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Cllinical Application

| 41 

40 s

40 mbar

Recruitment-Maneuver

 

Objective:

 

–

Re-expand collapsed lung tissue

 

–

Maintain sufficient PEEP to prevent de-recruitment after RM

  How-to: 

 

–

Increase end-inspiratory pressure (Pinsp) for a short time

 

–

Impose sufficient pressure to exceed the critical opening pressure  

    of the affected lung region and to recruit non ventilated or poorly  
    ventilated lung tissue

Inspiratory hold:
Inspiratory pressure of 40 mbar for 40 s

Step 2:   assess with Pulmovista® 500 if maneuver could open  

the lung

1. Open the End-inspiratory Trend View:  

 

Compare the status before (

Cursor Ref) and during the RM (Cursor C).

REF

C

D

-11946-2017

D

-11916-2017

D

-11917-2017

< 5 % ?

> 10 % ?

EXaMPLE: 40:40 ManEUvEr

Содержание PulmoVista 500

Страница 1: ... 1 Mini Manual Electrical Impedance Tomography EIT Device handling application tips and examples D 30766 2017 Christian Bozsak Eckhard Teschner ...

Страница 2: ......

Страница 3: ...are not in any way replaced or otherwise superseded by this manual Medical knowledge is subject to constant change due to research and clinical experience The authors of this publication have taken utmost care to ensure that all information provided in particular concerning applications and effects is current at the time of publication This does not however absolve readers of the obligation to tak...

Страница 4: ...thorax 1 2 6 General procedure when attaching the belt 1 3 Signal Check 1 4 Settings before starting an EIT measurement 1 5 Start the EIT session 1 6 Check the correct electrode belt position 1 7 Special Case 15 electrode mode 7 8 8 10 11 12 12 12 16 17 17 18 20 2 Different views and their special properties 21 2 1 Main and Fullscreen view 2 1 1 Referencing 2 1 2 Regions of Interest ROIs 2 2 Trend...

Страница 5: ... 500 3 6 Frame rate 32 34 35 37 38 39 4 Clinical Application 4 1 Identify responder or non responder to a recruitment maneuver RM 4 2 Identify possible de recruitment and overdistension 4 3 Influence of positioning on the distribution of ventilation 4 4 Patient proning 4 5 Intubation Check 4 6 Patient with pleural effusion 4 7 ΔEELI trend after suction 5 EIT Terminology 6 Contraindications 39 40 4...

Страница 6: ...llustration shows ventilated and non ventilated areas of the lungs as well as their changes as a function of time The device can be used in various situations in everyday clinical practice You have the ability to examine at the bedside the status of your patients lung track and assess therapeutic measures in real time This manual is intended to assist you in the use of this device and to provide t...

Страница 7: ...e The device check ensures that all components of the device and the trunk cable cable from the device to the patient function properly 1 Make sure the device is in standby mode Start Standby 2 Plug in the trunk cable into the trunk cable port and insert the patient cable plugs into their respective test connectors match label and color D 2280 2010 D 2281 2010 D 11961 2017 D 11960 2017 D 15487 201...

Страница 8: ...evice check fails check the message and if necessary the connectors If the problem persists stop using the device and contact customer service 1 2 1 Choose the right belt size The application requires an EIT patient interface This consists of an elastic electrode belt 16 electrodes and an attachable patient cable In order to cover a wide patient spectrum there are five belt sizes from 70 cm to 150...

Страница 9: ...xilla Left Axilla 1 Mid position marker 2 Closure holes D 11923 2017 D 11924 2017 Applying an EIT electrode belt to estimate the right fit This EIT electrode belt has the correct size How to find the right belt size b Determine the size with the electrode belt Choose the electrode belt which you think might possibly fit The electrode belt has a mid position marker 1 Hold it approx 5 cm below the r...

Страница 10: ... 1 of the electrode belt Pay attention to the correct orientation of the patient cable At the electrodes 1 and 16 there are lines that serve as a guide Ensure the orientation of the cable over the stud is maintained as illustrated and as marked on the electrode belt Electrode belt too short Electrode belt too long D 11922 2017 D 11925 2017 Orientation of the patient cable and electrode belt D 1254...

Страница 11: ...disease related problem areas may impair the placement of the belt or electrodes If possible the contact area should be exposed to improve skin contact However if one electrode has insufficient skin contact the EIT measurement can also be started in the so called 15 electrode mode Further information can be found in the chapter Checking signal quality D 11932 2017 D 11931 2017 When attaching the e...

Страница 12: ...his mid position marker is located between the 8th and 9th electrode and should be positioned on the spine between the 4th and 6th ICS 1 2 6 General procedure when attaching the electrode belt Apply the belt to the supine patient by lifting the patient s upper body or rolling the patient to the side D 2284 2010 Mid position marker If the patient condition allows it it may also be advisable to brin...

Страница 13: ...t s head and put the mid position marker of the belt to the cervical spine 2 Lift the upper body a bit to move the belt downwards to place it between the 4th and 6th intercostal space 3 Ensure that the mid position marker is still on the spine 4 Close the belt DL 18858 2015 Mid position marker 4th to 6th ICS If access from the head is restricted lift the upper body and put on the electrode belt fr...

Страница 14: ...atient back to the starting position Close the belt 1 The belt ends are brought together in the area of the sternum and connected to each other via one of the six closure positions If possible use one of the middle closure holes Note The electrode 1 is located on the left side of the patient end with closure holes the two connector ports from the patient cable point caudally to the right and left ...

Страница 15: ...Plug in the trunk cable into the trunk cable port and insert the patient cable plugs into their respective connectors Match label and color Reference electrode The belt does not have to sit too tight it is crucial that there is sufficient contact between the electrodes and the skin An offset of the electrodes or an asymmetrically arranged belt can lead to image rotation D 2282 2010 D 6063 2014 For...

Страница 16: ... Each electrode should have sufficient skin contact Blue bars for every electrode have to be below the red line If one electrode has bad skin contact skin electrode resistance 300 Ω the respective electrode is highlighted in red If the skin electrode impedance is not appropriate add tap water use electrode gel or wait a few minutes for moisture from the skin to improve the contact This also applie...

Страница 17: ...rame rate and filter 4 Select recording mode 5 Turn on artifact filter 6 Switch on the contour of the ventilated area 7 For coupling with a Dräger ventilator configure the Medibus interface More detailed information can be found in the instructions for use 1 5 Start the EIT session Press the start button After that the system performs a short calibration about 30 s and is then ready for the measur...

Страница 18: ...ally movements of the diaphragm affect the imaging Effect Negative impedance changes see page 34 become visible laterally in the Tidal Image This is an indicator that the belt is too low Case B If the belt is placed too far cranially the ventilated lung regions may appear smaller Effect Due to the low spatial resolution it is no longer possible to clearly distinguish between the left and right lun...

Страница 19: ...ast button 3 If you can see purple regions negative impedance changes left and right of the lung regions blue and white it is very likely that the belt has been placed too low 4 Reattach the electrode belt in a more cranial position 5 Verify that the purple regions dissappeared D 30762 2017 1 Enhance contrast 2 Negative impedance changes 2 1 2 ...

Страница 20: ... in yellow If an electrode fails after starting the measurement recalibration is required Then the message Electrode contact impaired is displayed but this does not pose a significant limitation for the measurement 1 7 SPECIAL CASE 15 ELECTRODE MODE In the special case that one electrode does not have enough skin contact the measurement can nevertheless be carried out reliably The device uses a sp...

Страница 21: ...view 2 1 Main and fullscreen view After starting the measurement you are in the main view This view provides an overview of the distribution of the tidal volume in the transverse EIT sensitivity region In the dynamic image the volume distribution is displayed in real time at up to 50 fps inspiratory and expiratory so inhomogeneities of the lungs can be quickly identified The Tidal Image captures t...

Страница 22: ...nd with the applied inhaled total volume The regional impedance changes i e tidal variations serve to compare different lung regions The numerical values indicate the volume distribution which together add up to 100 of the global value unless the overall window size ROI setting is changed 1 Dynamic Image 2 Tidal Image Minute Image 3 Regions of Interest 4 Global Impedance Curve 5 Regional Impedance...

Страница 23: ...and to the right of the Global Impedance Curve D 11911 2017 Distribution of the tidal volume in a cross sectional fullscreen view of the patient thorax in the caudal cranial direction D 11903 2017 Regions with 10 of max ventilation Regions with max ventilation Regions with 10 of max ventilation When looking at EIT images it should be noted that these are analogous to CT images displayed in caudo c...

Страница 24: ... Pneumothorax Bronchoscopic mucus removal Analysis of cardiac activity Detection of fluids Orange Loss of ventilation Blue Gain of ventilation Differential Image with positive and negative changes D 30759 2017 After activation a new window the Differential Image appears instead of the Tidal Image At the time of referencing the reference Tidal Image is captured and moved under the Differential Imag...

Страница 25: ...ariations TV should be 100 When comparing the right and left lung the use of ROI quadrants is recommended As an example the following image sequence shows the recruitment of the right lung and the percentage increase in tidal volume over time Before Recruitment Maneuver RM 10 Minutes after RM 4 hours after RM The fullscreen view hides the regional impedance curves and enlarges either the dynamic o...

Страница 26: ...ment overdistension and the redistribution of Vt A trend table shows the regional ventilation distributions i e tidal variations in with associated parameters of the ventilator 1 Differential image 2 Trend table 3 Tidal image Ref Set Cursor Ref as a reference point and move Cursor C to your point of interest to immediately see changes Orange Decrease of regional ventilation Light Blue Increase of ...

Страница 27: ...ime axis Changes can be seen in the ΔEELI differential image Areas in orange show a regional decrease e g caused by de recruitment areas in light blue a regional increase in EELV e g caused by recruitment In the above example a ΔEELI value of 0 62 x TVglobal Ref means a decrease in end expiratory lung impedance or EELV by the amount of global tidal variation at Ref i e 0 62 x Vt at location Ref in...

Страница 28: ...on Every selected time period is called a section The Conduct analysis dialog window is displayed first and should be used to prepare the analysis of a therapeutic maneuver The PEEP trial analysis function enables the automatic analysis of incremental or decremental PEEP maneuvers In contrast the Customized analysis function enables the evaluation of any other ventilation related intervention 1 2 ...

Страница 29: ...ive PEEP if available 3 Automatic section selection 4 Manual section selection add or remove sections and position them using the touchscreen or rotary knob 5 Define section length 1 10 breaths 6 For the customized analysis you need to define a reference section The ensuing analysis quantifies changes in comparison to this section 7 Regional Ventilation Delay RVD settings The RVD is a parameter wh...

Страница 30: ...rend parameters are displayed PEEP in green and EIP or PIP in pink 2 Tidal Image for every displayed section 3 Compliance loss image for every displayed section 4 Areas in which a regional ventilation delay was detected and corresponding RVD parameter displayed in yellow 5 Diagram with the numeric values of all sections depending on the settings and analysis type 6 Create report An image and a tex...

Страница 31: ...rs in dorsal regions at low PEEP levels and may be interpreted as collapse or derecruitment The parameter CL LP of 5 means that in this image there was a cumulative decrease of 5 in those white regions while the highest compliance was identified at a higher PEEP value D 30763 2017 The RVD parameter can be displayed in 2 different configurations as the standard deviation of the RVD RVD SD for every...

Страница 32: ...k the ventilated lung regions in form of a virtual footprint The contour allows the delimitation of the ventilated regions per breath and the identification of lung regions with e g restricted ventilation or delayed inspiratory procedures The setting of the contour of ventilated area is located in the setup menu Display The contour is displayed in the dynamic image main view fullscreen as well as ...

Страница 33: ... lung regions that are not ventilated at time Ref or C but have been ventilated at a different time within the selected observation period In the picture above the grey area at time Ref identifies the recruitable lung area at time C D 11905 2017 ...

Страница 34: ...horax The following conditions might cause negative impedance changes Heart activity Pleural effusion Movement of the diaphragm belt placed too low see page 18 Artifacts e g body movement repositioning of the belt strong electromagnetic fields Deeper expiration than inspiration Pendelluft Heart Mediastinum Pleural effusion Movement of the diaphragm D 11906 2017 ...

Страница 35: ... Display Low pass filter Display of impedance changes below a certain frequency Example Only respiratory signals are of interest i e signals with a frequency in the rage of the respiratory rate but below the heart rate e g HR 20 Band pass filter Display of impedance changes within a certain frequency range Example Only cardiac related impedance signals are of interest e g signals with a frequency ...

Страница 36: ...impedance curves With activated bandpass filtering the tidal rate will no longer be displayed Filter and boundary frequency settings only affect the display of data not on the data recording Unfiltered EIT data Filtered EIT data with low pass filter at HR 20 Filter menu D 11962 2017 D 30754 2017 D 11930 2017 ...

Страница 37: ...using the function Freeze display A recording of EIT files option ADAP required is possible with the following options The recording file length is between 30s and 10min To record press the button Record You can cancel the recording at any time by pressing this button again The recorded files can be analyzed by using the function Data Review or by loading them as a simulation file Via the menu Dat...

Страница 38: ...interface The necessary settings can be found in the menu under Screen layout Data Import For data transmission the following settings must be made at the ventilator Baudrate 19200 Parity non Stopbit 1 The data cable is connected to the COM1 port of PulmoVista 500 After successful pairing the ventilator name is displayed in the menu D 30756 2017 Data import menu with configuration of curves and pa...

Страница 39: ...cy processes such as cardiac activity In the EIT Settings menu you can adjust the frame rate i e the number of EIT images generated per second By default the frame rate is 20 Hz Adjustable frame rate 10 50 Hz pictures s 4 Clinical Application Chest EIT opens up new possibilities for everyday clinical practice in addition to already established technologies For more than 10 years the significance o...

Страница 40: ...I 1 properly represents ventral ventilation Check if RM might improve homogeneity of ventilation Is dorsal TV in ROI 4 5 If TV in ROI 4 suggests collapse Perform a recruitment maneuver according to hospital standards TV ROI 4 5 D 11945 2017 As the individual response of each patient might vary a lot RMs should be assessed in every single patient Look out for Volemic status of the patient Cardiac f...

Страница 41: ...t pressure to exceed the critical opening pressure of the affected lung region and to recruit non ventilated or poorly ventilated lung tissue Inspiratory hold Inspiratory pressure of 40 mbar for 40 s Step 2 Assess with PulmoVista 500 if maneuver could open the lung 1 Open the End inspiratory Trend View Compare the status before Cursor Ref and during the RM Cursor C REF C D 11946 2017 D 11916 2017 ...

Страница 42: ... areas In contrast the second case a non responder shows only a minimal increase in dorsal ventilation in ROI 4 TV 4 5 despite the relatively high PIP of 41 mbar A significant increase in ventilation can be seen in ROI 3 due to a significant increase in tidal volume from 434 ml to 861 ml In both cases a PEEP of 15 mbar was applied Responder TV in ROI 4 is significantly higher during the RM than be...

Страница 43: ...le decremental PEEP TRIAL Initial recruitment maneuver PEEP steps of 2 mbar Driving pressure ΔP PPlat PEEP should remain constant RM PEEP trial 14 mbar 6 mbar 2 mbar Definition of derecruitment A loss of ventilation towards lower PEEP levels indicates the onset of derecruitment This reduced ventilation can be caused by going below the alveoli s closing pressure and the subsequent collapse of alveo...

Страница 44: ...expected whenever a major loss of ventilation is observed during Peep trials in the non dependent lung areas towards higher airway pressures During pressure controlled ventilation this loss of ventilation can also be interpreted as reduction of regional compliance Step 2 Perform PEEP trial analysis 1 Prepare analysis Make sure that every PEEP level is represented by one section of appropriate leng...

Страница 45: ...of ventilation The positioning of a body has an influence on the ventilation of the lungs The change in ventilation can be visualized with PulmoVista 500 Whether and to what extent patient positioning promises success depends on the individual status of the patient but the effect can be seen immediately after the situation at EIT has changed Here is an example of a healthy lung during natural spon...

Страница 46: ...ilated and non ventilated lung areas It is therefore also suitable for visualizing and tracking changes in ventilation following the application of any therapeutic intervention such as after patient proning Initial Condition 20 min after 1st proning trial 20 min after 2nd proning trial Kotani T et al J Anesth 2016 Feb 7 30 1 161 5 Epub 2015 Oct 7 D 11909 2017 ...

Страница 47: ...xample ET tube inserted too deeply ventilation visible only in right lung 4 6 Patient with Pleural effusion The following example shows the effect of an area with fluid accumulation in the lungs here in the case of a pleural effusion The marked area is not ventilated and as long as there are no changes this region remains black Pleural effusion in CT Image Pleural effusion in EIT Image D 54 2011 D...

Страница 48: ... In this case a secretion suction was performed which initially resulted in a sharp drop in end expiratory lung impedance EELI 2 58 x TVglob C1 D 11912 2017 After about 5 minutes there is a significant increase in EELI globally and regionally but the original state has not yet been reached again 0 5 x TVglob Ref D 11913 2017 ...

Страница 49: ...tory lung impedance Nevertheless ΔEELI is strongly correlated to changes in the end expiratory lung volume within the EIT sensitivity region The PulmoVista 500 parameter ΔEELI expresses regional end expiratory lung impedance variations compared to the global tidal variation of Cursor Ref EELV end expiratory lung volume EELV is often used interchangeably with the term FRC However mechanically venti...

Страница 50: ...nt of regions for quantitative analysis of EIT images Tidal image The Tidal Image represents the tidal volume distribution of one entire breath from the end of expiration to the end of inspiration TV Tidal Variation Increase in impedance during inspiration correlates to the tidal volume VT TV global represents the tidal variation between the minimum value and the maximum value in the global impeda...

Страница 51: ...l lesions or fractures Patients with uncontrolled body movements Use during electricity based therapies such as electrosurgery or electrocautery Use in the presence of strong magnetic fields e g MRI Use the in conjunction with other bioimpedance measurement devices Safety and effectiveness have not been established in pregnancy Not validated for patients with tidal volumes smaller than 1 ml kg bod...

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Страница 53: ... 53 Notes ...

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Страница 55: ... 55 Notes ...

Страница 56: ...entral and south america Dräger Panama S de R L 59 East Street Nuevo Paitilla House 30 San Francisco Town Panama City Panama Tel 507 377 9100 Fax 507 377 9130 servicioalcliente draeger com Manufacturer Drägerwerk AG Co KGaA Moislinger Allee 53 55 23558 Lübeck Germany Locate your Regional Sales Representative at www draeger com contact Not all products features or services are for sale in all count...

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