MODES OF MECHANICAL

VENTILATION
Dr. P A VAIBHAV
 Mechanical ventilation is a useful modality for
patients who are unable to sustain the level of
ventilation necessary to maintain the gas
exchange functions (oxygenation and carbon
dioxide elimination).
Types of Mechanical Ventilation

 negative pressure ventilation,

 positive pressure ventilation,
 and high-frequency ventilation
Negative Pressure Ventilation
 It attempts to mimic the function of
the respiratory muscles to allow breathing through normal
physiological mechanisms.
 A tank ventilator, or “IRON LUNG” / lung CUIRASS
 Designed for resuscitation by Woillez in 1876.


During inspiration, intrapleural pressure drops from about -5 to -10

cm H2O ,
alveolar (intrapulmonary) pressure declines from 0 to -5 cm H2O, as
a result, air flows into the lungs. The alveolar pressure returns to zero
as the lungs fill.
 During exhalation, intrapleural pressure increases from about -10 to
-5 cm H2O ,
alveolar (intrapulmonary)pressure increases from 0 to +5 cm H2O,
as a result, air flows out of the lungs. The alveolar pressure returns to
Positive Pressure Ventilation

 Positive pressure ventilation (PPV) occurs when a

mechanical ventilator is used to deliver air into the
patient’s lungs by way of an endotracheal tube or
positive pressure mask.
 During inspiration, air flows into the lungs .
The alveolar pressure rises to about +12 cm H2O.
The intrapleural pressure rises from -5 cm H2O to +5 cm H2O

Flow stops when the ventilator cycles into exhalation.

 During exhalation, the upper airway pressure drops to zero.
The alveolar pressure drops from +12 cm H2O to 0, as the chest
wall and lung tissue recoil.
High-Frequency Ventilation

 High-frequency ventilation uses above-normal ventilating rates

with below-normal ventilating volumes.
 There are three types of high frequency ventilation strategies:

1. high-frequency positive pressure ventilation (HFPPV), which

uses respiratory rates of about 60 to 100 breaths/min;
2. high-frequency jet ventilation (HFJV), which uses rates between
about 100 and 400 to 600 breaths/min; and
3. high-frequency oscillatory ventilation (HFOV), which uses rates
into the thousands,up to about 4000 breaths/min.
Terminology and definition
 Positive end-expiratory pressure (PEEP)- Sometimes
baseline pressure is higher than 0, when the ventilator
operator selects a higher pressure to be present at the end of
exhalation. It increases the volume of gas remaining in the
lungs at the end of a normal exhalation.
PEEP applied by the operator is referred to as Extrinsic PEEP.
Auto-PEEP (or intrinsic PEEP), is air that is accidentally
trapped in the lung. It usually occurs when a patient does not
have enough time to exhale completely before the ventilator
delivers another breath.
Peak Pressure
 Thisis the highest pressure recorded at the end of
inspiration. Ppeak is also called peak inspiratory
pressure (PIP) or peak airway pressure .
Plateau Pressure
 The plateau pressure is measured after a breath has
been delivered to the patient and before exhalation
begins. Exhalation is prevented by the ventilator for a
brief moment (0.5 to 1.5 s). To obtain this
measurement, the ventilator operator normally selects a
control marked “inflation hold” or “inspiratory pause.”
INDICATIONS FOR MECHANICAL VENTILATION

 Acute ventilatory failure – Paco2 >50 mmHg (Higher for COPD).

pH< 7.30.
Apnea .
 Impending ventilatory failure- Tidal volume <3 to 5 mL/kg .
Frequency >25 to 35/min.
Minute ventilation >10 L/min .
Vital capacity <15 mL/kg.
Rising PaCO2 >50 mm Hg
 Severe hypoxemia- Pao2 <60 mm Hg at FiO2 >50%,
PaO2 <40 mm Hg at any FiO2.
PaO2/FIO2 =<300 mm Hg for ALI,

=<200 mm Hg for ARDS.

 Prophylactic ventilatory support
Reduce risk of pulmonary complications
(Prolonged shock, Head injury, Smoke inhalation)
Reduce hypoxia of major body organs.
Reduce cardiopulmonary stress
Common Methods of Delivering Inspiration
 Pressure-Controlled Ventilation

The clinician sets a pressure for delivery to the patient. Also called:
• Pressure-targeted ventilation
• Pressure ventilation
 Volume-Controlled Ventilation

The clinician sets a volume for delivery to the patient. Also called:
• Volume-targeted ventilation
• Volume ventilation
 The primary variable the ventilator adjusts to
achieve inspiration is called the control variable
 ventilatorcan control four variables: pressure,
volume, flow, and time.
 Itis important to recognize that the ventilator can
control only one variable at a time
Phases of a Breath and Phase Variables

PHASE VARIABLES
There are four distinct phases of ventilator breath
• Trigger- begins inspiration
• Limit- limits the pressure, volume, flow, or time during

inspiration but does not end the breath

• Cycle- ends the inspiratory phase and begins exhalation
• Baseline- Is the end-expiratory baseline (usually pressure)

before a breath is triggered.

Four parameters can be controlled or manipulated during
 TRIGGER VARIABLE
Determines the start of inspiration.
 Time trigger: Breath is delivered once the preset time interval
has elapsed. if the breathing rate is set at 20 breaths per minute,
the ventilator trigger inspiration after 3 seconds elapses .
 Pressure Trigger: Breath is delivered once preset negative
pressure is generated by patients' spontaneous (inspiratory)
effort.
 Flow Trigger: Breath is delivered when patients' inspiratory
flow reaches a specific value. More sensitive than pressure
trigger to detect inspiratory effort, hence less inspiratory work.
LIMIT VARIABLE
If one or more variables (pressure, flow, or volume) is not
allowed to rise above a preset value during the inspiratory
time, it is termed a limit variable.
• Flow limited
• Pressure limited
• Volume limited
INSPIRATORY TIME- time interval between the start of
inspiratory flow to the beginning of expiratory flow.
Inspiration does not end at the preset value, but the variable
is held fixed at the preset value during inspiration.
• The pressure and volume
waveforms for normal compliance
show pressure peaking at Time A
and the normal volume delivered
by Time A.
• Inspiration ends at Time B.
• With reduced compliance, the
pressure rises higher during
inspiration. Because excess
pressure is vented, the pressure
reaches a limit and goes no higher.
No more flow enters the patient's
lungs. Volume delivery has
reached its maximum at Time A.
CYCLE VARIABLE
Inspiration ends when a specific cycle variable is
reached. Only one cycling variable can be set at a time.
 Time cycled
 Flow cycled
 Pressure cycled
 Volume cycled .
Variable is measured by the ventilator and used as a
feedback signal to end inspiratory flow delivery which
then allows exhalation to begin.
Inflation Hold (Inspiratory Pause)
 Itmaintains air in the lungs at the end of inspiration,
before the exhalation valve opens. the inspired volume
remains in the patient’s lung and the expiratory valve
remains closed for a brief period or pause time.
 The pressure peaks at the end of insufflation and then
levels to a plateau (plateau pressure).
 Also called inspiratory pause, end-inspiratory pause, or
inspiratory hold.
 The plateau pressure is used to calculate static
compliance, is used to increase peripheral distribution
of gas and improve oxygenation.
 settingan inspiratory pause extends inspiratory time,
not inspiratory flow
BASELINE VARIABLE
 Expiratory time - Interval between start of expiration and
start of inspiration.
 Variable that is controlled during expiratory time is
baseline variable.
 most commonly it is pressure.
 PEEP and CPAP are applied to the baseline pressure
variable.
 If an adequate amount of time is not provided for
exhalation, air trapping and hyperinflation can occur,
leading to a phenomenon called auto-PEEP or intrinsic
PEEP
Expiratory Hold (End-Expiratory Pause)
 Thepurpose of this maneuver is to measure pressure
associated with air trapped in the lungs at the end of the
expiration (i.e., auto-PEEP).
Time-Limited Expiration
 mode that allows the clinician to control TI and expiratory
time (TE), called airway pressure release ventilation (APRV).
 During APRV, two time settings are used: Time 1 (T1)
controls the time high pressure is applied, and Time 2 (T2)
controls the release time, or the time low pressure is applied.
This mode of ventilation limits the expiratory time.
 APRV/ Bi-Vent / Duo-PAP.
Continuous Positive Airway Pressure and
Positive End Expiratory Pressure
 CPAP involves the application of pressures above ambient
pressure throughout inspiration and expiration to improve
oxygenation in a spontaneously breathing patient.
 PEEP involves applying positive pressure to the airway
throughout the respiratory cycle. The pressure in the airway
therefore remains above ambient even at the end of
expiration.
PEEP becomes the baseline variable during mechanical
ventilation.
 Anothervariation of PEEP and CPAP therapy that is
commonly used is bilevel positive airway pressure, or
BiPAP.
With bilevel positive pressure, the inspiratory positive
airway pressure (IPAP) is higher than the expiratory
positive airway pressure (EPAP). This form of ventilation is
patient triggered, pressure targeted, and flow or time cycled
The breath type (i.e., source of energy used to deliver
the breath) and pattern of breath delivery during
mechanical ventilation constitute the mode of
ventilation. The mode is determined by the following
factors:
1. Type of breath (mandatory, spontaneous, assisted)
2. Targeted control variable (volume or pressure)
3. Timing of breath delivery (continuous mandatory
ventilation [CMV], IMV, or continuous spontaneous
ventilation [CSV])
Type of Breath Delivery

Mandatory Breaths
 Mandatory breaths are breaths for which the ventilator
controls the timing, the VT, or the inspiratory pressure.
 For example, a patient-triggered, volume-targeted, volume-
cycled breath is a mandatory breath. The ventilator controls
VT delivery.
Spontaneous Breaths
For spontaneous breaths, the patient controls the timing and
the VT.
Assisted Breaths
In an assisted breath, all or part of the breath is
generated by the ventilator, which does part of the WOB
for the patient.

By choosing either volume or pressure ventilation, the

clinician determines the control variable that will be
used to establish gas flow to the patient.

• Control variables are independent variables

 VOLUME CONTROL
Allows pressure to vary with changes in resistance and
compliance while volume delivery remains constant.
Advantages:
1. Predictable regulation of TV, MV.
2. Better control over PaCO2 .
Disadvantages:
3. Higher incidence of barotrauma, volutrauma especially in
ARDS and ALI .
4. During assisted breath, flow rates may be insufficient
leading to desynchrony and auto PEEP.
Pressure-controlled
Advantages
1. Reduces the risk for overdistention of the lungs by
limiting the amount of positive pressure applied to the
lung.
2. Adequate flow: less flow dyssynchrony.
Disadvantages
3. VT and MV are variable, decrease in worsening
conditions.
4. auto PEEP May promote hypoventilation may cause
increase in PaCO2.
Timing of Breath Delivery
 Three types of breath delivery timing or sequence are
available on current ventilators:

1. Continuous mandatory ventilation (CMV)- either time-

triggered or patient-triggered breaths are mandatory breaths;
the patient is not generating any spontaneous breaths.
2. Intermittent mandatory ventilation (IMV)- the patient
receives a set number of mandatory breaths each minute but
is also allowed to breathe spontaneously between mandatory
breaths.
3. Continuous spontaneous ventilation (CSV)- all
breaths are spontaneous and are therefore patient
triggered. These spontaneous breaths may be assisted
(e.g., PSV) or unassisted (e.g., CPAP)
Modes of Ventilation

Five basic modes of ventilation

 VC-CMV,
 PC-CMV,
 VC-IMV,
 PC-IMV, and
 PC-CSV
Continuous Mandatory Ventilation

 WithCMV, all breaths are mandatory and can be volume or

pressure targeted.
 WithCMV, every breath (time triggered or patient triggered) is
a machine breath.
 When the breaths are time triggered, the breaths are described
as controlled ventilation.
 When the breaths are patient triggered during CMV, the breaths
are described as assisted ventilation. Although the patient can
trigger breaths at a faster rate than the set mandatory rate, the
set volume or pressure is delivered with each breath.
 Patient has no control over breathing.
 Appropriate use of sedatives and muscle relaxants.
 Decreases work of breathing if properly instituted.
Indications:
1. Initiation of Mechanical Ventilation,
2. to avoid desynchrony, 'fighting' or bucking.
Disadvantages:
3. Regardless of effort, patient cannot initiate flow.
4. Due to sedation and paralysis, potential for apnea if accidental
disconnection .
5. Cannot be used for weaning.
Volume-Controlled Continuous Mandatory
Ventilation (VC-CMV)

 Although VC-CMV was once thought to minimize WOB

during mechanical ventilation, studies have shown that
patients receiving this mode of ventilation may actually
perform 33% to 50% or more of the work of inspiration.
 Thisis especially true when inspiration is active and the set
gas flow does not match the patient’s inspiratory flow
demand. Clinically on the graphic display, If the pressure
does not rise smoothly and rapidly to peak during
inspiration, flow is inadequate.
 A concave pressure curve
indicates active
inspiration. Flow must be
increased until the
patient’s demand is met
and the curve becomes
Convex.
Pressure-Controlled Continuous Mandatory
Ventilation (PC-CMV)
 With PC-CMV all breaths are time or patient triggered,
pressure targeted, and time cycled.
 The ventilator provides a constant pressure to the patient
during inspiration.
 The VT delivered by the ventilator is influenced by the
compliance and resistance of the patient’s lungs, patient
effort, and the set pressure.
 The maximum pressure limit during PC-CMV is typically
set at approximately +10 cm H2O above the target or set
pressure,
Occasionally the inspiration time (TI) is set
longer than the expiration time (TE) during
PC-CMV.
It has been shown that a longer TI provides
better oxygenation to some patients with very
stiff lungs, by increasing mean airway
pressure (Paw).
This mode is referred to as pressure-
controlled inverse ratio ventilation (PC-
IRV).
Intermittent Mandatory Ventilation
 IMV involves periodic volume-targeted or pressure-targeted
breaths that occur at set intervals (time triggering).
 During IMV, the patient can breathe spontaneously between
mandatory (i.e., machine) breaths at any desired baseline
pressure without receiving a mandatory breath.
 The patient does the WOB by actively breathing and not
receiving complete support from the ventilator.
 the main advantages of using IMV is that it allows active
participation by the patient in breath delivery, thus
preserving a certain amount of respiratory muscle strength
(A)PC-CMV mode; breaths are
patient triggered.
(B) Pressure-controlled ventilation
using the spontaneous intermittent
mechanical ventilation (PC-IMV)
mode with spontaneous ventilation
at zero baseline.
(C) PC- IMV mode in which
pressure support (PS) has been
added for spontaneous breaths.
SYNCHRONIZED INTERMITTENT MANDATORY
VENTILATION (SIMV)
 Mandatory breaths are 'synchronised' with patient effort.
 Mandatory breaths may be time triggered (poor RR) or
patient triggered (good RR).
 Thus, mandatory breaths my be assisted or controlled.
 Mandatory breaths can be set as volume controlled or
pressure controlled.
 Theproblem of 'breath stacking' and dys-synchrony was
addressed by SIMV.


 Inspiratory flow is provided if inspiratory effort is sensed.

 Breath is terminated once patients inspiratory flow declines below a set
limit.
 Thus, patient triggered, pressure limited, flow cycled assisted
ventilation.
 Advantages
1. Maintains respiratory muscle strength/ avoids atrophy.
2. Reduces V/Q mismatch.
3. Facilitates weaning•
 Disadvantages:
1. May provide false sense of improvement of lung function.
2. It may cause a desire to wean too early and ultimately cause failed
weaning.
Spontaneous Modes

There are three basic means of providing support

for CSV during mechanical ventilation, as follows:
 Spontaneous breathing
 Continuous positive airway pressure (CPAP)
 Pressure support ventilation (PSV)
PRESSURE SUPPORT VENTILATION
 When used with SIMV it significantly decreases
patient's work of breathing and therefore oxygen
consumption is also reduced.
 Lowers the work of spontaneous breathing and
augments a patient's spontaneous tidal volume.
 Applies a preset plateau pressure to patient's airway for
duration of spontaneous breath.
 Tidal volume varies with the patient's inspiratory flow
demand.
 patient must have a consistent, reliable spontaneous
respiratory pattern for PSV to be successful.
 Inspiration lasts only for as long as the patient actively inspires .
 Pressure supported breath is- patient triggered, pressure
limited and flow cycled.
 Inspiration is terminated when the patient's inspiratory flow rate
falls to25% of the peak level.
 Pressure support is not active during mandatory breaths.
 Pressure support facilitates in a difficult to wean patient-
1. Increases spontaneous tidal volume
2. Decreases spontaneous frequency
3. Decreases work of breathing
Additional Modes of Ventilation
Pressure-Regulated Volume Control(PRVC)
 Pressure-regulated volume control delivers pressure
breaths that are patient-triggered or time-triggered,
volume-targeted, and time cycled breaths.
 During breath delivery, the ventilator measures the
VT delivered and compares it with the targeted VT,
which is set by the operator.
If the volume delivered is less than the set VT, the
ventilator increases pressure delivery progressively over
several breaths until the set and the targeted VT are
about equal.
 The first breath (left) is a volume-
targeted test breath with an
inspiratory hold to measure
plateau pressure.
 The second breath is a pressure-
targeted breath with a pressure
equal to the measured plateau
pressure.

Set tidal volume is 400 mL. Measured exhaled tidal volume is

about 350 mL. the pressure is increased by a few centimeters of
H₂O on the third breath for the ventilator to achieve the set
tidal volume.
Mandatory Minute Ventilation(MMV)
 Has been used primarily for weaning patients from the
ventilator.
 It allows the operator to set a minimum minute ventilation,
which usually is 70% to 90% of a patient’s current Ve.
 The ventilator monitors the patient’s spontaneous breathing
and provides whatever part of the minute ventilation the
patient is unable to accomplish by increasing the RR or the
preset pressure.
 This pattern increases dead space ventilation without
effectively increasing alveolar ventilation.
 MMV is rarely used in current practice.
Adaptive support ventilation (ASV)
 It was first described by Laubscher and colleagues in 1994 as
a variation of mandatory minute ventilation.
 With ASV, the clinician sets the targeted minute ventilation
Ve ,based on the patient’s IBW and estimated dead space
volume (i.e., 2.2 mL/kg of ideal body weight).
 It represents the total minute ventilation normally required for
the patient.
 The clinician can adjust the targeted ventilation based on the
patient’s needs (i.e., less than 100% of the targeted minute
ventilation during weaning or more than 100% in cases in
which ventilatory needs are increased, such as sepsis)
 The optimal breathing frequency that the ventilator
delivers is determined by delivering a test breath to the
patient, which estimates the expiratory time constant for
the patient’s respiratory system. This is used along with
the estimated dead space volume and the calculated
minute ventilation to calculate the optimal breath
frequency delivered by the ventilator.
 The optimal VT then can be calculated by dividing the
patient’s calculated minute ventilation by the optimal
breathing frequency.
 Ithas been suggested
that ASV may be
beneficial in weaning
of critically ill
patients from
mechanical
ventilation because it
automatically selects
the VT and respiratory
rate based on changes
in the patient’s lung
mechanics
Airway Pressure Release Ventilation (APRV)
APRV is designed to provide high and low airway
pressure levels and allow spontaneous breathing at both
levels when spontaneous effort is present.
 Both pressure levels are time triggered and time
cycled.
 The terms P high and P low indicate the levels of
pressure administered during APRV,and T high and T
low are used to describe the time spent in high and
low airway pressures.
 The P high level is interrupted intermittently to allow
pressures to drop very briefly (for about 1 second or
less) to a P low level.
 Reducing the CPAP reduces the patient’s FRC and
allows exhalation and ventilation (i.e., exhalation of
CO2). Expiratory flow generally is not permitted to
return to baseline (zero); therefore auto-PEEP is
intentionally present,which helps maintain an open lung
and prevents repeated collapse and reexpansion of
alveoli. As soon as the release period is complete, the P
high level is restored.
Other modes
Proportional Assist Ventilation
 The PAV approach is a different approach to mechanical
ventilation because pressure, flow, and volume delivery are
proportional to the patient’s spontaneous effort.
 The pressure, ventilator produces depends on two factors:
(1) the amount of patient’s effort; and
(2) the degree of amplification selected by the clinician. PAV is a
positive feedback system.
Pressure augmentation (PAug)
 Itis a dual-control mode .With P Aug ventilation,
the ventilator begins with a patient-triggered,
pressure-targeted breath (e.g., a pressure support
breath), but targets the volume preset by the
operator and delivers that volume with every
breath
NEURALLY ADJUSTED VENTILATORY ASSIST (NAVA)
 It is a mode in which patient's electrical activity of the
diaphragm is used to guide optimal functions of ventilator.
 Neural controls of respiration originated in patient's respiratory
centre are sent to diaphragm via phrenic nerves bipolar
electrodes are used to pick up this electrical activity.
1. In weaning of mechanically ventilated patients with spinal cord
injury.
2. In patients with head injury, COPD, history of ventilator
dependency.
3. Reduces or eliminates the incidence of disuse atrophy of
diaphragm.
REFERENCES

 Pilbeam’s mechanical ventilation 7 th edition.

 David W.
Chang‘s Clinical application of
mechanical ventilation 4th edition.