College of Medical Rehabilitation Sciences

Respiratory Therapy Department

Advanced Mechanical ventilation (RT 376)

Dr. Abdulrhman Hawsawi
2025
Outlines
• Automatic tube compensation (ATC)
• Pressure-regulated volume control (PRVC)
• High-frequency oscillatory Ventilation (HFOV)
ATC
• The WOB may increase when a spontaneously breathing patient
breathes unaided through an ET.
• Factors that increase the spontaneous WOB:
 the size of the artificial airway
 Flow.

it
Reducing the artificial tube diameter or increasing the length of the

Is
tube increases the resistance to flow, as do kinks in the tube.
ATC 2
• Usually Clinician use PSV to compensate for the increased resistance and WOB
associated with breathing through an ET. But that a fixed pressure, as with PSV,
cannot accurately compensate for the variable flow through the ET because
inspiratory flow demand can vary.

• Therefore, the issue of using fixed PSV, can result in excessive VT and flow, which
is uncomfortable for the patient.

• To overcome this problem, some ventilators are equipped with a feature called
automatic tube compensation (ATC).
ATC
• ATC was designed specifically to reduce the WOB associated with
increased ET resistance.

• ATC delivers exactly the amount of pressure required to overcome the

resistive load imposed by the ET for the flow measured at the time
(variable PSV with variable inspiratory flow compensation).
pism
• ATC targets pressure at the tracheal level, adjusting the delivered
pressure to try to maintain tracheal pressure at a constant level.
How it is done ‫ والفلو يزيدون من احتمالية املقاومة‬ETT ‫بمأن قلة دايميتر وزيادة طول‬
‫ بيسوي برشر دفرنس الخاصية بتعوض في البروكسمل‬ETT ‫الفلو بيروح‬

• Flow of gas through the ETT results in pressure difference between the distal and
proximal ends of ETT.

• Respiratory effort of patient results in a pressure drop ( below PEEP) in trachea.

• The magnitude of the pressure drop across the trachea has to be compensated for by
increased applied pressure from the ventilator at the proximal end of the ETT to equal
the pressure drop at the distal end of the ETT ( to negate or minimise the pressure drop
across the ETT )

• As the dimensions and physical properties of the ETT are known, the pressure difference
across the ETT is continuously calculated.
Les
• Pressure compensation is regulated based on current tracheal pressure .
Ii win
ATC- Benefits

• To support or overcome the work of breathing imposed by the artificial airway

during spontaneous breathing by a ventilator-supported patient.

• To improve patient-ventilator synchrony through variable compensation of

inspiratory flow based on patient demand.

• To reduce the risk of air trapping caused by expiratory resistance from the
endotracheal tube.

• To enhance patient comfort.

• To facilitate accurate prediction of readiness for extubation.

wast Éd may 2181

C

PRVC synonymous
• Pressure-regulated volume control (PRVC; Siemens 300; Siemens
Medical Systems)

• Adaptive pressure ventilation (APV; Hamilton Galileo; Hamilton

Medical, Reno, NV)

• Autoflow (Evita ; Drager Inc., Telford, PA)

PRVC

Indication:
Patient who require the lowest possible pressure and a
guaranteed consistent VT.

ALI/ARDS.

Patient with the possibility of CL or Raw changes. Asthmartnemonio

PRVC- How it is done
15 20 10
• First breath = 5-10 cm H2O above PEEP

• V/P relationship measured 7511

500
• Next 3 breaths, pressure increased to 75% needed for set TV

• Then up to +/- 3 cm H2O changes per breath

• Time ends inspiration

 ‫ يظل الضغط ثابت ًا؛‬،‫ مع القيمة املحددة‬VT ‫عندما يتوافق‬

PRVC. (1), Test breath (5 cm H2O); (2)pressure is increased to deliver set volume; (3),
maximum available pressure; (4), breath delivered at preset flow, at preset f, and during
preset TI; (5), when VT corresponds to set value, pressure remains constant; (6), if preset
volume increases, pressure decreases; the ventilator continually monitors and adapts to the
patient’s needs
 lominetg.SI
HFOV mostproteetmode doodindosexhantehighpkloyy

Introduction
• During conventional ventilation direct alveolar ventilation accomplishes

I_
pulmonary gas exchange. According to the classic concept of pulmonary
ventilation the amount of gas reaching the alveoli equals the applied tidal
volume minus the deadspace volume. VT dead

• At tidal volumes below the size of the anatomical deadspace this model
HF
fails to explain gas exchange. Instead, considerable mixingV2of fresh and
exhaled gas in the airways and lungs is believed to be the key to the
success of HFV in ventilating the lung at such very low tidal volumes.
HFOV
Goal in the lung
ventilation strategy is to
keep alveoli at “safe
window” –less prone
atelctroma, better gas
exchange & less pulmonary
vascular resistance (PVR)
HFOV
• High-frequency ventilation was first introduced 30 years ago as a
method for reducing intrathoracic pressure during thoracic and
laryngeal surgery.
• High-frequency oscillation was developed in the 1970's for the
treatment of lung disease of prematurity but is now used for acute
hypoxemic respiratory failure in all ages.

• HFV is any form of mechanical ventilation in which the breath

frequency exceeds 150 breaths/min.

• Uses small VT (≤ anatomical dead-space)

HFOV-Types
• High-Frequency Oscillatory Ventilation (HFOV)
• High-Frequency Jet Ventilation (HFJV)
• High-Frequency Positive Pressure Ventilation (HFPPV)
• High-Frequency Flow Interruption
• High-Frequency Percussive Ventilation (HFPV)
High-Frequency Oscillatory Ventilation in Adults
‚ Maximum airway pressure
 Directly affects PaO2 by changing lung volume
‚ Amplitude
 Influences the level of ventilation (PaCO2) and can be
adjusted by the power control
 “Chest wiggle”
‚ Frequency
 5 to 6 Hz
‚ Inspiratory time (TI)%
 33% (I:E of 1:2)
‚ Bias flow
 25 to 40 L/min

Copyright © 2020 by Elsevier, Inc. All Rights Reserved. 16

 High-Frequency Oscillatory Ventilation

‚ Indication criteria
 Patients with ARDS weighing at least 35 kg and who are not
responding to mechanical ventilation
 A diagnosis of H1N1 with ARDS
 Air leaks in patients
 Early intervention to recruit the lungs
 Clinical staff comfort with using the equipment

Copyright © 2020 by Elsevier, Inc. All Rights Reserved. 17

SO, Why ARDS?? HFOV??

Copyright © 2020 by Elsevier, Inc. All Rights Reserved. 18

Acute Respiratory Distress Syndrome (ARDS)
(1 of 2)
‚ In response to injury:
 Pulmonary capillaries become engorged
 Permeability of the alveolar-capillary membrane ‫احتقان النفاذية‬
increases ‫بني الكابلري‬
‫وااللفيوالر‬
I
 Interstitial and intra-alveolar edema and hemorrhage ‫ممبرين انكريز‬
‫سكاتدر مناطق‬
 Scattered areas of hemorrhagic alveolar consolidation ‫متفرقة تصلب‬
‫ونزيف‬
‚ Result in a decrease in alveolar surfactant and in
alveolar collapse, or atelectasis

Copyright © 2020 by Elsevier Inc. All rights reserved. 19

 ARDS (2 of 2)
‚ As the disease progresses:
 Intra-alveolar walls become lined with a thick, rippled
hyaline membrane
 Membrane contains fibrin and cellular debris
‚ The anatomic alterations that develop in ARDS
create a restrictive lung disorder

Copyright © 2020 by Elsevier Inc. All rights reserved. 20

Pathologic or Structural Changes Associated
With ARDS
‚ Interstitial and intra-alveolar edema and
hemorrhage
‚ Alveolar consolidation
‚ Intra-alveolar hyaline membrane
‚ Pulmonary surfactant deficiency or abnormality
‚ Atelectasis

Copyright © 2020 by Elsevier Inc. All rights reserved. 21

Etiology and Epidemiology of ARDS
‚ 10%–15% of all ICU admissions
‚ About 25% of patients on mechanical ventilation
‚ Clinical manifestations associated with ARDS
usually appear within 6–72 hours of an inciting
event and worsen rapidly

Copyright © 2020 by Elsevier Inc. All rights reserved. 22

High-Frequency Oscillatory Ventilation
‚ Exclusion criteria 2018
A
 No contraindications exist for the use of the 3100B
 Precautionary use
 Unstable cardiovascular status
 Acute bronchospasm
 Severe acidosis (the 3100B HFV is not designed
to ventilate so much as oxygenate)
 PregnancyChest vittle
 COPD or asthma requiring the use of aerosolized
bronchodilators

Copyright © 2020 by Elsevier, Inc. All Rights Reserved. 23

How does the gas exchange occur with HFV
Figure 3.

Following mechanism were

proposed to explain gas exchange in
HFOV:
• Direct bulk flow
• Pendeluft
• Taylor dispersion
• Augmented molecular diffusion
• Asymmetric velocity
• Cardiogenic mixing
How does the gas exchange occur with HFV

• Direct ventilation of most proximal alveoli units by bulk convection.

• Direct Bulk Flow: Some alveoli situated in the proximal tracheobronchial tree receive a direct
flow of inspired air. This leads to gas exchange by traditional mechanisms of convective or bulk
flow.
How does the gas exchange occur with HFV

• Pendalluft effect – asynchronous flow among alveoli due to asymmetries in airflow impedance.
This causes gas to re-circulate among lung units and improve gas exchange. In healthy and, more
so, in diseased lungs, the mechanics of air flow vary among lung regions and units within regions.
Variation in regional airway resistance and compliance cause some regions to fill and empty more
rapidly than others. Some gas may flow between regions if these characteristics vary among
regions that are in close proximity.
How does the gas exchange occur with HFV
.
I me I I
I
icfoi.to
II dispersion –Turbulent eddies and secondary swirling motions occur when convective flow
• Taylor
is superimposed on diffusion. Some fresh gas may mix with gas from alveoli, increasing the
amount of gas exchange that would occur from simple bulk flow.

• Collateral ventilation-through non-airway connections between neighboring alveoli

How does the gas exchange occur with HFV

‫التحريك امليكانيكي الناتج عن انقباض القلب‬

‫كونتراقتنق‬
‫يساهم في خلط الغازات‬
Cardiogenic Mixing

Mechanical agitation from the contracting heart contributes to gas mixing, especially in
peripheral lung units in close proximity to the heart.

Molecular Diffusion
3
As in other modes of ventilation, this mechanism may play an important role in mixing of
air in the smallest bronchioles and alveoli, near the alveolocapillary membranes.

is g3.04
How does the gas exchange occur with HFV

• Asymmetric velocity – convective gas transport is enhanced by asymmetry

between inspiratory and expiratory velocity profiles that occur at branch
points in the airways. The velocity profile of air moving through an airway
under laminar flow conditions is parabolic. Air closest to the
tracheobronchial wall has a lower velocity than air in the center of the
airway lumen. This parabolic velocity profile is usually more pronounced
during the inspiratory phase of respiration because of differences in flow
rates. With repeated respiratory cycles, gas in the center of the airway
lumen advances further into the lung while gas on the margin (close to the
airway wall) moves out toward the mouth.
HFOV-Settings-Sensor Medics 3100B Oscillatory Ventilator

All forms of HFV have common characteristics:

• Respiratory rate >150 bpm

• Tidal volume= 1-3 mL/kg
• noncompliant ventilator circuits

The adjustable parameters include:

 Power
 IT%
 Mean airway pressure (MAP)
 Bias flow
 Frequency (1Hz=60 breath/min)
 Amplitude
HFOV-Settings-Sensor Medics 3100B Oscillatory Ventilator

mesh

1, Display of mPaw; 2, indicator of piston movement; 3, amplitude display; 4, power control knob
(amplitude); 5, bias flow display and control; 6, adjustment for mPaw; 7, frequency control and display; 8,
TI% control and display; 9, on/off control for oscillating piston; 10, alarm settings and indicators panel.
HFOV- Initial settings
Initial Settings and suggestions for adult patient Use On 3100 B
• Patients with ARDS >35 Kg
• Set Paw 5 cmH20 above CV Paw
• FiO2 100% g
loof
• Set Hertz at 5-6 (1Hz=60 breath)
5
• Power 4.0, adjust for good chest wiggle
6
• I time % at 33%
• Set Bias Flow at >25 Lpm, may need to go higher 40
25
Minute ventilation
• Minute ventilation during conventional ventilation and spontaneous breathing is
calculated as:

Respiratory Rate X Tidal Volume

• Minute ventilation during high frequency ventilation is calculated as:

(Respiratory Rate) X (Tidal Volume)2

• Therefore, tidal volume is the primary determinant of minute ventilation during

high frequency ventilation.
• Oxygenation:
primarily controlled by Paw and the FiO2.
Initial Paw 5 cm H2O> CMV Paw
FiO2 : 100% initially
 ↑ Paw until you are able to ↓FiO2 to 60% with SaO2 of ≥ 90%
Avoid hyperinflation – CXR
Optimize preload, myocardial function
Mean Arterial Pressure > than 75 mmHg

• Ventilation:
Controlled by the movement of the pump/piston mechanism.
Alveolar ventilation during HFV is defined as f x Vt2
changes in volume have the most significant affect on ventilation.
Guidelines for Initial HFOV Settings:
• Prior to initiating HFOV, perform a recruitment maneuver on the oscillator
by increasing Paw to 40 cmH2O for 30-40 seconds.

• Set initial Paw at 5 cmH2O above conventional ventilator Pmaw.

31
• Set power to achieve initial amplitude at chest oscillation to mid-thigh.
w

• Set Hz at 5.

• Set IT to 33% (may increase to 50% if difficulty with oxygenation; this may
further raise carinal pressure an additional 2 – 4 cmH2O).

• If oxygenation worsens, increase Pmaw in 2 – 3 cmH2O increments q 30

minutes until maximum setting (approximately 45 – 55 cmH2O).
Guidelines for Initial HFOV Settings
• If PaCO2 worsens (but pH > 7.2), increase amplitude (power) up to
the maximum setting. After maximum amplitude is achieved, if
necessary, decrease Hz to the minimum setting of 3 Hz.

• If severe hypercapnea occurs, with pH < 7.2, bag patient, set

maximum amplitude, Hz at 3, and try a small cuff leak (5 cmH2O and
then compensate bias flow); rule out endotracheal tube obstruction.
Troubleshooting-summary
• Hypercapnia • Hypocapnia

 ↑ delta P 5
 ↑ AMP (power)  ↑ frequency
 ↓ frequency  ↓ delta P / AMP
 ↓ I time
 deflate cuff
 :‫الخالصة‬
SpO₂ > ‫ تدريج ًيا للحفاظ على‬FiO₂ ‫يتم خفض‬ •
.90%
HFOV- Weaning Paw ‫ يتم تقليل‬،FiO₂ ≤ 60% ‫بعد الوصول إلى‬
.‫تدريجيًا إذا كانت الرئة منتفخة بشكل مناسب‬
•

.PaCO₂ ‫ ببطء للتحكم في‬Delta P ‫يتم تقليل‬ •

‫ يجب الحفاظ عليه‬،‫بعد العثور على التردد األمثل‬ •
.‫دون تغيير‬

• Wean FiO2 for arterial saturation > 90% ‫ مع ضمان استقرار‬HFOV ‫هذا النهج يساعد في تقليل االعتماد على‬
.‫األكسجة والتهوية أثناء عملية الفطام‬

• Once FiO2 is 60% or less, re-check chest x-ray and if appropriate

inflation, begin decreasing the Paw in 2 - 3 cmH2O increments

• Wean Delta-P in 5 cmH2O increments for PaCO2

• Once the optimal frequency is found, leave it alone

 HFOS Standermy
Transition to Conventional Ventilation
• Mean airway pressure stable
• Tolerating position and nursing care
• No substantial physiologic changes
• Stable blood gases
• Resolution of original lung pathology
• Switch to PCV (TV 6 ml/kg, 1:1 with PEEP 10)
Thanks