11/8/22, 15:11 Trigger, Limit, Cycle: The Waterfall We Should Chase?

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TRIGGER, LIMIT, CYCLE: THE WATERFALL WE SHOULD CH

by Guest Author March 1, 2021

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The Pre-brief

Every good story has a beginning, a middle, and an end. Such is the case with
breaths delivered by a ventilator. Every machine-delivered breath has three par
trigger, target (“limit”), cycle. Every good story also has a hero and a villain. Ou
hero – ventilator synchrony; the villain – dyssynchrony. Understanding how the
ventilator delivers breaths allows us to deliver mechanical ventilation safely and
comfortably.

Trigger

The trigger variable is a monitored parameter that “tells” the ventilator to start the inspira
phase of a breath. Assist-control modes of mechanical ventilation rely on the ventilator’s
ability to deliver assisted breaths (triggered by the patient) and control breaths (triggered
the ventilator). The three common trigger variables are time, pressure, and flow.

Time. Time-triggered breaths are, by definition, control breaths. Let’s say you set th
respiratory rate to 12 breaths/minute. That’s one breath every five seconds. If at fiv
seconds, the patient hasn’t initiated a breath, the ventilator delivers a control breath.
the patient has a respiratory rate of over 12, the preset time-trigger variable is not
exceeded and the ventilator does not deliver a control breath. The idea of a time trig
is a similar phenomenon to VVI on a pacemaker.

Pressure or flow. Pressure or flow triggered breaths are assisted breaths. For bot
pressure and flow triggers, clinicians set a sensitivity – or an amount of effort that th
patient needs to contribute for the ventilator to recognize the effort as an intended

breath.uses
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Pressure.
CHANNELS When
TEAMthe machine
STORE senses a drop
ABOUT in airway pressure (because of a patie
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initiated effort), an assisted breath is delivered. For a pressure trigger to be “met” it
requires work done by the patient and can result in discomfort.

Flow. As work VTinspired×∆Ptrigger, a flow trigger requires less work by the patien
Flow triggers are subject to a phenomenon known as “autotriggers” – a phenomeno
where non-patient signals trigger a breath (ex: cardiogenic oscillations, leaks or wate
the circuit).

Target (“limit”)

The target is a variable which you want to sustain (and not exceed) during the breath.
Pressure, flow, or volume are common target variables. Prior to 2010, the target variable
known as a limit variable (changed in 2010 by the international standards organization, IS
Think of the target variable as either the pressure, flow, or volume that will not get excee
while achieving the cycle variable. Note: when the target variable is achieved, the breath
not terminated – the value is just held constant

Cycle (“control”)

The cycle (aka the “control”) variable (pressure, flow, volume, time), when met, switches
breath from inhalation to exhalation. Put simply, it is what turns the breath off.

Volume cycled: the cycle variable necessary for volume control ventilation.

Flow cycled: commonly used in pressure support and other spontaneous modes. Th
breath cycles when the inspiratory flow decreases to a set threshold (usually design
as the percentage of peak inspiratory flow).

Time cycled: the inspiratory valve is open for a pre-set time and delivers a constant
pressure. This is technically how “pressure control” is cycled.

Pressure cycled: the major use of this is as a safety feature. When the peak airway
pressure exceeds the value of the high pressure alarm, breath is cycled off to preve
further increase in airway pressure .

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Figure 1: Example of changing flow cycle threshold in pressure support ventilation

The Debrief

There are three phases to all breaths delivered by a ventilator: a trigger, a

target/limit, and a cycle.

Triggers start the breath, the target is the variable which is not exceeded du
the breath, and the cycle variable is what turns the breath from inhalation to
exhalation.
Understanding each phase of a mechanically-delivered breath lends itself to
understanding the enemy of mechanical ventilation, dyssynchrony.
For more on fundamentals of synchrony, see this related post! (and part 2 h
More to come on these topics in future posts!

References

1. Tobin, M. J. (2012). Principles and practice of mechanical ventilation, third edition (3rd ed.). Ne
York, NY: McGraw-Hill Medical.
2. Respir Care. 2011 Jan;56(1):52-60. doi: 10.4187/respcare.01088.

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FUNDAMENTALS MECHANICAL VENTILATION RESPIRATORY FAILURE

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