Bioinstrumentation

Medical Ventilators and Surgical Diathermy

BY: KAMUHANDA SUCCESS
MEDICAL VENTILATORS
Ventilators
• An integral component of the anesthetic delivery system is
the ventilator.
• The ventilator provides a positive force for transporting
respiratory and anesthetic gases into an apneic patient.
• The ventilators provide positive pressure ventilation at a
controlled minute volume (Tidal volume, Rate).
• They operate either electronically or mechanically with
pneumatic or electric power source.
• Anesthetic machine ventilators have a minimal number of
controls.
• The anesthetist could vary minute volume by setting tidal
volume and ventilatory frequency directly or by adjusting
inspiratory time, inspiratory flow rate and the ratio of
inspiratory to expiratory time.
• The newest models resemble critical care ventilators in their
capabilities.
• These may perform self-test upon start-up, volume or
pressure-controlled ventilation modes, assisted spontaneous
ventilation and electronically adjustable Positive End
Expiratory Pressure (PEEP).
• Sophisticated spirometry compensates for changes
in fresh gas flow, small leaks or patient compliance.
• Most of the currently used ventilators consist of a
bellows contained within another housing.
• The bellows communicate directly with the breathing
circuit and causes a pre-selected volume of gas to
flow into the patient.
• The flow of gas into the circuit results from collapsing
the ventilator bellows by pressurizing the
surrounding gas volume contained within the bellows
housing.
• The ventilator is either located within the mainframe
of the anesthesia machine or is attached as an
accessory unit. The outlet of the ventilator connects
directly to the patient breathing circuit of the
anesthetic delivery system at the location and in
place of the breathing reservoir bag.
• The ventilator thus functions as a controller for both
ventilation and circuit gas supply by replacing the
functions of the reservoir bag and APL valve.
• When artificial ventilation needs to be maintained for
a long time, a ventilator is used. Ventilators are also
used during anesthesia and are designed to match
human breathing waveform/pattern.
• These are sophisticated equipment with a large
number of controls which assist in maintaining
proper and regulated breathing activity. For short-
term or emergency use, resuscitators are employed.
These depend upon mechanical cycle operation and
are generally light-weight and portable.
• The main function of a ventilator is to ventilate the lungs
in a manner as close to natural respiration as possible.
• Since natural inspiration is a result of negative pressure
in the pleural cavity generated by the movement of the
diaphragm, ventilators were initially designed to create
the same effect.
• These ventilators are called negative-pressure
ventilators. In this design, the flow of air to the lungs is
facilitated by generating a negative-pressure around the
patient’s thoracic cage.
• The negative-pressure moves the thoracic walls
outward, expanding the intrathoracic volume and
dropping the pressure inside the lungs, resulting in a
pressure gradient between the atmosphere and the
lungs which causes the flow of atmospheric air into
the lungs.
• The inspiratory and expiratory phases of the
respiration are controlled by cycling the pressure
inside the body chamber.
Types of Ventilators
Positive Pressure Ventilators

• These generate the inspiratory flow by applying a positive

pressure—greater than the atmospheric pressure—to the
airways.
• During the inspiration, the inspiratory flow delivery system
creates a positive pressure in the patient circuit and the
exhalation control system closes the outlet to the atmosphere.
• During the expiratory phase, the inspiratory flow delivery
system stops the positive pressure at the exhalation system
and opens the valves to allow the exhaled air to the
atmosphere.
• Positive-pressure ventilators operate either in mandatory or
spontaneous mode. In spontaneous breath delivery, the
ventilator responds to the patient’s effort to breathe
independently.
• Therefore, the patient can control the volume and the rate of
respiration. Spontaneous breath delivery is used for those
patients who are on their way to full recovery but are not
completely ready to breathe from the atmosphere without
mechanical assistance.
• When delivering mandatory breaths, the ventilator controls all
parameters of the breath such as tidal volume, inspiratory flow
waveform, respiration rate and oxygen content of the breath.
Mandatory breaths are normally delivered to the patients who
are incapable of breathing on their own
Negative Pressure Ventilators

• In this type of ventilators application of negative pressure

allows lung ventilation. One of the examples of this type of
ventilator is the iron lung.
• Negative pressure means that the pressure in the air ways is
reduced below the atmospheric pressure and therefor since
atmospheric pressure is greater than the lung pressure, due
to the pressure gradient air moves in to the lungs causing
inspiration.
Usage of ventilators

• Anaesthesia Ventilators:
These are generally small and simple equipment used
to give regular assisted breathing during an operation.
• Intensive Care Ventilators:
Intensive care ventilators are more complicated, give
accurate control over a wider range of parameters and
often incorporate ‘patient triggering facility.
Ventilator terms

• 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 liters/cm H2O. Lung compliance is the
ability of the alveoli and lung tissue to expand on inspiration.
The lungs are passive, but they should stretch easily to ensure
the sufficient intake of the air.
• A ventilator and other parts of the breathing circuit also have
compliance and some of the delivered volume is used to
compress gas or expand gas in these parts.
• The compliance of a patient’s lungs is the ratio of pressure drop
across the airway to the resulting flow rate through it. It is also
expressed as cm H2O/liters (pressure drop/flow rate).
• 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
• 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.
Classification of Ventilators

• Based on the Method on Inspiratory Phase

• Based on Power Transmission
• Based on Pressure Pattern
• Based on the Type of Safety Limit
• Based on Cycling Control
• Cycling from Inspiration to Expiration
• Cycling from Expiration to Inspiration
• Based on the Source of Power
Modern Ventilators

• The current and future trends in critical care

ventilatory management demand precise flow,
pressure and oxygen control for application to both
adult and paediatric patients. Modern ventilator
machines consist of two separate but inter-
connected systems:
• The pneumatic flow system
• An electronic control system.
• The pneumatic flow system 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. The
normal operating range is 2 to 6 bar or 28 to 86 psi. These
gasses enter the air/oxygen mixer where they combine at the
required percentage and reduced in pressure to 350 cm H2O.
• The gasses then enter a large reservoir tank which holds about 8
litres of mixed gasses, when compressed to 350 cm H2O.
• 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.
• An electronically controlled flow valve proportions the gas flow
from the reservoir tank to the patient breathing circuit. In
some ventilators, an air compressor is used in place of a
compressed air tank.
• 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.
• The microprocessor controls each valve to deliver the desired
inspiratory air and oxygen flows for mandatory and
spontaneous ventilation.
• 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, and oxygen concentration of the
delivered breath, peak flow and PEEP.
• The PEEP selected in the mandatory mode is only used for
control of exhalation flow. The microprocessor utilizes the
above parameters to compute the desired inspiratory flow
trajectory. The system consists of monitors for pressure flow
and oxygen fraction
• 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 flow sensor usually consists of a variable orifice
and by measuring the pressure drop across the
variable orifice, the patient flows can be calculated.
Ventilators are lifesaving equipment and therefore
need regular maintenance and calibration.
Block Diagram
• The most common indices of the ventilation apparatus are the
absolute volume and changes of volume of the gas space in
the lungs achieved during a few breathing maneuvers. The
ventilator is constantly monitored and adjusted to maintain
appropriate arterial pH and PaO2.
• This system requires a set of sensors for pressure, volume
and flow. The information from the sensors modulates the
operations in the microcontroller unit (MCU). This MCU
receives information from the airways, lungs and chest wall
through the sensors and decides how the ventilator pump
responds.
• The signal that shows lung volume is a differential signal, but
this is not the signal measured directly from the lungs using
transducer. The air and oxygen blender provides a precise
oxygen concentration by mixing air and oxygen.
• Internally, a proportioning valve mixes the incoming air and
oxygen as the oxygen percentage dial is adjusted. Variation in
line pressure, flow or pressure requirements for any attached
device will not affect the oxygen concentration. The MCU
uses a PWM (Pulse Width Modulator) to control the blender
electro valves through a motor control design.
• An important part of the circuit is an alarm system that can
indicate different patient parameters such as exhaled volume
or airway pressure.
• The ventilation system must be able to detect whether a
breath has been taken. The MCU measures changes in
aspiratory flow and pressure by using sensors. If no
inspiration is detected within a certain period of time, the
monitor sounds an alarm. The conditions to be programmed
depend on each system. PWM cycles can be programmed to
sound the alarms.
 SURGICAL DIATHERMY

• Diathermy is a therapeutic treatment most commonly

prescribed for muscle and joint conditions. It uses a high-
frequency electric current to stimulate heat generation within
body tissues.
Principle of Diathermy

• High frequency currents, apart from their usefulness for

therapeutic applications, can also be used in operating rooms
for surgical l purposes involving cutting and coagulation.
• The frequency of currents used in surgical diathermy units is
in the range of 1 – 3 MHz in contrast with much higher
frequencies employed in short-wave therapeutic diathermy
machines.
• The power levels required for electrosurgery are below the
threshold of neural stimulation provided that the diathermy
frequency is in the radio frequency range.
• This then allows the exclusive utilization of the thermal effect
in high frequency surgery providing both the applications for
cutting and coagulation
• Surgical diathermy machines depend on the heating effect of
electric current. When high frequency current flows through
the sharp edge of a wire loop or band loop or the point of a
needle into the tissue, there is a high concentration of current
at this point.
• The tissue is heated to such an extent that the cells which are
immediately under the electrode, are torn apart by the boiling
of the cell fluid. The indifferent electrode establishes a large
area contact with the patient and the RF current is therefore,
dispersed so that very little heat is developed at this
electrode. This type of tissue separation forms the basis of
electrosurgical cutting.
Terms Used

• Electrosurgical coagulation of tissue is caused by the high

frequency current flowing through the tissue and heating it
locally so that it coagulates from inside. The coagulation
process is accompanied by a greyish-white discoloration of
the tissue at the edge of the electrode.
• Fulguration refers to a superficial tissue destruction without
affecting deep-seated tissues. This is undertaken by passing
sparks from a needle or a ball electrode of small diameter to
the tissue. When the electrode is held near the tissue without
touching it, an electric arc is produced, whose heat dries out
the tissue. Fulguration permits fistulas and residual cysts to
be cauterized and minor haemorrhages to be stopped.
• Desiccation, needle-point electrodes are stuck into the tissue
and then kept steady. Depending upon the intensity and
duration of the current, a high local increase in heat will be
obtained. The tissue changes due to drying and limited
coagulation
• The concurrent use of continuous radio-frequency
current for cutting and a burst wave radiofrequency
for coagulation is called Haemostasis mode.
• Different types of waveforms have been used to
produce different effects for surgical procedures.
Waveforms
Surgical Diathermy Machine

• Surgical diathermy machine consists of a high frequency

power oscillator. The earlier types of diathermy machines
consisted of spark-gap oscillators whereas the current
practice is to use thermionic valves or solid-state oscillators.
• A majority of the earlier units have access to both these
power sources, viz. an RF generator and a spark-gap
generator.
• The RF generator provides an undamped high frequency
current (typically 1.75 MHz) which is suitable for making clean
cuttings.
• The spark-gap generator produces damped high frequency
current which is specifically suitable for the coagulation of all
kinds of tissues.
• The mixing of both these currents signifies one of the most
important possibilities for use in electrosurgery. By blending
the currents of the tube and spark-gap generator, the degree
of coagulation of wound edges may be chosen according to
the requirements.
• Solid-state generators have replaced a substantial number of
vacuum tube and spark-gap units. Disposable, self-adhering
dispersive electrodes (generally known as ‘ground pads’) are
now widely used in place of the large area butt plate.
Block Diagram
• The heart of the system is the logic and control part which
produces the basic signal and provides various timing signals
for the cutting, coagulation and haemostasis modes of
operation. A stable multi-vibrator generates 500 kHz square
pulses. The output from this oscillator is divided into a number
of frequencies by using binary counters.
• These are the frequencies which are used as system timing
signals. A 250 kHz signal provides a split phase signal to drive
output stages on the power output circuit. A 15 kHz gating
signal produces the repetition rate for the three cycles of the
250 kHz signal which make up the coagulating output. The
pulse width of this output is set at about 12μs.
• The 250 kHz signal used for cutting is given to power output
stage where it controls the push- pull parallel power transistor
output stage.
• The output of this high power push-pull amplifier is applied to
a transformer which provides voltage step-up and isolation for
the output signal of the machine.
• The modern machines employ both bi-polar junction
transistors and power metal oxide-semiconductor field-effect
transistors(MOSFET) in a cascade configuration or the use of
a bridge connection of MOSFETs.
• For identification of each mode of operation, the machines
incorporate an audio tone generator. The tone signals are
derived from the counter at 1 kHz (coagulation), 500 Hz
(cutting) and 250 Hz (haemostasis).
• The isolator switch provides isolated switching control between
the active hand switch and the rest of the unit. A high frequency
transformer coupled power oscillator is used in which isolated
output winding produces a DC voltage.
• The load put on the DC output by the hand switch is reflected
back to the oscillator, accomplishing isolated switching.
• Logic circuits are used to receive external control signals and to
operate the isolating relays, give visual indications and
determine the alarm conditions.
• The logic circuits receive information from the foot-switch,
finger switch and alarm sensing points. A thermostat is
sometimes mounted on the power amplifier heat sink. In case
of overtemperature, it becomes open-circuited, signaling an
alarm and interrupting the output.
• The output circuit in the diathermy machine is generally
isolated and carefully insulated from low frequency primary
and secondary voltages. Blocking capacitors serve to
effectively prevent any low frequency from appearing in the
output circuit, and the isolated output reduces the possibility
of burns due to an alternate path to ground.
• Complaints of electrical shock during surgery can almost always
be attributed to muscle contractions of the patient. This is
caused by the rectification of the high frequency energy at the
junction of the active electrode and the tissue in the presence of
an arc, which is the actual means of performing electro surgery.
• This phenomenon is observed most when operating in a site of
sensitive nerve tissue.
• However, no danger to the patient or to the operator due to
this action It is advisable to avoid contacts with conducting
surfaces by those who happen to be near the machine or
cables. Solid-state machines mostly incorporate an
independent bi-polar RF generator for microsurgery
procedures offering a fine output power control. The output
waveform is a damped sinusoid at a repetition frequency
Automated Surgical Unit

• With a conventional electrosurgical unit, there is a

considerable fluctuation of the output voltage throughout the
3-s period of the cut. The cause of this undesirable fluctuation
is linked to the following factors:
– Size and Shape of the Cutting Electrode: The conditions
are different for the generator if, for instance, cutting is
performed with electrode of large surface area or with a fine
needle.
– Type and Speed of Cut: The cutting quality is determined
by the speed with which the electrode is moved (quick or
slow) and by the type of cut (superficial or deep)
• – Different Tissue Properties: The tissue itself has a strong
influence on the quality of the cut. The variations in the output
voltage due to the above factors considerably affect the quality
of the cut. At times, the maximum output voltage can become
so high (above 600°C) that severe carbonization occurs.
Conversely, the minimum value of the output voltage can
become so low (below 200°C) that cutting action is not
achieved. In order to overcome this problem, microprocessor-
controlled automated systems have been developed so that the
output voltage or the spark intensity remains constant In this
machine, the variables—current, tissue resistance, voltage and
spark intensity—are registered by means of an inbuilt sensor
system and then processed as defined output signals.
• The automatic control operates on two different
criteria:
– Voltage control: whereby the selected voltage is controlled
and held constant.
– Spark control: by which the selected spark intensity is held
constant.
• Electrosurgical generators use closed-loop control loops to
adjust the voltage and current to keep the output power
constant as the active monopolar electrode moves through
tissues of varying impedance
• The control of spark intensity is relatively complex because of
its non-linear nature.
• The design of the control system ensures that the cutting
quality is independent of size and shape of the electrode, the
type and speed of the cut and the varying tissue properties.
• Apart from ensuring a good quality of the cut, the
microprocessor-controlled machine also provides
the following coagulation modes:
➢ Soft coagulation
➢ Forced Coagulation
➢ Spray Coagulation
Types of Electrosurgery
Monopolar Electrosurgery

• Monopolar electrosurgery can be used for several modalities

including cut, blend, desiccation, and fulguration.
• Using a pencil instrument, the active electrode is placed in the
entry site and can be used to cut tissue and coagulate
bleeding.
• The return electrode pad is attached to the patient, so the
electrical current flows from the generator to the electrode
through the target tissue, to the patient return pad and back to
the generator.
• Monopolar electrosurgery is the most commonly used
because of its versatility and effectiveness.
Bipolar Electrosurgery

• Bipolar electrosurgery uses lower voltages so less energy is

required. But, because it has limited ability to cut and
coagulate large bleeding areas, it is more ideally used for
those procedures where tissues can be easily grabbed on
both sides by the forceps electrode.
• Electrosurgical current in the patient is restricted to just the
tissue between the arms of the forceps electrode. This gives
better control over the area being targeted, and helps prevent
damage to other sensitive tissues.
• With bipolar electrosurgery, the risk of patient burns is
reduced significantly. In the most common techniques, the
surgeon uses forceps that are connected to the
electrosurgical generator.
• The current moves through the tissue that is held between the
forceps. Because the path of the electrical current is confined
to the tissue between the two electrodes, it can be used in
patients with implanted devices to prevent electrical current
passing through the device causing a short-circuit or misfire.
• It is always recommended to review the implanted device
user manual prior to preforming any electrosurgical
application, to avoid complications.
Electrodes used in Surgical Diathermy
Safety Aspects in ESU

• The risks associated with electrosurgery fall into four

main categories viz.
➢Burns
➢Electrical interference with the heart muscles (ventricular
fibrillation),
➢Danger of explosions caused by sparks and
➢Electrical interference with pacemakers and other medical
electronic equipment
QUESTIONS??

END