CARDIAC PACEMAKER

 Pacemaker is an electrical pulse generator used for starting and/or maintaining

the normal heart beat.
 Pacemaker is an example of very low current, low-duty cycle stimulator.
 The output of the pacemaker is applied either externally to the chest or internally
to the heart muscle.

 The minimum energy required to excite the heart muscle is about 10 µJ. For better
stimulation and safety purposes, a pulse of energy 100 µJ is applied on the heart
muscle. i.e., a pulse of 5 V, 10 mA and 2 milli seconds duration is used.
 A pulse of energy more than 100 µJ may provoke ventricular fibrillation. Ventricular
fibrillation is a dangerous condition.
 A negative going pulse is used to stimulate the heart muscle to avoid the ionization
of the muscles.
 Pacemakers generate 50-150 pulses/min. The duration of each pulse is between 1
and 2 milli seconds.
 The pacemaker casing is made up of Biocompatible material like titanium or titanium
alloy. The lead is also made up of metal alloy but it is insulated by a polymer such as
polyurethane.
 Batteries used in pacemaker are, Nickel cadmium, Mercury, Lithium Iodide or
Lithium Ion.
 A pacemaker is a small device that's placed in the chest or abdomen to help control
abnormal heart rhythms.

Need for Pacemakers

 Rhythmic beating of heart is due to the triggering pulsed generated at the SA

node.

 If the SA node ceases to function, or if pulses do not reach the heart muscles, the
normal heart action gets disturbed.

 Pacemakers are used to treat arrhythmias. Arrhythmias are problems with the rate
or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too
slow, or with an irregular rhythm.

Pacemakers’ parts:

 All artificial cardiac pacemakers have

o a pulse generator (a device that gives off an electrical impulse at prescribed

intervals),

o electrical leads (which transmit the impulse to the myocardium), and

 o a battery (usually made of lithium iodide) encased in titanium and implanted
surgically in a subcutaneous pocket (usually in the chest).

 A small incision (cut) is made, most often on the left side of the chest below the
collarbone. The pacemaker generator is then placed under the skin at this location.

 The battery most commonly used in permanent pacers has a lifespan of five to nine
years.

Classification of Pacemakers based on placement:

 Based on the placement of the pacemaker, there are two types

o External pacemaker and

o Internal (Implanted) pacemaker

S.
External Pacemaker Internal Pacemaker
No
1. The pacemaker is placed outside the body. The pacemaker is surgically implanted beneath
It may be in the form of wrist watch or in the skin near the chest or abdomen with its
the pocket, from that one wire will go into output leads are connected directly to the
the heart through the vein. heart muscle.
2. Mostly these are used for temporary Mostly these are used for permanent
heart irregularities heart damages.
3. Endocardiac electrodes are used to Myocardiac electrodes are used to
stimulate the heart chamber. stimulate the heart chamber.
4. It does not need the open chest It requires a minor surgery to place the
surgery circuit.
5. The battery can be easily replaced. The battery can be replaced only by
minor surgery.
6. Any defect or adjustment in the circuit can Any defect or adjustment in the circuit cannot
be easily attended with the help of doctor. be easily attended. Doctor's' help is necessary
to rectify the defect in the circuit.
7. During placement, swelling and pain do not During placement swelling and pain arise due to
arise due to minimum foreign body reaction. foreign body reaction.

8. Here there is no safety for the Here there is a cent percent safety for
pacemaker particularly in the case of the circuit from the external
children carrying the pacemaker. disturbances.
9. Mostly these are used for temporary Mostly these are used for permanent
heart irregularities heart damages.
10. The size of the pacemaker is larger The size of the pacemaker is smaller
11. Electromagnetic Interference will be Electromagnetic Interference will be
more. less.
Types of Pacing Modes (or) Pacing Methods:

The pacing modes of the pacemaker are classified as Competitive and Non –
competitive modes.

Competitive Mode of the Pacemaker:

 The competitive mode of pulse generators produces fixed rate pulses that
are independent of natural cardiac activity (pacemaker).

 The fixed rate pulses are generated along with the heart‘s natural pulses. It
competes with them to control the heartbeat.

 This fixed rate pacemakers are implanted for the patient whose SA (Sino
Atrial) node has failed from its operation.

 The disadvantage of this type is less battery life.

Non – Competitive Mode of the Pacemaker

 This type of pacing mode generates either ventricular programmed or atrial

programmed pulses.

 Among these, the ventricular-programmed pacemaker will operate in either

demand mode (R wave stopped) or standby mode (R wave triggered).

 Atrial programmed pacemaker works in synchronization with P wave of ECG

waveform.
Classification of pacemaker based on operation or working:

 Based on the modes of operation of the pacemakers, they can be

divided into five types,

o Ventricular asynchronous pacemaker (Fixed rate pacemaker)

 o Ventricular synchronous pacemaker (R-wave Triggered (Or)
Standby)

o Ventricular inhibited pacemaker (R-wave Blocked (Or) Demand

pacemaker)

o Atrial synchronous pacemaker (P-wave Synchronized)

o Atrial sequential ventricular inhibited pacemaker (Dual

Chamber)
Ventricular Asynchronous Pacemaker (Fixed Rate Pacemaker)

 This type of pacemaker is installed in atrium or ventricles for the patients who
suffer from total AV (Atrial Ventricular) block and atrial arrhythmia.

 The generated impulses and normal heartbeat competes with each other.

 This pacemaker is constructed using square wave generator (Astable

Multivibrator) and monostable multivibrator (one shot Multivibrator).

 This pacemaker is suitable for patients with either a stable, total AV block,
a slow atrial rate or atrial arrhythmia.

 This pacemaker produces a stimulus at a fixed rate irrespective of the

behaviour of heart rhythm.

 It is constructed using a simple astable multivibrator (square wave

generator) and mono-stable multi-vibrator.

 The period of the square wave generator is given by

 The period of the oscillator can be changed by changing ‗‘or the time constant RC.
The maximum output voltage is always equal to the modulus of the saturation
voltage |Vsat| of the voltage level detector.
  The square wave generator is an astable multivibrator which periodically switches
between the output voltages |Vsat| and -|Vsat|.

 The output of the square wave generator is coupled to the negative edge triggered
monostable multivibrator circuit.

 At initial power ON, the output voltage has swung towards the positive supply rail
(+VCC). Then the voltage at the non-inverting input VB will be equal to (+VCC*β).

 The inverting input is held at 0.7v, the forward voltage of diode D1 and at the same
time, the capacitor 'C' charges upto the same 0.7V.

 When a negative pulse is given to the non-inverting input, the 0.7v at VA now
becomes greater than the voltage at VB. Thus the output of multivibrator switches
to negative rail (-VCC). The result is that the potential at VB is now equal to (-VCC*
β).

 Now, the capacitor starts to charge exponentially in the opposite direction through
the feedback resistor 'R' from 0.7v to saturated output. Diode 'D1' becomes
reverse biased so has no effect.

 The capacitor C will discharge at a time constant T=RC. As soon as the capacitor
voltage at VA reaches the same potential as VB, (VCC* β). The opamp switches back
to its original permanent state.

 The time delay period (T) of the rectangular pulse at the output is given as,

Advantages:
 It has the simplest mechanism and the longest battery life.
 It is cheap.
  It is least sensitive to outside interference.
Disadvantages:
 There may be competition between the natural heart beats and pacemaker beats
 Using the fixed rate pacemaker, the heart rate cannot be increased to match
greater physical effort.
 Stimulation with a fixed impulse frequency results in the ventricles and atria
beating at different rates. This varies the stroke volume of the heart causes some
loss in the cardiac output.
 Possibility for ventricular fibrillation will be more.

Ventricular Synchronous Pacemaker (Standby Pacemaker):

 This type of pacemaker is used for patients who suffer from a short period of AV
block.

 This pacemaker does not compete with normal heart beat signal.

 The electrode is placed in the right ventricle to sense R wave.

 The sensed R wave triggers the pacemaker. The detected signal is given to amplifier
and filter circuit. The R-wave amplifier increases the amplitude of the R-wave to
the required level.

 Filter removes the unwanted noise signal and allows only R-wave signal to pass to the
refractory period and timing circuit.

 If R-wave is absent or if its amplitude is below a particular level then fixed rate
pacemaker is turned on.

 The impulses from fixed rate pacemaker is amplified and given through electrode to
the ventricular chamber of the patient's heart.

 On the other case, if R-wave is present or the heartbeat is normal then fixed rate
pacemaker is not turned on.

 The pacemaker delivers impulses only when R wave is not detected and remains at
certain level. This type of pacemaker avoids ventricular fibrillation.

 The block diagram of ventricular synch pacemaker is as shown in the figure below.

 A single transverse electrode placed in the right ventricle senses both R wave as
well as delivers the stimulation so, no separate sensing electrode is required.
Advantages:

 To arrest the ventricular fibrillation, this circuit can be used.

 If the R-wave occurs with its normal value in amplitude and frequency then it would
not work. Therefore the power consumption is reduced

 There is no chance of getting side effects due to no competition between natural

and artificial pacemaker pulses.

 When the R wave is appearing with lesser amplitude, the circuit amplifies it and
delivers it in proper form. If the R wave period is too low or too high, the
asynchronous pacer in the circuit is working up to the returning of the heart into
normal one.

Disadvantages:

 Atrial and ventricular contractions are not synchronized.

 It produces fixed number of pulses.

Ventricular Inhibited Pacemaker (Demand Pacemaker Or R-wave Blocked Pacemaker):

 The R wave inhibited pacemaker allows the heart to pace at its normal rhythm when
it is able to. However if the R wave is missing for a preset period of time, the
pacemaker will supply a stimulus. Therefore if the heart rate falls below a
predetermined level then pacemaker will turn on and provide the heart a stimulus.
So, it is called as demand pacemaker.

 There is also a piezoelectric sensor shielded inside the pacemaker casing. When the
sensor is slightly stressed or bent by the patient's body activity, pacemaker can
automatically increase or decrease its rate. Thus it can match with the greater
physical effort.
 The refractory circuit provides a period of time following an output pulse or a
sensed R-wave during which the amplifier in the sensing circuit will not respond to
outside signals.

 The sensing circuit detects the R wave even in low level signal to noise ratio.

 The reversion circuit resets the timing circuit, if R wave is present. In the absence
of R wave, it allows the oscillator in the timing circuit to deliver pulses at its
preset rate.

 The timing circuit is the main unit of this pacemaker. It consists of RC network,
reference voltage source and a comparator. Comparator is used to determine the
pacing rate of generator. The obtained output is given to the second RC network.

 Pulse width circuit is the second RC network. The duration of stimulating pulse is
determined by pulse width circuit. After this, the signal goes to the third RC
network, which is rate-limiting circuit. It disables comparator and helps to limit
pacing rate.

 Finally obtained output is amplified and given as impulse for stimulating heart using
output amplifier.

 There is a special circuit called voltage monitor which senses the cell depletion and
signals the rate slow-down circuit and energy compensation circuit of this event.

 The rate slow-down 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 cell depletion
has occurred.

 The energy - compensation circuit produces an increase in the pulse duration as the
battery voltage decreases to maintain constant stimulation energy to the heart.
Atrial Synchronous Pacemaker

 This type of pacing is used for young patients with a mostly stable block.

 It can act as a temporary pacemaker for the atrial fibrillation.

 The block diagram for the atrial synchronous pacemaker is as shown below. The
atrial activity (P-wave) is picked up by a sensing electrode placed in a tissue close
to the dorsal wall of the atrium.

 If P-wave is absent or if its amplitude is below a particular level then pacemaker is

turned on.

 The impulses from the pacemaker is amplified and given through electrode to the
ventricular chamber of the patient's heart.

 On the other case, if P-wave is present or the heartbeat is normal then pacemaker
is not turned on.

 The pacemaker delivers impulses only when P wave is not detected.

 The detected P-wave is amplified and a delay of 0.12 second is provided by the AV
delay circuit. This is necessary corresponding to the actual delay in conducting the P
wave to the AV node in the heart. The signal is then used to trigger the resetable
multivibrator.

 The output of the multivibrator is given to the amplifier which produces the desired
stimulus to be applied to the heart. The stimulus is delivered to the ventricle
through the ventricular electrode.

 If the rate of atrial excitation becomes too fast as in atrial fibrillation or too slow
or absent, a resetable multivibrator takes over until the abnormal situation is over.
  Normally pacemaker pulse is so large that it would be detected by the atrial pick up
leads and cause the heart to beat. This problem has been eliminated by refractory
period control circuit. i.e., any signal detected on the atrial lead within 400
milliseconds of a paced heart beat is ignored.

Atrial sequential ventricular inhibited pacemaker:

 It has the capability of stimulating both the atria and ventricles and adopts its
method of stimulation to the patients needs.

 If atrial function fails, this pacemaker will stimulate the atrium and then sense the
subsequent ventricular beat. If it is working properly it will discontinue its
ventricular stimulating function. However if atrial beat is not conducted to
ventricle, the pacemaker on sensing this will fire the ventricle at a preset interval
of 0.12 second.

IMPLANTABLE PACEMAKERS

 The implantable pacemaker, along with its electrodes, is designed to be entirely

implanted beneath the skin.
 Its output leads are connected directly to the heart muscle.
 The pacemaker is a miniaturized pulse generator and is powered by small batteries.
 The circuit is so designed that the batteries supply sufficient power for a long
period.
 Since the pacemaker is located just beneath the skin, the replacement of the
pacemaker unit involving relatively minor surgery has become a routine procedure.
  For any implantable circuit, the basic requirements are:
o The components used in the circuit should be highly reliable;
o The power source should be in a position to supply sufficient power to the
circuit over prolonged periods of time;
o The circuit should be covered with a biological inert material so that the
implant is not rejected by the body; and
o The unit should be covered in such a way that body fluids do not find a way
inside the circuit and thus short-circuit the batteries or result in other
malfunctioning of the circuit.
 From 1968 to 1972, the average life of most pacemakers was 22 months and they
were too large (Furman, 1969). With important advances in many areas, particularly
in power sources, miniaturization of electronic circuits and hermetic encapsulation,
the average life of a pacemaker in 1974 was around 31 months. From 1975 onwards,
the life of pacemakers was increased to more than five years. Some of the present-
day pacemaker manufacturers even provide a life-time of pacing performance
warranty, though under certain conditions.

Types of Implantable Pacemakers

 There are three basic types of implantable pacemakers which are designed to serve
different purposes:

 Single-Chamber Pacemakers – In a single-chamber pacemaker, only one wire

(pacing lead) is placed into a chamber of the heart. Sometimes it is the upper
chamber, or atrium. Other times it is the lower chamber, or ventricle.

 Dual-Chamber Pacemakers – In dual chamber pacemakers, wires are placed in two

chambers of the heart. One lead paces the atrium and one paces the ventricle. This
approach more closely matches the natural pacing of the heart. This type of
pacemaker can coordinate function between the atria and ventricles.
  Rate-Responsive Pacemakers – These have sensors that automatically adjust to
changes in a person‘s physical activity.

Classification Codes for Pacemakers

 With rapid developments taking place in the implantable pacemaker technology, it

was felt necessary to develop a standard nomenclature to facilitate identification
of the type and functions of the pacemaker.

 The detailed nomenclature jointly adopted by the North American Society of

Pacing and Electro-physiology (NASPE) and the British Pacing and Electro-
physiology Group (BPEG) is given in Table as a 5-letter code.

 Five-letter code,

o First letter indicates the chamber or chambers that are paced.

o Second letter shows those chambers in which sensing takes place.

o Third letter reveals how the pacemaker will respond to a sensed event.

o Fourth letter describes the degree of programmability of the pacemaker

but is typically used to indicate that the device can provide rate response.

o Fifth letter is reserved specifically for anti-tachycardia functions.

Sensing Response

 Triggered (T): Sensed intrinsic depolarization will result in the pacemaker

discharging (this setting not used in current generation pacemakers)

 Inhibited (I): Sensed intrinsic depolarization will result in inhibition of the

pacemaker

 Dual (D): Dual inhibition of both atrial and ventricular pacing in response to
intrinsic ventricular depolarization

 None (O): Does not trigger or inhibit regardless of the native activity

 Example #1: DDD

 Chamber paced: Atrium and ventricle can be paced
 Chamber sensed: Intrinsic depolarization of the atrium and ventricle is
sensed
 Sensory response: Can inhibit pacemaker in response to an intrinsic
ventricular depolarization or trigger in response to an atrial intrinsic
depolarization without a ventricular response
 Example #2: VVI
 Device has a single lead in the ventricle that senses ventricular activity and
can pace the ventricle
 A ventricular event outside the refractory period will be inhibited
Programmable Pacemaker

 A programmable pacemaker consists of two parts: the external unit which

generates programmed stimuli which is transferred to an internal unit by one of the
several communication techniques.

 Fig. shows a functional block diagram of the programming interface. The commonly
used methods of transmitting information are:

 Magnetic—an electromagnet placed on the surface of the body establishes a

magnetic field which penetrates the skin and operates the pacemaker‘s reed switch

 radio-frequency waves—the information can be transmitted over high frequency

electromagnetic waves which are received inside the body by an antenna. The
antenna is usually in the shape of a coil housed within the pacemaker,

 acoustic-ultrasonic pressure waves from a suitable transducer placed over the

skin, can penetrate the human body. They are received by a suitable receiver in the
pacemaker which carries out the desired function.

 Out of all these methods, the magnetic field method is the most widely used
because of its simplicity and minimal power requirements.

 An essential requirement of programmable pacemakers is that they should be

immune to accidental programming from naturally occurring energy sources.

 To meet this requirement, the information is usually coded and the pacemaker
contains a decoding mechanism to recognize proper information.

 This programming security code method makes it practically impossible to

reprogram an implantable pacemaker through extraneous random magnetic fields.

Multi-programmable pacemaker

 Fig. below is a detailed block diagram of the multi-programmable pacemaker.

 It may be considered as being comprised of the three systems.

o System 1 controls the main timing functions of the pulse generator and
carries the rate limiter, the pulse output circuit and the stimulating
function of the electrode. Operating as directed by the programmable
control circuit, this system generates output pulses at the programmed rate,
width and amplitudes unless over-ridden by System 2.

o System 2 carries the sensing and signal discriminating function of the

circuit. Comprising the sensing function of the electrode, an RF filter, a
signal amplifier and comparator, this system identifies signals of cardiac
origin and, where appropriate, sends an inhibit signal to System 1.

o System 3 carries the programmable control circuit, the data validate

circuit, the reed switch and the master timing crystal. This system
effects program recognition, storage, and execution as well as control of the
battery and various test sequences.

 Under normal operating conditions, the timing control circuit periodically triggers
the output circuit causing the emission, at the programmed rate, of stimulation
pulses of programmed pulse width and amplitude.

 The period between each trigger signal is scrutinized by the rate limiter and in the
unlikely event of component failure causing a rate increase; the limiter holds the
rate of stimulation to less than 180 bpm.

 Upon receipt of inhibit signals from System 2, the timing control circuit compares
their time of arrival against the programmed refractory period.

 A signal detected by the electrode is filtered of high frequency components by the

RF filter.
 The signal is then selectively amplified by an amount determined by the
programmed sensitivity level and the resultant signal is compared with a preset
level at the comparator.

 Signals of either polarity with magnitude greater than the preset level enable an
input signal to be fed to the timing control circuit of System 1. Signals below the
preset level are ignored.

 System 3, acting on programming signals transmitted to the reed switch, directs

the pulse generator to function as programmed.

 The reed switch by opening and closing in connection with magnetic pulses emitted
by the programmer, feeds signals to the data validate circuit.

 After first verifying that the reed switch was closed for a minimum period of 300
ms, the data validate circuit checks and executes a code validation check.

 Only when all these checks are satisfied is the programmable control circuit
directed to store the new code.

 By activating appropriate electronic switches, the programmable control circuit

directs Systems 1 and 2 to implement the new program conditions.

 The pulse generator is non-invasively programmable by means of a programmer

which emits a magnetic code that enables the following parameters to be altered:
rate, pulse width, pulse amplitude, sensitivity, refractory period and hysteresis.

 The programmer contains a microprocessor-based transmitter/receiver that

operates by inductively coupling pulse-position modulated, binary coded data from
the programmer via the programming wand to the pulse generator.

 The programming information is contained in a 20-bit command code specifying the

desired rate, pulse width, pulse amplitude, sensitivity level, mode of operation, a
pulse generator model identification code and check codes.

 If an attempt is made intentionally or unintentionally to include in a programming

command a parameter that is not a feature of the pulse generator being used, that
parameter will simply remain at its nominal value.

 Part of the command code is a check code. If this check code is not correct, the
command is rejected by the pulse generator, and no programming occurs.

 The timing of the transmission is precise. Crystal oscillators in both the

programmer and the pulse generator control the frequency of data exchanges.

 Each data bit is transmitted within approximately 1.0 ms.

 The entire command code and its complement are transmitted within approximately
40 ms or 1/25th of a second.
 CARDIAC DEFIBRILLATOR
 Defibrillator is an electronic device that creates a sustained myocardial
depolarization of a patient’s heart in order to stop ventricular
fibrillation or atrial fibrillation.

 If the heart does not recover spontaneously after delivering the shock to
the heart using defibrillator then a pacemaker may be employed to restart
the rhythmic contraction of the myocardium.

 Ventricular fibrillation is dangerous when compared to arterial fibrillation.

 Cardiac arrest is when someone‘s heart stops pumping blood around the body and
they stop breathing normally.
 The most common cause of a cardiac arrest is a abnormal heart rhythm called
ventricular fibrillation (VF). Ventricular fibrillation happens when the electrical
activity of the heart becomes so chaotic that the heart stops pumping and quivers
or 'fibrillates' instead.
Types of Defibrillator:

There are two types of defibrillators based on the electrodes placement.

a) Internal defibrillator (Surgical Type)

b) External defibrillator (Therapeutic Type)

Internal defibrillator:

 It is used when chest is opened.

 Here large spoon shaped electrodes with insulated handle are used.

 Sometimes electrodes in the form of fine wires of Teflon coated stainless steel are
used.

 There are AC and DC defibrillator methods but DC defibrillator is used today.

 Since the electrode comes in direct contact with the heart, the contact impedance
is about 50 ohms.

 In internal defibrillation, the heart requires excitation energy of about 15 to 50 J.

 The amount of current that passes through chest is between 1 to 20 amperes

 Internal DC defibrillator uses voltage values range between 50 V to 1000 V to

provide shock

 The duration of the shock is about 2.5 to 5 milliseconds.

  The spoon shaped electrode is as shown below.

External defibrillator:

 It is used on the chest.

 Here paddle shaped electrodes are used.

 There are AC and DC defibrillator methods but DC defibrillator is used today.

 Since the electrodes are placed above the chest, the contact impedance on the
chest is about 100 ohms even after applying the gel.

 In external defibrillation, the heart requires excitation energy of about 50 to 400J.

 The amount of current that passes through chest is between 10 to 60 amperes

 External DC defibrillator uses voltage values range between 1000 V to 6000 V to

provide shock

 The duration of the shock is about 1 to 5 milliseconds.

 The paddle shaped electrode is used as shown below.

 The bottom of the electrode consists of a copper disc with 3 to 5 cm diameter for
pediatric patient and 8 to 10 cm diameter for adult patients with a highly insulated
handle.

 Electrodes can be placed on two ways either in anterior – anterior position or in

anterior – posterior position.

 In anterior – anterior position current flows through the heart. In this position,
one paddle is placed above the heart apex and another paddle on the sternum.
Hence, the current flows in the direction of bottom to top of the heart. Whereas,
in anterior – posterior position blood flows to chest from behind through heart.

Types of defibrillator based on operation or Voltage delivered:

 There are two broad classifications of defibrillators based on the nature of the
output voltage delivered.
  They are,

 AC defibrillator

 DC defibrillator

AC defibrillator:

 Although mechanical methods like chest massage for defibrillation have been tried
for years, the most successful method of defibrillation is the application of electric
shock to the area of the heart which makes all the heart muscle fibres enter their
refractory period together after which normal heart action may resume.

 One of the earliest forms of an electrical defibrillator is the AC defibrillator, which

applies several cycles of alternating current to the heart from the power line
through a step-up transformer.

 To achieve defibrillation with internal electrodes placed on the surface of the heart
(in open heart surgery), voltage ranging from 80 to 300V rms is required.

 When external electrodes are used on the chest, voltages of twice the value are
required.

 The transformer must be capable of supplying 4 to 6 amperes current during the

stimulus period.

Disadvantages:

 There are many disadvantages in using AC defibrillators.

o Successive attempts to correct ventricular fibrillation are often

required.

o AC defibrillator cannot be successfully used to correct atrial

fibrillation.

DC Defibrillators

 The Capacitive Discharge type DC Defibrillator is as shown in the figure

 below.
 The 230V AC main supply is connected to a variable autotransformer in the primary
circuit.
 An autotransformer is used to vary the input voltage level of the step-up
transformer to get the required output voltage level.

 The output of the autotransformer is fed as input to a step-up transformer to

produce high voltage with a rms value of about 8000 V.

 Diode 'D' acts as the rectifier that converts high AC voltage into pulsating DC
voltage, which charges the capacitor C.

 An AC voltmeter is connected across the primary of step-up transformer to

measure the output voltage level of autotransformer.

 With the electrodes firmly placed at appropriate positions on the chest (Sternum
and Apex), the technician discharges the capacitor by momentarily changing the
switch S from position 1 to position 2.

 The capacitor is discharged through the inductor L, the electrodes and the
patient's torso is represented by a resistive load.

 The inductor is used to shape the wave in order to eliminate a sharp, undesirable
current spike that would occur at the beginning of the discharge.
  The energy delivered to the patient is represented by the typical waveform shown in
figure below.

 The area under the curve is proportional to the energy delivered.

 The wave is monophasic and the peak value of the current is nearly 20 A.

 Depending on the defibrillator energy setting, the amount of electrical energy

discharged by the capacitor may range between 100 and 400 joules when the
electrodes are applied externally and the duration of the effective portion of the
discharge is approximately 5 milli seconds.

 Once the discharge is completed, the switch automatically returns to position 1 and
the process can be repeated, if necessary.

 When the electrodes are applied directly to the heart, about 50 to 100 joules only is
required for defibrillation.

 The energy stored in the capacitor is given by the equation

Where, C is the capacitance and V is the voltage to which the capacitor is charged.

Defibrillator Electrodes

 The two defibrillator electrodes applied to the thoracic walls are called either
Anterior-Anterior or Anterior-Posterior paddles.

 With anterior-anterior paddles, both paddles are applied to the chest.

 Anterior-posterior paddles are applied to both the patient's chest wall and back, so
that the energy is delivered through the heart. This method of paddle application
offers better control over arrhythmias that occur as a result of atrial activity.

 These two methods are shown in Figure below.

 To maintain good contact, the electrodes must be firmly placed against the patient.

 The posterior paddle is flat and has a larger disc (with a radial handle) than the
anterior paddle (axial handle).

 The electrodes must be sufficiently well insulated, so that the operator holding the
electrodes is safe.

 Two types of electrodes for defibrillation are shown in the above figure, and Figure
(a) shows the type of electrode used for external defibrillation.

 This electrode consists of a large metal disc, approximately 100 mm in diameter, in

an insulated housing.

 A control switch is located on the handle so that, once the electrodes are in place,
the operator can push the switch to initiate the pulse.

 While being used, the electrodes surface is coated with a conducting gel of the
type used with an ECG recording.

 Figure (b) shows an internal type of electrode which is spoon shaped, for applying
directly on the myocardium (during open-chest surgery), or it may be applied to the
chest of an infant.

 In these applications, the energy levels required for defibrillation may range from
10 to 50 watts.

 Special pediatric paddles are available with diameters ranging from 2 to 6 cm.

 The energy of a defibrillator is usually given in terms of watts/sec, referenced

across a 50 ohm resistor.

 Most defibrillators today have a charging capacity of 400 watts.

IMPLANTABLE DEFIBRILLATORS

 The use of Automatic Implantable Defibrillators (AID) is recommended for

patients who are at high risk for ventricular fibrillation.

 This is a small match box sized device that can be implanted in the body: in the
chest or abdomen.

 It can constantly monitor the heart rhythms, and deliver the necessary electrical
impulse before the disrupted rhythms translate to a cardiac arrest.

 An AID is a battery-powered device placed under the skin that keeps track of the
heart rate.

 Thin wires connect the AID to your heart.

 If an abnormal heart rhythm is detected the device will deliver an electric shock to
restore a normal heartbeat if your heart is beating chaotically and much too fast.

 AIDs have been very useful in preventing sudden death in patients with known,
sustained ventricular tachycardia or fibrillation.

 The AID has two parts:

o the lead(s) and

o a pulse generator.

 The lead(s) are made up of wires and sensors that monitor the heart rhythm and
deliver energy used for pacing and/or defibrillation.

 The generator houses the battery and a tiny computer.

 Energy is stored in the battery until it is needed.

  The computer receives information from the leads to determine how the heart is
beating.

 A battery-powered pulse generator is implanted in a pouch under the skin of the

chest or abdomen, often just below the collarbone.

 The generator is about the size of a pocket watch.

 Wires or leads run from the pulse generator to positions on the surface of or inside
the heart and can be installed through blood vessels.

 It knows when the heartbeat is not normal and tries to return the heartbeat to
normal.

 If the AID has a pacemaker feature when the heartbeat is too slow, it works as a
pacemaker and sends tiny electric signals to your heart.

 When the heartbeat is too fast or chaotic, it gives defibrillation shocks to stop the
abnormal rhythm.

 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

Types of Implantable Defibrillators

Depending on the number of leads, their placement into the cardiac chambers, as well as
the therapy offered, three types of ICDs are available:
  Single chamber: These have a single lead that is placed in the right ventricle, and
provide anti-bradycardia and anti-tachycardia therapies.

 Dual chamber: They have two leads that are placed in the right atrium and right
ventricle. These ICDs can provide anti-bradycardia pacing through the right atrium
and ventricle, as also provide anti-tachycardia therapies, cardioversion and
defibrillation through the right ventricle only.

 Biventricular: These ICDs have three leads, of which, one is placed in the right
atrium, and the remaining two are placed in the left and right ventricles each. In
addition to the functions provided by a dual chamber ICD, these ICDs are also
capable of synchronized pacing to the left and right ventricles which is useful for
individuals at a risk of heart failure.

Pacer Cardioverter Defibrillators

 These are used for patients having extreme brady arrhythmias.

 A multifunction defibrillator with external pacing.

 This has high output pacing function after defibrillator.

 A block diagram of the experimental device is shown in Fig.

 It is composed of five battery-powered units:

o sensing circuit,

o high voltage converter,

o switching circuit,

o defibrillation control circuit, and

o pacing control circuit.

  The heartbeat signal, which is detected by a catheter-type heartbeat sensor, is
amplified for heartbeat monitoring.

 The absence of a heartbeat for 3.5 s causes the fibrillation detecting circuit to
deliver the turn-on signal which then switches on the high voltage converter.

 At a predetermined voltage level (800 V), the thyristor switch allows the capacitor
to discharge its current through the right ventricular electrode.

 After defibrillation, high-output demand pacing is activated by using the residual

energy in the output-capacitor.

 The pacing rate and pulse width are controlled by the pacing control circuit, and the
heartbeat signal is used for demand function.

DEFIBRILLATOR ANALYZER

 Victims of sudden cardiac arrest (SCA) can be saved with a small, prompt lightning
bolt (i.e., a defibrillator shock) to the chest.

 The shock (3kV to 5kV and 50A) stops the heart from unproductive fluttering
(fibrillating) which fails to pump blood to the brain and other organs.

 This lightning bolt allows the heart to restart orderly pumping of blood.

 In hospitals it is common to monitor the heart using an electrocardiograph (ECG)

with a separate defibrillator.

 The ECG leads (i.e., electrodes) are on the patient when the defibrillator delivers
the shock.

 With no warning, the ECG must withstand this lightning bolt and continue working
properly.

 Without the protective skin a patient‘s heart is vulnerable to very small currents.

 In the electrically susceptible patient, moreover, even minute amounts of current

(10µA) can cause ventricular fibrillation.

 Remember that with an ECG and separate defibrillator it is not uncommon to have
several pieces of equipment attached to the patient at the same time.

 Clearly, the total leakage current must remain below the threshold that can harm a
human heart.

 Many think that a defibrillator restarts the heart, but actuality it stops the heart.

 There is a random beating in the heart called fibrillation, which means the heart is
not coordinated and not pumping blood.

 The defibrillator shocks the heart into inactivity, allowing the normal sinus rhythm
to restart.
Protecting the Defibrillator for ECGs

Typical ECG front-end defibrillator protection circuitry. LA = left arm; RA = right arm; RL = right leg.

 The above fig shows a defibrillator‘s typical protection circuitry for an ECG.

 For convenience, the components are labeled in the left arm (LA) input circuit at
the top.

 The normal ECG waveforms are on the order of a few (0.5mV to 7mV) millivolts, but
the high-voltage defibrillator is in kilovolts and can last 5ms to 20ms—a long time
for electronic components to survive such high voltage.

 Resistor R1 is in the range of 10kOhm to 20kOhm, and can be in the input of the
amplifier or built into the cables.

 It is the series element that limits the current in the neon lamps. Resistors R2 and
R3, along with capacitors C1, C2 and C3, form lowpass filters.

 The D1 diode limits the voltage to a lower level. D1 can be a zener or avalanche
diode, a metal-oxide varistor (MOV), or a thyristor surge protector.

 The D1 capacitance in conjunction with C1 is part of the lowpass filter. Capacitor C2

is the common-mode filter, whereas C3 provides differential filtering.

 Typically C3 is about 10 times larger than C2. SW1 is a high-voltage signal-line

protector: a switch that senses high-voltage, turns off the series switch, and turns
on a clamp to reduce the amount of voltage at the amplifier.
  SW1 can be replaced by a current-limiting diode which looks like a JFET with the
source and drain terminals tied together.

 Diodes D2 and D3 are ESD-protection diodes that clamp the amplifier input to the
power supplies. Notice C4 and zener diode D6 at the top of the amplifiers.

 They absorb and clamp the positive voltage rail.

 C5 and D7 do the same for the negative power rail.

Now the effects of radio frequency interference (RFI), electrostatic distortion (ESD),
electromagnetic interference (EMI), and susceptibility (EMS) must be considered on this
protection design.

Schematic for protection against unwanted electrical vulnerabilities such as ESD, EMI, EMS, and RFI.

 The devices in the above figure fall into three categories:

o Voltage-limiting devices: gas discharge arrestors, metal-oxide varistors,

suppressor diodes, triacs, diacs, and switches

o Current-limiting devices: fuses, circuit breakers, and thermal cutouts

o Risetime reducers: resistors, inductors, coils, ferrite beads, and capacitors,

all of which slow the risetime of a transient and, thereby, allow time for
other protection devices to function.

 Capacitors are used with the resistors; ferrite beads, and inductors to act as
lowpass filters.

 This approach controls the anti-alias filtering for the data converter. It slows the
ESD risetime by spreading the impulse over time and allows the capacitors to be
more effective.

 The working voltage, equivalent series resistance (ESR), and self-resonance point of
each capacitor need to match the application's frequency and bandwidth.

 The self-resonance point may mean that several smaller resistors are necessary in
parallel to absorb the fast risetime of ESD and a defibrillator shock pulse.
 CARDIAC ABLATION CATHETER
 Cardiac ablation is a procedure to treat heart rhythm problems referred to as
cardiac arrhythmias.

 It involves the use of heat or cold energy to destroy small areas of heart
tissue, blocking the abnormal electrical signals that move through the heart and
cause rhythmic disruptions.

 Cardiac ablation is most often done using thin, flexible tubes called catheters
inserted through the veins or arteries. Less commonly, ablation is performed during
cardiac surgery.

 When the root of the problem is discovered, the tissue causing the problem is
ablated or destroyed.

 When the heart beats, the electrical signals that cause the heart to squeeze
(contract) must follow a specific pathway through the heart. Any disruption in the
signaling pathway can trigger an irregular heartbeat (arrhythmia).

 Depending on the type of heart rhythm problem, cardiac ablation may be one of the
first treatments. Other times, it's done when other medicines or treatments don't
work.

Types of Cardiac Ablation Procedure

 Catheter ablation uses either hot or cold energy to destroy heart tissue.

 Physician will choose the method they are most comfortable with and that is most
appropriate for your condition.

 The patient will receive sedation or possibly general anesthesia during the
procedure and won‘t feel any extremes of hot or cold.
  The types of catheter ablation include:

o Radiofrequency ablation: This method utilizes catheters to convey

radiofrequency energy (similar to microwave heat) to destroy the
problematic heart tissue.

o Cryoablation: Cryoablation uses cold energy to freeze and scar heart tissue.
This method utilizes a single catheter to deliver a balloon tipped with a
freezing material to cause a scar in the problematic heart tissue.

Historical Development

 Catheters were first used for intracardiac recording and stimulation in the late
1960s, but surgical treatment for refractory tachyarrhythmias until it was
superseded by catheter ablation.

 The initial energy source used was direct current (DC) from a standard external
defibrillator.

 A shock was delivered between the distal catheter electrode and a cutaneous
surface electrode; however, this high-voltage discharge was difficult to control
and could cause extensive tissue damage.

 RF energy, a low-voltage, high-frequency form of electrical energy familiar to

physicians from its use in surgery (eg, electrocautery), quickly supplanted DC
ablation.

 RF energy produces small, uniform, necrotic lesions by heating tissue. Lesion

size is influenced, in part, by the length of the distal ablation electrode and the
type of catheter (standard vs saline-cooled).

 With typical power settings and good catheter contact pressure with cardiac
tissue, lesions are minimally about 5-7 mm in diameter and 3-5 mm in depth.
  Catheter-based cryoablation was developed after RFCA, and it utilizes tissue
cooling to cause tissue necrosis.

 Low-intensity cooling (cryomapping, -10°C) allows assessment of lesion efficacy

and safety, prior to delivering the deeper cooling (-70°C) that causes irreversible
tissue necrosis.

 Though not as versatile or widely used compared to RFCA, cryoablation is safer for
ablation near the compact atrioventricular (AV) node.

Procedure

 In general, cardiac ablation involves the following steps:

– The patient will be administered a sedative drug just before the procedure
to keep him relaxed.

– A small incision is made in the area where the catheter (a small, flexible
tube) is to be inserted.

– Next, a catheter is inserted through the incision into one of the blood
vessels in the area.

– The physician may inject a contrast medium (dye) through the catheter so
that the blood vessels are clearly visible on X-ray images.

– Under live X-ray guidance, the physician carefully passes the catheter
through the vessel up into your heart. Often, more than one catheter is
required.

– Electrodes at the tip of the catheter are utilized to convey electrical signals
and document your heart's electrical activity.

– The physician utilizes this information to determine where to apply the

ablation.
 – Once the source of the problem has been identified, the physician will use
electrical (or sometimes cold) energy to destroy the problem area in the
heart, eliminating the heart rhythm problem.

Risks and Complications Involved

 Cardiac ablation is a relatively safe procedure; however, as with any procedure

some risks and complications may occur such as:

– Bleeding

– Infection

– Damage to heart valves

– Damage to blood vessels

– Blood clots or deep vein thrombosis (DVT)

– Slow heart rate

– Stroke

– Heart attack

– Death, in rare instances

 VENTILATOR
 Respiration is the process of supplying oxygen to and removing carbon dioxide from

the tissues.

 These gasses are carried in the blood, oxygen from the lungs to the tissues

and carbon dioxide from the tissues to the lungs.

 The gas exchanges in the lungs are called external respiration and those in
the tissues are called internal respiration.

 A ventilator is a machine that supports breathing. These machines are

mainly used in hospitals. Ventilators:

o Get oxygen into the lungs.

o Remove carbon dioxide from the body.

o Help people breathe easier.

o Breathe for people who have lost all ability to breathe on their own.

 A ventilator often is used for short periods, such as during surgery when

you're under general anesthesia. (The term "anesthesia" refers to a loss of

feeling and awareness. General anesthesia temporarily puts you to sleep.)

 A ventilator also may be used during treatment for a serious lung disease or

other condition that affects normal breathing.

 A ventilator doesn't treat a disease or condition. It's used only for life

support.

 Other names of ventilators are,

o Mechanical ventilator

o Respirator

o Breathing machine

 It provides artificial respiration. Artificial respiration is given to the

patient because the cerebral cortex cannot survive without oxygen for
 more than 5 minutes. Ventilators provide enriched oxygen, medicated air

at a controlled temperature.

 They operate at different modes.

Methods of Artificial Respiration

 Non – mechanical

 Mechanical

Non-mechanical Methods of Artificial Respiration

 Holger – Nielson method and Mouth-to-Mouth breathing technique is used. Nielson

method is also called as Backpressure arm lift method, which gives a better result.

Mechanical Methods of Artificial Respiration

 During severe respiratory failures, artificial respiration is given for a longer time.

Two types of Mechanical methods are

o Negative Pressure Ventilator

o Positive Pressure Ventilator

Negative Pressure Ventilator

 This method consists of airtight chamber and electrically driven pump. Pump is used
to increase and decrease the pressure inside the chamber.

Procedure:

 The patient is made to sit inside the chamber with head and neck outside the
chamber. When pressure inside the chamber increases, due to negative pressure
chest wall expands. If chest wall expands, more air is drawn into the lungs. At the
same time, when pressure in the chamber increases, expiration occurs. The method
is used for respiratory muscle paralysis.

 Early negative-pressure ventilators were known as ―iron lungs.‖

 The patient‘s body was encased in an iron cylinder and negative pressure was
generated.
Positive Pressure Ventilator

 This method inflates the lungs with intermittent positive pressure. A tube passes
through mouth into the trachea. A pump delivers the oxygen supply or oxygen mixed
with carbon dioxide supply. Between each pump stroke, gas flow is disturbed. So
gas is expelled.

Working of a Ventilator:

 During inspiration process, the air compressor draws the air via air filter and gives
it to the main solenoid.

 The main component of the ventilator is the bellows.

 A bellows is a device constructed to furnish a strong blast of air.

 A bellows has bottom and top valves attached on it.

 After the air reaches, the solenoid forces inlet valve of bellow to open and outlet
valve to close.

 Control valve allows the oxygen to pass into the chamber in a controlled manner.

 Bellows chamber has high pressure and so it compresses the bellows and forces the
upper outlet valve to open.

 Hence, the oxygen enriched air passes through main solenoid, reaches the external
tubes.

 Then it goes to bacterial filter, humidifier, nebulizer (A device for producing a fine
spray of liquid) and lastly to lungs.

 Humidifier (a device for keeping the atmosphere in room moist) is used to prevent
lung damage of the patient.

 It humidifies the oxygen using heat steam.

 Nebulizer produces spray of water or medication (means drug or other form of

medicine that is used to treat or prevent disease) into patient‘s inspiration air.

 When the medicated air is forced into lungs through the valve 1, the spirometer is
in closed condition.

 When the inspiration is complete, the main solenoid switches the direction of the
pneumatic air to do the expiration cycle.

 During expiration, air is sucked into the spirometer chamber through the valve1.

 The volume of the chamber is varied by means of a light weight piston that moves
freely in a cylinder as air is withdrawn.
  A rubber seal between the piston and the cylinder wall keeps the chamber air tight.

 They measure volume of exhaled air and also send an alarm to stop expiration and
start inspiration.

 Meanwhile, air compressor draws room air via inlet filter.

 They close the upper outlet valve of bellow chamber.

 Due to the weight of bellow, bottom chamber opens and main solenoid instructs the
inlet valve of chamber to close.

 Volume of exhaled air is indicated using spirometer alarm.

 The expired air reaches main solenoid via outlet 2.

 The system electronics trips the solenoid at the end patient expiration.

Terminologies related to Ventilator

Lung Compliance:

The compliance of the patient‘s lungs is the ratio of volume delivered to the
pressure rise during the inspiratory phase in the lungs. This includes the compliance of the
airways. Compliance is usually expressed as litres/cm H2O.

Airway Resistance:

Airway resistance relates to the ease with which air flows through the tubular
respiratory structures. Higher resistances occur in smaller tubes such as the bronchioles
and alveoli that have not emptied properly.

Mean Airway Pressure (MAP):

An integral taken over one complete cycle expresses the mean airway pressure.
Inspiratory Pause Time:

When the pressure in the patient circuit and alveoli is equal, there is a period of no
flow. This period is called inspiratory pause time

Inspiratory Flow:

Inspiratory flow is represented as a positive flow above the zero line.

Expiratory Flow:

Expiratory flow is a negative flow below the zero line

Tidal Volume:

Tidal volume is the depth of breathing or the volume of gas inspired or expired
during each respiratory cycle.

It can be calculated by multiplying the flow rate (l/sec) setting by the set
inspiratory time (seconds).

Calibrated tidal volume settings range from 0.010 litre to 4.8 litres.

If the flow is set at 0.6 l/s and inspiratory time is set at 1 sec, the tidal volume is =
0.6 litres.
Minute Volume:

This refers to volume of gas exchanged per minute during quiet breathing. Minute
volume is obtained by multiplying the tidal volume by the breathing rate.

Respiration Rate:

This is the number of breaths per second. It represents total respiratory rate of
the patient.

Conventional Mechanical Ventilation (CMV):

This provides the force which determines the tidal volume (VT) at a respiratory
frequency (f) to achieve the desired minute ventilation (VE)

VE = VT * f

Intermittent Mandatory Ventilation (IMV):

This allows the insertion of a variable time delay between two successive breaths.

Inspiratory Expiratory Phase Time Ratio (I:E Ratio):

This signifies the ratio of inspiratory interval to expiratory interval of a mandatory

breath. This ratio is normally limited to 1:1, i.e. the inspiratory time should not exceed 50%
of the total ventilator cycle time as set by the breath/minute control.

Synchronized Intermittent Mandatory Ventilation (SIMV):

It represents a combination of machine ventilation and spontaneous breathing.

SIMV enables the patient to breathe spontaneously in regular prescribed cycles, with the
mechanical mandatory ventilation strokes providing minimum ventilation during the
remaining cycles.

Sigh Volume:

One sigh breath is 150% of the set tidal volume.

Patient Circuit:

This includes a set of tools collecting the patient airway to the outlet of a
ventilator.

Oxygen Percentage (F1O2):

In all ventilatory modes, oxygen is delivered during the inspiratory phase and the
percentage (F1O2) is adjustable from 21 to 91%.
Peak Airway Pressure:

It is the highest level of pressure reached over several breathes.

Spontaneous Ventilation:

This is a ventilation mode in which the patient initiates and breathes from the
ventilator at will.

Bias Flow:

In bias flow, mixed gas from the mixer is directed through the patient circuit
inbetween mechanical breaths. Bias flow stabilizes baseline pressure for spontaneously
breathing patients and decreases the response time of the demand valve.

Sensitivity:

It is used to detect spontaneous effort by the patient, in order to trigger

mandatory ventilation with the set respiration rate.

Mandatory Minutes Volume Ventilation (MMV):

This operating mode applies mandatory ventilation only if spontaneous breathing is

not yet sufficient and has fallen below a pre-selected minimum ventilation.

Controlled Mandatory Ventilation:

This term refers to mandatory ventilation of patients who are not able to initiate
or respire on their own.

Assisted Spontaneous Breathing (ASB):

It refers to the pressure support of insufficient spontaneous breathing.

Positive End Expiratory Pressure (PEEP):

PEEP is a therapist-selected pressure level for the patient airway at the end of
expiration in either mandatory or spontaneous breathing. PEEP is used to increase the end-
expiratory lung volume (EELV) or prolong expiration with a potentially similar effect on the
EELV

Continuous Positive Airway Pressure (CPAP):

CPAP is a spontaneous ventilation mode in which the ventilator maintains a constant

positive pressure, near or below PEEP Level, in the patient‘s airway while the patient
breathes at will.
Assist/Control Ventilation:

During this process, a positive pressure breath is delivered with each patient‘s
spontaneous inspiratory effort to reach the trigger level setting. In volume controlled
assist control, tidal volume is determined by flow and inspiratory time settings. If the
patient does not trigger the ventilation, it automatically delivers breaths according to the
set rate.

Pressure Relief Valve:

It determines the maximum pressure that can be reached in the patient circuit
during spontaneous mechanical and manual ventilation. It is adjustable from 0-100 cm H2O
and functions in all modes.

CLASSIFICATION OF VENTILATORS

Ventilators can be classified in terms of various methods. Discussed below are the
general criteria for systematic listing and description of these classifications.

Based on the Method on Inspiratory Phase

Controller:

 A ventilator which operates independent of the patient‘s inspiratory effort.

 The inspiration is initiated by a mechanism which is controlled with respect to time,

pressure or another similar factor.

 Controlled ventilation is required for patients who are unable to breathe on their
own.

Assistor:

 A ventilator which augments the inspiration of the patient by operating in response

to the patient‘s inspiratory effort.

 A pressure sensor detects the slight negative pressure that occurs each time the
patient attempts to inhale and triggers the process of inflating the lungs. Thus the
ventilator helps the patient to inspire when needed.

 The assist mode is required for those patients who are able to breathe but is
unable to inhale a sufficient amount of air or for whom breathing requires a great
deal of effort.

Assistor/Controller:

 A ventilator which combines both the controller and assistor functions.

  In these devices, if the patient fails to breathe within a pre-determined time, a
timer automatically triggers the inspiration process to inflate the lungs.

 Therefore, the breathing is controlled by the patient as long as it is possible, but in

case the patient should fail to do so, the machine is able to take over the function.
Such devices are most frequently used in critical care units.

Based on Power Transmission

Direct Power Transmission:

 A ventilator which delivers the gas directly from the source of compressed gas to
the patient.

Indirect Power Transmission:

 A ventilator which has separate patient and power systems. The pressure in the
power system determines the flow rate.

Based on Pressure Pattern

Positive-Atmosphere:

 A ventilator which produces a positive pressure in the patient‘s lungs during

inspiration, with an end expiratory pressure that is equal to the atmospheric
pressure.

 In this mode, the mean airway pressure is always higher than the atmospheric
pressure and the patient normally breathes spontaneously with this mode of
operation.

Positive-Negative:

 A ventilator which produces a positive pressure in the patient‘s lungs during

inspiration and below atmospheric pressure in the airway during part of expiratory
phase. A positive-negative pressure pattern results in a low mean airway pressure.
Positive-Positive:

 A ventilator which produces a positive pressure in the patient‘s lungs during

inspiration, with an end expiratory pressure that is greater than the atmospheric
pressure.

 In order to obtain an end expiratory pressure that is greater than the atmospheric
pressure, it is necessary to start the inspiratory phase before the airway pressure
reaches the atmospheric pressure.

Based on the Type of Safety Limit

Volume Limited:

 A ventilator in which pre-determined volume cannot be exceeded during inspiration.

Volume limit normally refers to tidal volume.

Pressure Limited:

 A ventilator designed in such a way that predetermined pressure cannot be

exceeded during inspiration.

Time Limited:

 A ventilator in which predetermined phase time cannot be exceeded.

 It limits the expiratory phase time if the patient does not initiate the inspiratory
phase and is common to ventilators used for assisted ventilation.

Based on Cycling Control

 Cycling control of a ventilator is the device which determines the change from the
inspiratory phase to the expiratory phase and vice versa.

Patient Cycled Ventilator

 Patient-ventilator interaction is a key element in optimizing mechanical ventilation.

 The change from inspiration to expiration is a crucial point in the mechanically

ventilated breath, and is termed ―cycling.‖

 Patient-ventilator asynchrony may occur if the flow at which the ventilator cycles
to exhalation does not coincide with the termination of neural inspiration. Ideally,
the ventilator terminates inspiratory flow in synchrony with the patient's neural
timing, but frequently the ventilator terminates inspiration either early or late.

 Most current mechanical ventilators include adjustable cycling features that, when
used in conjunction with waveform graphics, can enhance patient-ventilator
synchrony.
  The mechanical ventilator breath can be separated into 2 parts:

o Inspiratory phase and

o Expiratory phase.

 At the end of inspiration, gas flow ceases, and the breath is switched into
exhalation.

 This transition point from the inspiratory phase to the expiratory phase is termed
―cycling.‖

 Simply, the inspiratory phase is cycled into expiration when gas flow ceases from
the mechanical ventilator and expiratory flow begins.

 Many settings on the mechanical ventilator induce cycling, such as preset volume,
time.

Cycling Mechanisms

The cycling of a mechanical ventilator breath occurs after a set value is reached. These
values are often referred to as ―cycle variables.‖ All mechanical ventilator breath types
are governed by cycling variables. Four variables are used to determine when to cycle to
exhalation: pressure, time, volume, and flow.

Pressure Cycling

When a certain pressure threshold is reached, inspiration is cycled into exhalation. The
most common application for pressure cycling is for alarm settings. If a patient becomes
extremely asynchronous or coughs, the high-pressure alarm may be triggered and the
inspiratory phase ends, resulting in exhalation. Pressure cycling can be viewed as a safety
feature to avoid elevated and sustained inspiratory pressure.

Time Cycling

Time cycling indicates that the mechanical ventilator breath switches from inspiration to
expiration after a set time threshold is reached. This can be accomplished by setting the
respiratory rate, inspiratory time, or inspiratory-expiratory ratio. Many ventilators
terminate the inspiratory phase after a certain timeframe: typically 3–5 seconds.

Volume Cycling

With conventional volume-targeted breaths, inspiration stops once the target volume is
delivered. The ventilator cycles to expiration once a set tidal volume has been delivered.
Volume cycling is only adjustable as the clinician sets a tidal volume to be delivered or a
maximum tidal volume alarm setting.
  Ventilators are classified according to how the inspiratory phase ends. The factor
which terminates the inspiratory cycle reflects the machine type.

 They are classified as

o Pressure controlled ventilator

o Volume controlled ventilator

o Time controlled ventilator

Volume Controlled Ventilator

 Inspiration is terminated after a preset tidal volume has been delivered by the
ventilator.

 The ventilator delivers a preset tidal volume (TV), and inspiration stops when the
preset tidal volume is achieved.

Pressure Controlled Ventilator

 In which inspiration is terminated when a specific airway pressure has been

reached.

 The ventilator delivers a preset pressure; once this pressure is achieved, end
inspiration occurs.

Time Controlled Ventilator

 In which inspiration is terminated when a preset inspiratory time, has elapsed.

 Time cycled machines are not used in adult critical care settings. They are used in
pediatric intensive care areas.

Based on the Source of Power

Pneumatic:

 A ventilator powered by compressed gas.

Electric:

 A ventilator powered by an electrical device such as an electric motor, or similar

gadget.

MODERN VENTILATORS

 Modern ventilator machines consist of two separate but inter-connected systems:

 o the pneumatic flow system and

o an electronic control system.

Pneumatic Flow System

 It enables the flow of gas through the ventilator. Oxygen and medical grade air
enter the ventilator at 3.5 bar (50 psi) pressure through built-in 0.1 micron filters.

 These gasses enter the air/oxygen mixer where they combine at the required
percentage and reduced in pressure to 350 cm H2O.

 An electronically controlled flow valve proportions the gas flow from the reservoir
tank to the patient breathing circuit.

 The primary objective of the device is to ensure proper level of oxygen in the
inspiratory air and deliver a tidal volume according to the clinical requirements.

 As the gasses leave the ventilator, they pass by an oxygen analyser, a safety
ambient air inlet valve and a back-up mechanical over pressure valve.

 The ambient valve provides the patient the ability to breathe room air when the
ventilator fails or the pressure in the patient circuit drops below–10 cm of H2O.

 In the patient breathing circuit is a bi-directional flow sensor to measure the gas
flows.

 The exhaled gasses exit through an electronically controlled exhalation valve

located at the ventilator.
Electronic Control System

 The electronic control system may use one or more microprocessors and software
to perform monitoring and control functions in a ventilator.

 These parameters include setting of the respiration rate, flow waveform, tidal
volume, oxygen concentration of the delivered breath, peak flow and PEEP.

 The microprocessor utilizes the above parameters to compute the desired

inspiratory flow trajectory.

 The sensors are connected to electronic processing circuits which makes them
available for digital readouts.

 The signals are also compared with pre-set alarm levels so that if they fall outside
a pre-determined normal range, alarms are sounded.

 The pressure sensors are normally of semiconductor strain gauge type placed in a
bridge configuration.

 For measurement of fraction of oxygen in the inspired air, a fuel cell type oxygen
sensor is used.

 As this sensor is temperature sensitive, compensation for its operating

temperature is included in the circuit.

 Usually, a thermistor is used to carry out this function.

 The flow sensor usually consists of a variable orifice and by measuring the pressure
drop across the variable orifice, the patient flows can be calculated.

HIGH FREQUENCY VENTILATORS

 A new technique for ventilating patients at frequencies much higher than the
respiration rate has recently been introduced.

 The key principle in this technique is to provide tidal volumes equal to or smaller
than the dead space, at very high rates.

 Gas transport during conventional ventilation is attributed to two basic mechanisms:

o convection or flow of gas through the conducting airways, and

o molecular diffusion of gasses into the alveoli and pulmonary capillaries.

 High-frequency ventilators use small tidal volumes (1 to 3 mL/kg) at

frequencies greater than 100 breaths/minute.

 The high-frequency ventilator accomplishes oxygenation by the diffusion of

oxygen and carbon dioxide from high to low gradients of concentration.

 This diffusion movement is increased if the kinetic energy of the gas molecules is
increased.