysis 135

 Pressure/Volume Loop
It is the graphic representation of the dynamic relation between the
change in volume which takes place at all moments and the pressure
change in the airway.

Figure 10-26. Pressure/Volume loop obtained during volume-controlled

ventilation. The calculation of the dynamic compliance is shown breath
by breath.

The beginning of inspiration usually shows a quick increase in the pres-

sure with a slight change in volume. This is followed by an increase in
pressure accompanied by a progressive increase in volume.

The analysis of the pressure/volume loop during mechanical ventilation

gives information on some aspects of the lung mechanics such as varia-
tions of compliance and also allows the plotting of the result of a given
therapy, or warns about situations such as unsatisfied demand during
assist ventilation, helping to correct the regulation of the ventilator’s pa-
rameters.

Dynamic Compliance. It is a dynamic measurement providing information

on the general impedance of the respiratory system (thoracic-pulmonary
elasticity + airways resistance). The pressure/volume graph shows, in
each breath, the result of dynamic compliance.

The dynamic compliance may be determined by measuring the slope of

the line joining the points of zero flow in the pressure/volume loop. The
tilting of the line to the right indicates a reduction in dynamic compliance
due to the alteration of one of the factors determining it.

Involvement of the Respiratory Impedance. As it has already been pointed

out, the tilting observed in the pressure/volume loop represents the im-
pedance of the thoracic-pulmonary elasticity and the frictional resistance
of the airways.

136 Graph Analysis

By carefully observing the loop, the magnitude of the frictional resistance
of the airways may be determined, thus differentiating it from the elastic
component.

Figure 10-27. Left: Pressure/Volume Loop showing a reduction of the

dynamic compliance produced by alteration of the thoracic-pulmonary
elastic component (C20 R5). Right: Reduction of the dynamic compliance
equal to that produced by the increase in the frictional resistance (C50
R20).

Pulmonary Overdistension. The use of tidal volumes which are not ad-
equate for the lung may produce pulmonary overdistension and risk of
barotraumas or volutrauma.

Figure 10-28. Pressure/Volume Loop where the “beak” image character-

istic of pulmonary overdistension may be observed.

In the pressure/volume loop, this phenomenon is observed as a flattening

of the upper portion which gives the loop the “beak” shape. The tidal vol-
ume may now be corrected with continuous monitoring of the thoracic-
pulmonary mechanics.

Inspiratory Effort and Trigger Sensitivity. The patient’s effort to trigger the
ventilator is represented by a shifting to the left which is observed in the
initial portion of the pressure/volume loop.

Graph Analysis 137

 Figure 10-29. Shifting to the left of the initial portion of the pressure/vol-
ume loop indicating an incorrect regulation of the trigger sensitivity or
higher demand of inspiratory flow.

Trigger sensitivity may be corrected by observing the pressure/volume

loop in real time.

Adjustment of PCV and PSV. Pressure-controlled ventilation and pressure

support ventilation offer the advantage of providing an inspiratory flow
that can be regulated to satisfy the patient’s needs. In this ventilator, the
inspiratory flow is varied through the rise time control key.

Figure 10-30. PSV. Right: Shifting to the left of the inspiratory portion of
the pressure/volume loop indicating excessive demand and/or incorrect
regulation of “rise time”. Left: Adjustment of “rise time” to the patient’s
demand with observation in real time.

The shifting of the pressure/volume loop to the left during PCV assist or
PSV indicate a respiratory demand which is not satisfied by the flow or
“rise time” selected. By observing the loop, the demand flow may be ad-
equately adjusted to the patient’s needs.

138 Graph Analysis

Flow/Volume Loop
It is the graphic representation of the dynamic relation between the
change in volume which may take place at every moment and the change
in the airway flow. The tracing below the baseline is produced by the flow
generated by the ventilator. The one above the baseline is developed by
the patient and the ventilator’s circuit.

Figure 10-31. In the flow/volume

loop, the tracing below the base-
line is formed during the inspira-
tion, and that above the baseline
by the expiration. The tracing
shows the rectangular pattern of
the inspiratory flow used in this
example (volume-controlled
mode).

In the ventilated patients, the flow/volume tracing provides useful infor-

mation on the alteration of the expiration (bronchospasm, leaks in the
respiratory circuit including the tracheal tube or due to a drained
bronchopleural fistula, auto-PEEP).

An expiratory waveform with the concavity upwards leads to the suspicion

of an expiratory delay due to bronchospasm or partial tracheal obstruc-
tion or bronchial obstruction due to a defect of the tracheal tube or abun-
dant secretions. During a gas leak or when there is auto-PEEP, the
expiratory tracing does not return to the volume vertical baseline.

Figure 10-32. Flow/volume loop. Left: Modification of the expiratory flow

due to increase in the airways resistance. Center: Vibration in the inspira-
tory and expiratory flow due to secretions or condensed water in the cir-
cuit. Right: Alteration of the expiratory flow due to a leak in the respiratory
circuit; note that the expiratory tracing does not reach the volume zero
line.

Graph Analysis 139

 Trend
The trend graphs are obtained by pressing the [Menu] key. By pressing it
successively, the following trend charts appear on the screen:

• Airway pressure (high and low)

• Respiratory rate
• Inspiratory peak flow
• Tidal volume
• Minute volume
• Dynamic compliance

In all cases, the tracing starts on the left. Then it begins to shift to the
right. By pressing [Horz] the time scale turns yellow; the = sign is shown;
then, with the [ ] Selection key the screen can be moved horizontally.

To change the time (3, 6, 12, 24 hs) press twice the [Horz] key; the <> sign
is shown; the time scale turns yellow; change the period of time with the
Selection key.

The trend waveforms can be printed to a file using the VisualGraph soft-
ware.

Measured Values
.
Peak Flow TI I:E TE total VT VE
spont.
(L/min) (s) spont. (s) (bpm) (L) (L/min) Pressure
Limits

Category High Insp.

Pressure
Paw
Pressure
Peak Control (PCV)
(above PEEP)

Plateau
Pressure
Support (PSV)
Mean (above PEEP)

Pmax
Base PEEP/CPAP
(reference value)
Pmin

Oxygen
Monitor Low Insp.
Pressure

FIO2 Inspiratory I:E Machine Volume Sensitivity

Time Ratio Rate

Figure 10-33. Trend waveform for the airway pressure. Pmax: peak
pressure; Pmin: baseline pressure. The initial baseline pressure corre-
sponds to a PEEP of 5 cm H2O.

In all cases, the sampling for the trend is made once per minute.

End of
Chapter

140 Graph Analysis

 Chapter 11

All parts in contact with the patient are easily disassembled for a com-
plete cleaning. Thus, the different parts are then conveniently sterilized
and reassembled, being ready for later use.

The procedures indicated herein for the decontamination and cleaning of

the device are to be used as a guideline. These guidelines may be adapted
to the protocols on methods and frequency of each department bearing in
mind the warnings stated herein.

Respiratory circuit
Special care must be taken when cleaning and making aseptic the respi-
ratory circuit, including breathing tubes, expiratory valve, expiratory
pneumotachograph and humidifier. These parts must be routinely
changed and replaced by sterile or disinfected elements.

After removing them from the ventilator, the patient’s circuit must be dis-
assembled to expose all surfaces before cleaning. All parts to be disin-
fected or sterilized must be carefully cleaned to remove all rests of
material adhered to them (blood, tissue products or other residues). Clean
all parts using soft detergent solutions and then rinse them preferably
with distilled water.

WARNING
The breathing circuit tubes and the heater-humidifier are no parts made or
processed by TECME.
To maintenance and disinfection, refer to the manufacturer's instructions
and recommendations.

If the components are sterilized using ethylene oxide or known chemical

solutions (quaternary ammonium compounds) use the products according
to the manufacturer’s instructions and recommendations. Make sure the
compounds are compatible with the plastic material.

WARNING
The ethylene oxide may alter the surface of the plastic materials and accel-
erate the aging of the rubber components.

CAUTION
Ethylene oxide IS TOXIC. All components must be completely dried before
packing them for sterilization with ethylene oxide. After sterilization, they
must be appropriately aired to dissipate the residual gas absorbed by the
material. Follow the manufacturer’s recommendations as to the aeration
period.

Care and Maintenance 141

 WARNING: The ventilator should not be subjected to sterilization with
ethylene oxide gas. Irreparable damage of its components can take place.

CAUTION: Do not use solvents, acetone, chloroform or strong acid sub-

stances or chlorinated solvents to clean the plastic parts or the respiratory tubes.

Refer to the heater-humidifier manufacturer manual for the cleaning and

sterilization of the device.

CAUTION: Do not submerge the humidifier base in any kind of liquid.

The electric components may cause a short circuit.
It is also important for the assembly and reassembly to be correctly done
for a correct working of the ventilator.

Expiratory valve and flow sensor

The expiratory flow sensor (pneumotachograph) is part of the
expiratory valve assembly. The lower 22 mm free end consti-
tutes the tap to which the last tube of the patient’s respiratory
circuit is connected.
The small side tubes of the sensor are connected as follows,
the lower one to P1 and the upper one to P2 on the base of the
enclosure. This communication transmits pressures to the in-
ternal differential transducer for the integration of the expired
volume and flow. The upper tube also transmits the airway
pressure.

CAUTION
The flowmeter has in the middle internal part a membrane, the
integrity of which is essential for an adequate reading of the ex-
pired volume. When cleaning this piece, be careful not to damage
the membrane.

The expiratory valve itself, has a diaphragm inside. When com-

pletely assembled, it is screwed into the lower connection of the
enclosure.

CAUTION
A correct position of the diaphragm is essential for a correct op-
eration of the ventilator. The diaphragm must be placed in the
body of the valve so that the ring is looking outwards. Close with
the threaded cover tightly.

CAUTION
To replace diaphragm, always use original spare part.
Similar parts can produce valve malfunction.

142 Care and Maintenance

 CAUTION
The pneumotachograph incorporated to the expiratory valve has a
transparent membrane inside.
Make sure the membrane is not bent or damaged so that the
measurement of expiratory flow and volume is correct.

Membrane

Diagram of the Respiratory Circuit

NOTE
The following accesories are optional and are not
manufactured neither provided by TECME:
- Reusable or discarded breathing circuit:
Adult, Pediatric or Neonate.
- Heater-humidifier.

WARNING
Do not use antistatic neither electrically
conductive tubes in the breathing circuit
and gas supply.

NOTE
To discard the whole device or disused parts or elements provided by
other suppliers, follow the requirements of the institutional authority.

Care and Maintenance 143

 Internal Battery
The NEUMOVENT Graph contains an internal battery that can supply 2
hours 30 minutes of power depending on ventilator settings and battery
charge level. The ventilator automatically switches to the internal backup
battery when electrical power supply failure is detected. The internal bat-
tery is charged during ventilator operation if attached to an AC power
source. This can be either in standby mode or when the ventilator is
turned off.

CAUTION
If, when turning the ventilator on after being unplugged for an extended
period of time the “Depleted Battery” signal appears, the internal battery
must be recharged by plugging the ventilator into a power source for a mini-
mum of eight (8) hours.
Reappearance of the “Depleted Battery” signal after the battery has been
recharged indicates the need to replace the battery.

WARNING
Never begin a ventilatory procedure when the equipment is turned ON
and the battery icon indicates very low load. DO NOT USE the ventilator
until the load is completed maintaining the connection to the main source of
electrical energy.
If the battery icon continuously persist in a middle position, the battery
should be changed.

CAUTION
In case of battery discard follows the Institutional requirements. The dis-
carded unit should not be thrown to fire. Explosion may result.

Disassembled Air Filter

Air Filter
The air filter has an automatic drainage system for the condensed
water. Nevertheless, the following steps should be followed for its
normal operation:

➪ Connect the filter according to the instructions explained in

Filter
chapter 3 “Assembly and Installation Procedures”.
element
➪ Always keep the device vertically.
Lock ➪ Use, if necessary, a tube connected in the exit of the drainage in
order to collect the water in a container. The tube must have 8
mm (5/16 in.) of diameter and not more than 5 m (16,5 ft.) of
length. Be sure not to have any upward turns in the drain line
which would prevent drainage.
➪ Change the filter unit every two years or before the pressure fall
is greater to 1 kg/cm2 (0,1 MPa).
➪ To change the filter element pull down the frontal lock and turn
the bowl guard towards any side until the || marks are in front..
Throw downwards. Unscrew the filter element and replace it by a
new one.

144 Care and Maintenance

 Maintenance and revision every 5000 hours or once a year
(Procedure made by the specialized technician)

Substitution of the expiratory valve.

Inspection and verification of the operation of each key and the screen.
Disassembly of the air and oxygen supply inlet, with cleaning or change
the porous metallic filters.
Alarms test: lamps and sound (Ctrl + Reset).

Replacement of the exhalation valve.

Inspection and verification of the operation of each key and the screen.
Disassembling of the oxygen and air supply inlet with cleaning or
change of the porous metallic filters.
Verification of FIO2 (oxygen concentration) with and appropriated
measuring device. Recalibration if necessary.
Verification of sensors.
Lamp test and sound of alarms (Ctrl + Reset).
Verification of updates of software.
Control of the battery.
Verification of panel LEDs.
Opening of back cover and cleaning of the fan.
Visual verification of internal manifolds.
Cleaning of contacts and internal connections.
Pressure control of internal regulators.
Inspection and verification of the operation of Proportional Valves.
Recalibration if necessary.
Final control of operation.

Maintenance warning

Every 5000 running hours a tool icon appears on the right superior part
of the screen indicating the opportunity of service. The presence of the icon
on the screen is eliminated by the authorized Service once the maintenance
protocol is carried out.

Care and Maintenance 145

 Respiratory Circuit Tubes
Cleaning and Handling Instructions

WARNING
The following description and instruc- The tubes must be inspected to ensure there is
tion are included with the only purpose to make no damage after disinfection. Care must be
clear the handling and maintenance of a deter- taken, as recommended in all autoclave proce-
mined type of tubes that can be used in the res- dures, to clean all organic material from the
piratory circuit. These tubes are not made by tubes appropriately and to remove all residues
TECME. of the cleansers used. This is extremely impor-
tant when an autoclave procedure follows dis-
infection with concentrated or diluted
Reusable plastic tubes with smooth bore solutions. Any residual solution may cause
breaking or rupture of the material.
These respiratory circuit tubes are manufac-
tured with material for high temperature. The It is important to avoid the use of solutions
chemical composition is a polyester elastomer containing chloride in the disinfection. The
(Hytrel®). It incorporates at each end an inte- polyester may break or form small holes after
gral silicone rubber cuff. prolonged exposure to chlorinated solutions.
The damage process may be accelerated if the
CAUTION tube is sterilized in autoclave or dry-heated
with residues of these solutions.
To avoid any damage to the tubes, con-
nect and disconnect them by holding them only An appropriate handling of the tubes is also
from the silicone cuff. Do not pull or bend them important. Any contact of the tubes with hot
from the spiral part. Avoid any exposure to Ul- elements, shelves, etc. while in autoclave must
traviolet (UV) light. be avoided. When the tubes are put away, it is
important to avoid prolonged exposure to UV
light. This has a degeneration effect on the ma-
terial of the tubes and, with time, it may cause
Cleaning procedure
rupture or holes.
To avoid any damage to the tubes, follow the
cleaning procedure indicated below. The tubes
must be cleaned with soft detergent followed End of
by water cleaning before disinfection. Any of chapter
the following disinfection methods is satisfac-
tory:
• Autoclave – 132°C/ 270°F
• Ethylene Oxide – 55°C / 131°F
• Pasteurization – 75°C / 170°F
• Hydrogen peroxide gas plasma

The exact process must follow in each case the

standard hospital or institutional procedure.

The following solutions MUST NOT be used

They may cause the disintegration of the tubes:
Hypochlorite
Chlorinated hydrocarbons
Phenol (>5%)
Aromatic hydrocarbons
Formaldehyde
Inorganic acids
Acetone

146 Care and Maintenance

This equipment is sold under the terms of the warranty specified below, which
applies only to the purchaser who buys the equipment, new, directly from
TECME or from the manufacturer’s official distributors, agents or represen-
tatives.
TECME guarantees that this equipment is free from manufacturing defects
or defects in the material for a period of one year as from the delivery date and
provided that it is operated and maintained correctly under normal operating con-
ditions and in accordance with the instructions specified in this manual. Under
this warranty, TECME obliges itself to change or repair those parts which,
once examined by the manufacturer, prove to be defective or show alterations.
TECME does not assume responsibility for any consequent or special dam-
ages resulting thereof.
The above warranty is rendered invalid if the equipment has been repaired or
altered by unauthorized persons or if said equipment has been subject to abuse,
misuse, negligence or accidents.
TECME is bound by this warranty agreement only when the following re-
quirements are met:
1) TECME is notified promptly in writing by a letter from the purchaser ex-
plaining the defect or fault that has been found.
2) The defective unit is sent by prepaid carriage and within the period of time
specified in this warranty.
TECME does not assume any responsibility for any extension that any sales
firm can grant of the warranty’s time limit, unless there is a special agreement.

Warranty 147
 This Page Intentionally Left Blank

148 Warranty
A
Connection of the Power Supply 15
Abnormal flow curves 133 Expiratory Valve and Flowmeter 19
Abnormal Volume Curves 130 Pedestal assembly 14
Air supply 7 Pneumotachograph 19
Airway pressure release ventilation (APRV) 84 Asynchrony 126
Alarm and safety tests 103 Auto-PEEP 108, 134
Alarm in SIMV 89
Alarm limits 39 B
High inspiratory pressure 39
High tidal volume 40 Backup Ventilation 87
Low inspiratory pressure 39 Backup ventilation 33
Low tidal volume 40 Backup Ventilation Programming 88
Minute volume 40 Breathing circuit assembly 18
Oxygen concentration 40 Breathing tubes support 14
Respiratory rate 40 C
Alarm low priority signals (warn) 46
Alarms 8, 41 Care and maintenance 141
Apnea 46 Expiratory valve and flowmeter 142
Continuous pressure 43 Internal Battery 144
External power loss 43 Maintenance and revision every 5000 hours or
f max 46 once 145
Fan Failure 46 Respiratory circuit 141
FIO2 18% or below 44 Circuit leaks 129
High inspiratory pressure 42 Classification 7, 23
High priority signals (urgency) 42 Cleaning, disinfection and sterilization
Low inlet gas 43 Respiratory circuit tubes 145, 146
Low inspiratory pressure 42 Combined Modes 33
Low PEEP 47 Combined modes 75
Mask disconnection 44 MMV + PSV 75
Medium priority signals (danger) 44 PSV + VT Assured 75
NIV circuit leak 46 SIMV (PCV) + PSV 75
O2 concentration high 45 SIMV (VCV) + PSV 75
O2 concentration low 45 Commands of non required use 55
Technical failure 44 Commands of required use 55
VE high 47 Complementary Keys 35
VE low 47 Ctrl 35
VT high 44 Manual Trigger 36
VT low 45 Nebulizer 36
Altitude compensation 9, 22 O2 100% 35, 86
Apnea 8, 46 Reset 35
Apnea time 89 Standby 35
Application 7 Compliance 110
APRV Programming 85 Dynamic 111
Assembly and installation procedures 13 Static 111
Breathing circuit assembly 18 Connection of the Power Supply 15
Breathing tubes support 14 Continuous pressure alarm 43
Components 13 Continuous positive airway pressure (CPAP) 74

Index 149
Control Keys Fan Failure 46
[PSV] 86 Features 23
FIO2 34, 86 Classification 23
I:E Ratio 34, 85 Control panel 28
Inspiratory Time 34 Control subsystems 28
Minute Volume 34 Inspiratory waveforms 25
PEEP/CPAP 34 Modifications of the inspiratory flow 27
Pressure Support 34 Safety mechanisms 29
Pressure-Controlled 34 Variables for the respiratory phases 23
Rate 34, 86 FIO2 8, 34, 86
Rise Time 35 FIO2 18% or below alarm 44
Sensitivity 34 Flow and Volume Correction 22
Tidal Volume 34 Flow trigger sensitivity 67
Control panel 28 Flow waveform
Control subsystems 28 Ascending ramp 59
Control valves 28 Constant 57
Controls table 11 Descending ramp 57
CPAP 74 Selection 59
Ctrl key 35 Sine 58
Flow Waves 25
D Flow/Volume loop 139
Date and time setting 21 Freeze 9
Description 31 G
Alarm limits 39
Alarms 41 General tests 102
Backup ventilation 33 Graph analysis 121
Combined Modes 33 Abnormal flow curves 133
Complementary Keys 35 Abnormal pressure curves 126
Control Keys 34 Abnormal Volume Curves 130
FIO2 18% or below alarm 44 Asynchrony 126
Inspiratory flow waveform 48 Auto-PEEP 134
Mask disconnection alarm 44 Circuit leaks 129
Monitor 48 Flow/Volume loop 139
NIV circuit leak alarm 46 Graph characteristics 123
O2 concentration high alarm 45 Inspiratory Flow 128
O2 concentration low alarm 45 Normal flow curves 131
Operative modes 32 Normal pressure curves 124
Power source 32 Normal Volume Curves 130
Pressure alarms - Mode of operation 40 Pressure/Volume loop 136
Respiratory mechanics 49 Rise Time 128
Screen values 37 Trend 140
Trigger sensitivity. 127
E Graph characteristics 123
Emergency ventilation 90 H
Environment 7
Execution Characteristics 7 Hardware 7
Expiratory pause 108 High inspiratory pressure 42
Expiratory Sensitivity 8
Expiratory sensitivity 70 I
Expiratory Valve and Flowmeter 19 I:E Ratio 8, 34, 85
External power loss 43 Inspiratory effort 137
F Inspiratory Flow 128
Inspiratory Flow Waveform 8
f max 46 Inspiratory flow waveform 48

150 Index
 Pressure-Controlled Ventilation 92
Inspiratory Pause 8, 61 SIMV (PCV) + PSV 95
Inspiratory Time 8, 34 Time Cycled-Pressure Limited-Continuous Flow
Inspiratory waveforms 25 96
Intended use 3 Volume compensated 93
Internal Battery 144 NIV circuit leak alarm 46
Internal battery 7, 9 Non-Invasive Ventilation 79
Introduction 3 Normal flow curves 131
Normal Volume Curves 130
K
O
Key
Ctrl 9 O2 100% 8, 35, 86
Enter 9 O2 concentration high alarm 45
Freeze 9 O2 concentration low alarm 45
Manual 9 Occlusion Pressure During the First 100 ms of Insp
Nebulizer 9 116
Print 9 Operational verification test 105
Reset 9 Operative mode key selection 54
Scale 9 Operative modes 7, 32, 55
Selection of operative mode 9 Oxygen concentration 8
Standby 9 Oxygen concentration alarm 40
Oxygen sensor 19
L Oxygen supply 7
Low inlet gas 43 P
Low inspiratory pressure 42
Low PEEP 47 Parameter Selection 8
Lung mechanics 107 PCV programming 65
Auto-PEEP 108 Pedestal assembly 14
Compliance 110 PEEP Loss 8
Expiratory pause 108 PEEP/CPAP 8, 34
Pimax 119 Pimax 119
Slow vital capacity 114 Pneumatic requirements 7
Pneumotachograph 19
M Power Loss 8
Machine Rate 8 Power requirements 7
Main current 7 Power source 32
Maintenance and revision every 5000 hours or once Pressure alarms - Mode of operation 40
145 Pressure Support 34
Mandatory Minute Ventilation with Pressure Support Pressure Support Ventilation (PSV) 8, 32, 66
80 Pressure Support Ventilation with Tidal Volume
Manual Inspiration 8 Assured 82
Manual Trigger 36 Pressure trigger sensitivity 67
Mask disconnection alarm 44 Pressure ventilation 32
Maximum Respiratory Rate 8 Pressure Waves 25
Minute Volume 8, 34 Pressure-Controlled 34
Minute volume alarm 40 Pressure-Controlled Ventilation (PCV ) 32
Modifications of the inspiratory flow 27 Pressure-Controlled Ventilation (PCV) 8, 62
Monitor 9, 48 Pressure/Volume loop 136
Print 9
N Programming 51
APRV 85
Nebulizer 36 Backup Ventilation 88
Neonatal category 91 Combined modes 75
Backup Ventilation 99 Commands of non required use 55
Pressure Support/CPAP 94

Index 151
 Commands of required use 55 Support 78
Continuous Positive Airway Pressure (CPAP) 74 SIMV [Volume-Control Ventilation] with Pressure
Mandatory Minute Ventilation with Pressure Support 76
Support 80 Slow vital capacity 114
MMV with PSV 81 Software 7
NIV 79 Specifications
Operative mode key selection 54 Altitude compensation 9
Operative modes 55 Standby 35
PCV 65
Pressure Support Ventilation with Tidal Volume T
Assured 82 Technical data and specifications 7
Pressure-Controlled Ventilation (PCV) 62 Application 7
PSV 66, 72 Classification 7
PSV with VT Assured 83 Controls table 11
SIMV (PCV) + PSV 78 Environment 7
SIMV (VCV) + PSV 77 Execution Characteristics 7
SIMV [Pressure-Control Ventilation] with Pressure Internal battery 9
Support 78 Monitor 9
SIMV [Volume-Control Ventilation] with Pressure Operative Modes 7
Support 76 Panel with Screen 7
VCV 60 Pneumatic requirements 7
Volume-Controlled Ventilation (VCV) 56 Power requirements 7
Programming of MMV with PSV 81 Respiratory Mechanics 9
Programming of PSV with VT Assured 83 Serial Output 7
PSV programming 72 Technical failure 44
R Tidal Volume 8, 34
Time Cycled-Pressure Limited-Continuous Flow
Rate 34, 86 (TCPL) 96
Recalibration 53 Trend 140
Reset 35 Trigger sensitivity 137
Respiratory rate alarm 40
Rise Time 35, 63, 128 V
Rise time 67 Variables for the respiratory phases 23
RS232-C Connector 21 VCV Programming 60
S VE high 47
VE low 47
Safety mechanisms 29 Ventilator operational test 101
Selection sector 36 Alarm and safety tests 103
Sensitivity 8, 34 General tests 102
Expiratory sensitivity 70 Operational verification test 105
Flow trigger sensitivity 67 Preparation 101
Pressure trigger sensitivity 67 Volume ventilation 32
Trigger sensitivity. 127 Volume-Controlled Ventilation (VCV) 56
Serial Output 7 VT high 44
Sigh 8, 61 VT low 45
Silence 8
SIMV (PCV) + PSV 78 W
SIMV (VCV) + PSV 77 Watchdog 90
SIMV [Pressure-Control Ventilation] with Pressure

152 Index
Notes
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