Puritan Bennett™

840 Ventilator
Volume Ventilation Plus Software Option

Nellcor™
Puritan Bennett™
Airox™
Mallinckrodt™
DAR™
Shiley™
 A Breakthrough in Ventilatory Care
for Patients and Clinicians

Healthcare providers and patients throughout the world depend on

Covidien for state-of-the-art ventilation therapy. Whether your needs
include acute care for critically ill patients with chronic respiratory failure
or a solution to transition patients to home care, we have the right system
for the task at hand.

Healthcare professionals know all too well the range of issues that
impact ventilation outcomes today. At Covidien, our innovations are
systematically tackling the issues that truly matter—patient safety,
medical efficacy and healthcare efficiency. The Volume Ventilation
Plus software option is another example of how we’re helping medical
professionals improve ventilation outcomes and quality of life for
their patients.

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 Three Dimensions of Excellence A Brief Overview of Volume
Built into the Volume Ventilation Ventilation
Plus System Standard volume ventilation has been
• Patient Safety—Three specific alarms associated with increased work of
come with the VC+ and VS options that breathing, flow starvation and preven-
tion of spontaneous breathing or cough-
alert the clinician of changes in patient
ing during the inspiratory phase.1, 2 If
condition and provide lung protection.
higher sedation is used to treat ventila-
• Clinician Support—The VV+ option tor asynchrony, the increased sedation
offers the patient enhanced comfort and or paralysis could lead to increased time
synchrony (clinician support) while on the ventilator.3-7 In contrast, recent
research has indicated that limiting
offering clinicians a way to maintain
damage believed to be caused by over
targeted tidal volume.
distention of the lungs in acute respira-
• Healthcare Efficiency—The VV+ tory distress syndrome (ARDS) may
system expands the therapeutic range play an important role in improving
survival. Lower tidal volume and lower
options for clinicians. It is also effective
lung pressure have been associated with
in weaning patients from anesthesia,
improved survival.8-10 Whether volume
resulting in less time and money spent or pressure strategies are best for achiev-
on postoperative recovery. ing this lung protection goal remains
undetermined.

This clinical paper describes two new

breath delivery strategies with sig-
nificant improvements in spontaneous
breathing and preset volume delivery.

3
 Pressure-Based and A Volume breath type
Volume-Based Breaths A Volume breath type is determined
The phrase “dual modes” of ventilation by presetting a tidal volume, allowing
has caused some confusion regarding pressure to rise and fall as lung imped-
when to employ one kind of breath ance changes. Volume breath goals
type or another kind of breath type. include maintaining consistent ventila-
Dual modes are not actually modes but, tion, maintaining low volumes for lung
rather, breath types. A breath type is protection and eliminating CO2.
defined as the means by which either a
mandatory or spontaneous breath is de-
Volume Ventilation Plus
livered (i.e., Pressure Support, Pressure
Volume Ventilation Plus (VV+) is an
Control, Volume Control).
option that combines two different dual
A Pressure breath type (whether man- mode volume-targeted breath types–
datory or spontaneous) is determined Volume Control Plus (VC+) for delivery
by presetting the delivered peak pres- of mandatory breaths in A/C and SIMV,
sure, while allowing flow and or tidal and Volume Support (VS) for delivery
volume to vary. of spontaneous breaths in SPONT only.

Pressure and volume Breath Types

Pressure Constant Volume Constant
PC Volume Ventilation
(In A/C or SIMV) (in CMV or SIMV)

PS †
VC+/PRVC/AutoFlow
Mandatory
(In SIMV for Spont) VAPS/Pres Au

BiPAP Bi-Level
Spontaneous †
VS
(Conv I:E or APRV)
†
Dual Modes

Tube Compensation (TC) or Proportional Assist™* Ventilation (PAV™*)

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Volume Control Plus VC+ Clinical Advantages
Volume Control Plus (VC+) utilizes a Common uses of VC+:
clinician-set inspiratory time and clini- • The clinician sets only the target volume
cian-set target tidal volume. The ventila- and inspiratory time. The flow rate is
tor initially delivers a single standard
then delivered in a descending ramp
volume test breath with a decelerating
pattern, with a maximized initial inspi-
flow pattern and plateau to determine
the relative lung compliance. If the deliv- ratory flow. VC+ reduces the potential
ered tidal volume is either greater or less for inappropriately low flow settings and
than the preset value, the target pres- inadvertent flow starvation.1-13
sures for subsequent breaths are adjusted
• A pressure control style of breath
to correct any discrepancies.
allows active spontaneous breathing
The volume-targeted mandatory breath during the inspiratory phase of the
delivered in VC+ is designed to address mandatory breath. Breathing, cough-
problems sometimes encountered with ing or splinting is then allowed by
standard volume ventilation. When vol- venting excess pressure.
ume ventilation is desired, VC+ can help
assure a high level of synchrony.

Volume Test Breath Pressure target is adjusted to

determines PC target maintain target tidal volume

P t P t

F t F t

Note: The software program for VV+ includes the VC+ and VS options (part #4-078126-00).

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 Spontaneous Breathing •  Pressure is incrementally adjusted
During VC+ during start up. Pressure adjustment
• Spontaneous breathing is allowed during minimizes risk of large pressure and
the inspiratory phase through the use of tidal volume swings caused by sudden
the active exhalation valve. and momentary changes in compliance.

• Flow is determined automatically, • Tidal volume limits can be set to termi-

thereby reducing the potential for inap- nate breaths, should the tidal volume
propriately low flow rates. rise above desired levels before subse-
quent pressure targets are automati-
• A higher or lower initial flow rate is
cally lowered to deliver breath at preset
allowed, increasing the potential for
volumes.
patient synchrony during splinting or
aggressive flow demands. •  Any disconnect is recognized and
alarmed specifically as a circuit discon-
VC+ Operating Features nect. Reconnection results in immediate
The Puritan Bennett™ 840 Ventilator’s resumption of previous
VC+ option allows easy substitution for target pressure and volume levels, assur-
standard volume ventilation breaths in
ing immediate resumption of
A/C or SIMV modes, since VC+ is a
mean airway pressure.
volume breath type.

Operating features:
• The ventilator quickly attains target
tidal volume through its short series of
test breaths. Intelligent recognition of
adequate plateau helps protect against
incorrect target values.

Spontaneous Efforts

Peak
cm H2O P target

INSP Target Volume

V lpm (500ml) VT (400ml) VT (500ml)

EXP

Spontaneous Efforts

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 Volume Support Common uses for VS:
Volume Support (VS) utilizes a breath Weaning from anesthesia. Clinicians
delivery control algorithm similar to the set a target level of volume. As patients
one used in the VC+ option. However, breathe above or below the preset
VS utilizes pressure support, instead volume, the support is increased or
of pressure control, to adjust flow. The decreased to restore set volume. When
clinician still sets the target volume but patients begin to awaken and take larger
does not set the inspiratory time or ven- and more frequent spontaneous breaths,
tilator rate. The ventilator then delivers the ventilator decreases its VS. How-
a spontaneous pressure support style ever, if the patient’s level of conscious-
of breath and varies the pressure up or ness and respiratory drive decrease, VS
down to guarantee the preset tidal vol- increases. The VS option includes an
ume. As the patient assumes more of the apnea ventilation safety back up, should
work of breathing, the ventilator senses the patient cease breathing altogether.
increased tidal volumes and decreases
The problems associated with target-
pressure. Should the tidal volume de-
ing minute volume arise when patients
crease, the ventilator will automatically
satisfy the minute volume criteria by
increase VS to protect the patient from
breathing rapidly and shallowly. VS
hypoventilation.
focuses on tidal volume, instead of
Patient triggering determines the venti- minute volume.
latory rate; patient demand determines
Control tidal volume and increase pa-
the inspiratory time.
tient comfort. Although the literature
about the efficacy of VS as a primary
VS Clinical Advantages mode is scant, the VS option has also
The VS option is a spontaneous breath been used successfully as a primary
type utilizing a varying pressure mode of ventilation, especially in infants
­support strategy to maintain a target and pediatric patients. The clinician sets
tidal volume. the patient’s tidal volume. The ventilator
will limit pressure without terminat-
ing breaths, if pressure rises to within 5
cm H2O of the upper pressure limit. As
compliance improves and the pressure
falls, the patient can be ventilated with a
minimal tidal volume at the lowest pos-
sible pressure. The higher setting allows
patients more control over the support
they are receiving (control of inspiratory
time, control of respiratory rate and con-
Two different breath types for preset targeted tidal volumes and
spontaneous breathing trol of flow rate).

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 Volume Support and Pressure SUMMARY
Support New flexibility in breath delivery can
The VS option has advantages and increase comfort for patients breathing
limitations compared to Pressure Sup- spontaneously on mechanical ventila-
port (PS). The VS option may help keep tion. The Puritan Bennett™ 840 Ven-
patients in less danger of over- or under- tilator, with its VC+ and VS options,
ventilation, unless the patient’s respira- expands the therapeutic range for clini-
tory drive and effort exceed the set tidal cians and patients alike. The VC+ option
volume. PS will not decrease support, offers clinicians the opportunity to take
even if patient demand increases. The advantage of these new capabilities while
choice of VS or PS depends on the insti- maintaining control of tidal volume. VS
tution’s protocols, the disease entity, the may be useful in improving patient com-
acuity of the patient being treated and fort and/or in weaning from anesthesia.
the clinician’s therapeutic goals. Both options represent a breakthrough
in ventilatory care of patients.

1. Alonso JA, Kallet R, Siobal M, Kraemer RH, Marks JD. Does autoflow optimize inspiratory flow (Vi)? A lung model study. Critical Care Med. 1999;27(1):93A.
3. Leatherman JW, Fluegel WL, David WS, Davies SF, Iber C. Muscle weakness in mechanically ventilated patients with severe asthma. Am J Respir Crit Care Med.
1996;153(5):1686-1690.
4. Rudis MI, Guslits BJ, Peterson EL, et al. Economic impact of prolonged motor weakness complicating neuromuscular blockade in the intensive care unit. Crit Care Med.
1996;(10):1749-1756.
5. Kollef M, Levy N, Ahrens T, Schaif R. Prentice D, Sherman D. The use of continuous I.V. sedation is associated with prolongation of mechanical ventilation. Chest 1998;
114(2):541-8.
6. Behbehani NA, Al-Mane F, D’yachkova Y, Paré P, FitzGerald JM. Myopathy following mechanical ventilation for acute severe asthma: the role of muscle relaxants and
corticosteroids. Chest. 1999;115(6):1627-1631.
7. Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609-2615.
8. Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med.
1998;5;338(6):347-354.
9. Artigas A, Bernard GR, Carlet J, et al. The American-European Consensus Conference on ARDS, part 2. Ventilatory, pharmacologic, supportive therapy, study design
strategies and issues related to recovery and remodeling. Intensive Care Med. 1998;24(4):378-398.
10. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory
Distress Syndrome Network. N Engl J Med. 2000;4;342(18):1301-1308.
11. Amato MB, Barbas CS, Bonassa J, Saldiva PH, Zin WA, de Carvalho CR. Volume-assured pressure support ventilation (VAPSV). A new approach for reducing muscle
workload during acute respiratory failure. Chest. 1992;102(4):1225-1234.
12. MacIntyre N, Gropper C, Westfall T. Combining pressure-limiting and volume-cycling features in a patient-interactive mechanical breath. Critical Care Med. 1994; 22:353-
357.
13. Haas CD, Branson RD, Folk LM, et al. Patient-determined inspiratory flow during assisted mechanical ventilation. Respir Care. 1995; 40(7):716-721.

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