Overview:

The challenge of ventilating our most vulnerable newborns

At Covidien, our hope is to make newborns in the NICU as comfortable as possible. However, routine care including mechanical ventilation can often be uncomfortable.([FOOTNOTE=De Lima J, Carmo KB. Practical pain management in the neonate. Best Pract Res Clin Anaesthesiol. 2010;24(3):291-307.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=804955]),([FOOTNOTE=Simons SH, van Dijk M, Anand KS, Roofthooft D, van Lingen RA, Tibboel D. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med. 2003;157(11):1058-1064.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=804949]),([FOOTNOTE=Bellù R, de Waal KA, Zanini R. Opioids for neonates receiving mechanical ventilation. Cochrane Database Syst Rev. 2008;23;(1):CD004212. ],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=804952])

The newborn’s comfort level may be improved by reducing the time on mechanical ventilation or avoiding intubation.1 One of the major challenges to patient’s tolerance of both noninvasive and invasive mechanical ventilation is often the presence of an airway leak.([FOOTNOTE=Vignaux L, Vargas F, Roeseler J, et al. Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: A multicenter study. Intensive Care Med. 2009;35(5):840-846.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=603142]),([FOOTNOTE=Mahmoud RA, Proquitté H, Fawzy N, Bührer C, Schmalisch G. Tracheal tube airleak in clinical practice and impact on tidal volume measurement in ventilated neonates. Pediatr Crit Care Med. 2011;12(2):197-202.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805248]),([FOOTNOTE=Main E, Castle R, Stocks J, James I, Hatch D. The influence of endotracheal tube leak on the assessment of respiratory function in ventilated children. Intensive Care Med. 2001;27(11):1788-1797.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805243]),([FOOTNOTE=Berstein G, Knodel E, Heldt G. Airway leak size in neonates and autocycling of three flow-triggered ventilators. Crit Care Med.1995;23(10):1739-1744. ],[ANCHOR=View Abstract],[LINK=http:/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805239]) A leak can interfere with the ventilator’s ability to track the patient’s spontaneous breathing efforts. This in turn leads to asynchrony between the patient’s spontaneous breathing efforts and the ventilator’s response, increasing the work of breathing and potentially increasing the duration of mechanical ventilation. Puritan Bennett™ Leak Compensation software can help clinicians overcome the challenges of leakage and of maintaining synchrony during either invasive or noninvasive ventilation.([FOOTNOTE=Oto J, Chenelle CT, Marchese AD, Kacmarek RM. A comparison of leak compensation in acute care ventilators during noninvasive and invasive ventilation: a lung model study. Respir Care. 2013 Dec;58(12):2027-37.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=720870])

*Note to patients: All devices shown here are prescription products and must be obtained from a licensed provider or physician. Patients cannot purchase these devices directly from Covidien.

Features:

Puritan Bennett™ Leak Compensation Software Features

  • Reacts quickly to changing leaks, helping clinicians improve patient-ventilator synchrony
  • Helps reduce auto-triggering during both intubated and noninvasive ventilation.
  • May reduce the number of adjustments required to inspiratory and expiratory trigger sensitivity settings when the leak rate changes

Note to patients: All devices shown here are prescription products and must be obtained from a licensed provider or physician. Patients cannot purchase these devices directly from Covidien.

Specifications

Specifications:
Applicable vent type Intubated and noninvasive (NIV)
Modes supported Assist/control (A/C), synchronous intermittent mandatory ventilation (SIMV), spontaneous (SPONT) and bilevel
Breath types supported Volume control (VC), pressure control (PC) and pressure supported (PS)
Maximum compensated leak size Neonate—15 Lpm; pediatric—40 Lpm; adult—65 Lpm

*Note to patients: All devices shown here are prescription products and must be obtained from a licensed provider or physician. Patients cannot purchase these devices directly from Covidien.

Monitored Patient Data (Leak Compensation Option Enabled)

  • LEAK@PEEP Exhalation leak—the leak rate during exhalation at PEEP
  • %LEAK Percent leak—the percentage of total delivered volume attributed to the leak
  • VLEAK Inspiratory leak—the total volume delivered during inspiration to compensate for the leak
 

How it Works

Managing breathing circuit leaks is important to help ensure appropriate breath triggering, breath cycling, ventilation adequacy and valid patient data.

The Puritan Bennett™ 840 Leak Compensation software provides an estimate of instantaneous leak to improve patient-ventilator synchrony under varying airway pressures compared to ventilation without leak compensation.

The software enables the ventilator to determine the leak level and enables the operator to set the flow trigger and expiratory trigger sensitivities to a selected threshold. The base flow during exhalation is set to:

Flow triggering: 1.5 L/min + estimated leak flow at PEEP + flow sensitivity. Pressure triggering: 1.0 L/min + estimated leak flow at PEEP.

%LEAK calculation

The %LEAK monitored patient parameter is calculated as:

(Leak volume during inspiration / total delivered inspiratory volume) * 100

Below is an example of the lower screen when the leak compensation (lc) option is enabled:

  • A new leak or change in leak rate is typically quantified and compensated within three breaths. Monitored data stabilizes within a few breaths.
  • The upper left corner of the lower GUI screen alternates between displaying “LC” and the selected ventilation mode.
  • DSENS is displayed in units of L/min, rather than %.
  • The clinician can select inspiratory and expiratory trigger sensitivity settings as usual. If the ventilator auto-triggers, the clinician can try increasing flow trigger sensitivity (VSENS).

Table 1: DSENS settings
Breathing circuit type Neonatal Range: 1 to 15 L/min
DSENS setting maximum Default: 2 L/min (invasive ventilation); 5 L/min (noninvasive ventilation)
Total flow 50 L/min

Clinical Solution

Adjust effective trigger sensitivity in the presence of a leak.

The Puritan Bennett™ Leak Compensation software adjusts effective trigger sensitivity in the presence of a leak during both noninvasive and invasive ventilation. Adjusting trigger sensitivity can help keep the ventilated newborn at a more desirable work of breathing.

In two recent studies, the Puritan Bennett™ 840 ventilator with Leak Compensation software outperformed all other ventilators included in the studies.8

In both studies, leak compensation was compared in five acute care ventilators (the Maquet SERVO-i®*, Dräger V500, Covidien Puritan Bennett™ 840 ventilator, Philips Respironics V60®*, and Hamilton C3), using an ASL5000 lung simulator.8

Invasive ventilation model8 The study authors concluded that only the Puritan Bennett™ 840 and Philips Respironics®* V60 ventilators exhibited synchronization following all increasing and decreasing leak scenarios.
The Puritan Bennett™ 840 ventilator required fewer breaths to synchronize to increasing and decreasing leaks compared with the Philips Respironics®* V60 ventilator (p < 0.0001).
Noninvasive ventilation model8 The study authors concluded that, with the exception of the Dräger V500, all ventilators exhibited synchronization to increasing and decreasing leaks. The Puritan Bennett 840 ventilator required fewer breaths to synchronize to increasing and decreasing leaks compared with all other ventilators in this study (p < 0.0001).

By effectively managing airway leaks, Puritan Bennett™ Leak Compensation software can help clinicians provide the right ventilation even when faced with rapidly changing patient conditions, supporting the clinicians’ efforts to keep babies safe and comfortable.

Download the Leak Compensation Addendum to the Puritan Bennett™ 840 Ventilator System Operator’s and Technical Reference Manual

®* are trademarks of their respective owners.