Modes of Mechanical Ventilation

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Modes of Mechanical Ventilation
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Points of Discussions

• Advanced Basics
• Flow and Time
• Limit and cycling
• Rise Time
• Volume vs Pressure Control
• Mandatory Modes of Ventilation
• Controlled Mandatory Ventilation (CMV or IPPV)
• Triggered Modes of Ventilation
• Continuous Positive Airway Pressure (CPAP)
• Pressure Support Ventilation (PSV)
• Hybrid Modes of Ventilation
• Assist Control Mode (A/C)
• Synchronized Intermittent Mandatory Ventilation
  (SIMV)

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Respiratory Cycle
TransitionExpiratory Cycling
Inspiration
TransitionInspiratory Cycling
Expiration
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Mandatory, Spontaneous and Triggered Inspiratory
Cycling
M
M
M
M
M
M
S
S
S
M
M
Tsupp
Tsupp
Tsupp
Tsynch
M
Tsupp
Tsupp
Tsupp
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Pressure Limited Breath
Volume
Pressure Limit
Time
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Expiratory Flow Cycling
Flow
100
Flow Cycling
50
Time
7
Volume Controlled Inflation
Pressure
Flow
Tidal Volume
Volume
Time
TI
TE
8
Volume Control Breaths
50
Decreased Compliance
SEC
1
2
3
4
5
6
-20
120
INSP
Flow
SEC
1
2
3
4
5
6
L/min
120
EXH
If compliance decreases the pressure increases to
maintain the same Vt
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Pressure Controlled Inflation
Rise Time
Pressure
Peak Inspiratory Flow
Flow
Tidal Volume
Volume
Time
TI
TE
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Volume/Flow Control Pressure Control
Inspiration
Expiration
Inspiration
Expiration
20
20
Pressure
0
0
2
2
1
0
1
20
20
Volume
0
0
2
2
0
1
0
1
3
3
Flow
Time (s)
Time (s)
0
0
-3
-3
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Rise Time
Pressure
Flow
Volume
Time
TI
TE
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Volume Control with End-Inspiratory Pause
End Inspiratory Pause
Pressure
Flow
Tidal Volume
Volume
Time
TI
TE
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Relationship between Tidal Volume, Inspiratory
Time and Flow
Volume
VT 3
Exp
Insp
Flow 37.5 L/min
VT 1
Flow 30 L/min
VT 2
Flow 15 L/min
Time
Ti a
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Relationship between Tidal Volume, Inspiratory
Time and Flow
Volume
Exp
Insp
Insp
Insp
Exp
Flow 60 L/min
Flow 30 L/min
VT 1
Flow 20 L/min
Ti b
Ti c
Time
Ti a
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Triggered Modes of Ventilation

• CPAP and PSVV

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Spontaneous Breathing
Pressure (cm H2O)
Flow (L/m)
Volume (mL)
Time (sec)
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Continuous Positive Airway Pressure(CPAP)
Pressure (cm H2O)
CPAP Level
Flow (L/m)
Volume (mL)
Time (sec)
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Pressure Support Ventilation(PSV)
Pressure (cm H2O)
Flow (L/m)
Volume (mL)
Time (sec)
Patient Triggered, Flow Cycled, Pressure limited
Mode
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CPAPPSV
Pressure (cm H2O)
CPAP Level
Flow (L/m)
Volume (mL)
Time (sec)
Patient Triggered, Flow Cycled, Pressure limited
Mode
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Triggered Modes of VentilationPressure Support
Ventilation
Control Trigger Limit Target Cycle
Pressure Patient Pressure Flow
Patient Triggered Flow Cycled Ventilation
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Pressure Or Volume-Targeted Ventilation

• Advantages

• Disadvantages

• Full to partial ventilatory support
• Augments the patients spontaneous VT
• Decreases the patients spontaneous respiratory
  rate
• Decreases patient WOB by overcoming the
  resistance of the artificial airway, vent circuit
  and demand valves
• Allows patient control of TI, Vm I, f and VT
• Set peak pressure
• Prevents respiratory muscle atrophy
• Facilitates weaning
• Improves patient comfort and reduces need for
  sedation
• May be applied in any mode that allows
  spontaneous breathing, e.g., VC-SIMV, PC-SIMV

• Requires consistent spontaneous ventilation
• Patients in stand-alone mode should have back-up
  ventilation
• VT variable and dependant on lung characteristics
  and synchrony
• Low exhaled VE
• Fatigue and tachypnea if PS level is set too low

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Mandatory Modes of Ventilation

• CMV or IPPV

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Mandatory Modes of VentilationCMV
Control Trigger Limit Target Cycle
Pressure Or Volume Time Time
Time Triggered Time Cycled Ventilation
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Control Mode (Pressure-Targeted Ventilation)
Time Cycling
Set PC Level
Pressure (cm H2O)
Flow (L/m)
Volume (mL)
Time (sec)
Time Triggered, Pressure Limited, Time Cycled
Ventilation
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Control Mode(Volume-Targeted Ventilation)
Time Cycling
Pressure (cm H2O)
Dependent on CL Raw
Flow (L/m)
Preset VT Volume Cycling
Volume (mL)
Time (sec)
Time Triggered, Flow Limited, Volume Cycled
Ventilation
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Pressure Or Volume-Targeted Ventilation

• Advantages

• Disadvantages

• Decreases the work of breathing (WOB)
• Helps maintain a normal PaCO2

• Not able to assist the ventilator

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Hybrid Modes of Ventilation

• SIMV and A/C

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Hybrid Modes of VentilationA/C
Control Trigger Limit Target Cycle
Pressure Or Volume Time Or Patient Time
Time or PatientTriggered Time Cycled Ventilation
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Assisted Mode(Volume-Targeted Ventilation)
Time Cycling
Pressure (cm H2O)
Preset peak Flow
Flow (L/m)
Volume (mL)
Time (sec)
Patient Triggered, Flow limited, Volume Cycled
Ventilation
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Assisted Mode (Pressure-Targeted Ventilation)
Time Cycling
Set PC Level
Pressure (cm H2O)
Flow (L/m)
Volume (mL)
Time (sec)
Patient Triggered, Pressure Limited, Time Cycled
Ventilation
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Pressure Or Volume-Targeted Ventilation

• Advantages

• Disadvantages

• Decreases the work of breathing (WOB)
• Allows patients to regulate respiratory rate
• Helps maintain a normal PaCO2

• Alveolar hyperventilation

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Hybrid Modes of VentilationSIMV/PS
Breath Type Control Trigger Limit Cycle
Mandatory Pressure Or Volume Time Or Patient Time
Spontaneous Pressure Patient Pressure Flow
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SIMV(Volume Targeted Ventilation)
Pressure (cm H2O)
M
M
M
Spontaneous Breaths
Flow (L/m)
Volume (mL)
Time (sec)
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SIMVPS(Volume Targeted Ventilation)
Set PS Level
Tsupp
Tsynch
M
Pressure (cm H2O)
Flow-cycled
Flow (L/m)
Volume (mL)
Time (sec)
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SIMV PS (Pressure-Targeted Ventilation)
Tsynch
Tsynch
Tsupp
Pressure (cm H2O)
Set PC Level
Set PS Level
Time Cycled
Flow-cycled
Flow (L/m)
Volume (mL)
Time (sec)
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Hybrid Mode Ventilation Suppression
Tsupp
Tsupp
Pressure (cm H2O)
Tsupp
Tsupp
M
M
M
Flow (L/m)
Cycles
M
M
Time (sec)
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Hybrid Mode Ventilation Synchronization(SIMVPSV
)
M
Tsynch
Tsynch
Tsupp
M
Tsupp
Pressure (cm H2O)
Flow (L/m)
Mandatory Cycle Time
Cycles
Time (sec)
Triggered window for supported breaths
Triggered window for synchronized breaths
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SIMV

• Advantages

• Disadvantages

• Maintains respiratory muscle strength by avoiding
  muscle atrophy
• Decreases mean airway pressure
• Facilitates ventilator discontinuation
  weaning!

• When used for weaning, may be done too quickly
  and cause muscle fatigue
• Mechanical rate and spontaneous rate may
  asynchronous causing stacking
• May cause barotrauma or volutrauma

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All Modes tables
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Mandatory Modes of Ventilations Mandatory Modes of Ventilations Mandatory Modes of Ventilations Mandatory Modes of Ventilations Mandatory Modes of Ventilations
Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths
Inspiratory cycling Time Time Time Time
Control Volume Volume Volume (Pressure)
Target/Limit - Pressure-limited Volume-targeted
Feeadback - - Intra-breath Inter-breath
Expiratory cycling Time Time Time Time
Triggered Breaths Triggered Breaths Triggered Breaths Triggered Breaths Triggered Breaths
Types None None None None
Supported Breaths Supported Breaths Supported Breaths Supported Breaths Supported Breaths
Control - - - -
Target - - - -
Feedback - - - -
Expiratory Cycling - - - -
Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths
During mandatory inspiration Not accommodated Not accommodated Not accommodated Accommodated
Otherwise Not accommodated Accommodated Not accommodated Accommodated
Synonyms IPPV (Draeger) Controlled Mandatory Ventilation Intermittent Mandatory Ventilation IPPV (Draeger) trigger off, autoflow off IPPV (Draeger) trigger off, autoflow on
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Triggered Modes of Ventilations Triggered Modes of Ventilations Triggered Modes of Ventilations Triggered Modes of Ventilations
Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths
Inspiratory cycling - - -
Control - - -
Target/Limit - - -
Feeadback - - -
Expiratory cycling - - -
Triggered Breaths Triggered Breaths Triggered Breaths Triggered Breaths
Types Supported breaths Supported breaths Supported breaths
Supported Breaths Supported Breaths Supported Breaths Supported Breaths
Control Pressure (Pressure) (Pressure)
Target -- Volume-targeted Flow and Volume
Feedback -- Inter-breath Intra-breath
Expiratory Cycling Flow Flow Flow
Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths
During mandatory inspiration - - -
Otherwise - - -
Synonyms Assisted Spontaneus Breathing (Draeger) Spontaneous Mode (Hamilton, Puritan Bennet) Pressure Support (Maquet Pressure Support Ventilation (Viasys) CPAP (Respironics) Volume Support (Maquet, Puritan-Bennett) Propotional Assist Ventilation, Proportional Pressure Suport (Draeger) Propotional Assist Ventilation Plus (Puritan-Bennet)
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Hybrid Mode Assist Control Hybrid Mode Assist Control Hybrid Mode Assist Control Hybrid Mode Assist Control Hybrid Mode Assist Control
Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths
Inspiratory cycling Time or trigger Time or trigger Time or trigger Time or trigger
Control Volume Pressure Pressure (Pressure)
Target/Limit - - - Volume-targeted
Feeadback - - - Inter-breath
Expiratory cycling Time Time Time Time
Triggered Breaths Triggered Breaths Triggered Breaths Triggered Breaths Triggered Breaths
Types Mandatory pattern Mandatory pattern Mandatory pattern Mandatory pattern
Supported Breaths Supported Breaths Supported Breaths Supported Breaths Supported Breaths
Control - - - -
Target - - - -
Feedback - - - -
Expiratory Cycling - - - -
Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths
During mandatory inspiration Not accommodated Accommodated Accommodated Accommodated
Otherwise - - - -
Synonyms IPPVASSIST (Draeger) Synchronized cCntrolled Mandatory Ventilation (Hamilton) Volume Control (Maquet) VCV-A/C (Puritan-Bennett, Respironics) Volume A/C (Viasys) BIPAPASSIST (Draeger) P-CMV (Hamilton) Pressure Control (Maquet) PCV-A/C (Puritan-Bennett, Respironics) Pressure A/C (Viasys) BIPAPASSIST (Draeger) P-CMV (Hamilton) Pressure Control (Maquet) PCV-A/C (Puritan-Bennett, Respironics) Pressure A/C (Viasys) Adaptive Pressure Ventilation CMV PRVC (Maquet) VCA/C (Puritan-Bennet) PRVC A/C (Viasys) IPPV Assist Autoflow (Draeger)
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Hybrid Mode Synchronized Intermittent Mandatory Ventilation Hybrid Mode Synchronized Intermittent Mandatory Ventilation Hybrid Mode Synchronized Intermittent Mandatory Ventilation Hybrid Mode Synchronized Intermittent Mandatory Ventilation Hybrid Mode Synchronized Intermittent Mandatory Ventilation
Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths
Inspiratory cycling Time or trigger Time or trigger Time or trigger Time or trigger
Control Volume Volume Pressure (Pressure)
Target/Limit - - - Volume-targeted
Feeadback - - - Inter-breath
Expiratory cycling Time Time Time Time
Triggered Breaths Triggered Breaths Triggered Breaths Triggered Breaths Triggered Breaths
Types Mandatory and supported pattern Mandatory and supported pattern Mandatory and supported pattern Mandatory and supported pattern
Supported Breaths Supported Breaths Supported Breaths Supported Breaths Supported Breaths
Control Pressure Pressure Pressure Pressure
Target - - - -
Feedback - - - -
Expiratory Cycling Flow Flow Flow Flow
Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths
During mandatory inspiration Not accommodated Not accommodated Accommodated Accommodated
Otherwise Only if support is off Only if support is off Only if support is off Only if support is off
Synonyms SIMV (Draeger, Hamilton) SIMV (VC)PS (Maquet) VCV-SIMV (Puritan-Bennett, Respironics) Volume SIMV (Viasys) SIMV (Draeger, Hamilton) SIMV (VC)PS (Maquet) VCV-SIMV (Puritan-Bennett, Respironics) Volume SIMV (Viasys) P-SIMV (Hamilton) SIMV(PC)PS (Maquet) PCV-SIMV (Puritan-Bennett, Respironics) Pressure SIMV (Viasys) SIMVAutoflow Adaptive Pressure Ventilation SIMV (Hamilton) SIMV (PRVC)PS (Puritan-Bennett) PRVC SIMV (Viasys)
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Hybrid Mode Bi-Level Ventilatio Hybrid Mode Bi-Level Ventilatio Hybrid Mode Bi-Level Ventilatio Hybrid Mode Bi-Level Ventilatio Hybrid Mode Bi-Level Ventilatio Hybrid Mode Bi-Level Ventilatio
Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths Mandatory breaths
Inspiratory cycling Time or trigger Time or trigger Time or trigger Time or trigger Time or trigger
Control Pressure Pressure Pressure Pressure Pressure
Target/Limit - - - - -
Feeadback - - - - -
Expiratory cycling Time or trigger Time or trigger Time or trigger Time or trigger Time or trigger
Triggered Breaths Triggered Breaths Triggered Breaths Triggered Breaths Triggered Breaths
Interaction Mandatory and supported Mandatory pattern and supported Mandatory and supported Mandatory and supported Mandatory and supported
Supported Breaths Supported Breaths Supported Breaths Supported Breaths Supported Breaths
Control Pressure Pressure Pressure Pressure Pressure
Target - - - - -
Feedback - - - - -
Expiratory Cycling Flow Flow Flow Flow Flow
Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths Spontaneous Breaths
During mandatory inspiration Accommodated Trigers suuport to PEEPPsupport If thisgtPhigh (Hamilton DuoPAP) PlowPsupport If thisgtPhigh (Hamilton APRV) PEEPLPsuppIf thisgtPEEPH (Puritan-Bennett) Triggers support to PRES HIGH PSV if Thigh PSV is activated Triggers support to PRES HIGH PSV if Thigh PSV is activated Tigger support to PSV above PHigh
Otherwise Triggers support Triggers support to PEEPPsupport (Hamilton) DuoPAP) PlowPsupport (Hamilton APRV) PEEPLPsupp (Puritan-Bennett) Triggers support to PREDSLOWPSV Triggers support to PREDSLOWPSV Triggers support to PSV above PEEP
Synonyms BIPAP (Draeger) DuoPAP/APRV (Hamilton) BiLevel (Puritan-Bennet) APRV/Bi-phasic (Viasys) APRV/Bi-phasic (Viasys) Bi-vent (Maquet)
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