Cardiac Output - nSpire Health
Contents
1. 1 1 70 HbO2 4 2 0 HbO SP 0 5 701 HbO gt 2 ssl l o 50 T A 7 9354 8 975 Hb 507 Physiologische Kurve L 40 nijiet hake ea 55 40 50 60 mm Z CO Gehalt im E 0 Vollblut bei einer 30 0 Satti 60 ka 2 S ttigung von 5 l In LA 50 8 20 5 40 1 w 30 al 10 205 5 wi 0 0 10 20 30 40 50 70 80 10 20 30 40 50 60 70 80 90 100 CO Spannung mm Hg 0 oder CO Spannung mm Hg Abb 42 Dissoziationskurve f r CO Standard CO dissociation curve to convert into Cocoa Comroe 1959 The Lung Clinical Physiology and Pulmonary Function Tests ZAN 600 Cardiac Output 6 19 Part No 4 Hardware Set Up 4 1 Required Components INSPIRING RESPIRATORV HEALTH t PN ass N al The components above needed to perform the cardiac output measurement according to the indirect Fick principle A ZAN600 measurement instrument B ZAN610 controller Measuring head consisting of 1 Ergo Flow Sensor 2 Pneumo Valve 3 Breath Filter Adapter 4 Breath Filter 5 Breathing Bag Adapter 6 Breathing Bag Two set s of tubing are needed 1 One set with three tubes colours blue yellow white black to connect the ZAN600 with flow s2. Spire NSPIRING RESPIRATORY HEALTH Cardiac Output User Manual Part Number xxxxxxx ENG Version Revision A TAR INSPIRING RESPIRATORV HEALTH Disclaimer Information in this manual is subject to change without notice and does not represent a commitment on the part of nSpire Health The software described in this document is furnished under a license agreement The software may be used or copied only in accordance with the terms of the agreement It is against the law to copy the software on any medium except as specifically allowed in the license or nondisclosure agreement No part of this manual may be reproduced or transmitted in any form or by any means electronic or mechanical including photocopying and recording for any purpose without the express written permission of nSpire Health The software is provided as is without warranty of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular purpose Some states do not allow the exclusion of implied warranties so the above exclusion may not apply to you This warranty gives you specific legal rights and you may also have other rights which vary from state to state nSpire Health does not warrant that the functions contained in the system will meet your requirements or that the operation of the system will be uninterrupted or error free In no event will nSpire
3. equilibration In any case the test person must be instructed carefully so he knows about the effects of the test gas and does not get scared during the procedure 3 1 Measured and computed parameters VCO2 l min CO volume flow measured is the mean of the last n breaths before start of equilibration manoeuvre n is configurable PmvCO2 mm Hg mixed venous CO partial pressure measured alveolar partial CO2 pressure measured at rebreathing equilibrium PetCO2 mm Hg End tidal CO partial pressure measured mean of the last n breaths before start of equilibration manoeuvre n is configurable 96 Oxygen saturation mixed venous 96 Oxygen saturation arterial CmvCO2 ml l concentration mixed venous ZAN 600 Cardiac Output 5 19 Part No Cardiac pire User M INSPIRING RESPIRATORY HEALTH Formulas YOO CardOut cmvco2 Catos cmvco2 Cco2FromPco2 pmvco2 SmvO2 caco2 Cco2FromPco2 petco2 SaO2 To convert alveolar partial pressure to mixed venous arterial partial pressure the following formula is used 25 5 0 9 PA 0 0021 Vt With Pa arterial partial pressure PA alveolar partial pressure Vt tidal volume Jones Clinical Exercise Testing Cco2FromPco2 X Y is a function to extract cmvco2 and caco2 concentrations values from partial pressures using the curves below 70 1
4. ESPIRATORY HEALTH The mass of the pulmonary artery M is equal to the mass of CO exhaled Mex and the mass of returning to the left heart Mp M M Masses of a gas can be expressed as concentration multiplied by volume Using this Da Py Ga dO TES In a closed circuit we can say g Lure amas em ax Fy pr i ex ie Cp B Ch A volume divided by a time is a stream Dividing both sides of the equation by the time Fo 01 P Cp i Abbreviations p CardOut T Ca b es T WC Lardlut Cy ii Ci CardOut Cardiac output VCO stream measured during tidal breathing C CO concentration in the blood of the pulmonary artery Ch concentration in the blood of the pulmonary vein Now there is a formula to calculate the cardiac output from the exhalation the concentration in the blood which arrives in the lung and the concentration in the blood which leaves the lung The CO concentration in exhalation stream can be measured directly What is needed is to find out about the concentrations in the lung vessels before and after it has passed the alveoli ZAN 600 Cardiac Output 3 19 Part No A INSPIRING RESPIRATORV HEALTH diffusion from the vessel V to the alveolus A Carefull examinations proved that the concentration in the blood whic
5. Health be liable to you for any damages including any lost profits lost savings or other incidental or consequential damages arising out of the use or inability to use such system even if nSpire Health or an authorised nSpire Health dealer or distributor has been advised of the possibility of such damages or for any claim by any other party In the event you should have any claim whether based on the license agreement express or implied warranty or otherwise you agree to accept refund of your money in full satisfaction of your claim oome states do not allow the limitation or exclusion or liability for incidental or consequential damages so the above limitation or exclusion may not apply to you www nspirehealth com Manufactured for nSpire Health Inc Tel 1 800 574 7374 1830 lefthand Circle Email sales nspirehealth com Longmont Colorado 80501 USA Authorized Representative nSpire Health Ltd Tel 44 0 1992 526 300 Unit 10 Hartforde Court Email info nspirehealth com John Tate Road Hertford SG13 7NW U K nSpire Health GmbH Tel 49 097 36 8181 17 Schlimpfhofer Strasse 14 49 097 36 8181 27 D 97723 Oberthulba Email zan nspirehealth com Germany we YiSpire INSPIRING RESPIRATORY HEALTH Preface Thank you for purchasing the Cardiac Output option The product complies to the newest state of technical development In order to improve the lifetime of this product only materials of extremely high qu
6. P 8 43 ASSEMBLY STEP 2 MR 9 4 4 ASSEMBLY STEP 8 cccccccecececcccececsceccececececucaucusacaucesecseauausacecseauaesecseaueusacseucauaenscseaueesecseasaenans 10 25 ASSEMBLY STEP A ie a aa ha 11 4 6 ASSEMBLY STEP 5 SERA IR DRDA ERAS 12 eee A a A i 13 5 SOFTWARE OVERVIEW 2uicssivsseusesskeeXen2 eue sv op ese eue sive eub aes 14 6 MEASUREMENT GUIDELINES e eee eee eee eee eee sees 15 7 PERFORMING A MEASUREMENT sesessesesecsesecccsesecscsececsesecccsesecsesesecsesecseseseosesesecsesescesesecsesesecsesesees 15 7 1 GVMBOL DEFINITI OM EE E atc E a EATE 16 EVALDA E E A 17 9 END OF MEASUREMENT cccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccsccccccccccccccccccccccccccccccoccocess 17 10 REVIEWING CARDIAC OUTPUT 5 18 ZAN 600 Cardiac Output 1 19 Part No A wef Yispire INSPIRING RESPIRATORY HEALTH Cardiac Output Using the Fick Principle 1 History The Fick principle was firs
7. Procedure Performing the procedure is easy All the test person has to do is perform tidal breathing The procedures starts with the invocation of the CardOut subroutine or emptying of the bag and then starting the CardOut programme The system is measuring the tidal breath volume and computes the mean values of VI VCO2 and PETCO2 After the test has been started the system fills the breathing bag with a volume 1 5 times more than an average tidal breath with the test gas The test gas is composed of 10 and 90 The automatic valve switches to rebreathing position and the measurement is displayed in the measurement window After 12 seconds the system assumes the equilibration to be completed switches the valve back to normal breathing position and computes the result line displayed in the window The result line can be adjusted manually to the perfect position If equilibration takes longer or shorter than 12 seconds the time the systems samples data can be modified changing a parameter in the config ini file After the measurement the system waits 60 seconds to start normal data sampling again to avoid artificially high values getting mixed with regular CPET measurement values Although the test gas is not harmful to the test person breathing 10 CO is not very comfortable Some people feel a increasing hunger for breath and force breathing With regards to the test this is a beneficial effect and leads to quicker
8. ality are used All materials are environmentally safe and can be recycled The manual provides instructions for set up and use the cardiac output option together with the ZAN 600 device The instructions in this manual assume the user is familiar with the intended use and application of pulmonary laboratory systems To avoid damage to the devices or incorrect measurement it is strongly recommended to follow the introductions in the manual and the technical description Your nSpire Health Team Schlimpfhofer Str 14 97723 Oberthulba Germany TM Tel 449 9736 8181 0 re Fax 449 9736 8181 20 INFO NSPIREHEALTH COM WWW NSPIREHEALTH COM nSpire Health GmbH ET User Mi INSPIRING RESPIRATORY HEALTH Table of Contents 1 HITORI d 9 2 2 THEORETICAL BALCKCOROUND E euius Ue 2 3 OVERVIEW OVER THE PROCEDURE u cecccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccccscccccs 5 3 1 MEASURED AND COMPUTED PARAMETERS sccsceccecccececcececcecuccececaceucuenecueaecsececuuaucueaeueceuaecsuaesass 5 4 HARDWARE SETUP i Rar AAAF Ean 7 41 REQUIRED COMPONENTS a kiri nia ea ji ae i sua 7 A2 ASSEMBLY SIE
9. button or alternatively press P to empty the breathing bag and toggle the pump to test if all equipment is up and running v Pressing the button or the F5 key opens the measurement window below Cardiac Output 1 4 6 E Ff 4 14 H Cardiac output measurement window Basicallv all menus have a e button ESC to cancel the current procedure and return to next higher level It is possible to perform the cardiac output measurement during a running CPET procedure when the measurement head is connected to a headset ZAN 600 Cardiac Output 14 19 Part No A Cardiac ispire User Mar INSPIRING RESPIRATORV HEALTH 6 Measurement Guidelines e Valve of the gas cylinder is open close again after measurement e Correct gas mixture 10 90 Os medical gas e Breathing bag must be completely empty before start e Use breathing mask or nose clip e Take care to protect the test person against tumbling or collapse Important We recommend that a doctor or other suitably qualified and experienced physiologist be present during every stress test A defibrillator should be available The stress test should be terminated if the heart rate blood pressure or other vital parameters reach critical values or if abnormalities become apparent in the ECG signals 7 Performing a Measurement The Patient puts on the nose clip and starts with normal tidal breathing throu
10. e valve Left and right is determined from the patient s point of view Black tube in the left and blue tube in the right connector ZAN 600 Cardiac Output 10 19 Part No A 6 Cardiac Output pire User Manual INSPIRING RESPIRATORY HEALTH 4 5 Assembly Step 4 Connect the tube with the black connector to the outlet of the ZAN600 marked with the word Analyse Connection at the ZAN600 side T LE LN E fe p CN T d utu f sat m ike Pa FUP e 4 J1 tU Kor Fu AL 7 Lj Connection at the pneumo valve side Connect the tube from the Analyse port to the connector on the top of the pneumo valve see above ZAN 600 Cardiac Output 11 19 Part No A we pn INSPIRING RESPIRATORY HEALTH 4 6 Assembly Step 5 Connect the tubes with the yellow and blue marks to the outlets of the ZAN600 JA Erra TEA E DE nei ck i MEE EN L ei NR Connect the tube with the blue mark proximal and the vellow distal on the flow sensor ZAN 600 Cardiac Output 12 19 Part No we pn INSPIRING RESPIRATORY HEALTH 4 7 Assembly Step 6 Connect the tube from the pressure reducer of the gas cylinder to the connector at the back of the ZAN610 NS EO TT Proper connection of the tube from gas cylinder Check all connection for tight
11. ensor and gas suction outlet 2 And the other set colours blue black and yellow to connect the ZAN610 with the pneumo valve ZAN 600 Cardiac Output 7 19 Part No A INSPIRING RESPIRATORV HEALTH 4 2 Assembiv Step 1 Plug together all parts of the measuring head like shown below Patient side Make sure the outlet on the Ergo Flow sensor is locked with a stopper Measuring head assembled Check if all parts fit tightly together ZAN 600 Cardiac Output 8 19 Part No ispire INSPIRING RESPIRATORY HEALTH 4 3 Assembly Step 2 Connect the tube with the yellow mark to the Bag outlet of the ZAN610 on one side and the connector of the pneumo valve on the other side as shown in the pictures The connectors are marked with arrows Gas tube connection at the ZAN610 Connect the gas tube to the bottom part of the pneumo valve ZAN 600 Cardiac Output 9 19 Part No A we Yispire INSPIRING RESPIRATORY HEALTH 4 4 Assembly Step 3 Connect the tubes with the black and blue marks to the outlets of the ZAN610 The black tube belongs to the connector marked as Valve L and the blue one belongs to the connector marked as Valve R ET T E ir JETAP 1 uis Tubing at the ZAN610 Next connect the black tube to the left connector of the pneumo valve and the blue one to the right connector of th
12. gh the mouth piece If the patient is under CPET examination he she already has the mask on with the measurement head mounted on the outlet v Open the cardiac output measurement window by pressing the x F5 button Let the patient perform tidal breathing for at least 5 breaths Crys Press the op P button to empty the breathing bag This button has identical functionality as the button in the CPET menu see above ae After the bag is emptied press the xe Enter button to start the procedure Cardiac Qutput E x LI u 1 4 r ID di df H Window before starting the procedure The system starts filling the bag with test gas with 1 5 times the volume of a single tidal breath ZAN 600 Cardiac Output 15 19 Part No A Cardiac 2 INSPIRING RESPIRATORY HEALTH When the bag is filled the window aspect changes and the pneumo valve switches to rebreathing position Cardiac Output D HE 13 34 15 Start of measurement In the window the rebreathing curve is displaved The patient continues breathing After a predefined time default 12 sec the display switches to the image below and displays the results The pneumo valve switches back to normal position automatically Cardiac Output Hesult Cardiac output 6 82 l min 20 0 1 2 3 4 6 6 7 8 Q9 13 4 15 End of measure 7 1 Symbol Definition S Press thi
13. h leaves the lung can be calculated with appropriate accuracv from the the concentration the at the end of exhalation end tidal CO concentration D 090 e Indirect Fick Method non invasive using a Rebreathing Bag R CO The CO concentration of the blood which arrives the lung can be calculated from the the concentration the at the end of the equilibration while rebreathing into a Douglas bag There are two different methods to determine the equilibration point The extrapolation method by Defares and the plateau by Collier The Collier method turned out toprovide the best results for adult individuals B 22M fee Poor Bak Vi Plateau method Collier to determine the cardiac output The method is a good way to approximate the cardiac output especially under load and without invasive techniques It is easy to perform the test for both the test person and the researcher The disadvantage is that the test is not very exact compared to direct methods or Doppler ultra sound measurement which both have some problems to provide results under load The pulmonary shunt volume is not included in the model which leads to the effect that the results are more accurate under load then in rest condition ZAN 600 Cardiac Output 4 19 Part No NEL il Cardiac pn JM User Nar INSPIRING RESPIRATORY HEALTH 3 Overview over the
14. ness Connect the USB connectors of the ZAN600 and the ZAN610 devices to the computer The set up is now ready to work ZAN 600 Cardiac Output 13 19 Part No A TAR pire INSPIRING RESPIRATORY HEALTH 5 Software Overview The procedure is part of the cardiopulmonary exercise test software After starting the CPET option from the main program two additional buttons in the top menu are displayed to control the cardiac output measurement procedure tiles 28 oe BX adm Sequence of Test Total Time s Time to go s Protocol 25W 2511 2min gt 25mm s Rhythm trace ll 10 725 Stage f 00 20 24 ven ST limit 2 00mm Ref 1 20mm LI mifminikg change to diagram Time CO2 vo2 Time EQO2 EQCO2 IPetCO2 lO2puls ITime RRdia IsT V5 HR WU Start ra gt Posteingang Mier wergo VE RER fi GPI200 wergo Microsoft Innocor E Cardio Pulmona 4 Spacelabs Healthc tema GER 10 38 CPET Main Window 3 The ees
15. re INSPIRING RESPIRATORY HEALTH 10 Reviewing Cardiac Output manoeuvres All manoeuvres can be reviewed offline with a Cardiac Output Viewing tool To review a specific manoeuvre open the folder C ZAN GPI200 COP with the Windows Explorer and double click on the manoeuvre data file for example ZBodyATSTEST 160309 184250 cop This will open the correspondent window Cardiac Output X 2 Cardiac Output 5 54 s B8 vy 8 2 Jw 12 132 14 15 Use the E up arrow or 25 down arrow buttons to move the result line to find a better match Clicking on toolbar button or the F3 key displays the primary and secondary data from the calculation Calculation XI WOO as K p mw 46 376846 Cancel pet CO2 14 033733 Smvoz2 0 950000 Sade 000000 cmy CO 513 129517 455 541687 _ Changes made during this operations will not be saved to disc ZAN 600 Cardiac Output 18 19 Part No A
16. s button or Enter to save the results and end the d procedure a Press this button or the up arrow key to move the result line upwards one step Ae Press this button or the down arrow key to move the result line downwards one step ZAN 600 Cardiac Output 16 19 Part No A lt Cardiac User INSPIRING RESPIRATORV HEALTH e Press this button or ESC to cancel the procedure without saving 8 Evaluation e Before saving the results with adjust the result line so that it meets the last measured lower half wave This represents the last measured expiration Cardiac Output m Cardiac output 6 82 l min Last measured expiration 1 3 4 6 7 8 WH 117 1214 15 The result line can be moved stepwise using the up arrow and Be down arrow e Save the results pressing _ or the Enter key 9 End Of Measurement After the measurement close the gas cylinder After the measurement for a limited time no breath by breath data are recorded This time is called the PostTime During the equilibration manoeuvre oxygen is washed into the lungs Therefore after the manoeuvre oxygen is elevated and must be washed out During washout time breath by breath data are not recorded This time interval can be configured as PostTime This time is 60 sec by default and can be modified in the config file ZAN 600 Cardiac Output 17 19 Part No A TAR Spi
17. t described in 1870 by Adolph E Fick a German physiologist 1829 1901 after introducing his law of diffusion in 1855 which allows to calculate the diffusion of a gas across a membrane and which has been named after him Depending on how the gas measurement is done two different ways to use the Fick principle are in use The direct Fick method uses blood gas analysis and is an invasive Method The so called indirect Fick uses measurement of inhaled and exhaled gas in the breath to measure the cardiac output and is a non invasive method nSpire Health provides a procedure based the indirect Fick principle Adolf Fick 2 Theoretical Background In a simplified model of the human blood circuit all blood from the body is pumped by the right heart through the lung and from here to the left heart from where it is pumped through the body again All blood which runs through the lung must be pumped through the left heart to the body again or the lung is flooded with blood and the person will die Therefore in healthy humans we can approximately say that all the blood which passes the lung is the amount of blood pumped by the heart the cardiac output Simplified model of the human blood circuit The indirect Fick method is a way to approximate the amount of blood that perfuses the lung by measuring the exhalation For CO we can write ZAN 600 Cardiac Output 2 19 Part No we Yispire INSPIRING R
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