Post on 14-Apr-2018
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MODES OF MECHANICAL VENTILATION
Mazen Kherallah, MD, FCCP
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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)
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ADVANCED BASICS
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RESPIRATORYCYCLE
Inspiration
Expiration
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ExpInsp
RELATIONSHIP BETWEEN TIDALVOLUME,
INSPIRATORYTIME AND FLOW
VT 1
Ti a
VT 2
VT 3
Time
Volume
Flow= 30 L/min
Flow= 15 L/min
Flow= 37.5 L/min
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ExpExpInspInspInsp
RELATIONSHIP BETWEEN TIDALVOLUME,
INSPIRATORYTIME AND FLOW
VT 1
Ti a
Time
Volume
Ti b Ti c
Flow= 30 L/min
Flow= 20 L/min
Flow= 60 L/min
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PRESSURE LIMITED BREATH
Time
Volume
Pressure Limit
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EXPIRATORYFLOW CYCLING
Time
Flow
50%
100%
Flow Cycling
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RISE TIME
Time
Flow
Pressure
Volume
TI TE
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MANDATORY, SPONTANEOUS AND TRIGGERED
INSPIRATORYCYCLINGM
S
Tsynch
M M
M
MM
M
M
S
M
Tsupp Tsupp
Tsupp Tsupp
Tsupp
Tsupp
S
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VOLUME CONTROLLED INFLATION
Time
Flow
Pressure
Volume
TI TE
Tidal Volume
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If compliance decreases the pressure increases tomaintain the same Vt
1 2 3 4 5 6
SEC
1 2 3 4 5 6
PawcmH20
50
-20
120
120
SEC
INSP
EXH
FlowL/min
VOLUME CONTROL BREATHS
Decreased Compliance
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VOLUME CONTROL WITH END-INSPIRATORY
PAUSE
Time
Flow
Pressure
Volume
TI TE
Tidal Volume
End Inspiratory Pause
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PRESSURE CONTROLLED INFLATION
Time
Flow
Pressure
Volume
TI TE
Tidal Volume
Rise Time
Peak Inspiratory Flow
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Inspiration Expiration
0 1
20
00 1 2
3
-3
0
20
0 21
20
00 1 2
3
-3
0
20
0 2
Inspiration Expiration
Volume/Flow Control Pressure Control
Time (s) Time (s)
Paw
Paw
Pressure
Volume
Flow
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TRIGGERED MODES OF
VENTILATIONCPAP and PSVV
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SPONTANEOUS BREATHING
Time (sec)
Flow
(L/m)
Pressure(cm H2O)
Volume
(mL)
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PRESSURE SUPPORTVENTILATION
(PSV)
Time (sec)
Flow
(L/m)
Pressure(cm H2O)
Volume
(mL)
Set PS
Level
Flow
Cycling
Better Efforts
Longer Inspiration
Patient Triggered, Flow Cycled, Pressure limited Mode
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CPAP+PSV
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Set PS
Level
Flow
Cycling
Patient Triggered, Flow Cycled, Pressure limited Mode
CPAP Level
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TRIGGERED MODES OFVENTILATION
PRESSURE SUPPORTVENTILATION
Control Trigger Limit Target Cycle
Pressure Patient Pressure Flow
Patient Triggered Flow Cycled Ventilation
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PRESSURE ORVOLUME-TARGETED
VENTILATION
| Full to partial ventilatory support
| Augments the patients spontaneous VT
| Decreases the patients spontaneous
respiratory rate
| Decreases patient WOB by overcomingthe 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
Advantages Disadvantages
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MANDATORY MODES OF
VENTILATIONCMV or IPPV
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MANDATORYMODES OFVENTILATION
CMV
Control Trigger Limit Target Cycle
Pressure
Or
Volume
Time Time
Time Triggered Time Cycled Ventilation
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CONTROL MODE
(PRESSURE-TARGETEDVENTILATION)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Time Triggered, Pressure Limited, Time Cycled Ventilation
Time (sec)
Time CyclingSet PC Level
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CONTROL MODE
(VOLUME-TARGETEDVENTILATION)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Time Triggered, Flow Limited, Volume Cycled Ventilation
Time (sec)
Preset VTVolume Cycling
Time Cycling
Dependent on
CL& Raw
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PRESSURE ORVOLUME-TARGETED
VENTILATION
| Decreases the
work of breathing
(WOB)
| Helps maintain a
normal PaCO2
| Not able to assist the
ventilator
Advantages Disadvantages
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HYBRID MODES OF
VENTILATIONSIMV and A/C
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HYBRID MODES OFVENTILATION
A/C
Control Trigger Limit Target Cycle
Pressure
Or
Volume
Time
Or
Patient
Time
Time or PatientTriggered Time Cycled
Ventilation
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ASSISTED MODE
(VOLUME-TARGETEDVENTILATION)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Patient Triggered, Flow limited, Volume Cycled Ventilation
Time (sec)
Preset peak Flow
Time Cycling
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ASSISTED MODE
(PRESSURE-TARGETEDVENTILATION)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Patient Triggered, Pressure Limited, Time Cycled Ventilation
Time (sec)
Time CyclingSet PC Level
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PRESSURE ORVOLUME-TARGETED
VENTILATION
| Decreases the
work of breathing
(WOB)
| Allows patients to
regulate
respiratory rate
| Helps maintain anormal PaCO2
|Alveolar
hyperventilation
Advantages Disadvantages
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HYBRID MODES OFVENTILATION
SIMV/PS
Breath
Type
Control Trigger Limit Cycle
Mandatory Pressure
Or
Volume
Time
Or
Patient
Time
Spontaneous Pressure Patient Pressure Flow
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SIMV
(VOLUME
TARGETED
VENTILATION
)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Spontaneous Breaths
M M M
Time (sec)
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SIMV+PS
(VOLUME
TARGETED
VENTILATION
)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
MTsuppTsynch
Set PS Level
Flow-cycled
Time (sec)
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SIMV + PS
(PRESSURE
-TARGETED
VENTILATION
)
Flow
(L/m)
Pressure
(cm H2O)
Volume
(mL)
Tsupp
Tsynch
Time CycledFlow-cycled
Tsynch
Set PC Level Set PS Level
Time (sec)
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HYBRID MODEVENTILATION: SUPPRESSION
Time (sec)
Flow
(L/m)
Pres
sure
(cmH2O)
Cycles
M Tsupp MMTsupp
M M
Tsupp Tsupp
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HYBRID MODEVENTILATION: SYNCHRONIZATION
(SIMV+PSV)
Time (sec)
Flow
(L/m)
Pressure
(cm H2O)
Cycles
Triggered window for
supported breaths
Triggered window for
synchronized breaths
Mandatory Cycle Time
M Tsupp Tsynch M Tsynch Tsupp
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SIMV
| 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
stackingy May cause
barotrauma or
volutrauma
Advantages Disadvantages
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ALL MODES TABLES
Mandatory Modes of Ventilations
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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
Triggered Breaths
Types None None None None
Supported Breaths
Control - - - -
Target - - - -
Feedback - - - -
Expiratory Cycling - - - -
Spontaneous Breaths
During mandatory inspirationNot
accommodated
Not
accommodated
Not
accommodatedAccommodated
OtherwiseNot
accommodatedAccommodated
Not
accommodatedAccommodated
Synonyms
IPPV (Draeger)
ControlledMandatory
Ventilation
IntermittentMandatory
Ventilation
IPPV (Draeger):trigger off,
autoflow off
IPPV (Draeger):trigger off,
autoflow on
Triggered Modes of Ventilations
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Triggered Modes of Ventilations
Mandatory breaths
Inspiratory cycling - - -
Control - - -
Target/Limit - - -
Feeadback - - -
Expiratory cycling - - -
Triggered Breaths
Types Supported breaths 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
Spontaneous Breaths
During mandatory inspiration - - -
Otherwise - - -
Synonyms
Assisted Spontaneus Breathing
(Draeger)
Spontaneous Mode (Hamilton,
Puritan Bennet)
Pressure Support (MaquetPressure Support Ventilation
(Viasys)
CPAP (Respironics)
Volume Support
(Maquet, Puritan-
Bennett)
Propotional Assist
Ventilation,
Proportional Pressure
Suport (Draeger)
Propotional AssistVentilation Plus
(Puritan-Bennet)
Hybrid Mode: Assist Control
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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 - - -
Spontaneous Breaths
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 (Puritan-Bennett, Respironics)
Pressure A/C (Viasys)
Adaptive Pressure
Ventilation CMV
PRVC (Maquet)
VC+A/C (Puritan-
Bennet)PRVC A/C (Viasys)
IPPV Assist Autoflow
(Draeger)
Hybrid Mode: Synchronized Intermittent Mandatory Ventilation
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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
TypesMandatory and
supported pattern
Mandatory and supported
pattern
Mandatory and
supported pattern
Supported Breaths
Control Pressure Pressure Pressure
Target - - -
Feedback - - -
Expiratory Cycling Flow Flow Flow
Spontaneous Breaths
During mandatory inspiration Not accommodated Accommodated Accommodated
Otherwise Only if support is off Only if support is off Only if support is off
Synonyms
SIMV (Draeger, Hamilton)
SIMV (VC)+PS (Maquet)
VCV-SIMV (Puritan-Bennett, Respironics)
Volume SIMV (Viasys)
P-SIMV (Hamilton)
SIMV(PC)+PS
(Maquet)
PCV-SIMV (Puritan-Bennett, Respironics)
Pressure SIMV
(Viasys)
SIMV+Autoflow
Adaptive Pressure
Ventilation SIMV
(Hamilton)SIMV (PRVC)+PS
(Puritan-Bennett)
PRVC SIMV (Viasys)
Hybrid Mode: Bi-Level Ventilatio
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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
Triggered Breaths
InteractionMandatory andsupported
Mandatory pattern andsupported
Mandatory andsupported
Mandatory andsupported
Supported Breaths
Control Pressure Pressure Pressure Pressure
Target - - - -
Feedback - - - -
Expiratory Cycling Flow Flow Flow Flow
Spontaneous Breaths
During mandatoryinspiration
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 toPRES 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
SynonymsBIPAP
(Draeger)
DuoPAP/APRV (Hamilton)
BiLevel (Puritan-Bennet)
APRV/Bi-phasic
(Viasys)Bi-vent (Maquet)
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THANK
YOU