Modes of Mechanical

Ventilation

Fellow’s conference
December 7, 2011
Cheryl Pirozzi, MD
 Breath types
 Modes of ventilation
 Other strategies

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Positive-pressure mechanical
ventilators
 Most use piston/bellows
systems
 Tidal breaths generated by
gas flow, either controlled
entirely by the ventilator or
interactive with patient efforts
Breath types
Classified by:
1) trigger variable: what initiates the breath
 change in pressure or flow due to patient effort (patient-
initiated breaths) or a set time (vent-initiated)
2) target variable: what controls gas delivery during the
breath

set flow or set inspiratory pressure
3) Termination/cycle variable: what terminates the breath
 set volume, set inspiratory time, or a set flow
 pressure is usually a “backup” cycle variable to
terminate gas delivery if circuit pressure rises above an
alarm limit
5 basic breath types

1. volume assist (VA)

2. volume control (VC)
3. pressure assist (PA)
4. pressure control (PC)
5. pressure support (PS)

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5 basic breath types

Breath Trigger Target Termination /

cycle
VA Pt Inspir flow Set Vt

VC Vent Inspir flow Set Vt

PA Pt insp P Insp time

PC Vent insp P Insp time

PS Pt insp P % decrease
inspir flow
 5 basic breaths

FIGURE 89-1 ▪ Circuit pressure, flow, and volume tracings over time depicting the five basic
breaths available on most modern mechanical ventilators. Breaths are classified by the
variables that determine the trigger (machine time or patient effort), target/limit (set flow or
set pressure), and cycle (set volume, set time, or set flow). The solid lines represent set or
 Modes of mechanical ventilation
1. Controlled mechanical ventilation (CMV)
2. Assist-control ventilation (ACV)
3. Synchronized intermittent mandatory ventilation (SIMV or
IMV)
4. Pressure support (PS)
5. CPAP
6. BPAP
7. Pressure-regulated volume control (PRVC)
8. Airway pressure release ventilation (APRV) and Biphasic
9. Adaptive support ventilation (ASV)
10. Volume support / Automatic Pressure Ventilation
11. High-frequency ventilation (HFV)
Volume-limited vs. Pressure-limited

 Controlled mechanical ventilation (CMV),

assist/control (A/C) ventilation, and
synchronized intermittent mandatory
ventilation (SIMV) all can be supplied through
either pressure-limited or volume-limited
modes
Volume-limited

 Volume-limited
 clinician sets peak flow rate, flow pattern (ramp vs square),
tidal volume, respiratory rate, PEEP, and FiO2.
 Inspiration ends after delivery of the set tidal volume.
 (I:E) ratio determined by the peak inspiratory flow rate. ↑
peak inspiratory flow → ↓ inspiratory time, ↑ expiratory
time, and ↓ I:E ratio
 Airway pressures depend on set Vt and patient compliance
and airway resistance
Pressure-limited

 Pressure-limited
 clinician sets inspiratory pressure level, I:E ratio,
respiratory rate, applied PEEP, and FiO2
 Inspiration ends after delivery of the set
inspiratory pressure
 tidal volume is variable and determined by
inspiratory pressure, compliance, airway and
tubing resistance
 peak airway pressure is constant and equal to
sum of set inspiratory pressure and applied
PEEP.
Pressure-limited

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Volume-limited vs. Pressure-limited
 Rappaport et al. Crit Care Med. 1994;22(1):22
 RCT PCV vs VCV in 27 pts with acute,
severe hypoxic respiratory failure
(PaO2/FIO2 < 150), not LTVV
 Pressure-limited associated with lower peak
airway pressure, more rapid improvement in
compliance, fewer days of mech ventilation
Volume-limited vs. Pressure-limited
 Prella et al. Chest. 2002;122(4):1382
 Prospective, observational study of 10 pts with
ALI or ARDS: gas exchange, airway pressures,
and end-expir CT for PCV vs VCV
 No difference in PaO2, PaCO2, and PaO2/FiO2
 Peak airway pressure significantly lower in PCV
compared with VCV (26 vs 31cmH2O; p <
0.001)
 PCV more homogeneous gas distribution at the
apex on CT
 not using low tidal volume ventilation
Volume-limited vs. Pressure-limited

Conclusions:
 no statistically significant differences in mortality,

oxygenation, or work of breathing

 pressure-limited: lower peak airway pressures, more

homogeneous gas distribution, improved synchrony, and

earlier liberation from vent
 When ramp wave (decelerating flow pattern) used for VCV, no
longer higher peak pressures than PCV
 volume-limited: the only mode that can guarantee a
constant tidal volume, ensuring a minimum minute
ventilation or LTVV
 Modes of mechanical ventilation
1. Controlled mechanical ventilation (CMV)
2. Assist-control ventilation (ACV)
3. Synchronized intermittent mandatory ventilation (SIMV or
IMV)
4. Pressure support (PS)
5. CPAP
6. BPAP
7. Pressure-regulated volume control (PRVC)
8. Airway pressure release ventilation (APRV) and Biphasic
9. Adaptive support ventilation (ASV)
10. Volume support / Automatic Pressure Ventilation
11. High-frequency ventilation (HFV)
Controlled mechanical ventilation
(CMV)
 Minute ventilation is determined entirely by the set
respiratory rate and tidal volume / pressure.
 The patient does not initiate additional breaths
above that set on the ventilator.
 volume control ventilation (VCV): flow-targeted
volume-cycled breaths
 pressure control ventilation (PCV): pressure-
targeted time-cycled breaths
Assist-control ventilation (ACV)

1. volume assist-control ventilation (VACV): flow-

targeted volume-cycled breaths
2. pressure assist-control ventilation (PACV):
pressure-targeted time-cycled breaths
 guarantees a set number of positive-pressure
breaths.
 If respiratory rate exceeds this, breaths are
patient-triggered breaths (VA or PA). If respiratory
rate is below guarantee, ventilator delivers
mandatory breaths (VC or PC breaths).
Synchronized intermittent
mandatory ventilation (SIMV)
 Set ventilator breaths: set minimum minute
ventilation with respir rate + tidal volume (volume
SIMV) or inspiratory P (pressure SIMV)
 Ventilator breaths are synchronized with patient
inspiratory effort
 pts increase minute ventilation by add’l
spontaneous breaths, which can be unassisted or
PS
Pressure Support (PS)

 Flow-limited mode of ventilation (not volume-limited

or pressure-limited)
 Delivers inspiratory pressure until the inspiratory flow
decreases to ~25% of its peak value.
 Clinician sets inspiratory pressure, applied PEEP,
and FiO2.
 Patient triggers each breath
 Comfortable mode, good for weaning, can be
combined with SIMV
 Not good for full ventilatory support, high airway
resistance, or central apnea
Comparison of waveforms

Marx: Rosen's Emergency Medicine, 7th ed.2009.

CPAP

 Continuous level of positive airway pressure.

 Pt must initiate all breaths
 Functionally similar to PEEP
 Good for OSA, cardiogenic pulmonary edema
Bilevel positive airway pressure
(it’s called BPAP, not BiPAP)
 Mode used during NPPV
 Delivers set IPAP and EPAP
 Vt is determined by difference between IPAP-
EPAP
Pressure-regulated volume control
(PRVC)
 A form of PACV that uses tidal volume as a
feedback control for continuously adjusting the
pressure target
 clinician sets tidal volume target and the
ventilator then automatically sets the inspiratory
pressure within a clinician-set range to achieve
this goal
 As a patient's respiratory drive exceeds the
clinician-set guaranteed rate, some PRVC
systems will provide additional patient-triggered
PA or PS breaths
Airway pressure release
ventilation (APRV)
 Time-triggered, pressure-limited, and time-cycled
mode
 high continuous positive airway pressure (P high) is
delivered for a long duration (T high) and then falls
to a lower pressure (P low) for a shorter duration (T
low)
 allows spontaneous breathing (with or without PS)
during both the inflation and deflation phases

Gonza ́lez et al. Intensive Care Med (2010) 36:817–827

Airway pressure release
ventilation (APRV)
Airway pressure release
ventilation (APRV)
 Based on Open Lung Concept: maximize alveolar
recruitment by keeping the lung inflated for
extended time with high continuous positive airway
pressure
 Driving pressure= difference between P high and P
low. Size of the tidal volume is related to both the
driving pressure and the compliance.
 The transition from P high to P low deflates the
lungs and eliminates CO2.
 T high and T low determine the frequency of
inflations and deflations

Gonza ́lez et al. Intensive Care Med (2010) 36:817–827

Airway pressure release
ventilation (APRV)
 Potential benefits:
 improved alveolar recruitment and oxygenation
 Some observational studies show decreased
peak airway pressure, improved alveolar
recruitment, increased ventilation of the
dependent lung zones and improved oxygenation
 No mortality benefit
 Potential risks: In severe obstructive disease,
could lead to hyperinflation and barotrauma
APRV- Is it better?
 RCT of APRV vs SIMV plus PSV (not LTVV) in 58 pts
with ARDS: no difference in outcome
 Varpula.Acta Anaesth Scand 2004; 48:722-731.
 RCT of APRV vs LTVV with SIMV in 63 trauma pts (not
all with ARDS): no diff in mortality, trend towards ↑ MV
days and ICU LOS
 Maxwell et al. J Trauma. 2010;69: 501–511
 Secondary analysis of observational cohort study of 234
pts ventilated with APRV/BI-PAP vs 1,228 with A/C:
 no differences in ICU or hospital mortality, days of MV,

LOS
 Gonza ́lez et al. Intensive Care Med (2010) 36:817–827
Biphasic Ventilation
 Similar to APRV, except that T low is longer during
biphasic ventilation, allowing more spontaneous
breaths to occur at P low
 AKA Bi-Vent, BiLevel, BiPhasic, and DuoPAP
ventilation.
Biphasic Ventilation
 High-Frequency Oscillatory
Ventilation (HFOV or HFV)
 Also based on Open Lung Concept: keeping the
lung inflated for extended period of time to
maximize alveolar recruitment
 HFV uses very high breathing frequencies (120-900
breaths/min) coupled with very small tidal volumes
(<1 mL/kg) to provide gas exchange in the lungs
 supplied by either jets or oscillators.
 High-Frequency Oscillatory
Ventilation (HFOV or HFV)
 Rationale:
 very small alveolar tidal volumes minimize

cyclical overdistention and derecruitment

 maintains the alveoli open at a relatively constant

airway pressure and thus may prevent

atelectrauma and barotrauma
 improves ventilation/perfusion (V/Q) matching by

ensuring uniform aeration of the lung.


High-Frequency Oscillatory
Ventilation(HFOV or HFV)
 High-Frequency Oscillatory
Ventilation (HFOV or HFV)
 Several studies in adults have shown improved oxygenation
but no mortality benefit
 One RCT: HFV vs PCV (6 -10 mL/kg, mean 8) in 148
patients with ARDS on PEEP≥10
 HFV had higher mean airway pressure, early

improvement in oxygenation, and trend towards lower

mortality rate (37 vs 52%, p = 0.10)
 Derdak. Am J Respir Crit Care Med. 2002;166(6):801
Adaptive Support Ventilation (ASV)
 Based on respiratory mechanics vent automatically adjusts
respiratory rate and inspiratory pressure to achieve a
desired minute ventilation
 Clinician sets desired minute ventilation and a patient
weight (for estimating anatomic dead space).
 ASV calculates expiratory time constant from the flow
volume loop → determines the respiratory rate that
minimizes work of inspiration at a given minute ventilation.
 Breaths are pressure-control + pressure support for
triggered breaths to achieve desired respiratory rate.
 As respiratory mechanics change, the frequency–tidal
volume pattern is automatically adjusted to maintain this
“optimal” pattern.
Adaptive Support Ventilation (ASV)
 The delivered “minimal work” tidal volume with ASV
may be higher than 6 mL/kg
 No outcome studies comparing ASV to conventional
lung-protective strategies
Volume Support (VS)

 AKA “Automatic Pressure Ventilation”

 Pressure support mode that uses tidal volume as a
feedback control for continuously adjusting the pressure
support level.
 Clinicians select a target tidal volume, Vent makes
automatic adjustments in inspiratory pressure within a
clinician-prescribed range.
 Potential for automatic support reduction: could
“automatically” wean a patient by reducing PS as
patient effort and mechanics improve
 No trials comparing VS or ASV weaning to aggressive
daily SBT strategies
Other strategies

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Tracheal Gas Insufflation (TGI)
 Technique to reduce dead space in high pCO2
situations, eg lung-protective ventilatory strategies
like LTVV.
 Fresh gas is insufflated by a catheter placed at the
distal end of the ETT to flush the ETT tube free of
CO2 during exhalation
 Studies show TGI reduces dead space but also has
the potential to increase PEEP.

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Inverse ratio ventilation
 Strategy of inversing I:E ratio (I>E) to potentially
improve oxygenation
 When pt is severely hypoxemic despite optimal PEEP
and FiO2
 Can be used with volume-limited or pressure-limited
mechanical ventilation
 In pressure: increase I:E ratio

 In volume: ramp wave- decrease peak inspiratory

flow rate until I exceeds E

 In volume square wave- add and increase end-

inspiratory pause until I exceeds E

Inverse ratio ventilation
 In trials increases mean airway pressure, may
improve oxygenation, never been shown to
improve important clinical outcomes
 Requires increased sedation +/- paralysis
 Risks: increased risk of auto-PEEP, barotrauma
and hypotension
Strategies to optimize syncrony

 Interactive breaths improve comfort and

reduce sedation
 Strategies
 Endotracheal Tube Resistance Compensation
 Pressure-Targeted Inspiratory Pressure Slope
Adjusters
 Pressure Support Cycle Adjusters
 Proportional Assist Ventilation
 Neurally adjusted ventilatory assistance (NAVA)
Strategies to optimize syncrony

 Endotracheal tube resistance compensation /

Automatic tube compensation = type of PSV that
applies sufficient positive pressure to overcome the
work of breathing imposed by the ETT, which can
vary from breath to breath
 Clinicians input characteristics of ETT. Vent

adjusts circuit pressure during both inspiration

and expiration
 Good for SBT or combined with other mode.
Strategies to optimize syncrony

 Pressure-Targeted Inspiratory Pressure Slope

Adjusters
 For pressure-targeted breaths (PS, PA/C)
 Slope adjusters allow clinician to adjust pressure rate
of rise
 Pt with vigorous breaths may desire rapid rate of rise,
or vice versa if less vigorous demands
Strategies to optimize syncrony

 Pressure support cycle adjusters

 In PS, flow cycling mechanism terminating flow at 25%
can sometimes terminate breaths too early (if long
inspiratory demands) or too late (if obstruction)
 allow adjustments of the flow criteria to assure
synchrony with the end of patient effort
Strategies to optimize syncrony

 Proportional Assist Ventilation

 No set pressure, flow, or volume.
 The sensed patient effort is boosted according to a
proportion of the measured work of breathing set by
the clinician.
 The greater the patient effort, the greater the delivered
pressure, flow, and volume.
Strategies to optimize syncrony

 Neurally adjusted ventilatory assistance (NAVA)

 uses a diaphragmatic EMG signal to trigger and cycle
ventilatory assistance.
 EMG sensor positioned in the esophagus at the level of the
diaphragm
 Breaths triggered by phrenic nerve excitation of the
inspiratory muscles
 Expensive!

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Which mode to use when?

 Pressure- and volume-limited modes have

unique advantages and disadvantages, but
do not significantly effect mortality,
oxygenation, or work of breathing
 “innovative strategies” mostly proposed for
ARDS and “lung protection”
 Overall no significant outcome benefits. Consider
if severe or refractory hypoxemia
References
 Murray and Nadel's Textbook of Respiratory Medicine. 5 th edition
 Bozyk P, Hyzy R. Modes of mechanical ventilation. Up To Date. 2010
 Rappaport SH, Shpiner R, Yoshihara G, Wright J, Chang P, Abraham E. Randomized,
prospective trial of pressure-limited versus volume-controlled ventilation in severe
respiratory failure. Crit Care Med. 1994;22(1):22
 Prella M, Feihl F, Domenighetti G. Effects of short-term pressure-controlled ventilation on
gas exchange, airway pressures, and gas distribution in patients with acute lung
injury/ARDS: comparison with volume-controlled ventilation. Chest. 2002;122(4):1382
 Chiumello D, Pelosi P, Calvi E, Bigatello LM, Gattinoni. Different modes of assisted
ventilation in patients with acute respiratory failure. Eur Respir J. 2002;20(4):925
 Varpula T, Valta P, Niemi R, et al: Airway pressure release ventilation as a primary
ventilatory mode in acute respiratory distress syndrome. Acta Anaesth Scand 2004;
48:722-731.
 Derdak S, Mehta S, Stewart TE, Smith T, Rogers M, Buchman TG, Carlin B, Lowson S,
Granton J, Multicenter Oscillatory Ventilation For Acute Respiratory Distress Syndrome
Trial (MOAT) Study Investigators. High-frequency oscillatory ventilation for acute
respiratory distress syndrome in adults: a randomized, controlled trial. Am J Respir Crit
Care Med. 2002;166(6):801
 Stewart NI, Jagelman TA, Webster NR. Emerging modes of ventilation in the intensive
care unit. Br J Anaesth. 2011 Jul;107(1):74-82. Epub 2011 May 24
 Gonza ́lez et al. Airway pressure release ventilation versus assist-control ventilation: a
comparative propensity score and international cohort study. Intensive Care Med (2010)
36:817–827
 References
 Stawicki S.P. , Goyal M and Sarani B. High-Frequency Oscillatory Ventilation
(HFOV) and Airway Pressure Release Ventilation (APRV): A Practical Guide. J
Intensive Care Med 2009 24: 215-229
 Putensen C, Zech S, Wrigge H, Zinserling J, Stüber F, Von Spiegel T, Mutz N.
Long-term effects of spontaneous breathing during ventilatory support in
patients with acute lung injury. Am J Respir Crit Care Med. 2001;164(1):43.
 Maxwell et al. A Randomized Prospective Trial of Airway Pressure Release
Ventilation and Low Tidal Volume Ventilation in Adult Trauma Patients With
Acute Respiratory Failure. J Trauma. 2010;69: 501–511