In order to generate a tenuous connection between this resource and the needs of critical care education, one might reach out to the CICM WCA document (“Ventilation”), where a successful trainee “outlines requirement for power and gas supply” at least to a level which is described as “acceptable”. Without defining their anchors any further, the college leaves the assessor to decide which form of underachievement passes for “acceptable”, and what is sufficiently advanced to be described as “good”. This, of course, is worrying to the assessor, particularly where the assessor has not thought about these technical aspects in years, or perhaps decades. The purpose of this chapter is to arm these assessors with the relevant questions and to armour the trainee with sensible answers.
- Mechanical ventilators require electrical power and/or gas pressure
- Different permutations of ventilator power supply include:
- Gas pressure to drive inspiratorry flow and to to supply mechanical power to operate valves and switches (eg. “fluidic” valves)
- Gas pressure to drive inspiratory flow, but electrically powered valves and switches (this is the norm)
- Electrical power to drive turbines/compressors for inspiratory gas flow as well as to operate valves/switches (transport ventilators, home ventilators)
- Ventilators which rely on gas pressure for inspiratory flow are highly energy-efficient but require a stable supply of compressed gas, making them ideal for in-hospital applications
- Ventilators which use internal gas compressors to drive flow have reduced (or zero) reliance on compressed gas, and are ideally suited for transport and domiciliary purposes.
- An ideal ventilator gas supply system should have the following characteristics
- Provides stable gas flow (i.e. reliable)
- Free from contamination
- Economical (i.e. wasting the minimum amount of gas)
- Capable of high flow
- An ideal ventilator power supply should be portable and capable of continuous operation in the face of power failure.
Because medical gas supply systems are discussed in greater detail elsewhere, this chapter does not focus so much on what comes out from the wall, but on the requirements of the ventilator, and how these are affected by its design. Probably the best reference for this subject is the article by Campbell et al (2002); the authors compared several models in terms of their power and gas consumption.
As preambled above, it will suffice to say that most ventilators found in the hospital setting will take their gas from the wall supply. Domiciliary models (eg. CPAP machines designed for home use) will usually ventilate with room air only, and will have a filtered air intake. These may or may not have a little standardised nozzle to hook up to wall oxygen when additional FiO2 is required. In short, gas supply for mechanical ventilation would be some combination of:
Which of these are being used obviously determines the power supply requirements of the device. When the piped wall oxygen supply is used to drive the respiratory circuit flow, there is usually some minimum value for pressure (usually around 250-300 kPa). When cylinder gas is being used to trickle some oxygen into the gas mixture, this is
The ventilator usually requires some sort of a power source in order for it to functions. Again, in spite of the fact that there is a rich history of mechanical ventilators having been clockwork-powered or driven by hand, one needs to come to terms with the fact that in this century the majority of devices are powered by some combination of pressurised gas and electricity.
The electricity supplied to the ventilator could be used to generate some, or none, or all of its gas-blowing functions. Broadly, there are several possible permutations of this:
It should therefore make sense that the electrical power supply of a ventilator will work harder in a ventilator which relies on a compressor. It is, by contrast, relatively energy-cheap to just power the solenoid valves and ventilator display.
An ideal power supply for a mechanical ventilator is uninterruptable (i.e. with some built-in redundancy) and portable to permit transport. The availability of electricity even in large hospitals is not to be relied upon, and UPS circuits are usually available in ICU areas (by convention these wall sockets are blue). Internal ventilator batteries offer a third level of redundancy. They weren’t always internal, as demonstrated below – the HELP-115 lead acid battery depicted below comes from an article by Barton et al (1997); it took four people to transport a ventilated patient with this setup.
Push come to shove, most modern ventilators will run on an improvised power source; for example this brochure suggests that with an appropriate DC-to-AC converter one could power their ventilator using their car battery (via the cigarette lighter port). This is good to know. Blakeman et al (2011) found that the batteries of domiciliary models are highly variable in their performance characteristics, with some models lasting only about 100 minutes.
For example, the completely wall-gas-reliant Maquet Servo-I ventilator requires only 70W to operate even while fast-charging its batteries. At full charge, the energy consumption is about 38W (i.e. approximately the same power requirements as an incandescent light bulb). Most of that goes to the display and user interface: in standby mode, the power requirement drops only to 33W, i.e. while doing nothing clinically useful the Servo-I is wasting its batteries entertaining you with its “Standby” screen.
What batteries does it take, and how long do they last? Most modern ventilators use lithium-ion power sources. In case you were wondering, up to six 3.5Ah battery modules can be connected to the Servo-I simultaneously, offering a total operating time of roughly 3 hours (once discharged completely, the batteries take 12 hours to recharge).
A compressor-based ventilator has a turbine which entrains room air and compresses it. This air compressor contributes the pressure for the respiratory circuit. If some oxygen is also being used, this contributes some additional pressure. Most ventilator models which include an oxygen fitting will usually require a high-pressure fitting, allowing for the possibility that the patient will require 100% oxygen at a 200L/min flow rate (i.e where the air compressor turbine could be turned off, as it is not required). Where the turbine is in use, its power requirements will depend somewhat on the requirements of the circuit- higher flow and pressure will obviously require more RPMs from the turbine as compared to low flow or low pressure. Therefore, the power requirements of such a ventilator will dependent on the flow which needs to be generated, and on the percentage of entrained air. To use the Hamilton Model T-1 as an example, these power requirements may range from 50W to 150W.
Apart from its intrinsic design characteristics, the following factors can change the power requirements of a mechanical ventilator:
In general, it appears that the power requirements of ventilator models which rely on supply gas pressure are less affected by changes in patient lung characteristics and ventilator settings (Campbell et al, 2002). This makes sense because these models really just need to power the valves and monitor screens. Thus, if one is somehow trapped in a corridor somewhere with a ventilated patient running just on battery, one could conceivably add valuable minutes by turning down the screen brightness.
Barton, Andrew CH, Janet E. Tuttle-Newhall, and James E. Szalados. "Portable power supply for continuous mechanical ventilation during intrahospital transport of critically III patients with ARDS." Chest 112.2 (1997): 560-563.
Blakeman, Thomas C., et al. "Bench evaluation of 7 home-care ventilators." Respiratory Care 56.11 (2011): 1791-1798.
FAARC, Robert S. Campbell RRT, Jay A. Johannigman, and Gina Matacia. "‘Battery Duration of Portable Ventilators: Effects of Control Variable, Positive End-Expiratory Pressure, and Inspired Oxygen Concentration." Respiratory care 47.10 (2002).