School of Nursing: CCP4860
Different Modes of
Mechanical Ventilation
Justa Davids
Objectives
• Differentiate between the different modes of
ventilation
Modes of ventilation
• The term “ventilator mode” refers to the way the machine ventilates
the patient.
• Several different modes can be set.
• Control mode, Assist Control, Intermittent Mandatory, Synchronized
Intermittent Mandatory ventilation, CPAP, ST Mode/
• After deciding to start positive-pressure ventilation with a volume-
cycled ventilator, the clinician must now select the safest initial mode
of machine operation.
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Control Mode or Controlled Mandatory
Ventilation (CMV)
• In the control mode, ventilation is provided entirely by the ventilator
at a respiratory rate, VT, and FiO₂.
• Patient is not allowed to trigger a breath.
• At ventilatory rates greater than 8 inspirations per minute in
conjunction with VT of 6 - 8 ml/kg, it is reasonable to assume that full
alveolar ventilatory support is adequate in most instances.
• The use of barbiturate coma to treat head injury is an example
wherein ventilation is exclusively in the control mode.
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Assist Control Mode
• A minimum number of pre-set mandatory breaths are delivered by
the ventilator, but the patient can also trigger assisted breaths.
• The assist-control mode, in which a tidal volume and rate are pre-set
and guaranteed.
• The assisted breath is augmented by the preset tidal volume from the
ventilator.
• The total respiratory rate is determined by the number of
spontaneous inspirations initiated by the patient plus the number of
breaths set on the ventilator.
• The patient can affect the frequency and timing of the breaths.
• If the patient makes an inspiratory effort, the ventilator senses a
decrease in the circuit pressure and delivers the pre-set tidal volume.
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• In this way, the patient can dictate a comfortable respiratory pattern
and may trigger additional machine-assisted breaths above the set
rate.
• If the patient does not initiate inspiration, the ventilator
automatically delivers the pre-set rate and tidal volume, ensuring
minimum minute ventilation.
• In the assist-control mode, the work of breathing is reduced to the
amount of inspiration needed to trigger the inspiratory cycle of the
machine.
• This trigger is adjusted by setting the sensitivity of the machine to the
degree of pressure decrease desired in the circuit.
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• In the assist-control mode, the work of breathing is reduced to the
amount of inspiration needed to trigger the inspiratory cycle of the
machine.
• This trigger is adjusted by setting the sensitivity of the machine to the
degree of pressure decrease desired in the circuit (see image below).
• Assist-control differs from controlled ventilation because the patient
can trigger the ventilator to deliver a breath and, thereby, adjust their
minute ventilation.
• In controlled ventilation, the patient receives only breaths initiated
by the ventilator at the pre-set rate.
• Although the work of breathing is not eliminated, this mode gives the
respiratory muscles the greatest amount of rest because the patient
needs only to create enough negative pressure to trigger the
machine.
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• An added advantage is that the patient can achieve the required
minute ventilation by triggering additional breaths above the set
back-up rate.
• In most cases, a minute ventilation that provides a reasonable pH
based on the respiratory rate is determined by the patient's
chemoreceptors and stretch receptors.
• The respiratory center in the central nervous system receives input
from the chemical receptors (arterial blood gas tensions) and neural
pathways that sense the mechanical work of breathing
(mechanoreceptors).
• The respiratory rate and respiratory pattern are the result of input
from these chemoreceptors and mechanical receptors, which allow
the respiratory center to regulate gas exchange.
• In the assist-control mode, this process is accomplished with the
minimum work of breathing. 8
• A second possible advantage of this mode of mechanical ventilation
is that cycling the ventilator into the inspiratory phase maintains
normal ventilatory activity and, therefore, prevents atrophy of the
respiratory muscles.
• A potential disadvantage of the assist-control mode is respiratory
alkalosis (hyperventilation, hypocapnia) in a small subset of patients
whose respiratory drive supersedes the chemoreceptors and
mechanical receptors.
• Patients with a potential for alveolar hyperventilation and
hypocapnia in the assist-control mode include those with end-stage
liver disease, those in the hyperventilatory stage of sepsis, and those
with head trauma.
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• These conditions are typically identified with the first arterial blood
gas results, and the assist-control mode of ventilation can then be
changed to an alternate mode.
• Another possible disadvantage is the potential for serial pre-set
positive-pressure breathes to reduce venous return to the right side
of heart and to affect cardiac output.
• The effects of positive pressure ventilation on the cardiovascular
system are well known.
• In normal breathing, the negative pressure phase of inspiration
assists venous return, alleviates pressure on the pulmonary
capillaries, and encourages flow.
• With positive pressure ventilation, the intrathoracic pressure
increases during inspiration causing a decrease in venous return,
right ventricular output, and pulmonary blood flow.
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• The increased intrathoracic pressure decreases venous return and
right heart filling which may reduce cardiac output.
• Nevertheless, the assist-control mode may be the safest initial choice
for mechanical ventilation.
• It may be switched to another option if hypotension or hypocarbia
are evident from the first arterial blood gas results.
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Intermittent Mandatory Ventilation (IMV)
• IMV allows patient to breathe spontaneously between machine
cycled or mandatory breaths.
• IMV mode is similar to ACM
• At a high IMV rate in which the patient’s spontaneous efforts will be
depressed, IMV provides full ventilator support.
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Synchronized Intermittent Mandatory
ventilation (SIMV)
• Synchronized intermittent mandatory ventilation (SIMV) is a type of
volume control mode of ventilation.
• With this mode, the ventilator will deliver a mandatory (set) number
of breaths with a set volume while at the same time allowing
spontaneous breaths.
• The ventilator attempts to synchronize the delivery of mandatory
breaths with the spontaneous efforts of the patient.
• In contrast, to assist control ventilation (ACV), SIMV will deliver
spontaneous volumes that are 100% driven by patient effort.
• Pressure support (PS) may be added to enhance the volumes of
spontaneous breaths.
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Pressure Support Ventilation
• The pressure support ventilation (PSV) mode augments or assists
spontaneous breathing efforts to a point where the preset pressure is
reached in patients who have an intact respiratory drive.
• When PSV is used as a stand alone mode of ventilation, the pressure
support level is adjusted to achieve the targeted VT and RR.
• Pressure support ventilation (PSV) is a ventilatory mode that
supports spontaneous breaths partially or fully by a pressure assist
above baseline pressure to decrease the imposed work of breathing
created by the narrow lumen ETT, ventilator circuit, and demand
valve.
• At high pressure levels, PSV provides nearly total ventilatory support.
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• Specific uses of PSV are to promote patient comfort and synchrony
with the ventilator, to decrease the work of breathing necessary to
overcome the resistance of the ETT, and for weaning.
• ETT resistance can be related to the effort needed in breathing
through a straw if one is submerged under water.
• The smaller the straw, the larger the effort to move air from the
atmosphere in the lungs.
• Pressure support reduces this work.
• As a weaning tool, PSV is thought to increase the endurance of the
respiratory muscles by decreasing the physical work and oxygen
demands during spontaneous breathing.
•
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How does PPS support inspiratory
effort/ventilation
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ADJUNCTS TO MECHANICAL VENTILATION
Positive End-Expiratory Pressure (PEEP)
• When using a positive-pressure, volume-cycled ventilator, an
important option available for the intubated patient with hypoxemia
and ARF is PEEP.
• PEEP refers to the existence of an airway pressure above that of
ambient air at the end of exhalation.
• PEEP functions to increase functional residual capacity (FRC), which
appears to be the primary mechanism by which alveolar ventilation
and thus gas exchange are improved when PEEP therapy is instituted.
• PEEP increases FRC by distending airways and increasing alveolar size
by the application of positive pressure.
• In fact, in ventilated patients receiving PEEP, the entire respiratory
cycle is maintained under positive pressure.
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ADJUNCTS TO MECHANICAL VENTILATION
Positive end-expiratory pressure (PEEP)
• PEEP is a mode of therapy used in conjunction with mechanical
ventilation.
• At the end of mechanical or spontaneous exhalation, PEEP maintains
the patient's airway pressure above the atmospheric level by exerting
pressure that opposes passive emptying of the lung.
• This pressure is typically achieved by maintaining a positive pressure
flow at the end of exhalation.
• This pressure is measured in centimeters of water.
• PEEP therapy can be effective when used in patients with a diffuse
lung disease that results in an acute decrease in functional residual
capacity (FRC), which is the volume of gas that remains in the lung at
the end of a normal expiration.
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• PEEP therapy can be effective when used in patients with a diffuse
lung disease that results in an acute decrease in functional residual
capacity (FRC), which is the volume of gas that remains in the lung at
the end of a normal expiration.
• FRC is determined by primarily the elastic characteristics of the lung
and chest wall. In many pulmonary diseases, FRC is reduced because
of the collapse of the unstable alveoli.
• This reduction in lung volume decreases the surface area available for
gas exchange and results in intrapulmonary shunting (unoxygenated
blood returning to the left side of the heart).
• If FRC is not restored, a high concentration of inspired oxygen may be
required to maintain the arterial oxygen content of the blood in an
acceptable range.
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• Applying PEEP increases alveolar pressure and alveolar volume.
• The increased lung volume increases the surface area by reopening
and stabilizing collapsed or unstable alveoli.
• This splinting, or propping open, of the alveoli with positive pressure
improves the ventilation-perfusion match, reducing the shunt effect.
• After a true shunt is modified to a ventilation-perfusion mismatch
with PEEP, lowered concentrations of oxygen can be used to maintain
an adequate PaO2. PEEP therapy may also be effective in improving
lung compliance.
• After a true shunt is modified to a ventilation-perfusion mismatch
with PEEP, lowered concentrations of oxygen can be used to maintain
an adequate PaO2.
• PEEP therapy may also be effective in improving lung compliance.
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• When FRC and lung compliance are decreased, additional energy and
volume are required to inflate the lung.
• By applying PEEP, the lung volume at the end of exhalation is
increased.
• The already partially inflated lung requires less volume and energy
than before for full inflation.
• When used to treat patients with a diffuse lung disease, PEEP should
improve compliance, decrease dead space, and decrease the
intrapulmonary shunt effect.
• The most important benefit of the use of PEEP is that it enables the
patient to maintain an adequate PaO2 at a low and safe concentration
of oxygen (< 60%), reducing the risk of oxygen toxicity.
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• Because PEEP is not a benign mode of therapy and because it can
lead to serious hemodynamic consequences, the ventilator operator
should have a definite indication to use it.
• The addition of external PEEP is typically justified when a PaO2 of 60
mm Hg cannot be achieved with an FIO2 of 60% or if the estimated
initial shunt fraction is greater than 25%.
• A PEEP level of less than 10 cm water rarely causes hemodynamic
problems in the absence of intravascular volume depletion.
• The cardio depressant effects of PEEP are often minimized with
judicious intravascular volume support or cardiac inotropic support.
• A PEEP level greater than 10 cm water is generally an accepted
indication to monitor cardiac output by using a Swan-Ganz catheter.
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• Withdrawal of PEEP from a patient should not be attempted in most
clinical situations until the patient has achieved satisfactory
oxygenation with an FIO2 of 40% or less.
• Formal weaning from PEEP is then undertaken by reducing the PEEP
in 3- to 5-cm of water decrements while the hemoglobin-oxygen
saturations are monitored.
• An unacceptable decrease in the hemoglobin-oxygen saturation
should prompt the clinician to immediately reinstitute the last PEEP
level that provided good hemoglobin-oxygen saturation.
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Oxygen toxicity
• Oxygen toxicity is a function of increased FIO2 and its duration of use.
Oxygen toxicity is due to the production of oxygen free radicals, such
as superoxide anion, hydroxyl radical, and hydrogen peroxide.
• Oxygen toxicity can cause a variety of complications ranging from
mild tracheobronchitis and absorptive atelectasis to diffuse alveolar
damage that is indistinguishable from ARDS.
• No consensus has been established for the level of FIO2 required to
cause oxygen toxicity, but this complication has been reported in
patients given a maintenance FIO2 of 50% or greater.
• The clinician is encouraged to use the lowest FIO2 that accomplishes
satisfactory oxygenation.
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• The medical literature suggests that the clinician should attempt to
attain an FIO2 of 60% or less within the first 24 hours of mechanical
ventilation.
• If necessary, PEEP should be considered a means to improve
oxygenation while a safe FIO2 is maintained.
• When PEEP is effective and not contraindicated because of
hemodynamics or other reasons, the patient can usually be
oxygenated while the risks of oxygen toxicity are limited.
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Continuous Positive Airway Pressure (CPAP)
• Continuous positive airway pressure (CPAP) is one of two cardinal
modes of noninvasive ventilation (bilevel positive airway pressure,
or BPAP is the other).
• As the name suggests, CPAP provides continuous positive pressure in
airways throughout the respiratory cycle.
• It is used as a weaning mode and for nocturnal ventilation (nasal or
mask CPAP) to splint open the upper airway, preventing upper airway
obstruction in patients with obstructive sleep apnea.
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Illustration of CPAP
• CPAP provides one continuous pressure throughout the respiratory
cycle—the pressure is set to the same level for inspiration and
expiration.
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Ventilator settings for CPAP
• The ventilator settings for CPAP are the following:
❖One single pressure, measured in cm of water (cmH2O)
❖The fraction of inhaled oxygen (FIO2), set between 21% and 100%
Common clinical uses for continuous positive airway pressure (CPAP):
Acute pulmonary edema, obstructive sleep apnea, and obesity
hypoventilation syndrome (Pickwickian syndrome).
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BIPAP (Bilevel Ventilation)
• Bilevel is a pressure-controlled, time-triggered, time-cycled
mode that allows unrestricted spontaneous breathing with
or without pressure support (PS) throughout the entire
ventilatory cycle.
• Bilevel Positive Airway Pressure (BIPAP) delivers two set
pressures: a higher inspiratory pressure (IPAP) and a lower
expiratory pressure EPAP).
• Spontaneous mode BiPAP provides only patient-initiated
breaths.
•
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Bilevel Ventilation
• IPAP setting will determine how much volume the patient will receive.
• If IPAP is increased the volume is also increased
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• By increasing the IPAP we increase the volume.
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• On an arterial blood gas if the CO2 is high you can correct it by
increasing the volume.
•
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• Next setting is EPAP. This determine how much PEEP you are applying
to the alveoli. To keep alveoli open during exhalation.
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• If the PaO2 (Partial pressure of Oxygen) is low, you can correct it by
increasing the EPAP.
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Example of a blood gas
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• Main problem is ventilation (↑PaCO2.)
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• Notice how the IPAP setting created a small volume.
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• Increase the IPAP to increase the volume.
• So to correct that, increase the IPAP so that volume increases.
• This should help the CO2 (carbon dioxide) to be reduced.
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• Also, the more you increase the difference between IPAP and EPAP,
the more volume the patient receive.
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• The more you increase the IPAP the more volume the patient receive.
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• The recommended minimum IPAP-EPAP differential is 4 cmH2O .
• Increase by at least 1 cmH2O with an interval no shorter than 5
minutes with the goal of eliminating obstructive respiratory events.
• Starting IPAP at 8 cmH2O and EPAP at 4 cm H2O.
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• In this example oxygenation is low and ventilation (CO2) is normal.
• The general recommendation would be to increase the EPAP which
should bring oxygen back to normal. Be careful when you fix
oxygenation by increasing EPAP, you might actually reduce the
volume
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• We can compensate by increasing the IPAP simultaneously with EPAP.
• Keep tidal volume between 300 ml and 500 ml
• Keep SpO2 above 92%.
• This way we can adjust the IPAP to get a desired volume and adjust
the EPAP to get a desired saturation.
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ST Mode
• Spontaneous and Timed (S/T mode) involves a device delivered
breath if a patient initiated breath is not sensed in a pre-specified
time period.
• S/T (Spontaneous/Timed): Like spontaneous mode, the device
triggers on patient inspiratory effort. But in spontaneous/timed
mode a "backup" rate is also set to ensure that patients still receive a
minimum number of breaths per minute if they fail to breathe
spontaneously.
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• If the patient do not trigger a breath the inspiratory time will last for
1.00 seconds (machine mandatory breath).
• If the patient does trigger a breath the patient can actually determine
how long that inspiratory time can last.
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• The inspiratory time in ST mode is fixed during machine triggered
breaths but
• The inspiratory time may varies during patient triggered breaths.
• It makes this mode comfortable because if patient triggers a breath
they can actually determine how long they would inhale.
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Active Mode – PCV (Pressure control
ventilation) during spontaneous mode
• For example if Inspiratory Time (I-Time) is set on 1.00 seconds and
patient does not trigger a breath the inhalation will last for 1.00
seconds – machine trigger the breath.
• If patient trigger a breath the inhalation will still last for mandatory
1.00 seconds. Be careful choosing PCV mode because if patient want
to breath shorter of longer than the set I-Time they cannot
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Which patients can be put on PCV Mode?
• Consider patients who cannot maintain a normal inspiratory time (I-
Time) they usually have low volume and rapid respiratory rate.
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DEFINITIONS OR EXPLANATIONS
• Tidal Volume
• Definition: The amount of air that moves in and out the airways with
each breath.
• Tidal volumes formula = 6 to 8ml/kg of body weight.
• Research has identified a phenomenon of lung injury that has been
dubbed “volu-trauma”, in which forces produced on the lungs by the
ventilator may aggravate the damage inflicted on the lungs by the
pathological process that necessitated mechanical ventilation.
• For this reason, lower VT targets (6 - 8 ml/kg) are recommended.
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Minute Volume
• Amount of air that moves in and out the airway per minute.
• MV = Breaths per minute X tidal volume.
How do you assess if ventilation is adequate for patient – over
ventilate or under ventilate.
• Calculate Pt weight x 100 ml or
• Calculate Pt weight ÷ 10 – 1
• Minute volume (Ve) is a very important indicator together with
PaCO2 in determining ventilation of a patient.
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How are PaCO2 and minute ventilation
related?
• The arterial carbon dioxide tension (partial pressure of carbon
dioxide in the arteries, PaCO2) is determined by the rate of carbon
dioxide production (VCO2) and the level of minute alveolar
ventilation (VA).
• Hence, at a constant rate of carbon dioxide production, the arterial
carbon dioxide tension remains constant as long as alveolar
ventilation remains constant.
• Clinically, however, we don’t measure minute alveolar ventilation;
rather, we measure the overall level of a patient’s ventilation, or
minute ventilation (VE), which is the alveolar ventilation plus the
dead space ventilation (VD).
• So, we can use this to calculate the partial pressure of carbon dioxide
in the arteries by reworking an equation. Do not have to do equation
but can do blood gas and get paCO2 from blood gas.
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Pathological changes to PaCO2
• At a constant rate of carbon dioxide production, the arterial partial
pressure of carbon dioxide falls with increasing minute ventilation
and rises with declines in minute ventilation.
• Furthermore, PaCO2 rises with increasing dead space, as seen in
various disease states like chronic obstructive pulmonary disease
(COPD) and acute respiratory distress syndrome (ARDS), and falls
with declines in the proportion of dead space.
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Dead space
• Definition: about 30 % (150 ml in adult) of air breathed in at rest
remains in air passages and does not reach the alveoli.
• + 2 ml/kg body weight.
• Known as anatomical dead space.
• Dead space of the respiratory system refers to the volume of inspired
air in a given breath in which oxygen (O2) and carbon dioxide (CO2)
gasses are not exchanged across the alveolar membrane in the
respiratory tract.
• This is comprised of two segments: the anatomic dead space (parts
of the airway that are not alveolar exchange membranes) and the
alveolar dead space (alveoli that are ventilated but not perfused with
pulmonary capillary blood flow).
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• Anatomic dead space specifically refers to the volume of air located
in the respiratory tract segments that are responsible for conducting
air to the alveoli and respiratory bronchioles but do not take part in
the process of gas exchange itself.
• These segments of the respiratory tract include the upper airways,
trachea, bronchi, and terminal bronchioles.
• On the other hand, alveolar dead space refers to the volume of air in
alveoli that are ventilated but not perfused, and thus gas exchange
does not take place.
• Physiologic dead space is the sum of the anatomic and alveolar dead
space.
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• Dead space has particular significance in the concept of ventilation
(V) and perfusion (Q) in the lung, represented by the V/Q ratio.
• Alveoli with no perfusion have a V/Q of infinity (Q=0), whereas alveoli
with no ventilation have a V/Q of 0 (V=0).
• Therefore, in situations (i.e., V/Q =infinity) in which the alveoli are
ventilated but not perfused, gas exchange cannot occur, such as
when pulmonary embolism increases alveolar dead space.
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• Alveolar dead space is typically negligible in a healthy adult.
• Anatomic, and therefore physiological, dead space normally is
estimated at 2 mL/kg of body weight and comprises 1/3 of the TV in a
healthy adult patient; it is even higher in pediatric patients.
• Effectively, 1/3 of a TV of inhaled air is rebreathed due to dead space.
• At the end of expiration, the dead volume consists of a gas mixture
high in CO2 and low in O2 compared to ambient air.
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Sensitivity
• The sensitivity of the trigger determines how much effort the
patient has to exert before his inspiration is augmented by the
ventilator.
• The sensitivity knob controls the amount of patient effort needed to
initiate an inspiration, as expressed by required inspiratory effort.
• By turning the knob down or off will decrease the amount of work
the patient must do to initiate a ventilatory breath.
• By turning the knob on and above -2cm H2O increases the amount of
pressure that the patient needs to initiate inspiration and increases
the work of breathing. Usually set at about -2 cm H2O.
•
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Peak Inspiratory Pressure (PIP)
• As the volume of gas is delivered to a patient on a mechanical
ventilator, the ventilator’s pressure gauge slowly rises from zero to
peak inspiratory pressure. The rise in pressure is caused by
resistance to flow or resistance to lung and chest wall inflation.
Compliance
• Compliance is a measure of the distensibility or expansion of the
lungs and thorax, that is, the ease with which the lungs can be
inflated. Compliance is the inverse of elasticity - the property that
causes the lungs to recoil to their resting state.
• Factors affecting compliance include elasticity and surface tension
which is decreased by surfactant production
• Compliance is expressed in milliliters per cm of water (ml/cmH2O).
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Peak Inspiratory Flow (PIF)
• The inspiratory flow rate is measured in liters per minute, and it
determines how quickly the breath is delivered. The time required to
complete inspiration is determined by the tidal volume delivered and
the flow rate: Ti=VT/Flow Rate (TI= inspiration time; VT=Tidal
volume).
• The peak flow is set with two things in mind: if the flow rate is too
high, the volume is rapidly delivered to only the most compliant lung
tissues (and not to the inelastic diseased tissues), at very high peak
pressures.
• If the peak flow is too low, the patient will demand more gas than the
ventilator is set up to supply and dyssynchrony with the machine
occurs. Is usually achieved with a peak inspiratory flow rate between
40 and 70 l/min.
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Peak Pressure
• The peak pressure is representative of the resistance in the system
from the ventilator tubing all the way down to the segmental
bronchi.
• Anything that affects the resistance of these tubes (mucous plugging,
bronchospasm, blood clots, and kinked endotracheal tube) will cause
the peak pressure to rise.
• The machine displays the peak pressure with every breath.
• It is important to know that, while some of the same factors
contribute to both peak and static airway pressures, a number of
things that affect peak pressure are external to the patient and do
not necessarily reflect a change in the compliance of the patient’s
lungs.
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Plateau pressure
• The static or “plateau” pressure is representative of the compliance
of the respiratory system (lung, chest wall and abdomen).
• In essence, it is telling how much pressure is necessary to inflate the
alveoli with each breath.
• Any problem which causes a fall in the compliance of the respiratory
system will cause static pressures to rise.
• Examples of such problems include the onset of ARDS or pulmonary
edema, large pleural effusions, pneumothorax, abdominal distention,
or circumferential chest wall burns.
• The ventilator does not display this pressure with every breath.
Instead, you must use an inspiratory pause maneuver to see this
value.
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Reference
• Urden, Linda. D, Stacy, Kathleen. M., Lough, Mary. E. (2018) Critical
Care Nursing. Diagnosis and Management. 8th Edition. Elsevier.
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Thank You
