Evolution of ventilation modes

HAMILTON MEDICAL AG
Switzerland
2000
References made to Mosbys Respiratory Care Equipment, 6th Edition, 1999
Early ventilators
Historical account
before 1900: Different whole-body respirators are
being used for research purpose.
1832 Dr. John Dalziel, Scotland
1847 Ignez von Hauke, Austria
~1900 CPAP is invented. Thoracic surgery
demanded a device for lung-inflation purposes to
avoid problems with pneumothorax
~1930 US poliomyelitis causes EMERSON to
develop and produce his Iron Lung
~1940 IPPB devices are used for lung inflation
therapy and short term ventilation
~1950 Danish polio epidemic stimulated start of
more than 20 ventilator companies to fill market
need.
CMV
BIPAP
SIMV
APRV
ASB VAPS
PAV
PSV
PCV
The jungle of today
Clinical objectives
Reverse hypoxemia
Reverse acute respiratory acidosis
Relieve respiratory distress
Prevent or reverse atelectasis
Reverse respiratory muscle fatigue
Permit sedation and/or neurom. blockade
Decrease systemic or myocard. O
2
consumption
Reduce intracranial pressure
Stabilize chest wall
Physiological objectives
Alveolar ventilation
Arterial oxygenation (FiO
2
, FRC, V'A)
Respiratory pump support (WOB
manipulation)

Consensus conference on mechanical ventilation, Int
Care Med 1994, 20:64-79
Learning goals
Part 1: Conventional modes. Three (3)
criteria (+PEEP) to understand modes
Part 2: Combination modes and
adaptive modes
Part 1: Conventional modes
Old and new classifications
CMV
PCV
SPONT
SIMV


Old classifications
Based on:
Power source (motor, pneumatic,
circuit, fluidics)
Flow waveform produced (sine-
rectangular)
Start of inhalation (machine-initiated,
patient-triggered)
Proposed classification
Start of inhalation (triggering mechanism)
Gas delivery principle
Termination of inhalation (cycling
mechanism)
Maintenance of expiratory pressure level
Components of breath delivery
Triggering Inspiration Cycling Expiration
Flow
Time
Start of inhalation: Time trigger
Flow
Time
Ttot
Start of inhalation: Patient trigger
Paw
Time
Pressure trigger
Flow
Time
Flow trigger
Inspiration
Volume breath: Flow
Pressure
Ideal
Pressure breath: Pressure
Flow
Ideal
Cycling

Volume (Flow x Ti)
Pressure
Time (Ti)
Flow (ETS).......
Cycling with ETS
Flow
Time
Maintenance of expiratory pressure
Paw
PEEP
Time
Breath delivery principles (repetition)
Start of inhalation (triggering mechanism)
Gas delivery principle (flow/volume or pressure)
Termination of inhalation (cycling mechanism)
Maintenance of expiratory pressure level
CMV

p. 299
Controlled Mechanical Ventilation or Continuous
Mandatory Ventilation (machine-triggered inspiration).

If triggered or synchronized (S), then also known as
Assist/Control (patient-triggered inspiration).
CMV
Machine or patient-triggered
Gas delivery is flow-controlled (square, decelerating, etc.)
Time-cycled

Control settings are: tidal volume, respiratory rate, and I:E ratio. Other controls
include FiO
2
, PEEP/CPAP, flow pattern, and pause.
CMV
Flow



Pressure



Volume
CMV
Vt Alveolar ventilation
f Alveolar ventilation, Gas trapping
I:E Gas distribution, Gas trapping
PEEP FRC, PaO
2
, Cardiac output
Pause Gas distribution

Flow pattern (square, accelerating, decelerating): ?

Green: Direct proportional effect
Red: Inverse proportional effect
CMV



Good starting point for inactive patients, minute
ventilation is guaranteed.



Uncomfortable for the patient, triggers only additional
mechanical breaths, possible barotrauma, choice of
inspiratory flow is difficult, difficult to set for active
patients, may increase WOB.
CMV
P-CMV

p. 301
P-CMV
Pressure Controlled (mechanical) Ventilation
Machine- or patient-triggered (flow or pressure)

Gas delivery is pressure-controlled

Time-cycled

Control settings are: inspiratory pressure, respiratory rate, and I:E ratio.
Other controls include FiO
2
, PEEP/CPAP, pressure ramp, and trigger
sensitivity.
P-CMV
Flow



Pressure



Volume
P-CMV vs. CMV
Pinsp Vt
f Alveolar ventilation, AutoPEEP
I:E Gas distribution, AutoPEEP
PEEP FRC,PaO
2
, Cardiac output

Specialty:
PCV + IRV AutoPEEP, PaO
2


Green: Direct proportional effect
Red: Inverse proportional effect
P-CMV


Decreased peak airway pressures, improved alveolar
gas distribution, minimized regional overinflation
(barotrauma), inspiratory flow adapted to patient
demand



Minute ventilation not guaranteed, increased frequency
does not always lead to increased MV, possible hypo-
ventilation and air trapping (IRV), Ti needs to be tuned
to patient's needs.
P-CMV
SPONT

p. 301
SPONT
A purely spontaneous mode.

Also known as Pressure Support Ventilation (PSV),
Continuous Spontaneous Ventilation, and Assisted
Spontaneous Breathing (ASB).
Patient-triggered (flow or pressure)

Gas delivery is pressure-controlled, with or without
dynamic compensation for pressure drop across the
tubes (ATC)

Flow-cycled (ETS)
SPONT
Controls include pressure support level, CPAP, FiO
2
, flow/pressure
trigger, pressure ramp, and expiratory trigger sensitivity.
Pinsp Vt, f , WOB
CPAP/PEEP FRC, PaO
2
, Cardiac output
Trigger sens WOB
Pramp WOB, synchronization with patient
ETS Synchronization with patient

Green: Direct proportional effect
Red: Inverse proportional effect
SPONT



Most comfortable mode, easiest for patient to accept,
supports spontaneous activity, improves gas exchange
(V/Q matching).



Does not work in paralyzed patients. Minute ventilation
is not guaranteed! Pinsp needs to be carefully set
(clinically difficult).
SPONT
SIMV

p. 300
SIMV
Synchronized Intermittent Mandatory Ventilation
Triggered variant of Intermittent Mandatory Ventilation.
Machine- and/or patient-triggered.

Gas delivery is flow-controlled (for mandatory
breaths, different waveforms) or pressure-controlled
(for spontaneous breaths).

Mandatory breaths are time-cycled; spontaneous
breaths are flow-cycled.


SIMV
Control settings are: tidal volume, respiratory rate, I:E ratio, pressure
support, pressure ramp, and expiratory trigger sensitivity. Other
controls include FiO
2
, PEEP/CPAP, flow pattern, and pause.
Vt Alveolar ventilation
f Alveolar ventilation, AutoPEEP
I:E Gas distribution, AutoPEEP
PEEP FRC, PaO
2
, Cardiac output
Pause Gas distribution
Pinsp Vt, WOB, f
Trigger sens WOB
Pramp WOB
ETS Synchronization with patient

Green: Direct proportional effect
Red: Inverse proportional effect
SIMV



Better synchronized to the patient than CMV,
guarantees minimal minute ventilation.



Mandatory breaths are difficult to fine-tune: possible
barotrauma, choice of inspiratory flow is difficult, may
increase WOB. Complex mode since many
parameters must be set correctly.
SIMV
FSIMPV
"FSIMPV"
Fully Synchronized Intermittent Mandatory Pressure
Ventilation
"FSIMPV "
Machine- and/or patient-triggered.

Gas delivery is pressure-controlled for both
mandatory and spontaneous breaths. Pressure
levels are identical.

Mandatory breaths are time-cycled if they were NOT
triggered by the patient; spontaneous breaths are
flow-cycled.
Control settings are: inspiratory pressure, respiratory rate, I:E ratio,
pressure ramp, and expiratory trigger sensitivity. Other controls include
FiO
2
and PEEP/CPAP.
"FSIMPV "
Pinsp Vt, f, WOB
f Alveolar ventilation, AutoPEEP
I:E Gas distribution, AutoPEEP
PEEP FRC, PaO
2
, cardiac output
Trigger sens WOB
Pramp WOB
ETS Synchronization with patient

Green: Direct proportional effect
Red: Inverse proportional effect
# Controls # Pros # Cons
CMV
SIMV
SPONT
PCV
(P)SIMV
FSIMPV

Mode comparison (1)
7
10
6
7
10
8
1
2
4
4
4
5
6
4
3
4
2
1
Trigger Breath delivery Cycle
CMV (A/C)
SIMV
SPONT
PCV
(P)SIMV
FSIMPV

Mode comparison (2)
t and p
t and p
p
t and p
t and p
t or p
F
F and P
P
P
P
P
t
t and F
F
t
t and F
t or F
t: time F: Flow t: time
p: patient P: Pressure F: Flow
Part 2: Combination and adaptive
modes
Pressure Regulated Volume Control
Volume Support
AutoFlow
Adaptive Pressure Ventilation (APV)
CMV+
Adaptive Support Ventilation (ASV)
All are pressure-based modes (gas delivery)
Pressure-controlled ventilation
Ventilator
Pinsp fmech Ti PEEP FiO
2

Chigh Clow
Pressure-controlled ventilation
VT
Pressure
Flow
Adaptive Pressure Ventilation (APV)
Ventilator
Pinsp fmech Ti PEEP FiO
2

Vt
Vt
Pinsp
Adaptive Pressure Ventilation (APV)
Ventilator
Pinsp fmech Ti PEEP FiO
2

Vt
Vt
Adaptive Pressure Ventilation (APV)
VT
Flow
Pressure
Minimal Minute Ventilation (MMV)
Ventilator
Pinsp fmech Ti PEEP FiO
2

Vt ftotal
Vt ftotal
Pinsp fmech
Minimal Minute Ventilation (MMV)
Ventilator
Pinsp fmech Ti PEEP FiO
2

Vt ftotal
Vt ftotal
Adaptive Support Ventilation
Ventilator
Pinsp fmech PEEP FiO
2

%MinVol
Vt ftotal
Ti
Pinsp fmech Ti
Adaptive Support Ventilation
Ventilator
Pinsp fmech PEEP FiO
2

%MinVol
Vt ftotal
Ti
# Controls # Pros # Cons
CMV
SIMV
SPONT
PCV
APV/MMV
ASV

Mode comparison (3)
7
10
6
5
5
3 (4*)
1
2
4
4
3
5
6
4
3
4
2
1
*Ideal Body Weight
Appendix
Interrelation of timing parameters Ti, Te, Ttot, f, I:E
Flow, pressure, and volume patterns
SIMV
P-SIMV
FSIMPV
Mode comparison
Interrelation of timing variables
See box 9-29, p. 304
Flow



Pressure



Volume
SIMV
Flow



Pressure



Volume
SPONT
P-SIMV

P-SIMV
Pressure-Controlled Synchronized Intermittent
Mandatory Ventilation.
P-SIMV
Machine- and/or patient-triggered.

Gas delivery is pressure-controlled for both
mandatory and spontaneous breaths. Pressure levels
can be different.

Mandatory breaths are time-cycled; spontaneous
breaths are flow-cycled.
Control settings are: inspiratory pressure, respiratory rate, I:E ratio,
pressure support, pressure ramp, and expiratory trigger sensitivity. Other
controls include FiO
2
and PEEP/CPAP.
Pinsp Vt
f Alveolar ventilation, AutoPEEP
I:E Gas distribution, AutoPEEP
PEEP FRC, PaO
2
, Cardiac output
Pause ?
Psupp Vt, f, WOB
Trigger sens WOB
Pramp WOB
ETS Synchronization with patient

Green: Direct proportional effect
Red: Inverse proportional effect
P-SIMV


Reduced peak airway pressures, improved alveolar
gas distribution, prevention of barotrauma, inspiratory
flow of mandatory breaths automatically adapted to
patients effort.



No guaranteed minute ventilation; machines
mandatory Ti must be set to coincide with the patients
Ti breath by breath.
P-SIMV
Flow



Pressure



Volume
P-SIMV
Flow



Pressure



Volume
"FSIMPV"


Machine perfectly synchronized to patient timing
(decreased WOB), decreased peak airway pressures,
improved alveolar gas distribution, prevention of
barotrauma, inspiratory flow automatically adapted to
patients effort.



No guaranteed minute ventilation.
"FSIMPV "