Hamilton Ventilator - Non-Invasive Ventilation Documentation

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[00:00:00]hi my name is danielle hardy today we're going to be discussing the hamilton ventilators and the correlating documentation first i would like to begin with a few objectives the importance of understanding why this may be different than traditional bipap and cpap ventilators the hamilton c1 is peep compensated and with ventilators such as the v60 or bipap vision these are uncompensated ventilators we're going to review niv in niv st on the hamilton c1 ventilator along with the correlated documentation in regards to non-invasive ventilation on the hamilton c1 ventilator the following is terminology that we as respiratory therapists already understand i just wanted to review do you understand that pressure support and pms are the same thing on the hamilton ventilators delta p is your delta pressure but it's also known as your change pressure or drive pressure the peak inspiratory pressure is also known as positive airway pressure or total pressure any time you will be providing pressure onto a baseline the ventilator needs to understand where it is going to stop it for example anytime we are going to dial in a pressure control or pressure support setting the peep compensated versus uncompensated ventilator becomes very important and let me tell you why we're going to apply the above settings to a peep compensated and then to an uncompensated ventilator and i'm going to show you what your pressure waveform will look like and how it is going to differ so we said here we're going to set a pipa 5 and a pressure support of 15.

[00:01:40]in the compensated ventilator we're coming along with the pupa 5 and our patient is going to take a breath in with a pressure support of 15. the ventilator is going to take that pressure support of 15 and increase the pressure and apply it on top of the pipa 5. so you can see the delta p also known as the drive pressure or change pressure in this scenario means that it is 15.

[00:02:06]this means also that our peak inspiratory pressure or total pressure equals 20.

[00:02:13]we are compensated and the ventilator understands i'm going to put this 15 of pressure support on top of my peepa 5.

[00:02:22]now we're going to go to the uncompensated realm we'll start again by setting the peep of 5 and we're going to have the same setting of pressure support of 15.

[00:02:32]this is what our pressure waveform will look like see now here the ventilator only rises up to the pressure support setting the ventilator understands and it only functions to understand that the pressure set is what it will rise to and in that case it is 15. the reason this is important is if you look closely we only have a delta p or change pressure of 10.

[00:02:56]because we are set at 5 and raised to 15 the only difference here is the change pressure of 10. that means our total pressure or pip is 15 centimeters of water overall you can see even though these settings are the same what is actually happening to the patient is not the same the compensated ventilator results in a greater tidal volume thus having a greater impact on minute ventilation more so than the comp uncompensated ventilator to recap compensated ventilator the pressure control or pressure support is above the peep in the uncompensated ventilator whatever you have set is the total pressure delivered also known as pip in the v60 and in the bipap vision this is also known as ipap and remember the b60 and the vision are both uncompensated ventilators so now with this understanding you can also apply this in pressure control if you're utilizing an invasive mode of ventilation on compensated and uncompensated ventilators now let me give you one more example here in this case we have the same patient and we increased our peep to 10.

[00:04:13]this is the most important part of why it is important to understand the difference between both of these types of ventilators as a respiratory therapist your modifications could significantly impact your patient so in our compensated ventilator we set a heap of 10 and our pressure support above our peep we set to 15.

[00:04:35]this now makes our total pressure or peak inspiratory pressure 25 our delta pressure or change pressure also known as a pressure support remains at 15 in the compensated ventilator now let's go to our uncompensated ventilator on the right we set our peep at 10 so it begins at 10 and our pressure support or the terminology utilized in the v60 or vision is ipap is 15.

[00:05:04]so our pressure rises to 15 and now our delta p or change pressure is only 5.

[00:05:10]this obviously can significantly impact ventilation so why does this happen when we increased our peak to 10 from example 1 we reduced our delta p or change pressure which reduces our tidal volume which impacts our minute ventilation our patient now has to work harder in the uncompensated ventilator to sustain or maintain the same tidal volume so in our uncompensated ventilator our pip or total pressure is 15 or whatever you have set the big question asked often is how do you know if the ventilator you're working with is compensated or uncompensated and the answer is actually very simple if it is compensated the pressure control or pressure support set plus your peep is your peak inspiratory pressure or total pressure measured so if our pressure support is set to 15 and peep is set to 5 then our peak inspiratory pressure should be 20. this is the way compensated ventilators work if you're working with the uncompensated ventilator then your set pressure is your pip or total pressure so if we're setting a pressure support of 15 or the terminology utilized in the bipap vision or v60 the ipap is 15 then our total pressure or pip should be 15.

[00:06:32]in the photos above we have placed both ventilators on non-invasive ventilation spontaneous time with the settings of 20 over 7 and a rate of 16.

[00:06:42]in the hamilton c1 the pressure supports or pmp that is set is 20 and the set peep is 7 equaling a total pressure or peak inspiratory pressure of 27.

[00:06:57]in the v60 the ipap set is 20 and the set peep is 7. and if you can view the pip is 20 as the ventilator is recognizing the total pressure set is 20 as the v60 is the uncompensated ventilator there is a key difference on the total pressure delivered here as well as the change pressure so if you are used to utilizing an uncompensated ventilator you need to be able to understand all of what we just discussed for when you walk into the realm of a compensated ventilator when it comes to peak so now that we have a good understanding of the difference between compensated and uncompensated ventilators how do we document it during patient assessments now we're going to utilize the previous screenshot even though we most likely would not want the patient on these settings we're just going to review the parameters so please remember this is just an example so in the top left hand corner our peak inspiratory pressure also known as our total pressure measured is 27.

[00:08:02]our p imps also known as our pressure support which in the hamilton models correlates to change pressure is 20.

[00:08:10]our peep is set at seven so if we look on the right in our flow sheet the ventilator utilized is the c1 the patient is on bipap the fio2 is set to 21 but we have to document that we are setting a pressure support of 20 or pns in the hamilton ventilators we do not set an ipap or and we also do not set a pip so this has to remain blank we do set a peep and that is seven and our total measured is 27 as on the left of the screen let's look at this closer again we are not setting an ipap and we are not setting a peak inspiratory pressure setting here we are setting pressure support or pns depending on the mode so document what you are setting on the ventilator itself and the monitored values so now we're going to dive into some clinical scenarios here we have a 53 year old female she presented to the ed via ms with shortness of breath on two liters she has a history of insulated renal diseases on hemodialysis obstructive sleep apnea and heart failure her vitals on arrival heart rate of 119 respirations of 33 and a saturation of 89 and the ed physician requests the patient to be placed on cpap you place the patient on cpap of 12 and fio2 of 35 and you notice improvement in the worker breathing and saturation so you are now set to document so let's look at our settings and our monitored values here in this scenario on the right hand side you will notice the flow sheet that we have so this patient came in respiratory failure we write our biomed number we know it's a c1 ventilator they're on a face mask they're on cpap with a fio2 of 35 percent here even though the patient is on cpap we have to look at what we actually set so the pressure support is set to zero you have nothing there and the patient's peep is at 12 and the total measured is 12.

[00:10:24]so we have to think about should we document cpap or peep and here i would like for you guys to document what is on the ventilator itself in the future the vcg is going to be looking at to add cpap to the terminology of the epap slash peep row right now they're currently separated but this is going to take some time with upgrades and epic moving on to clinical scenario number two we have a 72 year old male he presents to the ed via ems he's short of breath is receiving a do a neb treatment upon arrival has a history of copd wears homo 2 at 3 liters vital signs are as follows heart rate 133 respirations of 28 with a saturation of 90 the ed physician requests the patient to be placed on bipap due to accessory muscle use you place the patient on non-invasive ventilation six over six and fio2 of 35 with improvement in worker breathing and saturations we do need to remember that the pressure support set in the hamilton c1 is also the change pressure drive pressure or delta p and we also need to remember that the pressure support plus the peep is the total pressure delivered now let's go document our settings so if we look at the right hand of the screen we have our flow sheet again patients have io2 set to 35 but note that the patient is on bypap this time so we did set a pressure support setting and that is six we did not however set an ipap or pip setting technically and we did set a peep of six the total pressure measured is twelve so this is what we should document on the hamilton c1 moving on to clinical scenario number three we have a 41 year old male transferred to the icu coveted positive he's been on 60 liters 50 percent has accessory muscle use is working pretty hard his vitals on arrival heart rate 128 respirations of 28 and at saturation at 84 percent his breast sounds are scattered fine crackles bilaterally with diminished lung sounds in the bases the physician orders for the patient to be placed on bipap so once again we need to remember the pressure support that is set is also the change or drive pressure or delta pressure we also need to remember that in the hamilton c1 as a compensated ventilator it is the pressure support plus the peep equals the total pressure so now let's go document so reviewing the flow sheet on the right side of the screen same scenario the patients on bipap they're on a fio2 50 we need to document a pressure support setting which is 10 that's also our change pressure we need to document a peep of 5 which we have we do not document an ipap or pip setting here and we need to document our niv or peak inspiratory pressure measured which is 15 in this case so to review and to conclude the hamilton c1 ventilator is a peep compensated ventilator our set pressure which could be our pressure support or pressure control plus our peep equals our total pressure or pip now we understand how to document when utilizing the hamilton c1 we do not utilize an ipap road at all when documenting on the hamilton c1 ventilator as that is not what is said