MODES OF MECHANICAL VENTILATION

Mazen Kherallah, MD, FCCP

POINTS OF DISCUSSIONS
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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 VT 1
Flow= 37.5 L/min

Flow= 30 L/min

Insp VT 2

Exp
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

Exp Exp

Ti b Ti a

Ti c

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 M M

M S S

M S

M Tsupp Tsupp

M Tsupp

Tsynch

Tsupp

Tsupp

M Tsupp

VOLUME CONTROLLED INFLATION

Pressure

Flow

Tidal Volume

Volume

TI

TE

Time

VOLUME CONTROL BREATHS

50
Decreased Compliance

Paw
cmH20 -20 120

SEC

6
INSP

Flow
L/min

SEC

6
EXH

120

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

Pressure

Rise Time

Peak Inspiratory Flow

Flow

Tidal Volume Volume

TI

TE

Time

Volume/Flow Control
Inspiration
20

Pressure Control
Inspiration
20

Expiration

Expiration

Paw

Pressure
0 20 1

Paw
2 0 0 20 1 2

Volume
0 3 0 1 2 0 3 0 1 2

Flow

Time (s)

Time (s)

-3

-3

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)

Flow Cycling

Better Efforts

Flow (L/m)

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

CPAP+PSV
Set PS Level CPAP Level

Pressure (cm H2O)

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
Pressure

Target

Cycle
Flow

Patient Triggered Flow Cycled Ventilation

PRESSURE OR VOLUME-TARGETED VENTILATION

Advantages
| | |

Disadvantages
|

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 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

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MANDATORY MODES OF VENTILATION

CMV or IPPV

MANDATORY MODES OF VENTILATION CMV

Control Trigger
Pressure Or Volume Time

Limit

Target

Cycle
Time

Time Triggered Time Cycled Ventilation

CONTROL MODE (PRESSURE-TARGETED VENTILATION)

Set PC Level Pressure (cm H2O) Time Cycling

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
|

Disadvantages
|

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

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 Time Or Patient

Limit

Target

Cycle
Time

Time or PatientTriggered Time Cycled Ventilation

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 Pressure (cm H2O) Time Cycling

Flow (L/m)

Volume (mL)

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

PRESSURE OR VOLUME-TARGETED VENTILATION

Advantages
|

Disadvantages
|

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

Alveolar hyperventilation

HYBRID MODES OF VENTILATION SIMV/PS

Breath Type
Mandatory

Control Trigger
Pressure Or Volume Pressure Time Or Patient Patient

Limit

Cycle
Time

Spontaneous

Pressure

Flow

SIMV (VOLUME TARGETED VENTILATION)

Pressure (cm H2O) M M M

Spontaneous Breaths
Flow (L/m)

Volume (mL)

Time (sec)

SIMV+PS (VOLUME TARGETED VENTILATION)

Set PS Level Pressure (cm H2O) Tsynch Tsupp M

Flow-cycled

Flow (L/m)

Volume (mL)

Time (sec)

SIMV + PS (PRESSURE-TARGETED VENTILATION)

Tsynch Pressure (cm H2O) Tsupp
Set PC Level

Tsynch

Set PS Level

Time Cycled

Flow-cycled

Flow (L/m)

Volume (mL)

Time (sec)

HYBRID MODE VENTILATION: SUPPRESSION

Pressure (cm H2O) M M Tsupp M Tsupp Tsupp Tsupp

Cycles

Flow (L/m) M

Time (sec)

HYBRID MODE VENTILATION: SYNCHRONIZATION (SIMV+PSV)

M Pressure (cm H2O) Tsupp Tsynch M Tsynch Tsupp

Flow (L/m)

Cycles

Mandatory Cycle Time

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

SIMV
Advantages
|

Disadvantages
|

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

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 Control Target/Limit Feeadback Expiratory cycling Triggered Breaths Types Supported Breaths Control Target Feedback Expiratory Cycling Spontaneous Breaths During mandatory inspiration Otherwise Not accommodated Not accommodated IPPV (Draeger) Controlled Mandatory Ventilation Not accommodated Accommodated Intermittent Mandatory Ventilation Not accommodated Not accommodated IPPV (Draeger): trigger off, autoflow off Accommodated Accommodated IPPV (Draeger): trigger off, autoflow on None None None None Time Volume Time Time Time Volume Time Volume Pressure-limited Intra-breath Time Time (Pressure) Volume-targeted Inter-breath Time

Synonyms

Triggered Modes of Ventilations

Mandatory breaths Inspiratory cycling Control Target/Limit Feeadback Expiratory cycling Triggered Breaths Types Supported Breaths Control Target Feedback Expiratory Cycling Spontaneous Breaths During mandatory inspiration Otherwise Assisted Spontaneus Breathing (Draeger) Spontaneous Mode (Hamilton, Puritan Bennet) Pressure Support (Maquet Pressure Support Ventilation (Viasys) CPAP (Respironics) Propotional Assist Ventilation, Proportional Pressure Suport (Draeger) Propotional Assist Ventilation Plus (Puritan-Bennet) Pressure --Flow (Pressure) Volume-targeted Inter-breath Flow (Pressure) Flow and Volume Intra-breath Flow Supported breaths Supported breaths Supported breaths -

Synonyms

Volume Support (Maquet, PuritanBennett)

Hybrid Mode: Assist Control

Mandatory breaths Inspiratory cycling Control Target/Limit Feeadback Expiratory cycling Triggered Breaths Types Supported Breaths Control Target Feedback Expiratory Cycling Spontaneous Breaths During mandatory inspiration Otherwise Not accommodated IPPVASSIST (Draeger) Synchronized cCntrolled Mandatory Ventilation (Hamilton) Volume Control (Maquet) VCV-A/C (Puritan-Bennett, Respironics) Volume A/C (Viasys) Accommodated BIPAPASSIST (Draeger) P-CMV (Hamilton) Pressure Control (Maquet) PCV-A/C (PuritanBennett, Respironics) Pressure A/C (Viasys) Accommodated Adaptive Pressure Ventilation CMV PRVC (Maquet) VC+A/C (PuritanBennet) PRVC A/C (Viasys) IPPV Assist Autoflow (Draeger) Mandatory pattern Mandatory pattern Mandatory pattern Time or trigger Volume Time Time or trigger Pressure Time Time or trigger (Pressure) Volume-targeted Inter-breath Time

Synonyms

Hybrid Mode: Synchronized Intermittent Mandatory Ventilation

Mandatory breaths Inspiratory cycling Control Target/Limit Feeadback Expiratory cycling Triggered Breaths Types Supported Breaths Control Target Feedback Expiratory Cycling Spontaneous Breaths During mandatory inspiration Otherwise Not accommodated Only if support is off SIMV (Draeger, Hamilton) SIMV (VC)+PS (Maquet) VCV-SIMV (PuritanBennett, Respironics) Volume SIMV (Viasys) Accommodated Only if support is off P-SIMV (Hamilton) SIMV(PC)+PS (Maquet) PCV-SIMV (PuritanBennett, Respironics) Pressure SIMV (Viasys) Accommodated Only if support is off SIMV+Autoflow Adaptive Pressure Ventilation SIMV (Hamilton) SIMV (PRVC)+PS (Puritan-Bennett) PRVC SIMV (Viasys) Pressure Flow Pressure Flow Pressure Flow Mandatory and supported pattern Mandatory and supported pattern Mandatory and supported pattern Time or trigger Volume Time Time or trigger Pressure Time Time or trigger (Pressure) Volume-targeted Inter-breath Time

Synonyms

Hybrid Mode: Bi-Level Ventilatio

Mandatory breaths Inspiratory cycling Control Target/Limit Feeadback Expiratory cycling Triggered Breaths Interaction Supported Breaths Control Target Feedback Expiratory Cycling Spontaneous Breaths
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 PEEP+Psupport (Hamilton) DuoPAP) Plow+Psupport (Hamilton APRV) PEEPL+Psupp (Puritan-Bennett) Triggers support to PRES HIGH + PSV if Thigh PSV is activated

Time or trigger Pressure Time or trigger Mandatory and supported Pressure Flow

Time or trigger Pressure Time or trigger Mandatory pattern and supported Pressure Flow

Time or trigger Pressure Time or trigger Mandatory and supported Pressure Flow

Time or trigger Pressure Time or trigger Mandatory and supported Pressure Flow

During mandatory inspiration

Accommodated

Tigger support to PSV above PHigh

Otherwise

Triggers support

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)

THANK YOU