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Engineering Principles Applied To Mechanical Ventilation: Robert L. Chatburn, RRT-NPS, FAARC
Engineering Principles Applied To Mechanical Ventilation: Robert L. Chatburn, RRT-NPS, FAARC
Abstract-Mechanical ventilators can be understood is dominated by convective flow and mixing in the
in terms of simple physical models that have alveoli occurs by molecular diffusion.
electrical analogs. These models provide the basis There is also a class of “high frequency
for designing and classifying ventilators as well as ventilator” that delivers tidal volumes less than dead
understanding ventilator-patient interactions. space volume at frequencies up to 15 Hz. High
Keywords-Mechanical ventilation, respiratory frequency ventilators, in theory, minimize the risk of
mechanics, modes of ventilation damage to diseased lung tissue that could be caused by
volumetric over distention with normal tidal volumes.
INTRODUCTION While this class of ventilator has been studied a great
Mechanical ventilators are designed and built by deal over the last two decades, its use is still
engineers. Yet, all textbooks on the subject of controversial.
mechanical ventilation, almost without exception, are It is interesting to note that modern mechanical
written by and for clinicians. A communication gap ventilators have evolved over the last 40 years through
exists between producers and end users of this device at least five generations. First generation ventilators
that causes much frustration on both sides. The had relatively primitive electrical or pneumatic control
purpose of this paper is to help bridge the gap by circuits, were capable of only one mode of ventilation,
clarifying terminology and outlining the conceptual had uncalibrated dials and no alarms. Second
models used to design and use mechanical ventilators. generation devices used simple analog electronic or
fluidic control circuits, offered several modes of
GOALS OF MECHANICAL VENTILATION ventilation, and provided some basic alarms. Third
generation machines are characterized by the use of
A mechanical ventilator is an automatic machine digital electronics (microprocessors), for both control
designed to provide all or part of the work the body and operator interface functions. Fourth generation
must produce to move gas into and out of the lungs. ventilators made full use of computerized operator
The act of moving air into and out of the lungs is interfaces (CRT and LCD displays). Software
called breathing, or, more formally, ventilation. developments allowed integration of waveform
The simplest mechanical device we could devise monitoring, calculated lung mechanics and extensive
to assist a person’s breathing would be a hand-driven, system diagnostics. The current, fifth generation
syringe-type pump that is fitted to the person’s mouth mechanical ventilator makes use of the “virtual
and nose using a mask. A variation of this is the self- instrument” operator interface design along with more
inflating, elastic resuscitation bag. Both of these advanced control software allowing for a “universal
require one-way valve arrangements to cause air to machine” that can ventilate neonatal, pediatric, and
flow from the device into the lungs when the device is adult patients. The hardware platform seems to have
compressed, and out from the lungs to the atmosphere stabilized and now upgrades are mainly control
as the device is expanded. These arrangements are not software and display enhancements.
automatic, requiring an operator to supply the energy
to push the gas into the lungs through the mouth and MODELS OF VENTILATOR-PATIENT
nose. Therefore, such devices are not considered INTERACTION
mechanical ventilators.
Automating the ventilator so that continual A ventilator is simply a machine designed to
operator intervention is not needed for safe, desired transmit applied energy in a predetermined manner to
operation requires: perform useful work. Ventilators are powered with
A stable attachment (interface) of the device energy in the form of either electricity or compressed
to the patient, gas. That energy is transmitted (by the ventilator’s
A source of energy to drive the device, drive mechanism) in a predetermined manner (by the
control circuit) to assist or replace the patient’s
A control system to regulate the timing and
muscular effort in performing the work of breathing
size of breaths, and
(the desired output). Thus, to understand ventilators
A means of monitoring the performance of
we must first understand their four mechanical
the device and the condition of the patient. characteristics:
The vast majority of ventilators used in the world
1) Input power
provide “conventional” ventilation. This employs 2) Power conversion and
breathing patterns that approximate those produced by
transmission
a normal spontaneously breathing person. Tidal 3) Control system
volumes are large enough to clear the anatomical dead
4) Output (pressure, volume, and
space during inspiration and the breathing rates are in flow waveforms)
the range of normal rates. Gas transport in the airways
We can expand this simple outline to add as
much detail about a given ventilator as desired.
Table 1. Mode classification scheme Figure 3. Waveforms for volume vs. pressure control.
Dual Control (DC)
I. Breathing pattern There are clinical advantages and disadvantages
A. Primary breath control variable to volume and pressure control. Simply put, volume
1. Volume control results in a more stable minute ventilation (and
2. Pressure hence more stable gas exchange) than pressure control
3. Dual if lung mechanics are unstable. On the other hand,
B. Breath sequence pressure control allows better synchronization with the
1. Continuous mandatory ventilation patient because inspiratory volume and flow are not
(CMV) limited to arbitrary preset values.
2. Intermittent mandatory ventilation While it is possible to control only one variable at
(IMV) a time, a ventilator can automatically switch between
3. Continuous spontaneous ventilation pressure control and volume control in an attempt to
(CSV) guarantee minute ventilation while maximizing patient
II. Control type synchrony. When a ventilator uses both pressure and
A. Set point volume signals to control the breath size, it is called
B. Servo dual control. There are two types of dual control.
C. Adaptive Dual control between breaths means that the ventilator
D. Optimal controls pressure during each breath but adjusts the
III. Control strategy pressure limit to achieve a tidal volume target over
A. Phase variables (trigger, limit, cycle) several breaths. Alternatively, the ventilator can
B. Operational logic (conditional variables, switch between volume and pressure control during a
output variables, performance function) single breath (dual control within breaths, as shown in
Breathing Pattern Fig. 4).
Primary Breath Control Variable Trigger on
volume control and pressure control (Fig. 3). Fow > set
yes
Pressure Control (PC) PEAK FLOW
Pressure control means that the airway pressure
waveform is preset (for example by setting peak
no
no
inspiratory pressure and end expiratory pressure).
Tidal volume and inspiratory flow are then dependent
on these settings and the elastance and resistance of VOLUME
the respiratory system. CONTROL
Flow limit
Inspiration Expiration Inspiration Expiration
at PEAK FLOW
Airway Pressure
setting
Time
Lung Pressure
Lung Pressure
Ariway pressure
Lung Volum e
yes
< set INSP PRESS
no
Flow
Volume = set
Cycle off yes no
TIDAL VOLUME
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ventilator adjusts the set pressure limit to bring the flow limited, and volume cycled, interspersed with
tidal volume closer to the target (required pressure pressure controlled spontaneous breaths that are
change = exhaled volume calculated compliance). pressure triggered, pressure limited, and flow cycled.
We say “target” tidal volume because the ventilator Each type of breath has a completely different set of
aims to achieve it, but for various reasons, may miss phase variables.
(which should trigger an alarm). Examples of adaptive Operational Logic
dual control can be seen in modes like Pressure Ventilators can also use pressure, volume, flow,
Regulated Volume Control (Servo 300 ventilator) and or time (and their derivatives such as minute
Auto Flow (Dräger Evita 4 ventilator). ventilation) as conditional variables. A conditional
To date, the most advanced control strategy may variable is used by a ventilator’s operational logic
be called optimum dual control. Here, the ventilator system to make decisions. The operational logic of a
automatically adjusts both the pressure and volume ventilator is a simple description of how the computer
setpoints to optimize other performance variables as uses the conditional variables. Operational logic often
respiratory mechanics change. The term optimum takes the form of “if-then” statements. That is, if the
implies that some measure of system performance is value of a conditional variable reaches some preset
maximized or minimized. The only example of this at level, then some action occurs to change the
present is the Adaptive Support mode on the Hamilton ventilatory pattern.
Galileo (perhaps not the best choice of names in light For example, if a preset time interval has elapsed
of this classification scheme). In this mode, each (the sigh interval), then the ventilator switches to the
breath is pressure controlled and the pressure limit is sigh pattern. Another example is the switch between
automatically adjusted between breaths to meet an patient-triggered breaths and machine-triggered
optimum tidal volume. The optimum tidal volume is breaths that occur during intermittent mandatory
based on the estimated minute alveolar ventilation and ventilation. An even more sophisticated example is the
the optimal frequency. The minute ventilation is operational logic for dual control within breaths.
estimated from the patient’s body weight. The optimal
frequency is based on the measured expiratory time CONCLUSION
constant using an equation that minimizes the work of Mechanical ventilator design has experienced
breathing. The control software also implements “lung rapid evolution in the last 40 years. In many cases,
protective strategies” by not allowing tidal volume or ventilator capabilities outstrip both scientific evidence
frequency to get too large or too small. For example, of efficacy and operator understanding. The
the maximum frequency is based on a minimum knowledge gap that exists between manufacturers and
inspiratory time equal to one time constant and end users is due in large part to the absence of a
minimum expiratory time of two time constants. standardized lexicon. A shared vocabulary, in turn,
depends on the knowledge of rather simple analytical
Control Strategy models of ventilator-patient interaction and control
Phase Variables schemes.
The phase variable is a signal that is measured Most education on the subject of mechanical
and used by the ventilator to initiate some part, or ventilation is conducted not in the schools but by
phase, of the breath cycle. manufacturers representatives. For this reason, design
The variable causing a breath to begin is the engineers are in a unique position to drive change in
trigger variable. A variable whose magnitude is the area of communication. Great good would accrue
constrained to some maximum value during simply by adopting informal standards and
inspiration is called a limit variable. The variable terminology for operator’s manuals across
causing a breath to end is the cycle variable. During manufacturers.
expiration, the ventilator usually maintains some level
of pressure at or above atmospheric pressure, which is REFERENCES
referred to as the baseline variable. Chatburn, RL. Classification of mechanical
Modes of ventilation can be described at various ventilators. In: Branson RD, Hess DR, Chatburn RL.
levels of detail, depending on how and with whom we Respiratory care equipment, 2nd edition. Philadelphia:
need to communicate. At the highest level of detail, Lippincott Williams & Wilkins, 1999.
we can fully characterize a mode by adding the
specific control strategy it employs. This begins with Chatburn RL. Classification of mechanical
naming the phase variables (pressure, volume, flow, ventilators. Respir Care 1992;37(10):1009-1025.
and time), followed by detailing the operational logic,
and, if necessary, giving the parameter values used in Chatburn RL, Primiano FPJr. A new system for
the conditional statements. understanding modes of mechanical ventilation.
A mode is a pattern of mandatory and Respir Care 2001;46(6):604-621.
spontaneous breaths. Because these breaths may vary
drastically in the way they are controlled, we must Chatburn RL, Primiano FPJr. Decision analysis for
specify the phase variables for both types of breaths. large capital purchases; How to buy a ventilator.
For example, a ventilator may provide volume Respir Care 2001;46(10):1038-1053.
controlled mandatory breaths that are time triggered,
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