Biomedical Engineering Module IV S5-ECE

Syllabus
Therapeutic Equipments: pacemakers, cardiac defibrillators, heart–lung machine, dialyzers,
ventilators, Lithotripsy, Infant incubator

I. Therapeutic Equipments:
Equipments that replace certain critical physiological functionalities, or provide needed pain
therapy.

Pacemakers
A device capable of generating artificial pacing impulses and delivering them to the heart is
known as a pacemaker system (commonly called a pacemaker). It consists of pulse generator
and appropriate electrodes.
 Cardiac pacemaker is an electric stimulator that produces periodic electric pulses
that are conducted to electrodes located on the surface of the heart, within heart
muscles or within the cavity of the heart or the lining of the heart.
 It is used for the treatment of;
1. Cardiac rhythm disorders
2. Abnormalities in SA node, AV node and Purkinje system

TYPES OF PACEMAKERS
 Classification of pacemakers into different types is based on the mode of application
 External Pacemaker
 Internal Pacemaker

EXTERNAL PACEMAKER: They are used when heart block presents itself as an
emergency and expected to be present for a short time.
INTERNAL PACEMAKER: They are used in cases requiring long term pacing
because of permanent damage that prevents normal cardiac operations.

MODES OF OPERATION
 Two modes of operation are possible with both internal and external pacemakers
and they are,
 Asynchronous: the fixed rate impulses occur along with natural pacing impulses.
 Synchronous: they are programmed either in demand or synchronized mode.

 The rhythmic beating of the heart is due to the triggering pulses that originate in an
area of specialized tissue in the right atrium of the heart. This area is known as the
sino-atrial node.
 In abnormal situations, if this natural pacemaker ceases to function or becomes
unreliable or if the triggering pulse does not reach the heart muscle because of
blocking by the damaged tissues, the natural and normal synchronization of the heart
action gets disturbed.

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 When monitored, this manifests itself through a decrease in the heart rate and changes
in the electrocardiogram (ECG) waveform.
 By giving external electrical stimulation impulses (Fig.1) to the heart muscle, it is
possible to regulate the heart rate. These impulses are given by an electronic
instrument called a 'pacemaker'.

A pacemaker basically consists of two parts:

(i) an electronic unit which generates stimulating impulses of controlled rate and amplitude,
known as pulse generator, and

(ii) the lead which carries the electrical pulses from the pulse generator to the heart. The lead
includes the termination which connects to the pulse generator and the insulated conductors,
which interface with electrodes and terminate within the heart.

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Types of Pacemakers

1. Internal Pacemakers:

 In this entire system is inside the body.

 Permanently implanted in the body whose SA node failed to function properly.
 The system is implanted with the pulse generator placed in a surgically formed pocket
below the right or left cavicle.
 Internal leads connected to electrodes that directly contact surface of myocardium
 Pulse generator must be self contained with a power source capable of continuously
operating the unit for a period of years.

 Above fig shows an RC, reference voltage source, and a comparator determines the
basic pacing rate of the pulse generator.
 Its output signal feeds into a second RC network, the pulse width circuit, which
determines the stimulating pulse duration.
 A third RC network, the rate-limiting circuit, disables the comparator for a preset
interval and thus limits the pacing rate to a maximum of 120 pulses per minute for
most dagfe-component failures.
 The output circuit provides a voltage pulse to stimulate the heart. The voltage monitor
circuit senses cell depletion and the rate slowdown circuit and energy compensation
circuit of this event.
 The rate slowdown circuit shuts off some of the current to the basic timing network to
cause the rate to slow down 8 ± 3 beats per minute when ceil depletion has occurred.
The energy-compensation circuit causes the pulse duration to increase as the battery
voltage decreases, to maintain nearly constant stimulation energy to the heart.
 There is also a feedback loop from the output circuit to the refractory circuit, which
provide a period of time following an output pulse or a sensed R-wave during which
the amplifier will not respond to outside signals.

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 The sensing circuit detects a spontaneous R wave and resets the oscillator timing
capacitor.
 The reversion circuit allows the amplifier to detect a spontaneous R wave in the
presence of low-level continuous wave interference. In the absence of an R wave, this
circuit allows the oscillator to pace at its preset rate ± 1 beat per minute.

2. External Pacemakers

 Employed to restart normal rhythm of heart in case of cardiac standstill.

 An external pacemaker usually consists of an externally worn pulse generator
connected to electrodes located on or within the myocardium.
 Used on patients with temporary heart irregularities.
 In this the pulse generator located outside the body and connected to ventricle using a
long thin tube called catheter.
 The pacing impulse(80 mA) is applied through metal electrodes placed on the surface
of the body.

Types of Pacing Modes

The noncompetitive method, which uses pulse generators that are either ventricular
programmed or programmed by the atria, is more popular. Ventricular-programmed
pacemakers arc designed to operate either in a demand (R-wave-inhibited) or standby (R-
wave-triggered) mode, whereas atrial-programmed pacers are always synchronized with the
P wave of the ECG

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1. Competitive [Fixed Rate or Asynchronous Pacemaker]

 The first (and simplest) pulse generators were fixed-rate or asynchronous devices that
produced pulses at a fixed rate and were independent of any natural cardiac activity:
 A synchronous pacing is called competitive pacing because the fixed-rate impulses
may occur along with natural pacing impulses generated by the heart and would
therefore be in competition with them in controlling the heartbeat. This competition is
largely eliminated through use of ventricular or atrial-programmed pulse generators.

2. Ventricular Programmed

 The problems of shorter battery life and competition for control of the heart led, in
part, to the development of ventricular-programmed (demand or standby) pulse
generators.

 Either type of ventricular-programmed pulse generator, when connected to the

ventricles via electrodes, is able to sense the presence (or. absence) of a naturally
occurring R wave.
 Above figure shows a functional block diagram of a ventricular synchronous demand
pacer.
 The pulse generator has two functions, viz., pacing and sensing. Sensing is
accomplished by picking up the ECG signal.
 In the case of dual-chamber pacing, the P wave is also sensed.
 Once the signal enters the sensing circuit, it is passed through a QRS bandpass filter.
This filter is design to pass signal components in the frequency range of 5-100 Hz,
with a centre frequency of 30 Hz.
 This is followed by an amplifier and threshold detector which is designed to operate
with a detection sensitivity of 1-2 mV. Sensitivity of this order ensures reliable

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detection of cardiac signals sensed on the electrodes which typically have amplitudes
in the 1-30 mV range depending onto 1 electrode surface area and the sensing circuit
loading impedance.
 Refractory period (T1) is necessarily incorporated to limit the pulse delivery rate,
particularly in the ' presence of electromagnetic interference. It is meant to prevent
multiple re-triggering of the astable multivibrator following a sensed or paced
contraction.
 The free-running multivibrator provides a fixed rate mode with an interval of T 2 via
the output driver circuit. The output pulses of a length T3 synchronous with input
signals that fall outside the sensing refractory period T1 are thus delivered at the
stimulating electrodes.

R-wave-inhibited (demand):
 The output of an R-wave-inhibited (demand) unit is suppressed (no output pulses are
produced) as long as natural (intrinsic) R waves are present. Thus, its output is held
back or inhibited when the heart is able to pace itself.
 However, should standstill occur, or should the intrinsic rate fall below the preset rate
of the pacer (around 70 BPM), the unit will automatically provide an output to pace
the heart after an escape interval at the designated rate.
 In this way, ventricular-inhibited pacers are able to pace on demand.
 A demand pacer, in the absence of R waves, automatically reverts to a fixed-rate
mode of operation.
R-wave- triggered :

 R-wave-triggered pulse generators, like the inhibited units, sense each intrinsic R
wave. However, this pacer emits an impulse with the occurrence of each sensed R
wave. Thus, the unit triggered rather than inhibited by each R wave.
 The pacing impulses are transmitted to the myocardium during its absolute refractory
period, so they will have no effect on normal heart activity.

3. Atrial Programmed

 In cases of complete heart block where the atria are able to depolarize but the impulse
fails to depolarize the ventricles, atrial synchronous pacing may be used. Here the
pulse generator is connected through wires and electrodes to both the atria and the
Ventricles.
 The atrial electrode couples atrial impulses to the pulse generator, which then emits
impulses to stimulate the ventricles via the ventricular electrode. In this way, the heart
is paced at the same rate as the natural pacemaker.
 When the SA node rate changes because of vagus or sympathetic neuronal control, the
ventricle will change its rate accordingly but not above some maximum rate (about
125 per minute).

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Atrial-synchronous pacemaker
 It is the pacemaker designed to replace the blocked conduction system of the heart.
 The heart‘s physiological pacemaker, located at the SA node, initiates the cardiac cycle
by stimulating the atria to contract and then providing a stimulus to the AV node, which,
after appropriate delay, stimulates the ventricles.
 If the SA node is able to stimulate the atria, the electric signal corresponding to atrial
contraction can be detected by an electrode implanted in the atrium and used to trigger
the pacemaker in the same way that it triggers the AV node
 SA node firing triggers the pacemaker

 Voltage v1 is detected by the atrial electrodes is the pulse that corresponds to each beat.
 The atrial signal is then amplified and passed through a gate to a monostable
multivibrator giving a pulse v2 of 120 ms duration, the approximate delay from SA
node to the AV node.
 Another monostable multivibrator giving a pulse duration of 500 ms is also triggered by
the atrial pulse. It produces v4, which causes the gate to block any signals from the atrial
electrodes for a period of 500 ms following contraction.
 Delays are used to simulate natural delay from SA to AV node (120ms) and to create a
refractory period (500ms)
 The falling edge of the 120 ms-duration pulse, v2, is used to trigger a monostable
multivibrator of 2 ms duration.

 Thus the pulse v2 acts as a delay, allowing the ventricular stimulus pulse v3 to be
produced.

 Then v3 controls an output circuit that applies the stimulus to appropriate ventricular
electrodes for ventricular contraction

 Combining the demand pacemaker with this design allows the device to let natural SA
node firing to control the cardiac activity

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CARDIAC DEFIBRILLATORS

NEED FOR A DEFIBRILLATOR

 Ventricular fibrillation is a serious cardiac emergency resulting from asynchronous

contraction of the heart muscles. This uncoordinated movement of the ventricle walls
of the heart may result from coronary occlusion, from electric shock or from
abnormalities of body chemistry.
 Because of this irregular contraction of the muscle fibres, the ventricles simply quiver
rather than pumping the blood effectively. This results in a steep fall of cardiac output
and can prove fatal if adequate steps are not taken promptly.
 In fibrillation, the main problem is that the heart muscle fibres are continuously
stimulated by adjacent cells so that there is no synchronised succession of events that
follow the heart action. Consequently, control over the normal sequence of cell action
cannot be captured by ordinary stimuli.

DEFIBRILLATOR

 Ventricular fibrillation can be converted into a more efficient rhythm by applying a

high energy shock to the heart. This sudden surge across the heart causes all muscle
fibres to contract simultaneously. Possibly, the fibres may then respond to normal
physiological pacemaking pulses. The instrument for administering the shock is called
a defibrillator.

Restoration of normal rhythm in fibrillating heart as achieved by direct

The shock can be delivered to the heart by means of electrodes placed on the chest of the
patient (external defibrillation) or the electrodes may be held directly against the heart when
the chest is open (internal defibrillation). Higher voltages are required for external
defibrillation than for internal defibrillation.

DC DEFIBRILLATOR

Basic Principle

In this an energy storage capacitor is charged at a relatively slow rate (in the order of
seconds) from the AC line by means of a step-up transformer and rectifier arrangement or
from a battery and a DC to DC converter arrangement. During defibrillation, the energy
stored in the capacitor is then delivered at a relatively rapid rate (in the order of milliseconds)
to the chest of the subject. For effective defibrillation, it is advantageous to adopt some

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shaping of the discharge current pulse. The simplest arrangement involves the discharge of
capacitor energy through the patient's own resistance (R). This yields an exponential
discharge typical of an RC circuit. If the discharge is truncated, so that the ratio of the
duration of the shock to the time constant of decay of the exponential waveform is small, the
pulse of current delivered to the chest has a nearly rectangular shape. For a somewhat larger
ratio, the pulse of current appears nearly trapezoidal. Rectangular and trapezoidal waveforms
have also been found to be effective in the trans-thoracic defibrillation and such waveforms
have been employed in defibrillators designed for clinical use (Schuder et al. 1980).

 The basic circuit diagram of a DC defibrillator is shown in Fig.

 A variable auto-transformer Tj forms the primary of a high voltage transformer T2.
 The output voltage of the transformer is rectified by a diode rectifier and is connected
to a vacuum type high vol tage change-over switch. In position A, the switch is
connected to one end of an oil-filled 16 micro-farad capacitor.
 In this position, the capacitor charges to a voltage set by the positioning of the auto-
transformer. When the shock is to be delivered to the patient, a foot switch or a push
button mounted on the handle of the electrode is operated. The high voltage switch
changes over to position 'B' and the capacitor is discharged across the heart through
the electrodes.
 In a defibrillator, an enormous voltage (approx. 4000 V) is initially applied to the
patient.

Discharging Pulse of a DC defibrillator

 A typical discharge pulse of the defibrillator is shown in Fig. below.

 The most common waveform utilized in the RLC circuit employs an under-damped
response with a damping lector leas than unity.
 This particular waveform is called a Lown' waveform. This waveform is more or leas
of an oscillatory character, with both positive and negative portion. The pulse width in
this waveform is defined as the time that elapses between the start of the impulse and
the moment that the current intensity passes the zero line for the first time and
changes direction.

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 The pulse duration is usually kept as 5 ms or 2.5 ms.

IMPLANTABLE DEFIBRILLATORS

 An implantable defibrillator is continuously monitors a patient's heart rhythm.

 If the device detects fibrillation, the capacitors within the device are charged up to
750 V. The capacitors then discharged into the heart which mostly represents a
resistive load of 50 ohm and to bring heart into normal rhythm.
 This may require delivery of more than one high energy pulse.
 Implantable defibrillator systems have three main system components: the
defibrillator itself (AID), the lead system, and the programmer recorder/monitor
(PRM). The AID houses the power source, sensing, defibrillation, pacing, and
telemetric communication system. The leads system provides physical and electrical
connection between the defibrillator and the heart tissue. The PRM communicates

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with the implanted AID and allows the physician to view status information and
modify the function of the device as needed.
 Programmer Recorder/Monitor (PRM): The PRM is an external device that
provides a bidirectional communications link to an implanted AID. This telemetry
link is established from a coil which is contained within the wand of the PRM, to a
coil which is contained within the implanted device. This telemetry channel may be
used to retrieve real-time and stored intracardiac ECG, therapy history, battery
status, and other information pertaining to device function. A number of
combinations of programmable therapy and detection options are available and it is
not unusual to alter these prescriptions dozens of times over the life of the implant.
 Leads: Until recently, the defibrillating high energy pulse was delivered to the
heart via a 6 cmx9 cm titanium mesh patch with electrodes placed directly on the
external surface of the heart. Sensing was provided through leads screwed in the
heart. This approach required an invasive surgical approach to provide access to the
heart. The modem implantable defibrillators make use of a single transvenous lead
with the multiple electrodes inserted into the right ventricle for ventricular pacing
and defibrillation.
 Pulse Generator: Major sub-systems of the implanted pulse generator are shown in
Fig. 26.8. It has a microprocessor which controls overall system functions. An 8-bit
device is sufficient for most systems. ROM provides non-volatile memory for
system start-up tasks and some program space,whereas RAM is required for storage
of operating parameters, and storage of electro-cardiogram data. The system control
part includes support circuitry for the microprocessor like a telemetry interface,
typically implemented with a UART-like (universal asynchronous
receiver/transmitter) interface and general purpose timers.
 The power supply to the circuit comes from lithium Silver Vanadium oxide (Li
SVO) batteries. Digital circuits operate from 3 V or lower supplies whereas analog
circuits typically require precision nanoampere current source inputs. Separate
voltage supplies are generated for pacing (approximately 5 V) and control of the
charging circuit (10-15 V),
 High power circuits convert the 3-6 V battery voltage to the 750 V necessary for a
defibrillation pulse, store the energy in high voltage capacitors for timed delivery,
and finally switch the high voltage to cardiac tissue or discharge the high voltage
internally if the cardiac arrhythmia self- terminates. The major components of these
circuits are the battery, the DC to DC converter, the output storage capacitors, and
the high power output switches.
 Commercially available implantable defibrillators all utilize lithium SVO cells,
with the most common configuration being two connected in series to form an
approximately 6 V battery. Unlike 2.8 V lithium iodide (LI) pacemaker cells which
develop high internal impedance as they discharge (up to 20,000 Q over their useful
life), SVO cells are characterized by low internal impedance (less than 1ft) over
their useful life. The output voltage of SVO is higher than LI ranging from 3.2 V
for a fresh cell to approximately 2.5 V when nearly depleted.
 DC to DC converter used to convert the 6 volt battery voltage to 750 V is of
classical configuration. They are operated at as high a frequency (in the range of
30-60 KHz) as practical to facilitate the use of the smallest possible core.
 The storage capacitors are typically aluminum electrolytics because of the high
volumetric efficiency and working voltage required. Most designs utilize at least
two such capacitors in series

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Defibrillator: Electrodes

Defibrillation by electric shock is carried out by passing current through electrodes placed:
 External –Shock delivered to the heart by means of electrodes placed on the chest.
 Internal –Electrodes placed directly against heart when the chest is opened.

 Defibrillator Electrodes should haveExcellent contact with the body is essential

 Serious burns can occur if proper contact is not maintained during discharge
 Sufficient insulation is required
 Prevents discharge into the physician
 Conventional electrode systems are circular , a little concave with sharp rims and
insulated back side.
Three types are used:

–Internal –used for direct cardiac stimulation

–External –used for transthoracic stimulation
–Disposable –used externally
For internal defibrillation when chest is open , large spoon shaped electrodes are used.

The two defibrillator electrodes applied to the thoracic walls are called either anterior-anterior
or anterior-posterior.
Anterior –anterior paddles are applied to the chest
Anterior –posterior paddles are applied to both the patients chest wall and back.

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VENTILATORS

Mechanism of respiration: it is the process of supplying oxygen to tissues and removing

carbon dioxide from the tissues.
 These gases are carried in blood, oxygen from lungs to the tissues and carbon dioxide
from the tissues to the lung.
 Respiration process: Inspiration – breathing in (air to lungs)
Expiration – breathing out (air out from lungs)
 Inspiration results from contraction of the diaphragm whereas expiration results from
their relaxation.
 For reduced or respiratory failure, mechanical ventilators or artificial respirators are
used in hospitals.
 A mechanical ventilator is a machine that makes it easier for patients to breath,
until they are able to breathe completely on their own.
 It gives breath in various modes in order to maintain the level of oxygen in the blood.
 These devices provide artificial ventilation, supply enough oxygen and eliminate
right amount of CO2.
 It maintains desired arterial partial pressure of O2 and CO2.
 An intensive care patient often requires assistance with breathing.
 When artificial ventilation needs to be maintained for a long time, a ventilator is
used to provide oxygen enriched medicated air to a patient at a controlled
temperature.
 Ventilators are also called as
 Mechanical ventilator

 Respirator

 Breathing machine

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 The pneumatic system is responsible for delivery of the gas mixture to the patient.
 The pneumatic system can be single circuited or double circuited
 In case of single circuit ventilators, the same gas that powers pneumatic system is the
same gas that is delivered to the patient.
 But for double circuit ventilators the gas delivered to the patient is different from the
gas that powers pneumatic system.
 The microprocessor controls the inspiratory and expiratory valves. The
microprocessor also controls the information flow from the monitoring system of the
ventilator , ie the pressure , flow and volume and display of that information.
 The ventilator alarms are also controlled by the microprocessor.

Ventilators most often are used:

1) During Surgery
 If you have general anesthesia during surgery, you'll likely be connected to a
ventilator. The medicines used to induce anesthesia can disrupt normal breathing. A
ventilator helps make sure that you continue breathing during surgery.
2) For Impaired Lung Function
 You may need a ventilator if a disease, condition, or other factor has impaired your
breathing.

 Although you might be able to breathe on your own, it's very hard work.

 You may feel short of breath and uncomfortable.

 A ventilator can help ease the work of breathing.

 People who can't breathe on their own also use ventilators.

Ventilators can operate in different modes:
 Can be separated into 3 general categories
 Controller type
 Assister type
 Assist-Control mode
 Another classification is

 Negative-pressure devices.
 Positive-pressure devices.

Controller type
 When a patient is connected to a controller type of ventilator, his or her respiratory
ventilation is determined by the machine.
 Breathing is controlled by a timer set to provide the desired respiration rate.
 Controlled ventilation is required for patients who are unable to breathe on their own.
Respirator has complete control over the patient‘s respiration and does not respond to
any respiratory effort on the part of the patient.

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Assister Type
 It is controlled by the patient and used to augment his or her own ventilation
activities.
 The assister detects the patient‘s attempt at ventilation and augments it mechanically.
 Respirator helps the patient inspire when he wants to breathe.
 It is used for patients who are able to control their breathing but are unable to inhale a
sufficient amount of air without assistance or for whom breathing requires too much
effort.
 Thus it assists rather than controls the patient in ventilation

Assist/Control type
 It is normally triggered by the patient‘s attempts to breathe, as in assist mode.
 If a patient fails to breathe within a predetermined time, a timer automatically triggers
the device to inflate the lungs.
 Thus the patient controls his own breathing as long as he can, but if he should fail to
do so, the machine is able to take over for him.
Negative-pressure ventilators
 Are more physiological, in that the body of the patient is contained in a sealed
chamber in which the pressure can be reduced.
 Producing a negative pressure around the chest and abdomen.
 Negative pressure moves across the chest and diaphragm and causes air to move into
the lungs in the normal fashion
 When the negative pressure stops being applied, the chest returns to atmospheric
pressure and the inspired air then is exhaled.
Positive-pressure ventilators
 Blow air into the lungs by increasing the pressure in the trachea.
 This causes the lungs to expand due to internal pressure and then to recoil naturally,
expelling a portion of the air once the positive pressure is removed.
 Even though negative pressure ventilators are more physiological, they are by
necessity large and limit access to the patient for therapy.
 For these reasons, they are seldom used clinically today.

Ventilators can be time cycled, volume cycled, or pressure cycled.

Time Cycled Ventilator :
 This means that the air/oxygen is applied to the body for a given period of time and
then released for another given period of time before the process is repeated.
 Modern time cycled ventilators are electronically controlled. Microprocessors are
used to establish the cycling or the rate of ventilation, as well as the ratio between
inspiration and expiration times or volumes.
volume-cycled ventilator
 A predetermined volume of gas has been delivered to the patient.
 The progression of the cycles of the ventilator is controlled by the volume of air
administered to the patient.
 Thus, if a machine is set to cycle on a given volume, it does not cycle until that
volume of air has been administered to the patient.

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pressure-cycled ventilator
 Air is administered to the patient until the pressure reaches a predetermined limit, at
which time the ventilator switches to its expiratory portion of the cycle, and the
process is repeated

Modern Microprocessor controlled Ventilator:

• Compressed air and oxygen are normally stored in high pressure tanks (s1400 kPa)
that are attached to the inlets of the ventilator. In some ventilators, an air compressor
is used in place of a compressed air tank.
• The primary mission of the device is to enrich the inspiratory air flow with the proper
level of oxygen and to deliver a tidal volume according to the therapist’s
specifications
• The air and oxygen valves are placed in closed feedback loops with the air and
oxygen flow sensors
• The microprocessor controls each the valves to deliver the desired inspiratory air and
oxygen flows for mandatory and spontaneous ventilation.
• During inhalation, the exhalation valve is closed to direct all the delivered flows to the
lungs.
• When exhalation starts, the microprocessor actuates the exhalation valve to achieve
the desired PEEP level.
• The airway pressure sensor generates the feedback signal necessary for maintaining
the desired PEEP (in both mandatory and spontaneous modes) and airway pressure
support level during spontaneous breath delivery.

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HEART-LUNG MACHINE
 During open heart surgery, the heart cannot maintain the circulation. 
 It is then necessary to provide extra corporeal (outside the body) circulation with a special
machine called heart lung machine.
 Heart-Lung Machine is a blood pumping machine that takes over the functions of the
heart and lungs during surgery (i.e. open-heart surgery).
 It is most commonly used to perform a cardiopulmonary bypass (CPB), which is the
technique whereby blood is totally or partially diverted from the heart into a machine with the
gas exchange capacity and subsequently returned to the arterial circulation at appropriate
pressures & flow rates.
 CPB allows for the heart to stop beating as its function is taken over by Heart Lung
Machine, which makes it easier to operate on, and surgeons can operate in a blood-free area.
Functions of a Heart Lung Machine
 RESPIRATION: Within which it includes Ventilation and Oxygenation.
 CIRCULATION: Maintaining circulation at appropriate pressures and flow rates.
 TEMPERATURE REGULATION: It involves controlled hypothermia.

The Components of Heart Lung Machine

 PUMPS: The pumps are designed to minimize the damage to blood cells and effective in
pumping within physiological range.
 MEMBRANE OXYGENATOR: It imitates the function of lungs. Membrane oxygenator are
more common now a days. Here O2 & CO2 Exchange takes place. Gas exchange take place by
the process of diffusion across a thin membrane separating blood and gas made of highly
permeable silicon rubber or microporous polypropylene, Teflon & polyacrylamide.
 HEAT EXCHANGER: Heat exchangers control body temperature by heating or cooling
blood passing through the perfusion circuit.
 Arterial filter/bubble trap: It is used to filter small air bubbles that may have entered, or been
generated by the machine.
 Aortic/atrial/vena caval cannulae through which blood is taken and returned to body.

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Different parts of heart lung machine:

FIVE PUMP ASSEMBLIES
1. A centrifugal or roller head pump can be used in the arterial position for
extracorporeal circulation of the blood.
2. Left ventricular blood return is accomplished by roller pump, drawing blood away
from the heart.
3. Surgical suction created by the roller pump removes accumulated fluid from the
general surgical field.
4. The cardioplegia delivery pump.
5. Emergency Backup of the arterial pump in case of mechanical failure. Centrifugal
pumps consist of plastic cones, which when rotated rapidly, propel blood by
centrifugal force.

 Forward blood flow, varies with the speed of rotation and the after load of the arterial
line.
 Centrifugal blood pumps generate up to 900 mm Hg of forward pressure, but only 400
to 500 mm Hg of negative pressure. Hence, less gaseous micro emboli.
 Centrifugal pumps produce pulse less blood flow
 Roller pumps consist tubing, which is compressed by two rollers 180° apart. Forward
flow is generated by roller compression and flow rate depends upon the diameter of
the tubing, rate of rotation.

VENOUS RESERVOIRS
 Reservoirs may be rigid (hard) plastic canisters ("open" types) or soft, collapsible
plastic bags ("closed" types).

 The venous reservoir serves as volume reservoir

 Facilitates gravity drainage,

 Venous bubble trap present,

 Provides a convenient place to add drugs, fluids, or blood, and adds storage capacity
for the perfusion system.
 Oxygenators The artificial lung also called oxygenator takes lung function and is
responsible for exchange of gases

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Membranous Oxygenators
 Imitate the natural lung by interspersing a thin membrane of either micro porous
polypropylene or silicone rubber between the gas and blood phases.
 With micro porous membranes, plasma-filled pores prevent gas entering blood but
facilitate transfer of both oxygen and CO2.

 The most popular design uses sheaves of hollow fibers connected to inlet and outlet
manifolds within a hard-shell jacket.

Bubble Oxygenators
 Large bubbles improve removal of co2 greater in oxygenation

 Smaller bubbles are very efficient at oxygenation but poor in co2 removal

 Venous blood drains directly into a chamber into which oxygen is infused through a
diffusion plate (sparger).

 The sparger produces thousands of small (approximately 36 μm) oxygen bubbles

within blood.

 Gas exchange occurs across a thin film at the blood-gas interface around each bubble

 Produce more particulate and gaseous microemboli are more reactive to blood
elements.

Heat Exchangers
 Control body temperature by heating or cooling blood passing through the perfusion
circuit
 Temperature differences within the body and perfusion circuit are limited to 5°C to
10°C to prevent bubble emboli

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Filters and Bubble Traps

 In the circuit, micro emboli are monitored by arterial line ultrasound or monitoring
screen filtration pressure.
 Depth filters consist of porous foam, have a large, wetted surface and remove micro
emboli by impaction and absorption

 Screen filters are usually made of woven polyester or nylon thread

Tubing
 Medical grade Polyvinyl Chloride (PVC) tubing
 It is flexible, compatible with blood, inert, nontoxic, smooth, nonwettable, tough,
transparent, resistant to kinking and collapse,
 Can be heat sterilized
 The Duraflo II heparin coating ionically attaches heparin to a quaternary ammonium
carrier (alkylbenzyl dimethyl - ammonium chloride), which binds to plastic surfaces.

Perfusion Monitors and Sensors

 A low-level sensor with alarms on the venous reservoir and a bubble detector on the
arterial line are desirable safety devices.
 Flow-through devices are available to continuously measure blood gases,
hemoglobin/hematocrit , and some electrolytes
 Temperatures of the water entering heat exchangers

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HEMODIALYSIS
 Main function of the kidney is to form urine out of blood plasma, which basically consists of
two process:
1. The removal of waste products from blood plasma
2. The regulation of the composition of blood plasma
 Kidney performs these functions through a process involving filtration, reabsorption,
excretion.

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Section of Kidney

Human body has two kidneys. Each kidney consists of about a million individual units which are
all having similar structure and function.
 These tiny units are called nephrons.
 Its main functions include regulating the concentration of sodium salts and water by filtering
the kidney's blood, excreting any excess in the urine and reabsorbing the necessary amounts.
 Healthy kidneys clean your blood and remove extra fluid in the form of urine. They also make
substances that keep your body healthy. Dialysis replaces some of these functions when your
kidneys no longer work.
 One of the most important prosthetic (artificial body part) device in modern is the artificial
kidney, which is periodically connected to the circulatory systems of uremic patients to remove
metabolic waste products from their body.
 In uremic patients,
Amino acids + proteins urea, creatinine
 Excess of these products in blood cause kidney failure.
 Hemodialysis is a therapy that filters waste, removes extra fluid and balances electrolytes
(sodium, potassium, bicarbonate, chloride, calcium, magnesium and phosphate).

In hemodialysis, blood is removed from the body and filtered through a man-made membrane
called a dialyzer, or artificial kidney, and then the filtered blood is returned to the body.
 The dialysis machine is like a big computer and a pump. It keeps track of blood flow, blood
pressure, how much fluid is removed and other vital information.
 It mixes the dialysate, or dialysis solution, which is the fluid bath that goes into the dialyzer.
 This fluid helps pull toxins from the blood, and then the bath goes down the drain.
 The dialysis machine has a blood pump that keeps the blood flowing by creating a pumping
action on the blood tubes that carry the blood from the body to the dialyzer and back to the body.

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How does hemodialysis work?

 The dialyzer is the key to hemodialysis. The dialyzer is called the artificial kidney because it
filters the blood — a job the kidneys used to do.
 The dialyzer is a hollow plastic tube about a foot long and three inches in diameter that
contains many tiny filters.
 There are two sections in the dialyzer; the section for dialysate and the section for the blood.
 The two sections are divided by a semipermeable membrane so that they don’t mix together.
 A semipermeable membrane has microscopic holes that allow only some substances to cross
the membrane.

Because it is semipermeable, the membrane allows water and waste to pass through, but does not
allow blood cells to pass through.
 Dialysate, also called dialysis fluid, dialysis solution or bath, is a solution of pure water,
electrolytes and salts, such as bicarbonate and sodium.
 The purpose of dialysate is to pull toxins from the blood into the dialysate.
 The way this works is through a process called diffusion.
 In the blood of the hemodialysis patient, there is a high concentration of waste, while the
dialysate has a low concentration of waste.
 Due to the difference in concentration, the waste will move through the semipermeable
membrane to create an equal amount on both sides.
 The dialysis solution is then flushed down the drain along with the waste.

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LITHOTRIPSY
 Kidney stones are small masses of salts and minerals that form inside the kidneys and may
travel down the urinary tract.
 Kidney stones range in size from just a speck to as large as a ping pong ball.
 Signs and symptoms of kidney stones include blood in the urine, and pain in the abdomen,
groin, or flank.
 An open incision surgical technique known as “lithotomy” can be used to remove stone but
that procedure include risk, complications, discomfort and disability of major surgery.
 Lithotripsy is a non-invasive or minimally invasive surgical technique for removing kidney
stones without risk and complications.

 The kidney stones are disintegration so that they will be removed from body in the form of
small particles without any discomfort.
 There are mainly two methods:
 Percutaneous Lithotripsy
 Extracorporeal shock wave lithotripsy

PERCUTANEOUS LITHOTRIPSY
 A probe is guided under x-ray fluoroscopy through a small incision into the location of kidney
stone.
 Mechanical shock waves are provided at tip of probe by a controlled electric discharge (spark)
or probe contains an ultrasonic transducer that provides ultrasonic waves.
 These waves break up the stone and are withdrawn through probe outside element.











 Figure 7: Percutaneous Lithotripsy


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EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY

 This is a non-invasive method to breakup kidney stone.
 Multiple shock waves are generated by multiple discharge up to 2000 shock wave may be
necessary to reduce the kidney stone through urinary tract.

 Patient lies down in an apparatus bed, with back supported by a water filled coupling device
placed at the level of kidney.
 Positioning of the patient is critical and biplane x-ray system used to establish position of
stone.
 A high voltage pulse is applied to spark gap and discharge produces a shock wave that is
propagated through water.
 Stone will observe on biplane x-ray monitors.
 Multiple shocks generated multiple discharges and reduce kidney stone.
 Up to 2000 shock may be necessary to reduce a kidney stone to 1-2 mm fragments that can
pass through urinary tract.
 With this treatment most patients are able to resume full activity within two days.

INFANT INCUBATOR
 Infant incubator is a biomedical device which provides warmth, humidity and O2 all in a
controlled environment as required by the new born.
 The temperature is maintained within specific temperature range, O2 requirements are
minimized.
 In premature newborns susceptible to respiratory problems, because lungs may be unable to
supply enough O2 to meet demands.
 Such controlled temperature environments are maintained infant incubators
 The control system uses the thermistor in a bridge circuit with the set point resistance as
another arm of the bridge

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 The bridge output is amplified giving the voltage V1 at the output which is proportional to the
difference in temperature between thermistor and the set point.
 Some incubators instead of controlling air temperature directly use the skin temperature of
infant as a control parameter.
 Thermistor is placed against the skin of infant and controller is set to maintain the infant skin
at a given temperature.
 If the infant is cooler than the set point, air entering the chamber of incubator is heated an
amount proportional to difference between the set temperature and baby’s actual temperature.
 Incubators also have a simple alarm system to alert the clinical staff if there is any dangerous
overheating of the device.
 If the infant is cooler than the set point, air entering the chamber of incubator is heated an
amount proportional to difference between the set temperature and baby’s actual temperature.

 Incubators also have a simple alarm system to alert the clinical staff if there is any dangerous
overheating of the device.
 A buzzer system keeps it simple and reliable and in some cases the circuit also immediately
reduces power to the heater to stop the overheating.
 If the temperature of the air entering the infant chamber is lower than the set temperature,
power is applied to heater to correct for this difference.

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


 The infant incubator is normally in the form of a trolley with a small mattress on the top
covered by a rigid clear plastic cover.
 Incubator chamber provides a clean environment, and helps to protect the baby from noise,
dust, infection, and excess handling.
 Underneath the baby is an air-blown electric heating system and humidification system which
circulates heated humid air at a desired temperature and humidity through the incubator
chamber.
 Additional oxygen may also be introduced into the chamber.

Figure 9: Infant incubator – simple block diagram

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