Auto Flow®

20 Questions – 20 Answers

Joseph Fitzgerald

Because you care

 Important Notice:
Medical knowledge changes
constantly as a result of new
research and clinical experience.
The author of this introductory
guide has made every effort to
ensure that the information
given is completely up to date,
particularly as regards applications
and mode of operation. However,
responsibility for all clinical
measures must remain with the
reader.

Written by:
Dräger Medizintechnik GmbH
Joseph Fitzgerald
Moislinger Allee 53/55
23542 Lübeck
Germany

All rights, in particular those of

duplication and distribution,
are reserved by Dräger Medizin-
technik GmbH. No part of this
work may be reproduced or stored
in any form using mechanical,
electronic or photographic means,
without the written permission of
Dräger Medizintechnik GmbH.

ISBN 3-926762-40-3
Auto Flow ®
20 Questions – 20 Answers

Joseph Fitzgerald
4 20 Questions – 20 Answers using AutoFlow®

Contents

■ What is AutoFlow®? 6

■ Is AutoFlow® a new Ventilator Mode? 7

■ When would you use AutoFlow®? 8

■ How does AutoFlow® compare to BIPAP 9

■ How is AutoFlow® combined with other modes

such as IPPV? 10

■ How does AutoFlow® work with SIMV? 11

■ How does AutoFlow® work with MMV? 12

■ How does ventilation with AutoFlow® compare

with volume controlled ventilation? 14

■ How does ventilation with AutoFlow® compare

to pressure regulated modes? 15

■ What type of lung diseases is AutoFlow®

suitable for? 16

■ Are there situations where it is not indicated? 17

■ What has to be considered when switching from

conventional modes to AutoFlow®? 18

■ How do you set up AutoFlow®? 19

■ What monitoring parameters are important to

observe when using AutoFlow®? 20
 20 Questions – 20 Answers using AutoFlow® 5

■ What are the advantages to observe when

using AutoFlow®? 22

■ What would be the subsequent management

of the patient? 23

■ What are the safeguards against

hypo/hyperinflation? 24

■ How does AutoFlow® interact with inverse ratio

ventilation? 25

■ How can mechanical ventilation and

spontaneous breathing be mixed in one mode? 26

■ What is the technology behind this latest

advance in therapy? 28

Explanatory note: In some regions of the world IPPV

mode of ventilation is referred to as CMV and
Assist/CMV. The mode BIPAP is referred to as PCV+ in
the USA and Canada. BIPAP* is trademark used under
licence. AutoFlow® is registered as a trademark of
Dräger Medizintechnik GmbH.
6 20 Questions – 20 Answers using AutoFlow®

1. What is AutoFlow®?

This is a new advance in volume controlled modes

of mechanical ventilation where the ventilator
automatically regulates inspiratory flow. This auto
regulation is in accordance with the set VT and
current lung compliance.
The set VT is always given at minimum possible
pressure and spontaneous breathing is possible (open
valves) through the whole Inspiratory and Expiratory
phases of the mechanical ventilatory cycle.
A decelerating flow pattern reduces Peak pressures
and as lung compliance changes further they are
recognised and responded to.

A decelerating flow pattern

reduces Peak pressures
Flow
®
Volume Controlled Switch-on AutoFlow

VT VT
 20 Questions – 20 Answers using AutoFlow® 7

2. Is AutoFlow®
a new Ventilator Mode?

It is a new addition to all volume controlled modes on

the Evita 4 and Evita 2 dura ventilator. It is not a mode
independently selected in itself. It could be compared
to the way one function enhances another such as
flow trigger enhances pressure support.
It is intended to simplify strategies in mechanical
volume controlled ventilation by offering more patient
benefits with a wider therapy range and with less
parameters to adjust.
8 20 Questions – 20 Answers using AutoFlow®

3. When would you use AutoFlow®?

There are very few exceptions to using AutoFlow® in

all volume oriented modes where it is available. In
general we can divide its use into two areas, that of
the type of ventilatory strategy we want to apply and
that of the type of patient that it is particularly suited
to. In the first case in volume strategy ventilation
where we want to reduce high airway pressures and
capitalise on spontaneous breathing with reduced use
of sedation and muscle relaxants. The decelerating
flow and the regulated inspiratory and expiratory
valves provide a response to every inhalatory and
exhalatory effort of the patient. This feels like breathing
through an open system.
In other strategies we may want to use inverse ratio
timings. The occlusion of the expiratory valve for such
lengths of time can produce risk of barotrauma for a
patient who becomes awake and starts breathing.
With an open breathing system this risk is greatly
reduced.
In terms of patient types, there are those with quite
variable compliance levels after surgery who require
careful manipulation of inspiratory pressure and
volume to prevent barotrauma and hyperinflation.
AutoFlow® continually adjusts the pressures as
compliance changes to ensure volume delivery at the
lowest possible pressures.
Finally, as a smooth weaning strategy we want the
first efforts by the patient to be responded to in all
phases of the mandatory stroke unlike conventional
modes of SIMV where there are closed phases in the
cycle. The fixed set VT delivery of SIMV is also addressed
for Bronchospasm patients with air hunger as all
demands for flow and volume are responded to by the
ventilator.
 20 Questions – 20 Answers using AutoFlow® 9

4. How does AutoFlow®

compare to BIPAP?

BIPAP has been established for a number of years as

a real advance in pressure controlled ventilation
strategies. Pressures are regulated at a specific value
and pressure peaks are eliminated and together with
time synchronisation the patient is able to breathe
spontaneously at any stage. Many of these features are
now transferred across into the volume controlled
modes as the benefits of this therapy have become
more extensively accepted. The prime parameter
setting in BIPAP is inspiratory pressure (Pinsp) and
tidal volume (VT) is variable, the prime adjustment in
AutoFlow® is VT and the pressure is the variable,
depending on the compliance.

Many benefits of BIPAP

are transferred into volume
controlled modes with
AutoFlow®
10 20 Questions – 20 Answers using AutoFlow®

5. How is AutoFlow®
combined with other modes
such as IPPV?

The addition of AutoFlow® to IPPV mode for example

is achieved by the on-going measurement of pressure,
flow, volume and lung compliance and a ventilator
response that regulates the flow to achieve the set VT
in the inspiratory time available. When you switch on
there is a change from manual control to an automatic
control of the inspiratory flow. Other than the removal
of the control knobs of pressure (Pmax) and flow from
the touch screen panel all the core settings including
trigger function and pressure support capability are
totally unaffected.

The core settings including

trigger function and pressure
support are unaffected.
 20 Questions – 20 Answers using AutoFlow® 11

6. How does AutoFlow®

work with SIMV?

AutoFlow® supports the

preservation of an intact
respiratory drive as
less sedation and muscle
relaxants are used.

Equally in SIMV any of the usual parameters such

as PEEP are fully functional and superimposing
AutoFlow brings auto-regulation to the flow and
pressure. The associated potential advantages have a
domino effect in that a lower peak pressure usually
means a lower mean airway pressure with a positive
effect on haemodynamics, the inspiratory flow varies
according to individual patient needs and may alter on
a breath to breath basis. AutoFlow® supports the
preservation of an intact respiratory drive as less
sedation and muscle relaxants are used. The matching
of flow and volume to patient needs in synchrony with
inspiratory time at minimum pressure promotes
harmony between patient and ventilator. This reduces
considerably the phenomena known as “fighting the
ventilator” which is a misnomer in that the “ventilator
fights the patient” with its imposed fixed settings.
12 20 Questions – 20 Answers using AutoFlow®

7. How does AutoFlow®

work with MMV?

The mode is similar to SIMV in many respects where

the clinician sets a rate and VT for the patient to satisfy
adequate gaseous exchange. It differs from SIMV in
that as spontaneous breathing activity increases and
the patient achieves more than the set mandatory
minute volume then the mechanical strokes fade into
the background. The patient, often with the aid of
pressure support takes over the full volume work of
minute ventilation. In MMV, AutoFlow influences the
mechanical strokes if present and reduces asynchrony
by allowing spontaneous breathing activity and
reducing pressures to a minimum.
No ventilator adjustment The logical progression of this is that the patient
required when going from can be sedated and on full controlled ventilation, as
fully controlled ventilation to
full spontaneous breathing.
he wakes up he will still get mechanical strokes but
he will be able to breathe through them and not
experience any discomfort with these breaths ,as his
contribution increases the ventilator breaths fade
away completely so the patient does not have to be
switched to a weaning mode.
In addition to this if we now use the Ideal Body
Weight setting and programme the weight into the
ventilator before start of therapy then the right volume
and ventilator settings will be selected for that patient
and appropriate alarm defaults also. All this means
that post operatively we can easily select what we want
for the patient and in straight forward ventilation
cases we can start with full ventilation therapy and go
right through to full spontaneous breathing without
having to readjust the ventilator.
 20 Questions – 20 Answers using AutoFlow® 13

MMV AutoFlow

Controlled Spont. efforts Total spontaneous

Ventilation and efforts
mandatory phases CPAP with
pressure support

Ideal body weight 70 kg

■ Select Ideal Body Weight (70 kg).

Key values and alarms set automatically

■ Set ventilator to standby function.

■ Connect arriving patient. Start ventilation

■ Record monitored parameters

■ Maintain observation of the patient as they wake up.

14 20 Questions – 20 Answers using AutoFlow®

8. How does ventilation with

AutoFlow® compare with
volume controlled ventilation?

The constant flow in Volume controlled modes does

not always match inspiration times, flow and volume
do not always match patient demand leading to asyn-
chrony. Peak pressures are often high sedation and
paralysis are used to adapt patient to the ventilator.
Spontaneous breathing if allowed is a futile struggle
against closed valves. Attempts to exhale during
mandatory phase activate
controlled patient activity high airway pressure
alarms. The freedom for
the patient to cough
freely and clear his own
Paw secretions during volume
controlled modes is
usually suppressed. In
any situation AutoFlow®
t
always provides safety
and lower pressures
Flow compared to normal
fixed volume controlled modes.
flow
inspiration
closed
in

ex
expiration
closed t
 20 Questions – 20 Answers using AutoFlow® 15

9. How does ventilation with

AutoFlow® compare to
pressure regulated modes?

AutoFlow® decelerates flow automatically similar to

pressure controlled ventilation. Inspiratory pressure
follows compliance similar to plateau pressure in
volume controlled ventilation.
It differs from conventional pressure limited modes
and Pressure Regulated Volume modes in allowing
spontaneous breathing at any phase. It guarantees a
set VT and keeps pressure to a minimum whereas
pressure controlled modes keep pressure constant and
allow the VT to vary. AutoFlow® brings many of the
features of PCV to volume oriented modes and allows
the benefits experienced by BIPAP users for example to
be shared with those who wish to pursue volume only
strategies.

controlled patient activity

Paw

Flow

in

ex
expiration
closed t
16 20 Questions – 20 Answers using AutoFlow®

10. What type of lung diseases

is AutoFlow® suitable for?

The use of AutoFlow® is indicated as part of a volume

oriented strategy in all cases where you can expect
quick changes and short term improvement of lung
compliance.
It is recommended in post surgical cases where
acute restriction is evident and you want to guarantee
normal ventilation. In acute lung oedema where high
airway pressures are initially acceptable but as the
treatment programme takes effect pressures will go
down automatically and volumes will stay constant.
Using AutoFlow® with a volume controlled mode is
easier to handle than pressure control in this situation.
In cases where local atelectasis resulting from
trauma or pneumonia requires frequent repositioning
of the patient, in these situations Pressure Control
would produce great volume changes and AutoFlow®
in volume control modes will provide stable volumes
at minimum pressures.
Finally, AutoFlow® is suitable for all start up
ventilation therapy scenarios where there is limited
information on disease status available and it is
important to get therapy underway where pressures
and flow are regulated and spontaneous activity is
not compromised.
 20 Questions – 20 Answers using AutoFlow® 17

11. Are there situations where

it is not indicated?

The range of uses of AutoFlow® is determined by the

limitations of volume controlled modes and these
modes are not always recommended for very severe
diseases with long term healing processes with several
days to weeks required to improve lung conditions.
These cases where Acute Lung Injury and ARDS are
clearly established often require a defined pressure
control strategy such as BIPAP or APRV mode where
the small volumes associated with the reopening lung
are essential for blood gas improvement. Current
opinion among the experts advocate reducing the risk
of barotrauma by regulation of pressure and minimal
volume strategy.
Volume controlled ventilation may not be indicated Lung disease is the real
where there is a risk of intrinsic PEEP and the associ- indicator and pressure or
volume strategy is selected
ated danger of over inflating the lung in a volume accordingly.
controlled strategy, especially where there are obstruc-
tive disorders or long (inverse) ratios are required. In
these cases BIPAP mode with respect to decelerating
flow and spontaneous breathing activity has the same
advantages as AutoFlow®.
18 20 Questions – 20 Answers using AutoFlow®

12. What has to be considered

when switching from
conventional modes to
AutoFlow®?

The important point is that settings stay the same and

if there is no patient activity there will be no variance
in VT. PEEP and Tinsp and mandatory frequency
remain stable. Setting the flow control is not necessary
as there is automatic regulation. As in all volume
control modes setting the upper Paw alarm is important
for the upper pressure threshold. Ventilation related
sedation can be reduced to avail of the full benefits of
spontaneous breathing.

Pressure
®
Volume Controlled Switch-on AutoFlow Compliance improvement

Pinsp
 20 Questions – 20 Answers using AutoFlow® 19

13. How do you set up AutoFlow®?

AutoFlow® is switched on through “extra settings” on

touch screen and rotary confirm knob. Conventional
parameters – Freq, Tinsp, VT and PEEP are set as
desired. Upper Paw alarm should be set to warn of
sudden compliance decrease or resistance increase
and subsequent pressure changes. Upper Insp VT
alarm can be set to indicate increasing spontaneous
breathing VT demands.

Set up operation is by
following screen prompts.
20 20 Questions – 20 Answers using AutoFlow®

14. What monitoring parameters

are important to observe
when using AutoFlow®?

On switch on Peak pressure decreases as flow

decelerates
Pinsp will adjust as compliance alters. Mean press-
In case the VT is not applied a ures will follow. The inspiratory flow pattern will alter
VT low alarm is automatically (may lengthen) to accommodate resistance changes.
generated.
Airway pressure high alarm unlike conventional
ventilation will not occur (but should always be set).
In case the VT is not applied because of high resistance
a VT low alarm is automatically generated.
Spontaneous breathing activity will appear on flow
curve. No high Paw alarm will activate on active
expiration and mean VT equals set VT. Pressure, VT
and SB rates are monitored and displayed in any
format which is preconfigured. Observance of the
PV loops on the screen will show much improved
pressure to volume relationships. Trends for many of
these parameters provide a good indicator of clinical
progress.
 20 Questions – 20 Answers using AutoFlow® 21

■ Peak pressure ■ No high Paw

decreases alarm on
with decel- spontaneous
erating flow breathing
■ Pinsp adjusts
to compliance

Paw
Paw

Pinsp. = f (V T,C)

PEEP
t

TI TE
1
f
Flow
VT

without spontaneous breathing with spontaneous breathing

■ Trends give ■ Spontaneous

best overview breathing
activity
seen on
flow curve
22 20 Questions – 20 Answers using AutoFlow®

15. What are the advantages to

observe when using AutoFlow®?

Peak and Mean airway pressures are reduced. Less

invasive, less mechanical controlling by the ventilator.
In the presence of leaks AutoFlow® recognises and
compensates accordingly. Less requirement for
sedation and muscle relaxants which have many other
systemic effects. Spontaneous breathing contributes to
better gas exchange and secretion clearance. Weaning
is more smooth and can start earlier. Greater comfort
and less stress for patients should in turn reduce
stress levels for clinical staff.
Finally, the need for fewer control knobs to adjust
and less alarms to manage are seen as real advantage
in the busy intensive care unit.
 20 Questions – 20 Answers using AutoFlow® 23

16. What would be the subsequent

management of the patient?

Each case is different but a general strategy during

weaning would be to reduce FiO2, maintain PEEP
above lower inflection point, reduce Tinsp to I:E of 1:1
and reduce Frequency.
As patient activity increases and patient inhales
with the mandatory stroke inspiratory pressures will
automatically reduce and the next step is Pressure
Support to assist the spontaneous breathing.
The significant point of management is the early The tranisition to final
move to spontaneous breathing because of the open weaning steps is simple and
system which allows an early parallel reduction in straightforward.
mechanical ventilation. The use of CPAP combined
with Pressure Support to compensate for the work of
breathing through the tube is usually indicated as the
final therapy stage.
24 20 Questions – 20 Answers using AutoFlow®

17. What are the safeguards

against hypo/hyperventilation?

The safeguards against too much or too little volume

come in three forms. Firstly the user is prevented
from making unusual inadvertent settings by use of on
screen advice and having to confirm before being able
to implement these settings. Secondly the increasing
incremental steps as compliance changes are just
3 mbar and are limited to 5 mbar below the set upper
airway pressure alarm. Thirdly, the automatically
activated Volume inconstant alarm warns if the set
VT is not applied due to compliance or resistance
changes. The upper airway pressure alarm warns of
extreme coughing or obstruction. The VTi alarm limits
the inspiratory volume in the event of too great a
volume demanded.
Frequent triggering by the patient does not lead to
hyperventilation in the modes SIMV and MMV and
where it might have been possible in CMV/Assist the
trigger can be turned off but the patient is still
allowed to breathe spontaneously.
 20 Questions – 20 Answers using AutoFlow® 25

18. How does AutoFlow® interact

with inverse ratio ventilation?

AutoFlow® is ideally suited to

extended inspiratory times.
Pressure

end-expiratory
alveolar pressure
Flow

AutoFlow® is an excellent adjunct to long inspiratory

time settings. Clinical experience is limited but if we
carry across the reported experiences of Sydow et al(2)
and apply a ventilatory strategy where spontaneous
breathing is encouraged with the longer inspiratory
times but overall pressures are low then this should
provide a good indication for its use in an IRV format.
Not withstanding the impact of air trapping this
should actively contribute to reducing the risk of
barotrauma which is often associated with IRV.
26 20 Questions – 20 Answers using AutoFlow®

19. How can mechanical venti-

lation and spontaneous
breathing be mixed in one
mode?

To facilitate spontaneous inspiration and expiration in

each phase of controlled mechanical ventilation is a
technological challenge. This unique solution is based
on an intelligent microprocessor system combined
with highly sophisticated valves, flow and pressure
sensors.
New microprocessor systems Conventional technology with the delivery of fixed
combined with sophisticated flow and volume in each mandatory breath is contrary
valves provide new solutions. to free spontaneous breathing by the patient. Volume
control with AutoFlow® is therefore provided on a
breath to breath basis. In each individual breath
the patient has the possibility to increase or reduce
the delivered volume. The ventilator monitors the
inspiratory volume and compensates for deviations
in the next breath.
In case the volume was too low, volume of the next
breath will be automatically adjusted by increased
inspiratory pressure (Plateau). If the volume was
too high either because of spontaneous inspiration
or improving compliance, inspiratory pressure will
automatically go down with the next breath. For
smooth interaction with the patient the pressure
changes are limited to maximum of 3 cm H2O from
breath to breath. Great pressure fluctuations because
of unique events like a cough or a spontaneous sigh
are thus avoided.
 20 Questions – 20 Answers using AutoFlow® 27

controlled patient activity

Patient
in

ex

Paw

Flow

inspiration
open
in

ex

expiration t
open

AutoFlow® responds like a CPAP system with CPAP

value set to Pinsp. Whenever the patient tries to inhale
more volume the demand valve will deliver more flow,
whenever he wants to exhale the expiration valve will
allow expiratory flow while the pressure/PEEP level is
kept constant. The graphs above illustrate this.
The patient can inhale and exhale as usual in SIMV/
MMV and now even in the expiratory phase of IPPV.
28 20 Questions – 20 Answers using AutoFlow®

20. What is the technology

behind this latest advance
in therapy?

All the electronic and pneumatic subsystems need to

be optimised for a function like AutoFlow®.
The accurate control of flows and pressures is an
essential basic requirement, but only intelligent
algorithms and fast adjustments of the valves can pro-
vide the required responsiveness to patient activities.
Evita ventilators have
highly responsive inspira-
tory demand valves that
Expiration
valve can open and close in
closed milliseconds on command
or of the microprocessor
Expiration system, while keeping
valve the FiO2 and pressure
controlled constant. This minimises
patient work of breathing
and helps avoid inefficient
breathing efforts.
The integrated special
exhalation valve design
with a large control orifice provides low resistance to
exhalation. Pressure is controlled smoothly with fast
responses throughout the whole setting range of PEEP
and inspiratory pressures. As the picture here on the
left illustrates, the exhalation valve is never occluded
completely, the closing pressure is always equal to the
corresponding PEEP or inspiratory pressure. Like a
pop off valve it permits expiratory flow if the pressure
exceeds the set value.
Last but not least accurate and robust pressure and
flow sensing systems on both in- and expiratory side
are a basis for all these functions.
 20 Questions – 20 Answers using AutoFlow® 29

Summary Statement of Benefits of Auto Flow®

Volume controlled ventilation
Physiologic facilitates the recognised takes a major step forward.
importance of spontaneous
breathing in controlled
ventilation

Synchrony flow and volume adapted to

patient needs

Automatic complete weaning therapy in

many situations when MMV is
combined with Ideal Body
Weight and one pre-setting.

Simplification ventilatory therapy with less

control knobs and less alarms

Evidence All proven benefits of BIPAP

now transferred to volume
controlled ventilation
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