Mechanical Ventilation -

Modes
Abdallah Adel Farah
 Types of Mechanical ventilators:

• Negative-pressure ventilators

• Positive-pressure ventilators.
 Negative-Pressure Ventilators
• Early negative-pressure ventilators were
known as “iron lungs.”

• The patient’s body was encased in an iron

cylinder and negative pressure was generated
.

• The iron lung are still occasionally used

today.
• Intermittent short-term negative-pressure
ventilation is sometimes used in patients with
chronic diseases.

• The use of negative-pressure ventilators is restricted

in clinical practice, however, because they limit
positioning and movement and they lack
adaptability to large or small body torsos (chests) .

• Our focus will be on the positive-pressure

ventilators.
 Positive-pressure ventilators

• Positive-pressure ventilators deliver gas to

the patient under positive-pressure, during
the inspiratory phase.
Types of Positive-Pressure Ventilators

1- Volume Ventilators.

2- Pressure Ventilators

3- High-Frequency Ventilators
 1- Volume Ventilators
• The volume ventilator is commonly used in critical
care settings.

• The basic principle of this ventilator is that a

designated volume of air is delivered with each
breath.

• The amount of pressure required to deliver the set

volume depends on :-

- Patient’s lung compliance

- Patient–ventilator resistance factors.
• Therefore, peak inspiratory pressure (PIP )
must be monitored in volume modes because
it varies from breath to breath.

• With this mode of ventilation, a respiratory

rate, inspiratory time, and tidal volume are
selected for the mechanical breaths.
 2- Pressure Ventilators
• The use of pressure ventilators is increasing in
critical care units.

• A typical pressure mode delivers a selected gas

pressure to the patient early in inspiration, and
sustains the pressure throughout the inspiratory
phase.

• By meeting the patient’s inspiratory flow demand

throughout inspiration, patient effort is reduced and
comfort increased.
• Although pressure is consistent with these modes,
volume is not.

• Volume will change with changes in resistance or

compliance,

• Therefore, exhaled tidal volume is the variable to

monitor closely.

• With pressure modes, the pressure level to be

delivered is selected, and with some mode options
(i.e., pressure controlled [PC], described later), rate
and inspiratory time are preset as well.
 3- High-Frequency Ventilators

• High-frequency ventilators use small tidal

volumes (1 to 3 mL/kg) at frequencies greater
than 100 breaths/minute.

• The high-frequency ventilator accomplishes

oxygenation by the diffusion of oxygen and
carbon dioxide from high to low gradients of
concentration.
• This diffusion movement is increased if the
kinetic energy of the gas molecules is
increased.

• A high-frequency ventilator would be used to

achieve lower peak ventilator pressures,
thereby lowering the risk of barotrauma.
 Classification of positive-pressure
ventilators:
• Ventilators are classified according to how the
inspiratory phase ends. The factor which terminates
the inspiratory cycle reflects the machine type.
• They are classified as:
1- Pressure cycled ventilator

2- Volume cycled ventilator

3- Time cycled ventilator

 1- Volume-cycled ventilator
• Inspiration is terminated after a preset tidal
volume has been delivered by the ventilator.

• The ventilator delivers a preset tidal volume

(VT), and inspiration stops when the preset
tidal volume is achieved.
 2- Pressure-cycled ventilator
• In which inspiration is terminated when a
specific airway pressure has been reached.

• The ventilator delivers a preset pressure;

once this pressure is achieved, end
inspiration occurs.
 3- Time-cycled ventilator
• In which inspiration is terminated when a
preset inspiratory time, has elapsed.

• Time cycled machines are not used in adult

critical care settings. They are used in
pediatric intensive care areas.
 Ventilator mode
• The way the machine ventilates the patient

• How much the patient will participate in his

own ventilatory pattern.

• Each mode is different in determining how

much work of breathing the patient has to
do.
 Type of modes - Mechanical Ventilation

A- Volume Modes

B- Pressure Modes
 A- Volume Modes

1- Assist-control (A/C)

2- Synchronized intermittent
mandatory ventilation (SIMV)
 1- Assist Control Mode A/C
• The ventilator provides the patient with a pre-set
tidal volume at a pre-set rate .

• The patient may initiate a breath on his own, but the

ventilator assists by delivering a specified tidal
volume to the patient. Client can initiate breaths that
are delivered at the preset tidal volume.

• Client can breathe at a higher rate than the preset

number of breaths/minute
• The total respiratory rate is determined by the
number of spontaneous inspiration initiated by the
patient plus the number of breaths set on the
ventilator.

• In A/C mode, a mandatory (or “control”) rate is

selected.

• If the patient wishes to breathe faster, he or she can

trigger the ventilator and receive a full-volume
breath.
• Often used as initial mode of ventilation

• When the patient is too weak to perform the

work of breathing (e.g., when emerging from
anesthesia) and decreases the work of
breathing.

Disadvantages:

• Hyperventilation, barotrauma ,, est.

 2- Synchronized Intermittent
Mandatory Ventilation (SIMV)
• The ventilator provides the patient with a pre-set
number of breaths/minute at a specified tidal
volume and FiO2.

• In between the ventilator-delivered breaths, the

patient is able to breathe spontaneously at his own
tidal volume and rate with no assistance from the
ventilator.

• However, unlike the A/C mode, any breaths taken

above the set rate are spontaneous breaths taken
through the ventilator circuit.
• The tidal volume of these breaths can vary
drastically from the tidal volume set on the
ventilator, because the tidal volume is determined
by the patient’s spontaneous effort.

• Adding pressure support during spontaneous

breaths can minimize the risk of increased work of
breathing.

• Ventilators breaths are synchronized with the

patient spontaneous breathe.
( no fighting)
• Used to wean the patient from the
mechanical ventilator.

• Weaning is accomplished by gradually

lowering the set rate and allowing the
patient to assume more work
 B- Pressure Modes
1- Pressure-controlled ventilation (PCV)

2- Pressure-support ventilation (PSV)

3- Continuous positive airway pressure

(CPAP)
 1- Pressure-Controlled
Ventilation Mode ( PCV)
• The PCV mode is used

– If compliance is decreased and the risk of

barotrauma is high.
– It is used when the patient has persistent
oxygenation problems despite a high FiO2 and
high levels of PEEP.

• The inspiratory pressure level, respiratory rate, and

inspiratory–expiratory (I:E) ratio must be selected.
 1- Pressure-Controlled
Ventilation Mode ( PCV)
• In pressure controlled ventilation the breathing
gas flows under constant pressure into the
lungs during the selected inspiratory time.
• The flow is highest at the beginning of
inspiration( i.e when the volume is lowest in the
lungs).
• As the pressure is constant the flow is initially
high and then decreases with increasing filling
of the lungs.
• Like volume controlled ventilation PCV is time
controlled.
• Inspiratory pressure is set instead of the tidal
volume
Advantages of pressure control (limitations)
mode are:
• 1- reduction of peak pressure and therefore
the risk of barotruma and tracheal injury.
• 2- effective ventilation and oxygenation.
• Improve gas exchange
• Tidal volume varies with compliance and airway
resistance and must be closely monitored.

• Sedation and the use of neuromuscular blocking

agents are frequently indicated, because any
patient–ventilator asynchrony usually results in
profound drops in the SaO2.

• This is especially true when inverse ratios are used.

The “unnatural” feeling of this mode often requires
muscle relaxants to ensure patient–ventilator
synchrony.
• When the PCV mode is used, the mean airway and
intrathoracic pressures rise, potentially resulting in
a decrease in cardiac output and oxygen delivery.
Therefore, the patient’s hemodynamic status must
be monitored closely.

• Used to limit plateau pressures that can cause

barotrauma & Severe ARDS
 2- Pressure Support Ventilation
( PSV)
• The patient breathes spontaneously while the
ventilator applies a pre-determined amount of
positive pressure to the airways upon inspiration.

• Pressure support ventilation augments patient’s

spontaneous breaths with positive pressure boost
during inspiration i.e. assisting each spontaneous
inspiration.

• Helps to overcome airway resistance and reducing

the work of breathing.
• Indicated for patients with small
spontaneous tidal volume and difficult to
wean patients.

• Patient must initiate all pressure support

breaths.

• Pressure support ventilation may be

combined with other modes such as
SIMV or used alone for a spontaneously
breathing patient.
• The patient’s effort determines the rate,
inspiratory flow, and tidal volume.

• In PSV mode, the inspired tidal volume and

respiratory rate must be monitored closely to
detect changes in lung compliance.

• It is a mode used primarily for weaning from

mechanical ventilation.
 3- Continuous Positive Airway
Pressure (CPAP)
• Constant positive airway pressure during spontaneous
breathing

• CPAP allows the clinician to observe the ability of the

patient to breathe spontaneously while still on the
ventilator.

• CPAP can be used for intubated and nonintubated patients.

• It may be used as a weaning mode and for nocturnal

ventilation (nasal or mask CPAP)
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