INDUSTRIAL TRAINING PROJECTMAQUET: VENTILATOR SYSYEM

SERVO – I V3.1

INSTITUION : UNIVERSITY OF MALAYA

NAME : ROSHIELD RANDASAN

TEAM LEADER : MR JASNI HJ SAPAR

SUPERVISOR : MR MARTIN LEE SZE EN

SITE : BEMS, HOSPITAL DUCHESS OF KENT, SANDAKAN

DATE OF SUBMISSION: 22 JULY 2011

TMD REF NO: REGION REF NO:

Table of Contents

Contents Page No

Abstract…………………………………………………………………….. 1

Acknowledgement…………………………………………………………. 2

Objectives………………………………………………………………….. 3

Introduction…………………………………………………………………

i. Human respiratory system…………………………………….. 4 - 5

ii. Ventilator history………………………………………………. 6 - 7

iii. Modes of mechanical ventilation……………………………… 8 - 9

iv. Waveform in mechanical ventilation………………………….. 10-11

v. Important parameters in ventilation……………………………. 12-14

Ventilator System Servo – I V3.1

i. Description………………………………………………………. 15-18

ii. Modes……………………………………………………………. 19-20

iii. Set – ups and preparations………………………………………. 21

iv. Pre – use check…………………………………………………... 22-25

v. User Interface and Keys…………………………………………. 26-27

vi. Starting Ventilation…...…………………………………………. 28-29

vii. Alarm Types and Alarm Handling………………………………. 30-31

viii. Cleaning and Maintenance……………………………………….. 32-34

ix. Troubleshooting and Servicing…………………………………… 35-37

x. Planned Preventive Maintenance………………………………… 38-40

xi. Asset management……………………………………………….. 41

Conclusions………………………………………………………………….. 42

References………………………………………………………………….... 43

Appendices…………………………………………………………………... 44-51

Prepared by:

Name: Roshield Randasan

Date: 22 July 2011

Institution: University of Malaya, Kuala Lumpur

Signature

Checked by:

Name: Mr. Martin Lee Sze En

Position: Technician, HDOK

Date: 22 July 2011

Signature

Acknowledged by:

Name: Mr. Jasni Hj Sapa

Position: Team Leader, Sandakan

Date: 22 July 2011

Signature

Approved Rejected

Name: Mr. Herman Abu Saini

Position: Regional Head, Sabah

Signature

Abstract

Human respiratory system is consist of two lungs and trachea that function as a tube

that will be the path of air or gaseous when it is inhale or exhale from the lung. In lung, there

is site called gas exchange site that consist of bronchioles, alveolar ducts and alveoli.

However, the primary site for gaseous exchange is the alveoli where exchange of oxygen and

carbon dioxide from and into the blood will occur. Since human body cells need oxygen to

live and run their function, respiratory system is considered one of the vital human systems in

the body aside from the heart. However, respiratory system can also infected by several

diseases that may interrupt its function. Diseases such as bronchitis may cause the exchange

of gas to failure. Patient with polio will also have problem with their respiratory system as

they may not be able to breathe thus failed to exchange gaseous in their blood. To overcome

this problem, ventilator machine was introduced. Firstly, this report will focus on the Maquet

Ventilator System Servo – I V3.1. So, in this report, details on the history of the ventilator

machine will be explained. The modes of ventilator that used for treatment such as pressure

or volume control will also be explained in detailed. Besides that, procedure of Planned

Preventive Maintenance, User Training and Testing and Commissioning will also be

explained later. Documentation for ventilator management as one of the assets in hospital will

also be included and explained in this report especially on Maquet Ventilator System Servo –

I V3.1.

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Acknowledgement

After several weeks of research and training, the report on Maquet Ventilator System

Servo – I V3.1 can finally be done. Firstly I want to thanks University of Malaya especially

Department of Biomedical Engineering and also CITRA for giving me the chance to undergo

industrial training which is an essential opportunity for me and other students to exactly see

the situation in the job world and also gained experience from people who is actually

working. Also big thanks to all my lecturers for the knowledge that they have given as it help

me the most during my training and in doing this report.

Lots of thank and gratitude also to Healthronics (M) Sdn Bhd for giving me the

chance to undergo training in their company. Also to Mr Herman Abu Saini, the Regional

Head of Sabah region Healthronics for giving advice in my project proposal form, to Mr Jasni

Hj Sapar whom is the Team Leader of Healthronics Sandakan for giving lots of knowledge

and advice along my journey in doing this report and also in my industrial training. Big

thanks also for the Healthronics Sandakan staff for their support and knowledge that they

have shared me during the making of this report. To Mr Martin Lee Tze En, my supervisor in

doing my report, for his knowledge and guidance that extremely helping me. Once again big

thank and gratitude from my heart to all of you for helping me in making this report and

while I undergo my industrial training. Last but not least, to my family that always got my

back and supported me while I am making this report and undergo training, thank you very

much. Also to other people that contribute directly or indirectly in making in this report, a big

thanks to all of you. May this report will be beneficial to people who read it and most likely

give if not much, a bit information on ventilator machine on how important it is in treating

patient with respiratory failure.

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Objectives

There are several objectives that need to be achieved through this report. Those objectives

are:

i. To know and understand the history of ventilator machine and how it has

developed throughout the years before.

ii. To learn and understand the function of ventilator machine.

iii. To learn and understand the mode of treatment used in ventilator for respiratory

failure treatment.

iv. To learn and understand on how to do Planned Preventive Maintenance for

ventilator machine.

v. To learn and understand how to use equipment needed for doing Planned

Preventive Maintenance such as safety test analyser.

vi. To learn and understand about the documentation needed for registering and

managing ventilator machine as one of the assets in the hospital.

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Introduction

I. Human respiratory system

Human body consists of several system that run their own function such as skeletal

system, digestive system, muscular system and also circulatory system. Each system run their

own function in order so that human do their daily activity. Every day in human life, there is

one most crucial and certain thing that must they done which is breathing. Breathing is

important as it enable human body to receive oxygen and remove carbon dioxide that not

used by the cells. In order for human to breath and exchange gaseous, respiratory system is

needed. This system consists of several organs such as nose, lung, trachea and bronchi. These

organs take part in the process of gaseous exchanging as some of them function as passage

for the airway such as nose and trachea while some function as gas exchanger such as lung

and bronchi.

Figure 1. Human Respiratory System

Taken from: http://bcscience8.wikispaces.com/The+Respiratory+System

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When air is inhaled, it will first enter the nose passage. So, nose is important in here

as it become the medium of air to go into the lungs. However, air can also enter from the

mouth as nose and mouth are connected in the passage called the trachea. After the air have

gone through the passage, it will then arrive at the lungs. There are actually two lungs in

human body, which is the right and left lung. Each of them is actually covered by thin

membrane called plural membrane. Inside the lung there is bronchi where there is bronchioles

and alveoli (Jakab, 2007). All these are like tree branches that spread out in the lungs. The

most important site or part in the lungs is actually the alveoli. This is the main site for the

exchanges of oxygen and also carbon dioxide. Alveoli as mentioned before is the exchange

site of gaseous, but how does it happen will be explained here.

Alveoli is a sac like shape and have an elastic characteristic. It is able to expand and

deflate due to its elasticity. It is also surrounded by many blood vessels around its wall. It is

very tiny and given lots of empty space in the lungs due to its size. It walls is very thin and

about the same thickness as one cell. Due to its thin wall, oxygen that goes in from the nose

can diffused into it and goes into the blood. The same process happen to carbon dioxide

where it also diffuse into alveoli and into the air and follow the air out from the lungs.

Figure 2. Exchange of gas in alveoli

Taken from:

http://peer.tamu.edu/curriculum_modules/organsystems/module_4/whatweknow_lungs2.htm

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II. Ventilator history

Ventilator machine is a machine used mechanically move air or gaseous mixture into

and out of the lung. It is also delivers either controlled or supported breaths with either

constant volume or pressure with a set of oxygen concentration (Maquet, 2004). Ventilator

was first introduced during the 20th century when polio diseases spread during that time.

However, the first form of ventilator introduced was using negative pressure and non -

invasive (Geddes, 2007). The improvement was then made by the person named John Haven

in 1931. There are also other forms of non – invasive ventilators such as rocking bed,

biphasic cuirass ventilation and iron lung and these types of ventilators were used widely for

polio patient (Geddes, 2007). Later in 1950, ventilator machine began to be used in

anaesthesia and intensive care due to the development of mechanical assister by John Haven

with the cooperation of Harvard University in 1949. The first positive pressure ventilator was

introduced back in year 1952 by Roger Manley and the ventilator was named Mark I. It then

developed become Manley Mark II after a collaboration of Roger Manley with Blease

company was made. The ventilator then widely used around Europe and was the starting

point of the used of positive pressure ventilation around the continent.

In 1955, the Americans introduced a ventilator that widely known as “Bird” or Bird

Mark 7. This ventilator was a pneumatic device thus not required any electrical power source

to operate. By the time of 1971, the intensive care environments revolutionized due to the

introduction of the SERVO 900 ventilator machine. This ventilator is small, silent and

effective in operating. It also has SERVO feedback system that enable user to regulate and set

the delivery of gaseous to patient. Later in 1991, SERVO 300 ventilator series was

introduced. This version enable the used of ventilator for all range or categories of patient,

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form neonate to adult in one single unit of ventilator. It also has rapid flow – triggering

response.

The latest model, which used mostly nowadays, the SERVO – i was introduced in

2001. This model used modular concept, a concept that enable user to choose different mode

of mechanical ventilation from single ventilator. This type of ventilator is extremely easy and

saved more space in certain ward.

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III. Modes of Ventilation

As mentioned earlier, ventilator is used as a machine that will help carried air and

oxygen into and out of the lung so that gas exchange in the alveoli can occur. So basically,

patient that need ventilator for in their treatment is usually patient that have respiratory

diseases or patient that not able to breath themselves such as patient that is on comma or

having stroke and paralyzed on the upper body parts. Respiratory problem mentioned here is

including acute respiratory distress syndrome, pneumonia, heart failure and complications

from surgery and trauma. COPD or chronic obstructive pulmonary disease and

neuromuscular disorder are also the factor that will lead to respiratory failure (Carbery,

2008).

To determine the right treatment for certain treatment, clinician or doctor must

considered several factors such as patient’s history and appropriate lung’s compliance. But

the most important assessment can be obtained from the ABG test. ABG test or arterial blood

gas test is important because it can give information such as blood pH, partial pressure of

CO2, and also partial pressure of O2. From this test, an acute respiratory can be determined if

the partial pressure of oxygen is less than 60 mmHg, partial pressure of carbon dioxide is

greater than 50 mmHg, and the blood pH is lower than 7.25 and falling (Carbery, 2008).

Respiratory failure if not treated can lead to more chronic diseases such as CNS (Central

Nervous System) disorder.

In mechanical ventilation, there are several modes that used in delivering breath or air

into patient. Those modes are volume control, volume support, pressure control, pressure

support, SIMV (Synchronized Intermittent Mandatory Ventilation), and CPAP (Continuous

Positive Airway Pressure). Basically, there are three basic of breath delivering system which

is controlled, support and continuous. In control mode such as volume or pressure control, the

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whole patient breath is supported by the ventilator machine. The first mode in controlled

breath delivering system is the volume control. In volume control, the volume or Tidal

Volume is set by the user and the pressure will be dependent on patient’s Tidal Volume,

inspiration time and the resistance and compliance of the patient’s respiratory system

(Maquet, 2002). The other mode is the pressure control mode. In pressure controlled, the

parameter that set as constant is the pressure meanwhile the volume (Tidal volume) will be

independent on pressure above PEEP, lung compliance and also the resistance in the patient’s

circuit. Volume and pressure control mode can also be called as the control – assist mode.

Usually in many books or reference, the word control – assist mode is used instead of control

mode, but these two carried the same meaning.

Besides control mode, there is also support mode in mechanical ventilation. Support

mode happen whenever a patient triggered the ventilator. After being triggered, ventilator

will give positive pressure ventilation to the patient. This mode is also divided into two which

is pressure and volume support. Support mode that need to be used is determined by the

doctor or clinician. The next mode is the spontaneous mode or continuous positive airway

pressure. In this mode, patient is breathing on their own, but trigger function will also be

provided in this mode if patient effort is not sufficient to be said as spontaneous breathing.

Another mode is the Synchronize Intermittent Ventilation mode. In this mode, patient

breathing is synchronized with the ventilation given by ventilator itself. SIMV in Maquet

Servo – I is used with other mode which is the control mode and also support mode.

Triggered also available in this mode too. Triggered function will be explained more in the

Servo – I V3.1 section, on how to use the ventilator.

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IV. Waveform in Mechanical Ventilation

There are several waveforms that need to be observed during different mechanical

ventilation. These waveforms will indicate several parameters that will be important in

assessments of lung condition or the flow of air that travel through the lungs. Three main

important waveforms that usually observed in mechanical ventilation are the pressure, flow

and volume waveform. In a mode where pressure is the variable that being set as a constant,

the waveform will be looked like in the Figure 2a below.

Figure 2a. Pressure controlled waveform

Taken from: http://www.frca.co.uk/article.aspx?articleid=100421

Volume also will be constant in a mode where volume is delivered constantly in a same value

throughout the ventilation. The waveform when volume is being fixed is pictured as in the

Figure 2b.

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Figure 2b. Volume controlled waveform

Taken from: http://fn.bmj.com/content/77/3/F202.abstract

As can be seen from these two types of waveform, it can be said that pressure and volume

waveform changed it shapes as the mode changes. The flow waveform also change shape but

still same process happen in both waveform which is inspiration and expiration. There is also

one similarity between the flow waveform in pressure and volume control modes, which both

of the flow waveform have negative value. The negative phase in the flow volume is actually

referring to the expiration phase of a breathing (Chatburn, 2003). Meanwhile the positive

value is indicating the inspiration phase of certain breathing.

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Inspiration phase

Expiration phase

Volume

Pressure

Flow

V. Important Parameters in Ventilation

There are many parameters in mechanical ventilation that need to be focus on while

on treatment. It is also called as breathing parameters since it is all important to maintain

sufficient or efficient breath that delivered to the patient. This report will mentioned some of

the important parameters such as tidal volum, peak expiratory end pressure (PEEP) and

breath rate. First parameter would be the oxygen concentration (O2 concentration). This

parameter is important and need to be observed during ventilation so that patient will receive

enough oxygen to their lungs and blood. The range of oxygen given to patient is usually 20 –

100% of concentration. The second one is the respiratory rate or also called as breath rate or

frequency. Normally, a person should breath total of 12 cycles of breath in one minute

(Rakhimov, 2011). But this value can be higher in person that is sick or in an infant. By

determining respiratory rate, the total of tidal volume per minute can also be calculated. Next

is the tidal volume which is volume that delivered in one breath. Some also called tidal

volume as the target volume that need to be achieved during ventilation. Then there is PEEP

or peak expiratory end pressure. PEEP is actually the pressure that left behind in the lungs

after the expiration is done. The need of PEEP in mechanical ventilation is to ensure that

human lungs do not flattened completely. This is important as lungs that contained PEEP will

be accepting more oxygen during the next breath due to increase in mean airway pressure.

Usually PEEP is set to be 5cmH2O. The next parameters would be inspiratory rise time which

is the time for a person to inhaled air into their lung. Longer inspiratory rise time will

increase the oxygen absorption and also make the patient more comfortable. Other parameter

that also important is shown in the Table 1.

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Parameters Definition and Range

Inspiratory cycle-off (%)Fraction of maximum flow at which

inspiration should switch to expiration.

Minute volume (Vmin)

Volume per minute or target Minute volume (ml/min or l/min).

Note: Presentation can be configured to either tidal or minute volume.

Trigger sensitivity

Determines the level of patient effort required to trigger inspiration. The sensitivity is set as high as possible without self-triggering. This ensures that triggering is patient initiated and avoids autocycling by the ventilator.

There are two types of triggering:

1) Pressure triggering—This is the pressurebelow PEEP which the patient must create toinitiate an inspiration. The allowed range is:• -20 to 0 cmH2O.

2) Flow triggering—As the dial is advanced to the right (step wise from the green into thered area) the trigger sensitivity increases sothat the inhaled fraction of the bias flow leading to triggering is reduced. The allowedrange is:• 100% to 0% of the bias flow.

Note: You can’t set trigger sensitivity in NIVmode.

PC above PEEPInspiratory pressure level for each breath (cmH2O) in Pressure Control.Important: In all pressure controlled modes,it is important to set alarm limits to adequatelevels.

Pause time (Tpause) Time for no flow or pressure delivery (% or

13

s).

I:E ratio (I:E) Ratio of Inspiration time + Pause time to Expiration time. Usually set as 1:2.

Table 1. Other parameters in mechanical ventilation

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Maquet Servo – I V3.0 Ventiilator

I. Description

Maquet Servo – I V3.0 is a ventilator from Maquet Getinge Group which is a

company from Sweden. This machine is a Class 1 and Type B machine which means that it

has protected ground and it also have long conductivity contact to the person, but not directly

to the patient’s heart. This product wa launched in the year 2001, which is 10 years ago.

Servo – I as mentioned earlier is a ventilator which comprises of many different mode within

a ventilator. This is a major advantage of this type of ventilator as it is made easy for user

plus save cost or space in getting many ventilator with different function each. Based on

Figure 3 below, it can be seen that Servo – I V3.0 has three main sections which is the user

interface, patient unit and also the ari compressor below the patient unit. There are also other

accessories that comes with this ventilator which will be explained in detail later.

Figure 3: Maquet Servo – I V3.0 Ventilator

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User Interface

Patient Unit

Air Compressor

Patient Breathing System

As seen from Figure 3, there is one section called the User Interface, which is the

place for user such as doctor or nurse to operate the system of the machine or setting any

values that correlated to any mechanical ventilation. This User Interface is also the place for

data to be displayed so that clinician will be able to monitor patient’s condition. All the

alarms related to patient or even the ventilator itself will also indicated in the User Interface.

There are also several keys and buttons that important in managing the settings for

mechanical ventilation. All these keys will be displayed and explained further in the User

Interface section in this chapter.

Next part is the patient unit where all the gas from the module will flow in together

before flowing into the inspiratory circuit. Servo – I V3.0 can support different modules such

as air module, oxygen module and carbon dioxide module. But in this report, only two

module will be included which is the air and the O2 module. After gaseous flow from this two

modules, it will then enter patient unit where the gas can be said to be mixed before it is

proceed into the inspiratory circuit. The next section is the patient breathing system which

comprises of patient circuits. There are actually two patient circuit which is the inspiratory

and the expiratory circuit. The inspiratory circuit or tubing carry the breath that goes into a

patient’s lung while the expiratory circuit carry the air that exhaled by the patient. These two

patient circuit is important and any leakage in any of these two circuit will bring complication

to the patient. To find out whether there is any leakage in the tubing system, a Pre – Use

check must be done on the machine. Tubing compensation must also be done to make sure

that the breath that delivered to the patient is same as the one that is being set in the system.

Compensation is done also during the Pre – Use check. Pre – Use check procedure will be

explained later in detailed.

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Other than these three main components, there are also others accessories that used

together with Servo – I ventilator such as humidifier and nebulizer. Humidifier in mechanical

ventilation is very important as it helps prevent patient from inhaling dry air. Without the

usage of humidifier, the epithelium cell of a patient will undergo destruction. Patient can also

suffered hypothermia which is a condition of low in body temperature. When using

humidifier, the temperature is set to be maximum of 37°C, and using sterile water to be

vapored (AARC, 1992). The humidifier used in this Servo – I V3.1 ventilator is the Fisher &

Paykel humidifier with model MR340E.

Figure 4. Fisher & Paykel Heated Humidifier MR340E

Other than humidifier, heat and moist exchanger can also be used to provide humidity to

patient’s breath. Heat and moist exchanger is also called as HME. The other accessory is the

nebulizer or Servo Ultra Nebulizer. Same as basic nebulizer, Servo Ultra Nebulizer also

deliver medication through mist that produced by vibration. When using Servo Ultra

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Nebulizer, the HME or humidifier cannot be used to prevent any blockage to any of these

two.

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II. Modes

There are several modes that can be run on Servo – I V3.1. Modes that provided in

this ventilator is almost same as the basic mechanical ventilation that already explained in the

previous chapter. But there is an addition of mode which is the Pressure Regulated Volume

Control or PRVC. PRVC mode means that pressure is also one of the key factor in giving

controlled volume breath to patient. For example, if a tidal volume is set to be sent at certain

level, the pressure that comes along must suitable with lung compliance as high pressure that

may come with high volume may burst the lung. If this case happen, PRVC mode will cut off

the tidal volume value that need to delivered if the pressure that comes with it exceeded the

limit set in the system or not compatible with lung compliance.

In Servo – I V3.1, there is actually many modes which is the pressure and volume

control, pressure and volume support, SIMV mode, PRVC mode, spontaneous mode and also

the automode. Automode in this machine provides unique mechanisms that enable the

controlled and supported mode to exchange whenever patient initiated breath or not. There is

also backup ventilation is support mode except in controlled and Automode. Backup

ventilation is important because if patient suddenly having apnea, this backup ventilation can

replaced the patient initiated breath.

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Figure 5. Ventilation Modes in Servo – I V3.1

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III. Sets – up and Preparation

Before starting using Servo – I Ventilator, several set – ups and preparation need to be

done to make sure that the ventilator is safe to use. The most important thing would the Pre –

Use check that must be done each time a new patient circuit or expiratory cassette are

changed. The detail procedure of Pre – Use check will be explained later in the next section

of this chapter. Battery module must also be inserted at least two to support the machine if

any blackout happen during ventilation. There are actually six slots for battery module, and if

all of it are inserted, these batteries can support the machine for at least 3 hours of operation

time. Figure 6 below shows the battery module location on Servo – I V3.1.

Figure 6. Battery module

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IV. Pre – Use Check

Pre – Use Check is actually the most important process before starting of using the

Servo – I. Other than making sure that all pressure transducer is working fine, it also able to

compensate the volume in the patient circuit that will be useful in delivering breath later. Pre

– Use check also test the ability of the machine to transform into battery support if the mains

is not connected to the machine. Any leakage will also be tested and detected (if any) in this

procedure. Calibration process for new O2 cell and expiratory cassette membrane will also be

done in this process even though the process is not actually appear on the screen during the

test. Servo – I that installed with new patient circuit must also undergo this test to make sure

that the volume compensation for patient circuit can be done. To run Pre – Use check,

equipment that will be needed is the “blue test tube” that provided by the manufacturer that

will be used later to connect the inspiratory and the expiratory outlet.

Figure 7. Pre – Use check flow22

While doing the Pre – Use check, some instructions will appear on the screen of the Servo –

i. First will be the “ Connect the inspiratory and the expiratory outlet”, which means the “blue

test tube” should be used to connect inspiratory and expiratory outlet. Other type of tube

cannot be used in this process as it will failed the test. The next instruction will be to unplug

and plugged the power source to test the battery operation. Then the patient circuit is

connected and Y – piece is blocked. Compensation will be done in this section. If there is Y –

sensor module on the machine, Y – sensor test will also be done.

Figure 7. Y – Sensor module

After all test is done and pass, the Pre – Use checked can be completed. If any error message

appear, action needed for be taken will be explained in the Table 2 and Table 3.

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Message Description Remedy if test fails

Cancelled Test cancelled by user Users are recommended to perform Pre – Use Check before connecting ventilator to patient

Failed Test did not pass Check all connections and expiratory cassette.

Not Completed Test was not completed Test pass with some limitation.i. Battery capacity less than 10 minutesii.Gas missing while Pre –

Use check.Passed Test has passed -Running Test in progress -

Table 2. Pre – Use check status

Display message Description Remedy if test fails

Alarm state test Checks that no Technical error alarms are active during Pre-Use check.

Refer to Service Manual

Barometer test Check the barometric pressure measured by the internal barometer

Check barometer pressure in

Status in touch panel.

Gas supply test Check whether gas supply measured by transducer are within the specified range.

Check whether gas connected is within the range for air and oxygen.

Internal leakage test Check patient circuit or any other tube connected to machine.

Make sure blue test tube is connected properly and patient circuit connection is clean and connected properly.

Pressure transducer test Calibrates and check inspiratory and expiratory transducer.

Check/replace transducer for inspiratory/expiratory section or make sure expiratory cassette is cleaned and dried thoroughly.

Safety valve test Check or adjust safety valve Check whether safety valve

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opening pressure to 117 ± 3 cmH2O.

membrane is placed and closed properly during Pre – Use check. Also check if the inspiratory pipe is mounted properly.

O2 cell/sensor test Check O2 lifespan and calibrates it at 21% and 100% of oxygen.

Check/replace O2 sensor or gas modules.

Flow transducer test Check/calibrate inspiratory and expiratory flow transducers.

Check whether gas supplied is within range or expiratory cassette is properly mounted in its place.

Battery switch test Checks if the power supply change to battery if mains is disconnected and vice versa.

Check battery status. Battery status must be more than 10 minutes.

Patient circuit test Check patient circuit leakage Check/replace patient circuit

Y sensor test Check the pressure and flow

measurement of Y sensor

Check Y module and Y

sensor and replaced if

necessary.

Alarm state test Checks that no Technical error alarms are active during Pre-Use check.

-

Table 3. Pre – Use check error

V. User Interface and Keys

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The User Interface of Servo – I is a touchscreen interface. Thus it made easier for the

user as all can be seen and access directly on the screen. Figure below shows how the screen

appear on the Standby mode after the Pre – Use check. All the entry such as ventilation

mode, patient data, and status of battery or oxygen cell can be observed from the User

Interface.

Figure 8. Screen (User interface) of Servo – I V3.1

On the top left corner, there is mode appear and user can just press it to enter the ventilation

mode, beside it is the patient category and now it shows infant category for this ventilator.

There is also Admit Patient column specially for entering patient data and the Status column

for the general status of machine such as battery, oxygen cell and expiratory membrane life

span. There is also Additional Setting column for Additional Value parameter setting. Other

than User Interface in the touchscreen panel, there are also few keys or button that also

function as parameter setter for the ventilator. There are also some rotary dial that will be

26

used to set the values of any parameter on the ventilator. All of these keys and rotary dial are

shown in the figures below.

Figure 9. Fixed keys, Quick Access Keys and Main Rotary Dial

Figure 10. Direct Access Knob and Special Function Keys

All these knob and keys have their own function. It will be explained in detail in the

Appendices section.

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VI. Starting Ventilation

To start a ventilation, first a mode need to be selected. The mode should be selected

from the modes provided on the Touchscreen panel.

Figure 11. Selecting ventilation mode

After mode is being selected such as Pressure Control like in the figure above, parameters

such as PEEP, respiratory rate, and oxygen concentration can be set using the Direct Access

Knob. As a reminder, the changes made using Direct Access mode will be automatically

applied to the next cycle of breath without any confirmation. After all setting is done the

Standby key beside the Direct Access Knob is pressed to start the ventilation.

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Select mode from here

Figure 12. Standby button for start ventilation

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Press to start ventilation

VII. Alarm Types and Alarm Handling

In Servo – I V3.1, there are actually three types of alarm. These alarm are high

priority alarm, medium priority alarm and low priority alarm. High priority alarm is indicated

by red colour while medium and low priority alarms are indicated by yellow colour. The high

priority alarm will turn into yellow colour after it is fixed or reduced. Details of several

important high, medium and low alarms and action needed to be taken to fixed the alarm will

be explained in the table below.

Alarm messages Possible Cause Remedy

Apnea Preset or default alarm exceeded. Time between two consecutive inspiratory exceeded the limit.

Check ventilator setting, patient and breathing system.

Gas supply pressures: Low Air and O2 is below 2.0kPa Check gas connection for any leakage

Expiratory Minute Volume: Low

Preset or default alarm exceeded.

Check breathing system and patient. Change alarm limit settings

No battery capacity Less than 3 minutes of battery capacity

Change power supply to mains and recharge battery.

Paw high Airway pressure exceed Upper pressure limit

Check patient and also breathing system. Check also ventilator and alarm settings.

Restart ventilator! Software related error Restart ventilator and perform Pre-Use check.

Table 4. High priority alarms

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Alarm messages Possible Cause Remedy

Air supply pressure: Low Air supply below 2kPa Check gas supply lines and perform Pre-Use check

Battery operation Mains voltage disappears Check mains connectionCheck Y sensor Y sensor in not working

properly or not connected to patient breathing system.

Check sensor connection or replace Y sensor module

Inspiratory flow over range Combination of settings exceed allowable inspiration flow range

Check ventilator settings or increase the gas inlet pressure.

Nebulizer disconnected Cable connection problem or nebulizer disconnected during nebulization.

Connect nebulizer or change cable connection.

Respiratory rate: High Respiratory frequency too high. Auto triggering.

Attend patient and check trigger settings.

Table 5. Medium priority alarms

Alarm messages Possible Cause Remedy

Touch screen or knob press time exceeded.

Screen or knob has been pressed for more than 1 min. Screen or knob hardware time out.

Check screen and knobs. Contact technician if problem persist.

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VIII. Cleaning and maintenance

Servo – I ventilator must be clean and maintain regularly to make sure that it perform

to the fullest and to make sure that any bacteria or harmful virus did not spread into patient’s

body through the patient circuit. For cleanliness of the machine, any blood or other form of

liquid should not left dry on the machine. This is to prevent any bacteria to build up at the

machine. To clean the body of the machine, soap or bacteria disinfector should be used. The

patient unit must also be cleaned especially in the ventilation area such as the fan to prevent

any dirt from built up in the patient unit. This is to make sure that in the future, the dirt does

not interrupt the function and ventilation of the Servo – I itself.

Figure 13. Fan of the patient unit that need cleaning for clear ventilation of the Servo

– I itself

Next feature of cleaning would be the cleaning of the expiratory cassette. It is

recommended that the expiratory cassette is cleaned with soap or medical dish disinfector.

But the use of alcohol is also can and isopropyl is used. The use of glutaraldeyhde however is

not recommended. After cleaning and rinsing the expiratory cassette, it should be dried in the

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dryer and not by using any pressure or force as it may damage the expiratory membrane.

However, the expiratory cassette can be shake a little bit to let out all the liquid from the

disinfectant earlier. The best is to hang the expiratory cassette vertically in the dryer. The

expiratory cassette should be dry or it will fail the Pre – Use check. Sterilization can also be

done on the expiratory cassette but it is not recommended as autoclaving can reduce the

lifetime of the expiratory cassette itself.

To make sure that any bacteria from patient is not exposed to the surrounding

environment, Servo Guard bacteria filter is mounted in the expiratory outlet. The inspiratory

inlet is also mounted with filter to prevent any bacteria from outside environment to enter the

patient circuit and patient’s lungs.

Maintenance of Servo – I is including the maintenance kit of the Servo – I itself and

the replacement of other parts such as battery and expiratory membrane. Maintenance kit

mentioned earlier is including filter of the gas module, nozzle unit for gas module, bacteria

filter for inspiratory circuit and bacteria filter for oxygen cell. This kit actually need to be

changed every 5000 hours. The oxygen cell must also be replaced if its status shown in the

Status menu in the User Interface is less than 10%. After replacement, a Pre – Use check

must be performed. The membrane of the expiratory cassette is also recommended for

exchanged if its status is shown as 0% in the Status menu. Even though the status shows that

the status is already 0%, the membrane still can actually be used, but the manufacturer

suggest that it should be replaced. The handling of expiratory should be done as in the Figure

15.

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Figure 15. Handling of expiratory membrane

Figure 16. Parts of the expiratory membrane

After replacing the expiratory cassette, it lifespan value should be reset back to 100%

in Biomed menu right after Pre – Use check is done.

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IX. Troubleshooting

In troubleshooting, there is actually two parts which is action needed for Pre – Use

check error and also the Technical errors. This report will explained some of them and the

full troubleshooting procedure can be refer from the Service Manual of the Servo – I V3.1.

Pre – use Check

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Technical Error Codes

36

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X. Planned Preventive Maintenance

This section will explained about the procedure and tools used in doing Planned

Preventive Maintenance by Biomedical Engineer Maintenance and Service staff. In the

planned preventive maintenance, the most important will be the safety test and also the test

that included in the checklist provide by Ministry of Health. Basically there are two

equipment needed which is the ventilator analyser and also the safety test analyser. The

model used for ventilator analyser in this PPM is Certifier FA Plus which is manufactured by

TSI company. Some of the parts of the ventilator analyser is shown in the figures below.

Figure 17. Certifier FA Plus kit

Figure 18. High Flow Module

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Figure 19. Oxygen sensor tester

To perform PPM, the ventilator should be connected to the analyser as shown in Figure 20.

After connection is done, parameters such as Tidal Volume, Breath Rate, FiO2 and Peak

Inspiratory Pressure are set in a certain value according to the checklist. The value set should

be display in the Certifier FA Plus and must be within the range given.

39

For safety test, safety test analyser is used. The voltage, current and the resistance are

measured in this test. Earth leakage current and leakage current is also included in the

procedure. Details about the value will be shown in the Appendix section.

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XI. Asset Management

Asset management is severely important in every BEMS department and also

hospitals. Document such as KEW – PA is important as it is considered as a birth certificate

for a machine. It will later useful for variation order or beyond economic procedure which is

very important for a machine. Testing and commissioning form is also important as it will be

the from that needed for a machine to be registered to the Central Management System.

Other than that, there is also Condition Appraisal form that needed for beyond

economic repair procedure. This form is actually not available for Servo – I since there is no

Servo - I ventilator that need to undergo BER. Other form such as Material Request form is

also important as it is the form used for ordering any parts that need to be replaced. All these

forms will be shown in the Appendix section.

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Conclusions

From this report it can be conclude that Servo – I is actually important in treating

patient with respiratory problem. Other than easy to use, it also give much user friendly

function such as touchscreen interface. The asset management form such as Training and

Commissioning and KEW-PA is also important for any asset especially Servo – I so that

proper disposal of the machine when it undergo Beyond Economic Repair can be done.

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References

1. American Association of Respiratory Care. (1992). Humidification during Mechanical

Ventilation. Journal of Respiration Care. 37. pp 887 – 890.

2. Artour Rakhimov. (2011). Normal Respiratory Rate and Ideal Breathing. Retrieved

July 20, 2011 from Normal Breathing website:

http://www.normalbreathing.com/index-rate.php

3. Catherine Carbery. (2008). Basic Concept in Mechanical Ventilation. Retrieved June

29, 2011 from Bnet website:

findarticles.com/p/articles/mi_m074B/is_3_18/ai_n31345616

4. Cheryl Jakab. (2006). Respiratory System. Smart Apple Media. Minnesota.

5. Geddes LA. (2007). The History of Artificial Repiration. IEEE Engineering in

Medicine and Biology Magazine. 26(6). pp 38 – 41

6. Maquet. (2004). Servo – I V3.1 Service Manual. Maquet Getinge Group. Sweden.

7. Robert Chartburn. (2003). Fundamentals of Mechanical Ventilation: A Short Course

in The Theory and Application of Mechanical Ventilators. Mandu Press Ltd.

Cleveland.

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Appendices

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45

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47

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49

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51