MODES OF VENTILATION

Newer strategies

Carla Sabrina Speziale

HJSD - CESR ICU fellow
Queen Elizabeth Hospital
Birmingham University Hospitals NHS Trust
 Definition of MODE

 Sequence of breath types & timing of breath delivery

 Set of ventilator operations with one or more

predefined mechanical breath types
A= what initiates a breath
- TRIGGER

B = what controls / limits

it LIMIT

C= What ends a breath

CYCLING
Med intensiva 2014. 38:49-55
Conventional modes of
ventilation
VOLUME PRESSURE
VENTILATION VENTILATION
Constant volume Variable volume
Variable inspiratory pressures Constant inspiratory
pressures

Constant inspiratory flow Variable inspiratory flow

Flow and TV determine Tinsp Inspiratory time set

Paw depends on Compliance Flowi depends on compliance

CMV –SIMV-ACMV PCV –PSV-CPAP

 Problems (?) with
conventional modes
• Parameters of the equation of motion are dynamic
• A ventilator setting at one point of time may not be appropriate at a
different time
• No feedback – Open loop

VOLUME VENTILATION PRESSURE VENTILATION

•Guaranteed TV •Limits excessive airway P
•Less atelectasis •Better gas distribution
•Less air-trapping
•Lower WOB
•Lower PIP

•Limited flow may not meet patients •Variable TV

desired insp flow rate- flow hunger ↑TV as compliance ↑
•May cause high Paw ( barotrauma) ↓TV as resistance ↑
 CMV

G. Singh, et al. Respiratory Medicine Case Reports 29 (2020)

100822
 PCV

G. Singh, et al. Respiratory Medicine Case Reports 29 (2020)

100822
 Better PCV??

Rationale for PCV:

• VILI
M V
• Ateletrauma
S C
•
•
V
Pre-existing lung damage or inflammation
V
C
Flow characteristics may be more comfortable for patient
P
C E
The CONS: E N
ID
V of volutrauma / atelectasis
• Variable VT Erisk
O
• If compliance improves-> excessive TV
N changes in TV with changes in PIP and PEEP
• Inconsistent
ASSIT CONTROL MANDATORY
VENTILATION (ACMV)
 SYNCHRONIZED INTERMITTENT
MANDATORY VENTILATION (SIMV)

 Ventilator delivers either assisted breaths to the patient

at beginning of a spontaneous breath or time triggered
mandatory breath.
 Does not cause breath stacking as mandatory breath
are delivered within a time window = synchronisation
window
 Synchronization window: time interval from previous
mandatory breath to just prior to the next tie triggering,
during which ventilator is responsive to patients
sponaneous inspiratory effort
SIMV
SIMV
 Maintains respiratory muscle strength thus avoids
muscle atrophy
 Reduces V/Q mismatch
 Lower peak inspiratory pressure and inspiratory time-
decreases mean airway pressure
 Facilitates weaning

cycle

Spontaneous

Time
 MANDATORY MINUTE
VENTILATION (MMV)

 Provides predetermined minute ventilation when

patient`s spontaneous effort becomes inadequate
 An additional function of SIMV mode
 Increase of mandatory RR is triggered when the actual
minute volume is less than the preset minimal minute
volume
 Especially useful in preventing hypoventilation and
respiratory acidosis in the final stages of weaning
with SIMV
Pressure support ventilation
(PSV)
 Patient triggered, pressure limited and flow cycled.
 Pressure limited- Aw P max cannot exceed the preset
pressure support
 Flow cycled- expiration starts when the flow reaches
minimum level
 After the trigger, ventilator generates a flow sufficient to
raise and then maintain airway pressure (Pplat) at a
preset level for the duration of the patient’s
spontaneous respiratory effort
PSV
 PSV

ADVANTAGES DISADVANTAGES
Synchronization (?) Variable tidal volume
Comfort Same support to different efforts
Reduces WOB Over assisting vs under assisting
Reduces O2 consumption Synchronization(?)
Weaning Back up needed
Continuous positive airway
pressure (CPAP)
 Newer modes of ventilation
 Allow ventilators to control one variable or the other
based on a feedback loop

Volume
controlled
Has the
Is the Airway P
desired/ set
Feedback loop exceeding set P
TV been
limit ?
delivered ?

Pressure
controlled
Dual modes of ventilation

Within a breath From breath to

breath
Switches from P to V
control during the P limit ↑ or ↓ to
same breath maintain a clinician set
TV
Newer modes of ventilation

1. Volume assured pressure support (VAPS)

2. Volume support (VS)
3. Pressure regulated volume controlled (PRVC)
4. Airway pressure release ventilation (APRV)
 (BILEVEL)
5. Adaptative support ventilation (ASV)
6. Proportional Assist Ventilation (PAV)
7. Neurally Adjusted Ventilatory Assist (NAVA)
 VOLUME ASSURED PRESSURE
SUPPORT (VAPS)

Stable TV in patients Minimum TV and

Modification of PCV with irregular breathing pressure support level
patterns must be preset

If volume delivered by Unlike typical PSV, VAPS

the pressure supported assures stable tidal
breath falls short of VAPS may prolong the volume along with
preset volume- the vent inspiratory time – can pressure support in
switches from pressure lead to air trapping patients with
limited to volume limited irregular breathing
breath patterns
 VAPS

! Limit Pressures too

high

! Flow rates too low

 VOLUME SUPPORT
(VS)
 Spontaneous
 Ventilator assesses first breaths and steps up pressure
support according to pre-set TV
 Increases patient comfort
 Automatic weaning of P support as compliance alters
 Pressure changes <3cmh20 each change
 Feedback: tidal volume
 Trigger: patient’s
 VS
! If ↑ RR TV ↓
! Dif. mean Paw
! Same TV for
different
demands
 Pressure regulated volume
controlled (PRVC)
 To achieve volume support while keeping PIP at the
lowest.
 Peak flow and inspiratory time is altered in response
to changing compliance and airway resistance
 To keep PIP at lowest, inspiratory flow is reduced
 Compensatory increase in inspiratory time to deliver
target TV
 Patient or time triggered
 PRVC

SET AND
FORGET?

Not ideal for initial setting where drive is very

variable.
In high respiratory drive, decrease Pvent and
increase Pmusc-> Increase WOB

G. Singh, et al. Respiratory Medicine Case Reports 29 (2020)

100822
ADAPTATIVE SUSPPORT
VENTILATION (ASV)

 Provides mandatory minute ventilation

 Minimal WOB alternating PCV and PSV to maintain MV set
 Ventilator optimizes I:E ratio to avoid autopeep
 Adapts to patients demands increasing or decreasing support ,
according to elastic and resistive loads
 Input: body weight and MV desired
 Ventilator uses test breaths to measure system compliance, AW
resistance and iPEEP
 It adapts to patient respiratory effort. Depending on the
spontaneous RR, ASV can work as PCV, if there is no
spontaneous breathing; as pressure SIMV (P‑SIMV), when
patient RR is lower than target; or as PSV, if the RR is higher
 ASV

Indian Journal of Critical Care Medicine January-February 2013 Vol 17 Issue 1

Advantages Disadvantages
WOB Can not adapt to
changes in DS
Ventilator adapts to p. Muscle atrophy?
Automatic weaning Variable mean Paw
Improve gas distribution Increase in demand ->
lower support
Guaranteed TV
Airway pressure release
ventilation (APRV)

 High level of CPAP with brief intermittent release of

PEEP to a lower level
 Starts at elevated Pressures and releases pressure to
accomplish TV
 Higher plateau P – improves oxygenation
 Release phase – alveolar ventilation & removal of CO2
 Active patient – spontaneous breathing at both P levels
 Passive patient – ventilation completed by P release
 APR
V
! High ICP
! Obstruction, high
R
! B-P fistula
! Haemodinamic
! Synchrony
 APR
V
Advantages

1. Allows I/R ventilation

2. Less need for sedation
3. Improves mean airway pressure
4. Improves oxygenation by stability of collapsed
alveoli
5. breathing occurring at high CPAP
6. Better V/Q matching, decreases dead space
BIPHASIC VENTILATION / BILEVEL
POSITIVE PRESSURE VENTILATION
(BILEVEL)
 Different names according to brand of ventilator
 Mandatory breaths are PC and spontaneous are PS
 Similar to SIMV with pressure support for Spont. breaths
 Sets: RR, Ph, Pl, Th, Tl, PS level and FiO2

D. Singer, Southern medical journal, 104(10) 201

Proportional Assist Ventilation
(PAV)
 Patient’s electrical activity of the diaphragm (EAdi) is
used to guide the optimal functions of the ventilator
 Ventilator – patient synchrony
 Patient’s own breathing pattern, including I:E
 Change in pressure support according to the volume,
elastance, airflow resistance and flow demand (patients
air hunger)
 Automatically adjusts flow, volume and pressure needed
in each breath
 PAV

D Jackson, Mechanical ventilation, 2020, medscape

Advantages Disadvantages
Synchrony Elastance (E) & resistance
(R) cannot be measured
Protective role accurately.

Improve sleep quality Proportion of support has

to be change by physician

Requires spont breathing

Neuraly Adjusted Ventilatory
Assist (NAVA)

 Electrical activity of respiratory muscles used as input

Eadi (electrical activity of diaphragm)

 Cycling on, cycling off: determined by Eadi

 Synchrony between neural & mechanical inspiratory

time is guaranteed

 Patient comfort
NAVA

A Shorko, JICS.14(4)2013
Advantages Disadvantages
Synchrony Spontaneous drive

Leaks do not cause Variable TV or PIP NAVA

false initiation breaths
Correct determination of
Protection against VILI C and Raw is essential.

Adapts to altered Autopeep – trigger effort

metabolic demands
Controversial while active
Quality of sleep ARDS

CONTRAINDICATIONS:
• Trauma preventing NG/OG tube
• Brainstem or high spinal cord injury
• Severe neuropathy (phrenic nerve)
• Raised ICP
• Sedation-lack of respiratory drive
• N muscle relaxants
• RCT
• 1200 patients
• Outcome: days free of ventilation and alive at day 28

• Started recruiting 10/2020- 3 years

• First RCT with good power to compare close-loops

against conventional ventilation
Thank
you!