Leak-compensated proportional assist ventilation

Abstract

This disclosure describes systems and methods for compensating for leakage when during delivery of gas from a medical ventilator in a proportional assist mode to a patient. The technology described herein includes systems and methods to compensate the delivery of PA ventilation for leakage in the patient circuit by using leak-compensated lung flows as well as leak-compensated respiratory mechanics parameters (lung compliance and lung resistance) estimated in a manner that compensates for elastic and inelastic leaks from the ventilation system.

Description

INTRODUCTION

In mechanical ventilation, proportional assist (PA) refers to a type of ventilation in which the ventilator acts as an inspiratory amplifier that provides pressure support based on the patient's effort. The degree of amplification (the “support setting”) is set by an operator, for example as a percentage based on the patient's effort. In one implementation of PA ventilation, the ventilator may continuously monitor the patient's instantaneous inspiratory flow and instantaneous net lung volume, which are indicators of the patient's inspiratory effort. These signals, together with ongoing estimates of the patient's lung compliance and lung resistance, allow the ventilator to compute the instantaneous pressure at a point in the ventilation circuit that assists the patient's inspiratory muscles to the degree selected by the operator as the support setting.

PA ventilation relies on certain physiological principles. The act of inspiration requires the patient's inspiratory muscles to develop a pressure gradient between the mouth and the alveoli sufficient to draw in breathing gas and inflate the lungs. Some of this pressure gradient is dissipated as gas travels through the artificial airway and the patient's conducting airways, and some of the pressure gradient is dissipated in the inflation of the lungs and thorax. Each element of pressure dissipation is characterized by a measurable property: the resistance of the artificial and patient airways, and the compliance (or elastance) of the lung and thorax.

The ventilator providing PA ventilation uses specific information, including resistance of the artificial airway, resistance of the patient's airways, lung compliance, instantaneous inspiratory flow and net lung volume, and the support setting to compute the instantaneous pressure to be applied at the wye. The ventilator may estimate patient lung resistance and lung compliance, for example approximately every four to ten breaths. In one implementation, every computational cycle (e.g., 5 milliseconds), the ventilator estimates lung flow, based on an estimate of circuit flow, and lung volume, based on the integral value of estimated circuit flow.

PA ventilation begins inspiratory assist when flow (generated by the patient's inspiratory muscles) is detected. If the patient ceases inspiration, the assist also ceases. Once inspiratory flow begins, the ventilator monitors instantaneous flow and volume and applies the pressure calculated to deliver a proportion (determined by the support setting) of the total demand as determined by the patient's inspiratory effort. In Tube Compensation (TC) ventilation, the ventilator monitors instantaneous flow and volume and applies the pressure calculated to overcome a proportion (determined by the support setting) of the pressure losses dissipated across the resistance of the artificial airways (e.g., endotracheal tube).

The lung compliance and lung resistance of a patient may be collectively referred to as the respiratory mechanics of the lung or, simply, the patient's respiratory mechanics. Because PA relies on the patient's respiratory mechanics, more accurate determination of respiratory mechanics is essential to performance of the ventilator when providing PA.

Leak-Compensated Proportional Assist Ventilation

This disclosure describes systems and methods for compensating for leakage when during delivery of gas to a patient from a medical ventilator in a proportional assist (PA) mode. The technology described herein includes systems and methods that compensate the delivery of PA ventilation for leakage in the patient circuit by using leak-compensated lung flows as well as respiratory mechanics (lung compliance and lung resistance) estimated in a manner that compensates for elastic and inelastic leaks from the ventilation system.

In part, this disclosure describes a method of compensating for leakage in a ventilation system during delivery of gas from a medical ventilator providing PA to a patient. The method includes monitoring an instantaneous flow in the ventilation system based on one or more measurements of pressure and flow in ventilation system. Leakage from the system is modeled as a first leakage component through a first orifice of a fixed size and a second leakage component through a second orifice of a varying size, in which the first and second leakage components are different functions of instantaneous pressure in the ventilation system. A leak-compensated instantaneous lung flow of gas inhaled or exhaled by the patient is estimated based on the one or more measurements, the first leakage component and second leakage component. The leak-compensated lung flow and a predetermined respiratory mechanics model are used to estimate a leak-compensated lung compliance and a leak-compensated lung resistance. A pressure to be delivered to the patient is then calculated based on the leak-compensated lung flow, the leak-compensated lung compliance and the leak-compensated lung resistance.

This disclosure describes a method of compensating for leakage in a ventilation tubing system during delivery of gas from a medical ventilator to a patient. The method includes receiving a support setting identifying an amount of proportional assistance to provide to the patient. An inelastic leakage in the ventilation system is identified as a first function of at least one of a pressure measurement and a flow measurement in the ventilation system. An elastic leakage in the ventilation system is also identified as a second function of at least one of the pressure measurement and the flow measurement in the ventilation system. The circuit compliance and circuit resistance of the ventilation tubing system is then used along with estimated lung compliance of the patient and estimated lung resistance of the patient based on the inelastic leakage, the elastic leakage, the circuit compliance, circuit resistance and the at least one of the pressure measurement and the flow measurement in the ventilation system. Ventilation is then delivered to the patient based on estimated patient effort and the support setting, in which the patient effort is determined from estimated lung flow using the inelastic leakage, the elastic leakage, the lung compliance and the lung resistance.

The disclosure also describes a pressure support system that includes a pressure generating system adapted to generate a flow of breathing gas and a ventilation tubing system including a patient interface device for connecting the pressure generating system to a patient. One or more sensors are operatively coupled to the pressure generating system or the ventilation system, in which each sensor capable of generating an output indicative of a pressure of the breathing gas. A leak estimation module is provided that identifies leakage in the ventilation system and compensates the calculation of lung flow for the estimated leakage in the system. A respiratory mechanics calculation module is further provided that generates a leak-compensated lung compliance and a leak-compensated lung resistance based on the leakage and at least one output indicative of a pressure of the breathing gas. The system further includes a proportional assistance ventilation module that causes the pressure generating system to provide ventilation to the patient based on patient effort and a support setting, in which the patient effort is determined from estimated lung flow using the leakage, the leak-compensated lung compliance and the leak-compensated lung resistance.

The disclosure flutter describes a PA ventilation controller for a medical ventilator. The controller includes a microprocessor, a module that compensates calculations of lung compliance and lung resistance based on instantaneous elastic leakage and instantaneous inelastic leakage of breathing gas from a ventilation system, and a pressure control module that provides proportional assist ventilation based on the compensated lung compliance and lung resistance.

These and various other features as well as advantages which characterize the systems and methods described herein will be apparent from a reading of the following detailed description and a review of the associated drawings. Additional features are set forth in the description which follows, and in part will be apparent from the description, or may be learned by practice of the technology. The benefits and features of the technology will be realized and attained by the structure particularly pointed out in the written description and claims hereof as well as the appended drawings.

It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory and are intended to provide further explanation of the invention as claimed.

BRIEF DESCRIPTION OF THE DRAWINGS

The following drawing figures, which form a part of this application, are illustrative of described technology and are not meant to limit the scope of the invention as claimed in any manner, which scope shall be based on the claims appended hereto.

FIG. 1 illustrates an embodiment of a ventilator connected to a human patient.

FIG. 2 schematically depicts example systems and methods of ventilator control.

FIG. 3 illustrates an embodiment of a method of compensating for leakage in a ventilator providing pressure assistance to a patient.

FIG. 4 illustrates an embodiment of a method for providing a leak-compensated PA breath to a patient.

FIG. 5 illustrates an embodiment of a method for estimating respiratory mechanics of patient that utilizes a respiratory mechanics maneuver.

FIG. 6 illustrates an embodiment of a method for dynamically estimating respiratory mechanics of patient.

FIG. 7 illustrates a functional block diagram of modules and other components that may be used in an embodiment of ventilator that compensates for elastic and rigid orifice sources of leaks when performing PA ventilation.

DETAILED DESCRIPTION

Although the techniques introduced above and discussed in detail below may be implemented for a variety of medical devices, the present disclosure will discuss the implementation of these techniques in the context of a medical ventilator providing pressure assist (PA) ventilation to a human patient. The reader will understand that the technology described in the context of a medical ventilator for human patients could be adapted for use with other systems such as ventilators for non-human patients and general gas transport systems in which leaks may cause a degradation of performance.

FIG. 1 illustrates an embodiment of a ventilator 20 connected to a human patient 24. Ventilator 20 includes a pneumatic system 22 (also referred to as a pressure generating system 22) for circulating breathing gases to and from patient 24 via the ventilation tubing system 26, which couples the patient to the pneumatic system via physical patient interface 28 and ventilator circuit 30. Ventilator circuit 30 could be a dual-limb or single-limb circuit for carrying gas to and from the patient. In a dual-limb embodiment as shown, a wye fitting 36 may be provided as shown to couple the patient interface 28 to the inspiratory limb 32 and the expiratory limb 34 of the circuit 30.

The present systems and methods have proved particularly advantageous in noninvasive settings, such as with facial breathing masks, as those settings typically are more susceptible to leaks. However, leaks do occur in a variety of settings, and the present description contemplates that the patient interface may be invasive or non-invasive, and of any configuration suitable for communicating a flow of breathing gas from the patient circuit to an airway of the patient. Examples of suitable patient interface devices include a nasal mask, nasal/oral mask (which is shown in FIG. 1), nasal prong, full-face mask, tracheal tube, endotracheal tube, nasal pillow, etc.

Pneumatic system 22 may be configured in a variety of ways. In the present example, system 22 includes an expiratory module 40 coupled with an expiratory limb 34 and an inspiratory module 42 coupled with an inspiratory limb 32. Compressor 44 or another source(s) of pressurized gas (e.g., air and oxygen) is coupled with inspiratory module 42 to provide a gas source for ventilatory support via inspiratory limb 32.

The pneumatic system may include a variety of other components, including sources for pressurized air and/or oxygen, mixing modules, valves, sensors, tubing, accumulators, filters, etc. Controller 50 is operatively coupled with pneumatic system 22, signal measurement and acquisition systems, and an operator interface 52 may be provided to enable an operator to interact with the ventilator (e.g., change ventilator settings, select operational modes, view monitored parameters, etc.). Controller 50 may include memory 54, one or more processors 56, storage 58, and/or other components of the type commonly found in command and control computing devices.

The memory 54 is computer-readable storage media that stores software that is executed by the processor 56 and which controls the operation of the ventilator 20. In an embodiment, the memory 54 comprises one or more solid-state storage devices such as flash memory chips. In an alternative embodiment, the memory 54 may be mass storage connected to the processor 56 through a mass storage controller (not shown) and a communications bus (not shown). Although the description of computer-readable media contained herein refers to a solid-state storage, it should be appreciated by those skilled in the art that computer-readable storage media can be any available media that can be accessed by the processor 56. Computer-readable storage media includes volatile and non-volatile, removable and non-removable media implemented in any method or technology for storage of information such as computer-readable instructions, data structures, program modules or other data. Computer-readable storage media includes, but is not limited to, RAM, ROM, EPROM, EEPROM, flash memory or other solid state memory technology, CD-ROM, DVD, or other optical storage, magnetic cassettes, magnetic tape, magnetic disk storage or other magnetic storage devices, or any other medium which can be used to store the desired information and which can be accessed by the computer.

As described in more detail below, controller 50 issues commands to pneumatic system 22 in order to control the breathing assistance provided to the patient by the ventilator. The specific commands may be based on inputs received from an operator, the patient 24, the pneumatic system 22 and sensors, the operator interface 52 and/or other components of the ventilator. In the depicted example, operator interface includes a display 59 that is touch-sensitive, enabling the display to serve both as an input and output device.

FIG. 2 schematically depicts exemplary systems and methods of ventilator control. As shown, controller 50 issues control commands 60 to drive pneumatic system 22 and thereby circulate breathing gas to and from patient 24. The depicted schematic interaction between pneumatic system 22 and patient 24 may be viewed in terms of pressure and/or flow “signals.” For example, signal 62 may be an increased pressure which is applied to the patient via inspiratory limb 32. Control commands 60 are based upon inputs received at controller 50 which may include, among other things, inputs from operator interface 52, and feedback from pneumatic system 22 (e.g., from pressure/flow sensors) and/or sensed from patient 24.

In an embodiment, before the respiratory mechanics of a patient can be determined, the mechanics of the ventilation tubing system may be determined. For example, when modeling the delivery of gas to and from a patient 24 via a closed-circuit ventilator, one simple assumption is that compliance of the ventilator circuit 30 (the “circuit compliance”) is fixed and that all gas injected into the ventilator circuit 30 that does not exit the circuit 30 via the expiratory limb 34 (in a dual-limb embodiment) fills the circuit as well as the patient's lungs and causes an increase in pressure. As gas is injected (L₁), the lung responds to the increased gas pressure in the circuit 30 by expanding. The amount the lung expands is proportional to the lung compliance and is defined as a function of gas pressure differential (e.g., lung compliance=volume delivered/pressure difference). As discussed in greater detail below, this assumption is not valid when leaks are present.

The term circuit compliance is used to refer to the relationship between the amount the pressure in the ventilator circuit 30 (or ventilator circuit 30 and attached patient interface 28, depending on how the compliance is determined) and changes in volume delivered into the circuit. In an embodiment, the circuit compliance may be estimated by pressurizing the ventilator circuit 30 (or circuit 30 and interface 28 combination) when flow to the patient is blocked and measuring the volume of additional gas introduced to cause the pressure change (compliance=volume delivered/pressure difference).

The term circuit resistance is used to refer to the amount the pressure changes between two sites upstream and downstream the ventilator circuit as a function of volumetric flow rate through that circuit. Circuit resistance may be modeled as a two-parameter function of flow and several methods for modeling and calculating circuit resistance are known in the art. For example, in an embodiment, the circuit resistance may be estimated by passing several fixed flow rates through the circuit and measuring the pressure difference between certain upstream and downstream sites and finding the best curve fit to the collected data.

Methods of determining circuit compliance and circuit resistance (such as those described above) may be executed by the operator prior to attaching the patient to the ventilator as part of the set up of the ventilator 20 to provide therapy. Other methods of determining circuit compliance and/or resistance are also known and could be adapted for use with the disclosed leak-compensation systems and methods described herein.

In many cases, it may be desirable to establish a baseline pressure and/or flow trajectory for a given respiratory therapy session. The volume of breathing gas delivered to the patient's lung (L₁) and the volume of the gas exhaled by the patient (L₂) are measured or determined, and the measured or predicted/estimated leaks are accounted for to ensure accurate delivery and data reporting and monitoring. Accordingly, the more accurate the leak estimation, the better the baseline calculation of delivered and exhaled flow rates and volumes.

Errors may be introduced due to leaks in the ventilation tubing system 26. The term ventilation tubing system 26 is used herein to describe the ventilator circuit 30, any equipment attached to or used in the ventilator circuit 30 such as water traps, monitors, drug delivery devices, etc. (not shown), and the patient interface 28. Depending on the embodiment, this may include some equipment contained in the inspiration module 42 and/or the expiration module 40. When referring to leaks in or from the ventilation tubing system 26, such leaks include leaks within the tubing system 26 and leaks where the tubing system 26 connects to the pressure generator 22 or the patient 24. Thus, leaks from the ventilation tubing system 26 include leaks from the ventilator circuit 30, leaks from the patient interface 28 (e.g., masks are often provided with holes or other pressure relief devices through which some leakage may occur), leaks from the point of connection of the patient interface 28 to the patient 24 (e.g., leaks around the edges of a mask due to a poor fit or patient movement), and leaks from the point of connection of the patient interface 28 to the circuit 30 (e.g., due to a poor connection between the patient interface 28 and the circuit 30).

For the purpose of estimating how a leak flow rate changes based on changes in pressure in the ventilation tubing system 26, the instantaneous leak may be modeled as a leak through a single rigid orifice or opening of a fixed size in which that size is determined based on comparing the total flow into the inspiratory limb 32 and out of the expiratory limb 34. However, this leak model does not take into account any elastic component of leak source(s) in the system 26, that is how much of the area of any of the holes or openings in the ventilation tubing system 26 through which leakage occurs may change due to an increase or decrease in pressure.

It has been determined that not accounting for elastic leakage from the ventilation tubing system 26 can cause many problems. First, if only the inelastic/fixed orifice model is used to estimate leak, the subsequent errors caused by ignoring the elastic effects of any actual leaks end up generating inaccurate estimates of flow rates into the lung. This can cause the ventilator 20 to estimate gas volume delivered into the lung inaccurately when, in fact, the elastic leaks in the system 26 have let more gas escape than estimated. Second, if the elasticity of the leak source is ignored, any other calculation, estimate, or action that the ventilator 20 may perform which is affected by the leak estimate will be less accurate.

In the systems and methods described herein, the provision of PA ventilation is made more accurate by compensating for tubing system leakage. In the embodiments described herein fixed (rigid) and elastic components of the system leakage are used when determining the lung flow, net lung volume, lung compliance and lung resistance of the patient. This results in a more accurate determination of lung compliance and lung resistance and, therefore, ventilation of patients based on respiratory mechanics. While the systems and methods are presented in the context of specific leakage models, the technology described herein could be used to compensate the respiratory mechanics determined by any model for leakage using any type of mechanical ventilator or other device that provides gas.

FIG. 3 illustrates an embodiment of a method of compensating PA ventilation for leakage during delivery of gas from a medical ventilator to a patient. In the method 300 shown, a medical ventilator such as that described above with reference to FIGS. 1 and 2 is used to provide PA ventilation to a patient.

The method 300 illustrated starts with a circuit compliance and resistance operation 302. In that operation 302, the ventilator circuit compliance and resistance are estimated. In an embodiment, this may be performed prior to connecting the ventilator to the patient (as previously described). Alternatively, it may be dynamically determined periodically throughout the delivery of ventilatory support to the patient.

After the circuit compliance and resistance have been determined, the ventilator is connected to the patient and an initialization operation 304 is performed. In the initialization operation 304 the ventilator operates for an initialization or startup period in order to generate an initial estimate of lung compliance and lung resistance. If the ventilator already has some knowledge of the respiratory mechanics of the patient (e.g., the respiratory mechanics have been recently determined during provision of a different type of ventilation or an operator has provided initial settings for lung compliance and resistance), this operation 304 may be automatically or manually omitted in favor of the previously determined values.

A description of an embodiment of the initialization operation 304 is as follows. Because the ventilator does not know the patient's mechanics when the PA breath type is selected, it performs a startup routine to obtain initial data. In an embodiment, upon startup the ventilator delivers some number (e.g., two, four, etc.) of consecutive PA breaths, each of which includes an end-inspiratory maneuver that yields estimates of the patient's resistance and compliance. Using four training breaths for the initialization operation 304 as an example, the first breath is delivered using a predicted resistance for the artificial airway and conservative estimates for patient resistance and compliance. The predicted values may be determined based on known characteristics of the patient, such as based on the patient's ideal body weight (IBW), height, gender, age, physical condition, etc. Each of the following three PA breath's averages stepwise decreased physiologic values with the estimated resistance and compliance values from the previous breath, weighting earlier estimates less with each successive breath, and yielding more reliable estimates for lung resistance and lung compliance.

In an embodiment of the method 300, a leakage estimate may also be done prior to the initialization operation 304. Prior determination of leak parameters allows for estimates of respiratory mechanics to be made. This may include delivering pressure-regulated breaths with specific settings or performing specific “leak maneuvers”, that is a specified set of controlled actions on the part of the ventilator that allow leakage parameters to be identified and quantified, such as interrupting the therapeutic delivery of respiratory gas and holding or changing the pressure and flow, so that data concerning the leakage of the system during the controlled actions may be obtained. For example, a leak maneuver may include periodically holding the pressure and flow in the circuit constant while determining (based on a comparison of the measured flow into the inspiratory limb and the measured flow out of the expiratory limb via the exhalation valve) the net leakage from the system. In an embodiment, such a leak maneuver may be performed during specific parts of the respiratory phase, e.g., at the end of the expiratory phase. In yet another embodiment, a sequence of pressure-based test breaths is delivered with specific settings to determine leak parameters prior to execution of test breaths for respiratory mechanics determinations.

After the initialization operation 304, the ventilator provides ongoing PA ventilation to the patient in a PA ventilation operation 306. PA ventilation begins inspiratory assist when an inspiratory trigger is detected such as leak-compensated lung flow (generated by the patient's inspiratory muscles) exceeds a set sensitivity threshold. If the patient ceases inspiration, the assist also ceases. Once inspiratory flow begins, the ventilator monitors instantaneous flow and volume and applies the pressure calculated to deliver a proportion (determined by the support setting) of the total demand as determined by the patient's inspiratory effort.

During PA ventilation, pressure assistance is provided to the patient based on the patient's effort and the operator-selected support setting. PA ventilation determines how much to assist the patient's efforts based on one or more equations of motion used to describe the mechanics of the lung. Such equations use respiratory mechanics of the patient, e.g., lung resistance and lung compliance, and the circuit when calculating how much flow and/or pressure to provide. One example of an equation of motion for use in determining the pressure to provide during PA ventilation is as follows:P_aw(t)=E∫Qdt+QR−P_m(t)where P_aw is the pressure measured at the patient interface, P_m is the pressure generated by the inspiratory muscles of the patient which is may be used as the index of the patient's effort, E is the lung elastance (which is the inverse of lung compliance, i.e., E=1/C), Q is the instantaneous leak-compensated lung flow and R is the lung resistance. By manipulating this equation slightly, an equation for the amount of desired pressure assistance at the patient interface to provide can be obtained:P_aw(t)=kE∫Qdt+kQR where k is the % support setting based on the patient effort, P_m. The equations above are one example of how PA ventilation may be provided based on patient effort. PA ventilation is known in the art and any suitable technique or set of equations for determining the assistance to provide may be used.

As described above, the patient's effort is determined based on the pressure and leak-compensated lung flow in the circuit. In order to compensate for leakage in the circuit, in the method 300 shown the PA ventilation operation 306 includes the ongoing calculation of leakage while providing ventilation, as illustrated by the leakage calculation/compensation operation 307. As discussed in greater detail below with reference to FIG. 4, the leakage is calculated and the leak-compensated values for lung flow, current lung volume and net delivered lung flow may be determined taking into account the calculated leakage.

The method 300 also includes periodically or randomly performing a respiratory mechanics maneuver in order to recalculate the lung compliance and lung resistance of the patient. In an embodiment, the respiratory mechanics maneuver operation 308 is performed randomly once every four to ten PA breaths.

The respiratory mechanics maneuver operation 308 compensates for leakage as determined by the leakage calculation/compensation operation 307 when calculating the respiratory mechanics for the patient. This may include stabilizing the pressure and flow in the patient circuit based on the calculated leakage at that pressure so that the flow into the patient circuit is approximately equal to the calculated amount of gas leaking from the patient circuit at that pressure; a period of stable pressure during which there is no flow into or out of the patient's lungs even though there is leakage flow in the ventilator tubing system. The respiratory mechanics maneuver operation 308 may further include using leak-compensated values of lung flow and lung volume when determining the respiratory mechanics.

The newly determined values of lung compliance and lung resistance may be averaged, low-pass filtered or otherwise combined with the previously determined values. These revised values are then stored for use in later delivery of PA ventilation and the ventilator returns to providing PA ventilation to the patient.

FIG. 4 illustrates an embodiment of a method for providing a leak-compensated PA breath to a patient. In an embodiment, the method 400 corresponds to the operations performed during the PA ventilation operation 306 and the respiratory mechanics maneuver operation 308 discussed with reference to FIG. 3. In the embodiment of the method 400 illustrated, the operations occur repeatedly while the ventilator is providing PA ventilation, such as once a sample period or computation cycle.

During PA ventilation, the pressure and flow and other parameters of the system are monitored, illustrated by the monitoring operation 402. In an embodiment, the monitoring operation 402 collects data including the instantaneous pressure and/or flow at or indicative of one or more locations in the ventilation tubing system. Depending upon how a particular leak model is defined, the operation 402 may also include making one or more calculations using data from pressure and flow measurements taken by the sensors. For example, a model may require a flow measurement as observed at the patient interface even though the ventilation system may not have a flow sensor at that location in the ventilation tubing system. Thus, a measurement from a sensor or sensors located elsewhere in the system (or data from a different type of sensor at the location) may be mathematically manipulated in order to obtain an estimate of the flow observed at the patient interface in order to calculate the leak using the model.

The data obtained in the monitoring operation 402 is then used to calculate leakage from the ventilator tubing system in a leakage calculation operation 404. In an embodiment, the leakage calculation operation 404 uses the data obtained in the monitoring operation 402, e.g., some or all of the instantaneous pressure and flow data collected during the monitoring operation 402 as well as information about the current respiratory phase (inhalation or exhalation).

The leakage calculation operation 404 calculates an instantaneous leakage flow or volume for the sample period. The instantaneous leakage is calculated using a mathematical formula that has been previously determined. Any leakage model, now known or later developed, may be used. In an embodiment, the mathematical formula is a leakage model that separates the leak into the sum of two leak components, inelastic leak and elastic leak, in which each component represents a different relationship between the quantity of leakage from the ventilation system and the measured current/instantaneous pressure and/or flow of gas in the ventilation system. As discussed above, the inelastic leak may be modeled as the flow through a rigid orifice of a fixed size while the elastic leak may be modeled as the flow through a different orifice of a size that changes based on the pressure (or flow) of the gas in the ventilation system.

An example of a method and system for modeling leak in a ventilation system as a combination of an elastic leak component and an inelastic leak component can be found in commonly-assigned U.S. Provisional Patent Application Ser. No. 61/041,070, filed Mar. 31, 2008, titled VENTILATOR LEAK COMPENSATION, which application is hereby incorporated by reference herein. The VENTILATOR LEAK COMPENSATION represents one way of characterizing the leak from a ventilation system as a combination of elastic and inelastic components. Other methods and models are also possible and may be adapted for use with this technology.

The mathematical formula used to calculate leakage may contain several parameters that are empirically determined and that may be periodically or occasionally revised in order to maintain the accuracy of the leakage estimate. For example, in an embodiment the parameters of a leakage formula include a first constant associated with the rigid orifice and a second constant associated with the variable-sized orifice. At various times during ventilation, the calculated leakage may be checked against a measured leakage and, if the estimate is significantly different from the measured leakage, the constants may be revised. This revision of the parameters in a leakage formula may be done as part of the leakage calculation operation 404 or may be done as a separate operation (not shown) that may, or may not, be performed every sample period.

The term instantaneous is used herein to describe a determination made for any particular instant or sampling period based on the measured data for that instant. For example, if a pressure measurement is taken every 5 milliseconds (sample period), the pressure measurement and the leakage model can be used to determine an instantaneous leak flow based on the instantaneous pressure measurement. With knowledge of the length of the sample period, the instantaneous flow may then be used to determine an instantaneous volume of gas leaking out of the circuit during that sample period. For longer periods covering multiple sample periods the instantaneous values for each sample period may be summed to obtain a total leakage volume. If a measurement is also the most recent measurement taken, then the instantaneous value may also be referred to as the current value.

After the current leak has been calculated, the method 400 further estimates the leak-compensated instantaneous lung flow to or from the patient in a lung flow estimation operation 406. The estimated lung flow is compensated for the leak flow calculated in the instantaneous leak calculation operation 404 so that it represents a more accurate estimate of the actual flow into (or out of depending on the point of view and period selected) the lungs of the patient.

In the embodiment illustrated, the leak-compensated net lung volume is also calculated as part of the lung flow estimation operation 406. In an embodiment, this may be performed by maintaining a running summation of net flow into/out of the lung over the period of a breath. For example, upon triggering inhalation, the ventilator may set a variable corresponding to net lung volume to zero and, each sample period, update this net lung volume to include the detected leak-compensated instantaneous lung flow delivered to the patient during that sample period.

In the PA ventilation method 400 illustrated, the leak-compensated lung flow or net volume is then used along with the support setting and the previously determined lung resistance and lung compliance (which were themselves determined using leak-compensated lung flows and net lung volumes) to calculate the amount of assistance to provide during ventilation.

The PA ventilation method 400 also includes calculating the patient effort in effort calculation operation 408. As described above, the operation 408 may use one or more equations that relate the amount of pressure to calculate the patient's effort based on the instantaneous lung flow, current lung volume, lung compliance, lung resistance, support setting and other factors such as circuit compliance and resistance. Various methods are known in the art for calculating patient effort that use one or more respiratory mechanics and other parameters measurable while providing ventilatory support. Any such method for determining patient effort, now known or later developed, may be used herein.

The appropriate amount of ventilation is then provided in a ventilation operation 410. In this operation, the patient effort calculated above and the support setting are used to determine how much assistance to provide. Of course, if there is no patient effort (i.e., during the expiratory phase), no ventilation is provided. In this case, the appropriate ventilation may be providing a predetermined positive end expiratory pressure (PEEP) level. Depending on the equations used, the effort calculation operation 408 may not be technically necessary as the amount of ventilation to provide may be determined directly from the monitored data and the previously determined values of lung compliance and resistance using an appropriate algorithm.

The PA ventilation method 400 also periodically determines the respiratory mechanics from the leak-compensated lung parameters, which is illustrated by the determination operation 412. For example, in an embodiment respiratory mechanics may be calculated on a fixed or random schedule or calculated in response to an explicit operator command. In addition, depending on the respiratory mechanics determination method used, there may be a requirement that the respiratory mechanics calculation (using data collected during the breath) be performed at a certain point within the patient's respiration such as at the end of the inspiratory phase or the end of the expiratory phase or after the completion of a specific maneuver (e.g., an Inspiratory Hold Maneuver). The respiratory mechanics calculation includes the performance a respiratory mechanics “maneuver,” that is a specified set of controlled actions on the part of the ventilator. In an embodiment, the maneuver includes interrupting the therapeutic delivery of respiratory gas for a period of time and monitoring and/or changing the pressure and flow, so that data concerning the response of the patient's lung to the controlled actions may be obtained. An example of a respiratory mechanics maneuver is provided below with reference to the static determination of lung compliance.

If it is time to calculate respiratory mechanics, a calculate respiratory mechanics operation 414 is performed. The calculate respiratory mechanics operation 414 may also include performing the appropriate maneuver, as necessary to obtain the data for the respiratory mechanics model being used. In the operation 414, the necessary data for the respiratory mechanics model being used is obtained and the respiratory mechanics parameters are estimated.

In the calculate respiratory mechanics operation 414 leak-compensated values are used to estimate the respiratory mechanics. For example, if the respiratory mechanics model being used requires a total delivered lung volume, the leak-compensated lung volume is used. Likewise, if an instantaneous lung flow is required, a leak-compensated instantaneous lung flow is used in generating the estimate.

The method 400 is then repeated every computational cycle or sample period, as illustrated by the feedback loop, so that the instantaneous lung flow and net lung flow are continuously determined and, when appropriate, the respiratory mechanics are recalculated based on the current leak-compensated data. In an alternative embodiment, the leak-compensation of lung flow and net delivered lung volume may be performed as part of the calculate respiratory mechanics operation 414 in order to reduce the number of calculations a processor must perform every cycle.

The following is a discussion of two embodiments of methods for compensating the estimation of respiratory mechanics in the presence of leaks. The first embodiment is that of applying leak compensation to a static compliance and resistance determination. The second embodiment is that of applying leak compensation to a dynamic compliance determination.

Leak-Compensation of Static Determination of Lung Compliance

FIG. 5 illustrates an embodiment of a method for estimating respiratory mechanics of patient that utilizes a respiratory mechanics maneuver. In the embodiment shown, the ventilator is providing respiratory gas to a patient in accordance with some mode of operation such as a mandatory mode or a pressure assist mode (e.g., a mandatory volume-controlled (VCV) inspiration under square waveform setting or a mandatory pressure-controlled (PCV) inspiration with specific settings, or execute an inspiratory hold at the end of a PA inspiration), as is well known in the art. During operation, an operator command to estimate the compliance of the patient is received in a receive command operation 502. In an embodiment, the command may be entered by the operator of the ventilator via selection of a button or other interface element on a user interface of the ventilator. In an alternative embodiment, the ventilator may perform the method 500 automatically such as periodically, randomly or upon the detection of predetermined respiratory event.

In the embodiment shown, the system performs a respiratory maneuver which includes the forced imposition of a stable period at the end of an inspiratory phase so that there is no flow delivery to or from the patient's lung. The method 500 includes a delay until the next end of an inspiratory phase is detected, as illustrated by detect end of inspiratory phase operation 504.

When the end of the inspiratory phase is detected, a stabilization operation 506 is performed. In an embodiment, the operation 506 includes stabilizing the pressure and flow in the patient circuit so that there is no flow into or out of the patient's lungs at the point in which the lungs have taken a breath and thus are expanded with a known volume of gas (as determined during normal operation of the ventilator as discussed above with reference to the leak-compensated lung volume).

The stabilization operation 506 and the maintain stable condition operation 508 (discussed below) may sometimes be referred to collectively as a pause maneuver or a plateau maneuver. They are separated in this discussion for clarity purposes.

In order to stabilize the pressure and flow to achieve no flow between the circuit and the patient, if there are leaks in the tubing system these leaks are compensated for by the ventilator. Thus, in order to stabilize the flow the ventilator provides a leak-compensation flow that is equal to the amount of leakage from the system estimated by the leakage model at the stable pressure.

In practice, the stabilization of the pressure and flow is an iterative process in which the ventilator monitors the pressure and adjusts delivered flow until the pressure and flow stabilize at the point where the pressure and flow correspond to a solution to the leak model and the lung flow is practically zero, i.e., the current flow provided by the ventilator is the leakage flow determined from the model using the current pressure. In an embodiment, for a flow and pressure to be considered stable, a certain acceptable error may be allowed between the calculated leakage (calculated based on the current pressure) and the actual measured flow. Such an error may be predetermined amount or range based on an absolute difference between delivery and calculated flow or pressure or relative difference (e.g., calculated flow within x % of actual stable flow at a given pressure). Various methods for stabilizing pressure and flow in a ventilation tubing system are known in the art and any suitable method may be adapted for use in conjunction with the technology described in this disclosure.

When attempting to stabilize the pressure and flow during the stabilization operation 506, the leakage model may be used to increase the speed of the stabilization through a prediction of the likely resulting leakage flow at different pressures. This information may be used to determine a more accurate initial starting point for the stabilization and determine more accurate selection of adjustments to be made in order to more quickly converge on the stable pressure and flow.

After a stable pressure has been achieved, in the embodiment shown a maintain stable condition operation 508 is performed. The maintain stable condition operation 508 may maintain the stable pressure and stable, leak-compensating flow for a predetermined period of time such as 25-200 milliseconds or more preferably between 50-100 milliseconds. During the operation 458, the drop in pressure over the period of the maneuver may be monitored to ensure that it is within some acceptable performance threshold. If it is not, the ventilator may resume attempting to stabilize the pressure and flow or may abort the method and attempt the method 500 at the end of the next inspiratory phase.

The stable pressure observed during the maintain stable condition operation 508 is then used to calculate the leak-compensated compliance in a lung compliance calculation operation 510. The pressure value used may be an actual pressure or an average pressure observed over the maneuver period. Alternatively, different values derived from or based on the observed stable pressure may be calculated and used depending on the data required by the particular respiratory mechanics model being utilized.

In addition to using the stable pressure obtained during the pause maneuver, the compliance calculation operation 510 further utilizes leak-compensated lung flow and leak-compensated net lung volume when performing the calculation.

As discussed above, any suitable model for calculating lung compliance may be used. For example, in an embodiment of the compliance calculation operation 510 compliance is calculated using the following simple model:Stable pressure=Leak-Compensated Net Lung Volume/Compliance,or, stated a different way,Compliance=Leak-Compensated Net Lung Volume/Stable pressure.

By using a leak-compensated value for lung volume and a stable pressure determined while compensating for leaks in the patient circuit, a more accurate leak-compensated lung compliance is estimated.

The leak-compensated compliance then may be used in a subsequent operation to determine a leak-compensated lung resistance. In the embodiment of the method 500 shown, this is illustrated by optional resistance calculation operation 512. In an embodiment of the resistance calculation operation 512 after the leak-compensated compliance has been determined, a resistance model that calculates lung resistance based on pressure, flow and compliance may be used to calculate resistance. An example of one such resistance model is as follows:P(t₂)−P(t₁)=(V(t₂)−V(t₁))/C+R*(Q(t₂)−Q(t₁))In which t₁ and t₂ are different times during a breath, P(t) is the airway pressure at time t, V(t) is the delivered lung volume at time t, C is the lung compliance, R is the lung resistance and Q(t) is the net lung flow at time t. In the resistance model provided above, leak-compensated lung flow, leak-compensated net lung volume and leak-compensated lung compliance are utilized to obtain a leak-compensated resistance. This computation may be performed repeatedly over several appropriate time windows and combined together (e.g., by an averaging method) to generate an estimate for lung resistance. Also, lung resistance may be determined from the leak-compensated exhalation flow waveform subsequent to the inspiratory pause maneuver using algorithms for resistance estimation under no leak conditions.

In an alternative embodiment of method 500, if it is determined that the ventilator has relatively low leakage, the lung compliance calculation operation 510 may forego the use of leak-compensated lung flow and net lung volume but still utilize the stable pressure determined through the provision of a leak-compensating flow during the pause maneuver. Lung compliance calculated in this fashion is still considered leak-compensated as the stable pressure was determined by compensating for leakage during the pause maneuver when generating the stable pressure.

Leak-Compensation of Dynamic Determination of Luna Compliance and Resistance

FIG. 6 illustrates an embodiment of a method for dynamically estimating respiratory mechanics of patient. This may be used as an alternative method of calculating lung compliance and resistance, thereby obviating the need to perform respiratory maneuvers during PA ventilation.

In the embodiment shown, the ventilator is providing respiratory gas to a patient in accordance with some mode of operation such as a mandatory mode or a pressure assist or support or PA mode, as is well known in the art. During operation, the ventilator detects a condition that indicates that it is time to estimate the respiratory mechanics of the patient. This is illustrated by the detection operation 602. In an embodiment, the condition detected may be a command entered by the operator of the ventilator via selection of a button or other interface element on a user interface of the ventilator. Alternatively, the ventilator may perform the dynamic estimation automatically such as during every breath, after a predetermined period of time or after the detection of some occurrence such as once every 100 breaths or upon detection of certain flow conditions.

Following determination that it is time to calculate the dynamic respiratory mechanics, the method 600 retrieves and/or calculates leak-compensated lung flow and leak-compensated net lung volume as necessary depending on whether the leak-compensated data already exists or not. For example, in an embodiment the leak-compensated lung flows for each sampling period may be available but the leak-compensated net lung volume may only be available “as needed” by calculating it from the compensated lung flow data.

The method 600 then calculates the leak-compensated respiratory mechanics in a calculation operation 606. The leak-compensated respiratory mechanics are calculated from a predetermined dynamic respiratory mechanics model using the leak-compensated lung flows, leak-compensated net lung volume(s) and pressure in order to obtain estimates of dynamic compliance and dynamic resistance that are compensated for the leaks in the tubing system. The method 600 is then repeated as necessary.

Any respiratory mechanics model may be used as long as the model may be adapted to be used in a dynamic calculation, that is without interrupting the ventilation of the patient. Many such models are known in the art, some requiring iterative solutions of a set of multiple equations using data obtained over of a period of time.

FIG. 7 illustrates a functional block diagram of modules and other components that may be used in an embodiment of ventilator that compensates for elastic and rigid orifice sources of leaks when determining patient respiratory mechanics. In the embodiment shown, the ventilator 700 includes pressure sensors 706 (two are shown placed at different locations in the system), flow sensors (one is shown), and a ventilator control system 702. The ventilator control system 702 controls the operation of the ventilator and includes a plurality of modules described by their function. In the embodiment shown, the ventilator control system 702 includes a processor 708, memory 714 which may include mass storage as described above, a leak estimation module 712 incorporating a parametric leak model accounting for both elastic and rigid orifice leak sources such as that described in U.S. Provisional Application 61/041,070 previously incorporated herein, a leak-compensated static respiratory mechanics module 716, a pressure and flow control module 718, a monitoring module 722, a leak model module 720, a leak-compensated dynamic respiratory mechanics module 724, and a leak-compensated lung flow and volume estimation module 726. The processor 708 and memory 716 have been discussed above. Each of the other modules will be discussed in turn below.

The main functions of the ventilator such as receiving and interpreting operator inputs and providing therapy via changing pressure and flow of gas in the ventilator circuit are performed by the control module 718. In the context of the methods and systems described herein, the module 718 will perform one or more actions upon the determination that a patient receiving therapy is inhaling or exhaling.

In the embodiment described herein, the control module 718 determines and provides the appropriate amount of ventilation when in PA ventilation mode. This may include calculating patient effort and, based on the patient effort and the support setting, determining the appropriate amount of ventilation, i.e., the pressure and/or flow to provide to the patient. This may include performing one or more calculations based on leak-compensated lung flow, leak-compensated lung volume, leak-compensated lung compliance and leak-compensated lung resistance. PA ventilation is based on an estimation of patient's respiratory effort, therefore, patient effort may be first calculated and then the amount of ventilation (desired pressure reference) calculated therefrom.

The static calculation of respiratory mechanics is performed by the leak-compensated static respiratory mechanics module 716. The module 716 utilizes one or more respiratory models suitable for static determination of respiratory mechanics and one or more embodiments of the method 400 described above to calculate leak-compensated respiratory mechanics such as lung compliance and lung resistance. The module 716 uses leak-compensated values for one or both of lung flows and net lung volume. Leak-compensated values may be retrieved if they have already been calculated or may be calculated as needed from leakage information received from the leak-compensated lung flow and net lung volume estimation module 726. When calculating static respiratory mechanics, the module 716 may control the operation of the ventilator so that a pause maneuver is performed when required. Alternatively, some or all of the actions required in a pause maneuver may be controlled by the control module 718 in response to a respiratory mechanics calculation request and the data obtained during the maneuver provided to the static respiratory mechanics module 716.

The dynamic calculation of respiratory mechanics is performed by the leak-compensated dynamic respiratory mechanics module 724. The module 724 utilizes one or more dynamic respiratory models and one or more embodiments of the method 500 described above to calculate leak-compensated respiratory mechanics such as lung compliance and lung resistance. The module 724 uses leak-compensated values for one or both of lung flows and net lung volume. Leak-compensated values may be retrieved if they have already been calculated or may be calculated from leakage information received from the leak-compensated lung flow and net lung volume estimation module 726.

The current conditions in the ventilation system are monitored by the monitoring module 722. This module 722 collects the data generated by the sensors 704, 706 and may also perform certain calculations on the data to make the data more readily usable by other modules or may process the current data and or previously acquired data or operator input to derive auxiliary parameters or attributes of interest. In an embodiment, the monitoring module 722 receives data and provides it to each of the other modules in the ventilator control system 702 that need the current pressure or flow data for the system.

In the embodiment shown, compensated lung flows are calculated by the lung flow module 726. The lung flow module 726 uses a quantitative model for lung flow of the patient during both inhalation and exhalation and from this characterization and pressure and flow measurements generates an estimate for instantaneous lung flow. In an embodiment, lung flow may be simply determined based on subtracting the estimated leak flow and measured outflow via the expiratory limb from the flow into the inspiratory limb, thereby generating a leak-compensated net flow into (or out of) the lung. The lung flow module 726 may or may not also calculate an ongoing leak-compensated net lung volume during a patient's breath as described above. Compression in the circuits and accessories may also be accounted for to improve the accuracy of estimated lung flow.

The leak model parameters are generated by the leak estimation module 712 which creates one or more quantitative mathematical models, equations or correlations that uses pressure and flow observed in the ventilation system over regular periods of respiratory cycles (inhalation and exhalation) and apply physical and mathematical principles derived from mass balance and characteristic waveform settings of ventilation modalities (regulated pressure or flow trajectories) to derive the parameters of the leak model incorporating both rigid and elastic (variable pressure-dependent) orifices. In an embodiment, the mathematical model may be a model such as:Q_inelastic=R₁*P_i^x Q_elastic=R₂*P_i^y wherein Q_elastic is the instantaneous leak flow due to elastic leaks in the ventilation system, Q_inelastic is the instantaneous leak flow due to inelastic leaks in the ventilation system, R₁ is the inelastic leak constant, R₂ is the elastic leak constant, P_i is the current or instantaneous pressure measurement, x is an exponent for use when determining the inelastic leak and y is an exponent different than x for use when determining the elastic leak. The group R₁*P_i^x represents flow through an orifice of fixed size as a function of instantaneous pressure P_i and the group R₂*P_i^y represents flow through a different orifice that varies in size based on the instantaneous pressure. The equations above presuppose that there will always be an elastic component and an inelastic component of leakage from the ventilation system. In the absence of an elastic component or a leak source of varying size, R₂ would turn out be zero.

In the embodiment shown, the current or instantaneous elastic leak is calculated by the leak estimation module 712. The calculation is made using the elastic leak portion of the leak model developed by the leak estimation module 712 and the pressure data obtained by the monitoring module 722. The leak estimation module 712 may calculate a new instantaneous elastic leak flow or volume for each pressure sample taken (i.e., for each sampling period) by the monitoring module 722. The calculated elastic leak may then be provided to any other module as needed.

In the embodiment shown, the current or instantaneous inelastic leak is also calculated by the leak estimation module 712. The calculation is made using the inelastic leak portion of the leak model and the pressure data obtained by the monitoring module 722. The leak estimation module 712 may calculate a new instantaneous inelastic leak flow or volume for each pressure sample taken (i.e., for each sampling period) by the monitoring module 722. The calculated inelastic leak may then be provided to any other module as needed.

The system 700 illustrated will compensate lung flow for leaks due to elastic and inelastic leaks in the ventilation system. Furthermore, the system may perform a dynamic compensation of lung flow based on the changing leak conditions of the ventilation system and the instantaneous pressure and flow measurements. The system then compensates the respiratory mechanics calculations based on the estimated leakage in the system. By compensating for the inelastic as well as the elastic components of dynamic leaks, the medical ventilator can more accurately and precisely estimate the respiratory mechanics of a patient including estimating the lung compliance and lung resistance.

It will be clear that the systems and methods described herein are well adapted to attain the ends and advantages mentioned as well as those inherent therein. Those skilled in the art will recognize that the methods and systems within this specification may be implemented in many manners and as such is not to be limited by the foregoing exemplified embodiments and examples. For example, the operations and steps of the embodiments of methods described herein may be combined or the sequence of the operations may be changed while still achieving the goals of the technology. In addition, specific functions and/or actions may also be allocated in such as a way as to be performed by a different module or method step without deviating from the overall disclosure. In other words, functional elements being performed by a single or multiple components, in various combinations of hardware and software, and individual functions can be distributed among software applications. In this regard, any number of the features of the different embodiments described herein may be combined into one single embodiment and alternate embodiments having fewer than or more than all of the features herein described are possible.

While various embodiments have been described for purposes of this disclosure, various changes and modifications may be made which are well within the scope of the technology described herein. For example, the systems and methods described herein could be adapted to automatically determine leak-compensated resistance and/or compliance and initiate an alarm if the leak-compensated values are outside of a specified range for predetermined leakage values, thus eliminating false resistance and compliance alarms due to changes in leakage. Numerous other changes may be made which will readily suggest themselves to those skilled in the art and which are encompassed in the spirit of the disclosure and as defined in the appended claims.

Claims

1. A pressure support system comprising: a pressure generating system adapted to generate a flow of breathing gas;a ventilation tubing system including a patient interface device for connecting the pressure generating system to a patient;one or more sensors operatively coupled to the pressure generating system or the ventilation tubing system, each sensor capable of generating an output indicative of a pressure of the breathing gas;a leak estimation module that identifies leakage in the ventilation tubing system;a respiratory mechanics calculation module that generates a leak-compensated lung compliance and a leak-compensated lung resistance based on the leakage and at least one output indicative of a pressure of the breathing gas; anda proportional assistance ventilation module that causes the pressure generating system to provide ventilation to the patient based on patient effort and a support setting, wherein the patient effort is determined from the leakage, the leak-compensated lung compliance and the leak-compensated lung resistance.

2. The system of claim 1 wherein the respiratory mechanics module is a static respiratory mechanics module that uses a static respiratory mechanics model to determine a leak-compensated static lung compliance and a leak-compensated static lung resistance based on a leak-compensated lung flow and an output of at least one sensor.

3. The system of claim 1 wherein the respiratory mechanics module is a dynamic respiratory mechanics module that uses a dynamic respiratory mechanics model to determine at least one of a leak-compensated dynamic lung compliance and a leak-compensated dynamic lung resistance based on the leak-compensated lung flow and an output of at least one sensor.

4. The system of claim 1 wherein the leak estimation module further identifies an inelastic leakage in the ventilation tubing system and wherein the compensation module further generates the leak-compensated lung flow based on the inelastic leakage.

5. The system of claim 4 further comprising: a pressure monitoring module that monitors at least one output of the one or more sensors and provides data indicative of the pressure of the breathing gas to the leak estimation module.

6. A controller for a medical ventilator comprising: a microprocessor;a module that compensates calculations of lung compliance and lung resistance based on an instantaneous elastic leakage of breathing gas from a variable orifice and an instantaneous inelastic leakage of breathing gas from a fixed orifice of a ventilation tubing system; anda pressure generating module controlled by the microprocessor that provides proportional assist ventilation based on the compensated lung compliance and lung resistance.

7. The controller of claim 6 further comprising: a leak estimation module that identifies the instantaneous inelastic leakage from the associated ventilation tubing system and the instantaneous elastic leakage from the associated ventilation tubing system.