Respiratory Support

M6506 Clinical and Healthcare

Services Engineering
21/2/2008
 Applications
• Mechanical Ventilation
– Negative and Positive Pressure Ventilation
• Artificial lung
– Bubble and Membrane Oxygenators
 Negative Pressure Ventilation
• Used to treat respiratory paralysis,
especially when caused by polio
• First demonstration in 1824
• Two types:
– Tank
– Cuirass
 Negative Pressure Ventilation -
Principle

Motor Hypobaric Chamber

 Iron Lungs

Image Courtesy of Virtual Museum of the Iron Lung, © Richard Hill

Iron Lung, Singapore, 1952
 Modern Iron Lung c. 1980

Image Courtesy of Virtual Museum of the Iron Lung, © Richard Hill

 Other Negative Pressure
Ventilators

Cuirass Ventilator
Bodysuit ventilator
(Hayek Oscillator)
Images from A.K. Simonds (ed.), “Non-invasive Respiratory Support”,
Arnold, London, 2001
 Cuirass
Ventilator
 Negative Pressure Ventilation
• Advantages
– Patient can talk
• Disadvantages
– Uncomfortable
– Pooling of blood in abdomen with tank
ventilator
– Not as effective as PPV
 Positive Pressure Ventilation
• Invasive
– Tracheotomy or tracheal device
• Non-invasive
– access via face/nose mask
Positive Pressure Ventilation

Oxygen Supply Ventilator Face mask

(optional) controller
 PPV Equipment

For more, visit: http://freespace.virgin.net/michael.bowell/ventgall.html

 PPV Equipment

For more, visit: http://freespace.virgin.net/michael.bowell/ventgall.html

 Positive Pressure Ventilation
• Volume targeted
– Ventilator is programmed to deliver a fixed
volume of gas with each breath
• More efficient
• Uncomfortable
 Positive Pressure Ventilation
• Pressure targeted
– Ventilator is programmed to stop delivering gas
when maximum pressure is achieved
• More comfortable
• May not deliver enough O2
 Other Ventilation Modes
• Continuous Positive Airway Pressure
(CPAP)
– Positive pressure maintains patency of airway
– Used to treat obstructive diseases of the airways
such as tracheal cancer
Critical Care, 1960s
Critical Care, 1980s
Critical Care, 1990s
Communicating on a ventilator
 Artificial Lung (Oxygenator)
• Needed when:
– Obstructive condition prevents gas entering
lungs
– Surgeons are operating on the lungs or heart
• Mechanical pumping can damage lungs
– Condition of lung prevents sufficient gas
transfer
 Extracorporeal Oxygenation
• Used for relief of heart and lung function in
cardiopulmonary bypass and adult and
neonatal respiratory failure
– Mechanical replacement of heart/lung function
– Hypothermic conditions
– Duration: ECLS - hours
ECMO/ECCO2R - days / weeks
 Modes of Operation
• Extracorporeal Life Support (ECLS)
– Heart and Lungs are isolated
– Pump and Oxygenator take over their function
– Principal means of life support in
cardiopulmonary bypass procedures
– Short term - hours
 Modes of Operation
• Extracorporeal Membrane Oxygenation
(ECMO)
– Long term life support (days-months)
– Partial bypass
– Blood is taken from patient, oxygenated and
returned
– Some mechanical ventilation of lungs (very low
frequency
 Modes of Operation
• Extracorporeal Carbon Dioxide Removal
(ECCO2R)
– Long term life support (days-months)
– Removes all metabolically produced CO2 from blood
– Oxygen is taken up by passive diffusion in lungs
– Flow rate is lower than ECMO - less biomaterial
exposure
 Short history of Oxygenators
1885 - Demonstration of disc oxygenator.
1916 - Discovery of Heparin, the first safe reversible anticoagulant
1920s & 30s animal experiments demonstrate feasibility of
extracorporeal circulation using excised lungs and direct contact
devices
1953 - First clinical use of Oxygenator (Gibbon)
1956 - First disposable membrane oxygenator
1971 - Introduction of silicone rubber hollow fibres
1980s - Hollow fibre membrane oxygenators overtake direct contact
(bubble) oxygenators for first time
Oxygenators - 1953 to 2004
Gibbon’s screen
oxygenator, 1953

Early flat plate

membrane
oxygenator
1956
Univox Oxygenator, 1992
CPB in Practice
Nursing students observing cardiothoracic surgery,
TTSH, 1977 – note perfusionists
perfusionists
 Extracorporeal Oxygenation
• Patient is resting
– Low metabolic demand
– Metabolic demand is reduced further by
hypothermia
– Venous blood (O2 pressure = 40 mmHg) is
oxygenated (O2 pressure = 100-300 mmHg)
– CO2 is removed
 Heart Lung Bypass Circuit
Venous blood
from vena cava

Gas in

Oxygenator

Water in
Filter and
reservoir Gas out

Heat
exchanger

Water out
 Types of Oxygenators
1. Bubble Oxygenator

• Advantages: Relatively cheap, simple to use

• Disadvantages: Increased risk of

thrombosis, poor compatibility, defoamers
required. Longer post operative recovery.
 Bubble oxygenator
1 Oxygen and venous blood
enter oxygenator
3
2 Tiny O2 bubbles mix with
ascending blood stream, Gas
4 exchange occurs
3 Arterialised blood contacts
chemical defoamer and
2 exhaust gas is expelled
4 Arterialised blood leaves
1 oxygenator before going on
O2 to filters and bubble traps
Venous blood
 Types of Oxygenators
2. Membrane Oxygenator

• Advantages: Less damaging to blood than

bubble. Can be used for longer periods,
with shorter post operative course.
• Disadvantages: Longer set up time. More
expensive than bubble.
Membrane Oxygenator - Principle
1 Venous blood enters device
at gas outlet (counter-
current operation)
3
2 Blood and gas sides
separated by membrane
permeable only to gas. Gas
2 exchange takes place.
3 Arterialised blood collects
in arterial manifold and
1 passes to body via filter to
remove any thrombi (blood
clots).
Membrane Oxygenator
Geometry
Gas Blood

Blood
a Gas b

Blood
Gas

Gas
c d
Blood

a: Intraluminal flow
b: Extraluminal parallel flow
c: Cross flow (perpendicular)
d: Cross flow (spiral wound)
 Types of Oxygenators
3. Intravascular Oxygenator
• Inserted into vena cava via femoral vein
• Advantages: Non biologic surface contact
area minimised.
• Disadvantages: Cannot yet supply all
patient’s metabolic O needs. Systemic
2

anticoagulant needed.
 Performance of membrane
oxygenator
• Under-pressure vs. over-pressure
– Air Embolisms are bad!
• Boundary layers
• Pore wetting in microporous oxygenators
 Performance of membrane
oxygenator
• Under-pressure

Membrane ruptures,
Leaking blood clots,
blood leaks out
oxygenator can still
function
 Performance of membrane
oxygenator
• Over-pressure

Air embolus
Membrane lodges
ruptures, airin
artery:
enters blood
compartment
Stroke, CVA, PVD
 Build up of oxygenated layer
Arterialised blood, S=100%

Oxygen

Venous blood, S=0.65

 Computational Model -
Haemoglobin Saturation
65%

100%

l=0 l=L
– Note that the boundary between saturated and
unsaturated is quite sharp!
 Computational Model -
Oxygen Partial Pressure
Pin

Pgas

l=0 l=L
– For pressure the gradient is larger, as can be
seen here
 Computational Model -
Oxygen Concentration
Cin

Cmax
l=0 l=L
– The difference in concentration between red
layer and the wall is mostly due to dissolved O2
 Mechanism of pore wetting

Polar Phospholipids coat

hydrophobic membrane Blood plug infiltrates
into pores
 Ways to prevent pore wetting
• Use homogeneous membranes (currently
the only way!
• Develop microporous membranes with an
ultra-thin homogeneous layer
Full model of cross flow
oxygenator: Advanced
Simulation and Design
Gmbh