MODES OF MECHANICAL VENTILATION

Mazen Kherallah, MD, FCCP

POINTS OF DISCUSSIONS
|

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

ADVANCED BASICS

RESPIRATORY CYCLE

Inspiration

Expiration

RELATIONSHIP BETWEEN TIDAL VOLUME,

INSPIRATORY TIME AND FLOW
Volume
VT 3

Flow= 37.5 L/min

VT 1

Flow= 30 L/min

Insp

Exp

VT 2
Flow= 15 L/min

Time
Ti a

RELATIONSHIP BETWEEN TIDAL VOLUME,

INSPIRATORY TIME AND FLOW
Volume
Flow= 60 L/min
Flow= 30 L/min

VT 1

Flow= 20 L/min

Insp
Insp
Insp

Ti b
Ti a

Ti c

ExpExp

Time

PRESSURE LIMITED BREATH

Volume

Pressure Limit

Time

EXPIRATORY FLOW CYCLING

Flow

100%

Flow Cycling
50%

Time

RISE TIME

Pressure

Flow

Volume

TI

TE

Time

MANDATORY, SPONTANEOUS AND TRIGGERED

INSPIRATORY CYCLING
M

M
S

Tsynch

M
Tsupp

Tsupp

Tsupp

Tsupp

Tsupp

M
Tsupp

VOLUME CONTROLLED INFLATION

Pressure

Flow

Tidal Volume

Volume

TI

TE

Time

VOLUME CONTROL BREATHS

50
Decreased Compliance

Paw

SEC

cmH20
-20
120

6
INSP

SEC

Flow
L/min

120

6
EXH

If compliance decreases the pressure increases to

maintain the same Vt

VOLUME CONTROL WITH END-INSPIRATORY

PAUSE
End Inspiratory Pause

Pressure

Flow

Tidal Volume

Volume

TI

TE

Time

PRESSURE CONTROLLED INFLATION

Rise Time

Pressure

Peak Inspiratory Flow

Flow

Tidal Volume
Volume

TI

TE

Time

Volume/Flow Control
Inspiration

Pressure Control

Expiration

20

Inspiration

Expiration

20

Paw

Pressure

Paw
0

20

20

Volume
0

Flow

-3

Time (s)

-3

Time (s)

TRIGGERED MODES OF
VENTILATION
CPAP and PSVV

SPONTANEOUS BREATHING

Pressure
(cm H2O)

Flow
(L/m)
Volume
(mL)
Time (sec)

CONTINUOUS POSITIVE AIRWAY PRESSURE

(CPAP)

Pressure
(cm H2O)

CPAP Level

Flow
(L/m)
Volume
(mL)
Time (sec)

PRESSURE SUPPORT VENTILATION

(PSV)
Longer Inspiration
Set PS
Level

Pressure
(cm H2O)

Better Efforts
Flow
Cycling

Flow
(L/m)

Volume
(mL)
Time (sec)
Patient Triggered, Flow Cycled, Pressure limited Mode

CPAP+PSV

Pressure
(cm H2O)

Set PS
Level
CPAP Level

Flow
Cycling

Flow
(L/m)

Volume
(mL)
Time (sec)
Patient Triggered, Flow Cycled, Pressure limited Mode

TRIGGERED MODES OF VENTILATION

PRESSURE SUPPORT VENTILATION

Control Trigger
Pressure

Patient

Limit

Target

Pressure

Patient Triggered Flow Cycled Ventilation

Cycle
Flow

PRESSURE OR VOLUME-TARGETED
VENTILATION
Advantages
|

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

Disadvantages
|

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

MANDATORY MODES OF
VENTILATION
CMV or IPPV

MANDATORY MODES OF VENTILATION

CMV

Control Trigger
Pressure
Or
Volume

Limit

Target

Time

Time Triggered Time Cycled Ventilation

Cycle
Time

CONTROL MODE
(PRESSURE-TARGETED VENTILATION)
Set PC Level

Time Cycling

Pressure
(cm H2O)

Flow
(L/m)

Volume
(mL)

Time (sec)
Time Triggered, Pressure Limited, Time Cycled Ventilation

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

PRESSURE OR VOLUME-TARGETED
VENTILATION
Advantages
|

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

Disadvantages
|

Not able to assist the

ventilator

HYBRID MODES OF
VENTILATION
SIMV and A/C

HYBRID MODES OF VENTILATION

A/C

Control Trigger
Pressure
Or
Volume

Limit

Target

Time
Or
Patient

Time or PatientTriggered Time Cycled

Ventilation

Cycle
Time

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

ASSISTED MODE
(PRESSURE-TARGETED VENTILATION)
Set PC Level

Time Cycling

Pressure
(cm H2O)

Flow
(L/m)

Volume
(mL)

Time (sec)
Patient Triggered, Pressure Limited, Time Cycled Ventilation

PRESSURE OR VOLUME-TARGETED
VENTILATION
Advantages
|

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

Disadvantages
|

Alveolar
hyperventilation

HYBRID MODES OF VENTILATION

SIMV/PS
Breath
Type

Control Trigger

Mandatory

Pressure
Or
Volume

Time
Or
Patient

Spontaneous

Pressure

Patient

Limit

Cycle
Time

Pressure

Flow

SIMV
(VOLUME TARGETED VENTILATION)
Pressure
(cm H2O)

Spontaneous Breaths
Flow
(L/m)

Volume
(mL)

Time (sec)

SIMV+PS
(VOLUME TARGETED VENTILATION)
Set PS Level
Pressure
(cm H2O)

Tsynch

Tsupp

Flow-cycled

Flow
(L/m)

Volume
(mL)

Time (sec)

SIMV + PS
(PRESSURE-TARGETED VENTILATION)
Tsynch
Pressure
(cm H2O)

Tsynch

Tsupp
Set PC Level

Time Cycled

Set PS Level

Flow-cycled

Flow
(L/m)

Volume
(mL)

Time (sec)

Tsupp

Cycles

Flow
(L/m)

Pressure
(cm H2O)

HYBRID MODE VENTILATION: SUPPRESSION

Time (sec)

Tsupp

Tsupp

Tsupp

HYBRID MODE VENTILATION: SYNCHRONIZATION

(SIMV+PSV)
M

Tsupp

Tsynch

Pressure
(cm H2O)

Flow
(L/m)

Cycles

Mandatory Cycle Time

Time (sec)
Triggered window for Triggered window for
supported breaths synchronized breaths

Tsynch

Tsupp

SIMV
Advantages
|

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

Disadvantages
|

When used for

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

ALL MODES TABLES

Mandatory Modes of Ventilations

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

None

None

None

None

Control

Target

Feedback

Expiratory Cycling

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

Triggered Breaths
Types
Supported Breaths

Spontaneous Breaths

Triggered Modes of Ventilations

Mandatory breaths
Inspiratory cycling

Control

Target/Limit

Feeadback

Expiratory cycling

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

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, PuritanBennett)

Propotional Assist
Ventilation,
Proportional Pressure
Suport (Draeger)
Propotional Assist
Ventilation Plus
(Puritan-Bennet)

Triggered Breaths
Types
Supported Breaths

Spontaneous Breaths

Hybrid Mode: Assist Control

Mandatory breaths
Inspiratory cycling

Time or trigger

Time or trigger

Time or trigger

Control

Volume

Pressure

(Pressure)

Target/Limit

Volume-targeted

Feeadback

Inter-breath

Expiratory cycling

Time

Time

Time

Triggered Breaths
Types

Mandatory pattern

Mandatory pattern

Mandatory pattern

Supported Breaths
Control

Target

Feedback

Expiratory Cycling

During mandatory inspiration

Not 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 (PuritanBennett, Respironics)
Pressure A/C (Viasys)

Adaptive Pressure
Ventilation CMV
PRVC (Maquet)
VC+A/C (PuritanBennet)
PRVC A/C (Viasys)
IPPV Assist Autoflow
(Draeger)

Spontaneous Breaths

Hybrid Mode: Synchronized Intermittent Mandatory Ventilation

Mandatory breaths
Inspiratory cycling

Time or trigger

Time or trigger

Time or trigger

Control

Volume

Pressure

(Pressure)

Target/Limit

Volume-targeted

Feeadback

Inter-breath

Expiratory cycling

Time

Time

Time

Triggered Breaths
Types

Mandatory and
supported pattern

Mandatory and supported

pattern

Mandatory and
supported pattern

Supported Breaths
Control

Pressure

Pressure

Pressure

Target

Feedback

Expiratory Cycling

Flow

Flow

Flow

During mandatory inspiration

Not accommodated

Accommodated

Accommodated

Otherwise

Only if support is off

Only if support is off

Only if support is off

SIMV (Draeger, Hamilton)

SIMV (VC)+PS (Maquet)
VCV-SIMV (PuritanBennett, Respironics)
Volume SIMV (Viasys)

P-SIMV (Hamilton)
SIMV(PC)+PS
(Maquet)
PCV-SIMV (PuritanBennett, Respironics)
Pressure SIMV
(Viasys)

SIMV+Autoflow
Adaptive Pressure
Ventilation SIMV
(Hamilton)
SIMV (PRVC)+PS
(Puritan-Bennett)
PRVC SIMV (Viasys)

Spontaneous Breaths

Synonyms

Hybrid Mode: Bi-Level Ventilatio

Mandatory breaths
Inspiratory cycling

Time or trigger

Time or trigger

Time or trigger

Time or trigger

Control

Pressure

Pressure

Pressure

Pressure

Target/Limit

Feeadback

Expiratory cycling

Time or trigger

Time or trigger

Time or trigger

Time or trigger

Mandatory and
supported

Mandatory pattern and

supported

Mandatory and
supported

Mandatory and
supported

Control

Pressure

Pressure

Pressure

Pressure

Target

Feedback

Expiratory Cycling

Flow

Flow

Flow

Flow

Accommodated

Trigers suuport to PEEP+Psupport If

this>Phigh (Hamilton DuoPAP)
Plow+Psupport If this>Phigh (Hamilton
APRV)
PEEPL+PsuppIf this>PEEPH
(Puritan-Bennett)

Triggers support to
PRES HIGH + PSV if
Thigh PSV is activated

Tigger support to
PSV above PHigh

Otherwise

Triggers support

Triggers support to PEEP+Psupport

(Hamilton) DuoPAP)
Plow+Psupport (Hamilton APRV)
PEEPL+Psupp (Puritan-Bennett)

Triggers support to
PREDSLOW=PSV

Triggers support to
PSV above PEEP

Synonyms

BIPAP
(Draeger)

DuoPAP/APRV (Hamilton)
BiLevel (Puritan-Bennet)

APRV/Bi-phasic
(Viasys)

Bi-vent (Maquet)

Triggered Breaths
Interaction
Supported Breaths

Spontaneous Breaths

During mandatory
inspiration

THANK YOU