Mechanical ventilation is an essential part of critical

care medicine.
Three main physiological functions are supported
by ventilators:
oxygenation, i.e. the transport of oxygen
into the alveoli of the lung,
ventilation, i.e. the transport of carbon
dioxide out of the alveoli of the lung,
respiratory activity, i.e. the support of the
inspiratory muscle activity.
It is very difficult to adapt a mechanical ventilator
perfectly to the patient's current needs.
Up to twelve parameters have to be adjusted.
Adaptation is made even more difficult by the fact
that each manufacturer offers several types of
ventilators - each of them with different ventilation
modes and different special features. Even if a
ventilation mode is called equally by two
manufacturers (i.e. synchronized intermittend
mandatory ventilation - SIMV) this does not
necessarily mean the same. Therefore, it is hard for
physicians on an intensive care unit to keep familiar
with all new ventilation modes and parameters,
featured by modern ventilators.
During the weaning process it is most complicated
to optimize mechanical ventilation.
In this phase, the artificial coma is reduced and the
activity of breath muscles has to be supported. The
therapeutic aim is the durable ability to breath

spontaneously without the help of a device. During

this process the patient largely influenced by the
mechanical ventilator and vice versa, and the needs
of the patient may vary within a very short time.
It is the aim of our project to develop an automatic
mechanical ventilation system which relieves the
physicians' from selecting of an suitable ventilation
mode and from permanently adjusting the special
mode parameters to the patient's current situation.
.IS BNT h9e7 8-p3h-y9s5i2c4ia1n7 3-s5h-o5u ld be able to control the
therapeutic mechanical ventilation process with the
colloquial language familiar to him. This should be
applicable in clinical practice to each patient and
with conventional ventilators, too. In addition, our
project requires further information about the
patient, which only can be provided by patient data
management systems (PDMS).
Controlling the ventilator
according to the "Adaptive
Lung Ventilation" concept
Different approaches to adjust the mechanical
ventilator automatically have already been
published. The most advanced solution, which is
suitable for the daily clinical routine, is the
"Adaptive Lung Ventilation" (ALV) concept
developed by Brunner et al [1-2]. It is implemented
in a stand alone" ventilator, i.e. a machine which
cannot communicate with the patient's monitor, the
acid base laboratory or other sources of patient

information [1-4].
The aim of ALV is to maintain a given alveolar
ventilation (V'gA). It is based on a model, which
calculates an optimum respiratory rate (f) and an
optimum tidal volume (VT) by means of the
patient's respiratory time constant (RC) and the
serial dead space (VdS) [5].
Basically, the ALV controller regulates two
ventilatory parameters: (1) the rate of the
controlled applied mechanical cycles (fiMv) and (2)
the inspiratory pressure support (psup) for the
spontaneously generated cycles. Thus, ALV makes
it possible to ventilate patients during their whole
ICU stay: from the time of absolutely paralyzed
respiratory activity during the artificial coma up to
the sufficient spontaneous breathing at the end of
the weaning process.
When using ALV the physician has to set three
ventilatory parameters only:
alveolar ventilation (V'gA): to control the
alveolar ventilation and to support the
respiratory muscle function,
inspirational oxygen fraction (F,02): a
main parameter to provide a sufficient
capillary oxygen tension.
the amount of positive end expiratory
pressure (PEEP): a second parameter
which influences oxygenation.
This is a fundamental improvement. Instead of

selecting a ventilation pattern and adjusting a

variety of parameters, the physician has only to set
the three values mentioned above. But, since this is
a stand alone" concept, there are some limitations:
Oxygenation is controlled by F ^ and PEEP.
The ventilator, however, neither detects the
oxygenation need, nor controls these
parameters automatically.
The ALV ventilator controls the selected
target-V'gA but does not detect whether
ventilation is adequate to the patient's current
situation.
The ALV controller supports the respiratory
activity by adaptive pressure support. But, the
respiratory activity itself is not controlled. For
the weaning process it would be useful to
control the respiratory activity, too, in order to
increase or decrease the patients' portion of the
work of breathing (WOB) depending on the
fitness (ability) of the respiratory muscles.
The physician' therapeutic decision is made in
colloquial language (e.g. 'standard therapy', or
'slight hyperventilation at low respiratory
muscle activity'), which has to be transformed
into the parameters V'gA, PEEP and F[02.
The aim of our project is to overcome these
limitations. Therefore, two additional components
are necessary:
We need more information about the patient,

i.e. monitoring measurement data, the results of

the acid base laboratory and data of the clinical
laboratories and clinical observations.
A system which can deliver these information
is the PDMS. A data connection to this system
is needed.
The decisions to be made are very complex. A
mathematical model is not available. It is
necessary to integrate medical knowledge into
the automatic decision process with the help of
a knowledge based system (KBS). We are
going to use the FLORIDA system, which is a
suitable instrument for processing medical
knowledge [6-8].
Concepts in the FLORIDA
knowledge-based system for
the translation of medical
knowledge
To establish an expert system for use in medicine it
is not only necessary to transform the knowledge
into it, the way humans use this knowledge has to be
implemented too. Our concepts for processing the
knowledge are the result of discussions with
physicians to find out how they think. With the help
of the following principles we tried to come as
close as possible to this human way of thinking. So
not only the knowledge itself but also the intrinsic
meaning is conserved.
The knowledge base (KB) is built from medical

knowledge in linguistic form. Our task was to form

it by the help of only a few examples from indistinct
formulated rules that explain common principles.
This can be reached with fuzzy logic.
If we look closer at the classification of
physiological functions we see that there are usually
independent components which cover different
physiological effects. We introduced the concept of
knowledge constituents for this task. Knowledge
constituents serve as a tool to value the different
aspects of a physiological state. An aspect is an
independent pointer to a dysfunction and will be
transformed into a knowledge constituent in
FLORIDA. Different aspects are based on different
physiological principles. They can intensify or
neutralize each other. Neutralization leads to
contradictions in the result.
The quality of input data varies over time. We have
to take into account missing values or values
measured some time ago. We manage this by
introduction of age and span of the input data:
Physicians are able to give an estimation about the
patient's state even if some of the input data is
missing or aged. The results are less certain in such
a circumstance. In FLORIDA each input variable
has an individual span. At the current time each
measured value has an age. Vital signs are measured
quite often and are typically 'young'. Most lab
values are determined once a day and more often

older. The significance of older values is reduced.

In FLORIDA we consider this by reducing the
importance during the span linearly. The
importance of input leads to the importance of a
result for a knowledge constituent.
A knowledge base processed by FLORIDA contains
the limits of all fuzzy sets for the input parameters.
These fuzzy sets are connected with linguistic
values (like normal or high) and their meanings. In
some cases such a meaning is not adequate to the
current state of a patient. The reason can be the use
of a special therapy or may depend on the patient
itself, for example on age or sex. If there exists the
knowledge which values count as normal in a
particular situation, FLORIDA is able to adapt the
fuzzy set limits. In such cases physicians must be
able to tell what is the normal then or there exist a
method for calculating this value form other
information.
Resulting values for the physiological dysfunctions
have to show the quality of the available input data.
As output we use the triage of intensity, certainty
and consistency for the description of a result. Here
intensity classifies the physiological effect and is
therewith the main result. It is calculated by
defuzzysation. It is further important to know to
which degree the aspects intensify or neutralize
each other. For this reason we introduced the result
consistency. A maximal value of consistency means

the absence of contradictions between the aspects.

The certainty reflects the quality of input for a result
in form of the importance of the knowledge
constituents used for it. Therewith, certainty and
consistency reflect the reliability of the result.
A knowledge base processed by FLORIDA contains
the limits of all fuzzy sets for the input parameters.
These fuzzy sets are connected with linguistic
values (like normal or high) and their meanings. In
some cases such a meaning is not adequate to the
current state of a patient. The reason can be the use
of a special therapy or may depend on the patient
itself, for example on age or sex. If there exists the
knowledge which values count as normal in a
particular situation, FLORIDA is able to adapt the
fuzzy set limits. In such cases physicians may be
able to tell what is the normal then. However, the
definition of a fuzzy variable requires seven values.
To solve this conflict we decided to implement a
simplified method of adaptation fuzzy set limits.
FLORIDA is able to explain its results. The
explanation consists of three parts:
_ a linguistic description of the knowledge
integrated in the knowledge base,
_ a description of the result in colloquial form,
_ the reasons for the result,
_ missing input: This values has to provided to
increase certainty,
A more detailed description of FLORIDA can be

found in [8] and in the additional material [9].

Concept of an automatic
control system for mechanical
ventilators
Fig. 1 gives an overview about the designed system.
Please refer to this figure when you read the
following explanation. The database for the new
automatic mechanical ventilation control system is
the PDMS. It comprises all electronically available
clinical observations and measuring values about
the patients' current state and history.
Thus, the technical controller receives almost the
same information available as the human controller
in the form of the physician. This is a decisive
advantage compared with the 'stand alone'
ventilators, which obtain their information
exclusively from measuring signals such as airway
pressure, flow, volume, C02 and 02 gas fraction.
Basis of the knowledge processing is the KBS
'FLORIDA' which involves two different
knowledge bases (KB). The first (left branch) is the
KB for the assessment of oxygenation, ventilation,
and the respiratory activity. It describes the
patient's actual respiratory state with numerical
values for oxygenation, ventilation, and the
respiratory activity.
The second (right branch) is the KB for the
interpretation of the therapeutic decision. The
physicians made their therapeutic decision in

colloquial language. Therefore notations like

'standard therapy' or 'slight hyperventilation at low
respiratory muscle activity' are used. The KB has to
interpret these notations in connection with specific
patient information (age, weight, previous diseases
...), his current critical disease and the previous
clinical development and to calculate numerical
target values for oxygenation, ventilation and the
respiratory activity. Basic roles for a 'standard
therapy' of mechanical ventilation have to be
defined and implemented for this purpose.
Additional facilities are necessary to give the
physician the possibility to deviate from the
standard therapy in case of a special disease (e.g.
'hyperventilation without muscle activity' at the
beginning of the treatment of a severe head trauma
or 'normo ventilation with minimum alveolar
pressure stress' in case of injured lung tissue). Thus,
this KB transforms the physician's decision into the
numerical target values for mechanical ventilation.
The numerical values for the patients' actual and
target states are the input values for the mechanical
ventilation controller and the parameter generator.
It involves two consecutive functions: (1) control
algorithms to minimize the differences of the actual
values and the target values by calculating
numerical control values for oxygenation,
ventilation and the respiratory activity and (2)
parameter generator algorithms, which are able to

transform the control values into the specific

parameters of the conventional ventilatory modes
(e.g. ALV or SIMV, BIPAP...).
The parameters of the conventional ventilatory
modes are the output values for the mechanical
ventilator. In case of ALV they are V'gA, FI02
and PEEP. They are visualized by the PDMS
together with numerical values about the patient'
actual and target states.
In the first step of the system test these values must
be confirmed by a physician and handled manually
(open loop control) in each case. In the second step
the mature system should be able to control the
ventilator directly (closed loop control).
4206
Visualization serves only for the physicians'
information then.
The ventilation control system contains two closed
loops:
The first loop ensures a set of target values
(e.g. O? and C02 partial pressures in the
alveoli) which are obtained by the
interpretation of a special therapeutic decision.
Deviations from the therapeutic goal are under
the control of this loop.
The second loop is to adapt the therapeutic
decision on the patient's requirements of
mechanical ventilation according to the rules of
the 'standard therapy'. The requirements may

vary as a result of the ventilation itself or other

therapeutic interventions. In both cases the
system detects the changed requirements and
adapts the target values of the fist loop.
Though this concept is very promising there are still
a number of problems to be solved, typical
problems connected with knowledge processing in
medicine:
1. What does optimization of ventilation,, really
mean? The best way to ventilate a patient is still
under discussion. We have to define a 'standard
therapy' for ventilating patients'.
We are well aware of the fact that such a
automatically applied standard therapy will not
meet with positive response by all physicians. We
know there are still a lot of clinical studies to be
performed until something like the best way to
ventilate a patient,, will be found.
2. Decisions in medicine are not only guided by
measurable parameters. Many clinical observations
(e.g. is the patient calm or not, does he/she breathe
regularly, does he/she sweat ...) form a subjective
impression which is still very important for decision
making. To find a technical solution for an adequate
and objective computer-base description of those
clinical observations which is suitable for the
application in the daily clinical routine is one of the
main tasks of this project.
References

[1] T.P. Laubscher, W. Heinrichs, N Wieler, G.

Hartmann and J.X. Brunner, An adaptive lung
ventilator controller, IEEE Trans. Biomed. Eng. 41
(1994)51-60.
[2] T.P. Laubscher, A. Frutiger, S. Fanconi, H. Jutzi
and J.X. Brunner, The automatic selection of
ventilation parameters during the initial phase of
mechanical ventilation, Intensive Care Med. 22
(1996) 199-207.
[3] U. Hannemann, J.X. Brunner, U. Klrin and
R.Freyer, Adaptive Unterstutzung der
Spontanatmung mit Negativ-Impedanz-