Semin Neonatol 2002; 7: 401407

doi:10.1053/siny.2002.0134, available online at http://www.idealibrary.com on

Newer techniques of mechanical ventilation:

an overview
Steven M. Donna and Sunil K. Sinhab
a

Division of Neonatal-Perinatal
Medicine, University of Michigan Health
System, Ann Arbor, Michigan, USA;
b
The James Cook University Hospital,
Middlesbrough, UK

Key words: newer ventilatory

techniques, synchronized ventilation,
pressure versus volume targeted
modes of ventilation

The introduction of newer, state-of-the-art, microprocessor controlled ventilator

systems provides clinicians with opportunities to apply a number of advanced
ventilatory modalities which were not previously available for treating newborns. Some
of these techniques will need further scientific evaluation in controlled trials, but this
should not preclude their use in clinical settings, as their safety has already been
proved by standard setters for use in neonates. There is a firm physiological rationale
for their use, and individual centres have already acquired substantial experience in the
application of these modalities. The trend towards increasing sophistication and greater
versatility is likely to continue, and clinicians involved in the care of sick newborn
infants must keep abreast of these developments.
! 2002 Elsevier Science Ltd. All rights reserved.

Introduction

3. Reduce the patients work of breathing, and

4. Optimize patient comfort.

For more than 30 years, newborns with respiratory

failure have been treated with assisted mechanical
ventilation. For most of this time, the major mode
of ventilation was intermittent mandatory ventilation (IMV) using time-cycled, pressure-limited
devices. This form of ventilation is easy to use and
leaves all parameters to the discretion of the
clinician. The baby may breathe spontaneously
between breaths from continuous flow in the ventilator circuit, but spontaneous breaths receive
ventilatory support by positive end expiratory
pressure (PEEP) only.
Recent technological advances have introduced
newer modes and forms of mechanical ventilation
to the neonatal intensive care unit [1,2]. While
these new modes and devices can be intimidating
to the inexperienced, they are based on sound
physiological principles and have in common the
same goals of mechanical ventilation:

The ideal mode of ventilation is one that delivers

a breath which is synchronized to the patients
spontaneous respiratory effort, maintains adequate
and consistent tidal volume delivery and minute
ventilation at low airway pressure, responds to
rapid changes in pulmonary mechanics or patient
demand, and provides the lowest possible work
of breathing. Accordingly, the ideal ventilator
design consists of a device that achieves all of the
important goals of mechanical ventilation while
providing a variety of modes that can ventilate
patients with even the most challenging pulmonary diseases. It should have monitoring
capabilities to adequately assess the ventilator, the
patient, and their interaction. It should also have
safety features and alarms that offer the development of lung protective strategies. Recent times
have also seen the re-introduction of volumetargeted ventilation to the neonatal population.
Volume-targeted ventilation can be provided
using the same modes as pressure-limited
ventilation and it should be realised that no
matter what the mode, there are very few

1. Achieve and maintain adequate pulmonary gas

exchange,
2. Minimize the risk of lung injury,
10842756/02/$-see front matter

2002 Elsevier Science Ltd. All rights reserved.

402

differences between pressure-limited and volume

targetted ventilation.

Ventilatory modes
Intermittent mandatory ventilation or intermittent
positive pressure ventilation (IPPV) is a ventilator
mode that functions independently of spontaneous
patient effort. Mechanical breaths are programmed
according to a frequency and limit variable, chosen
by the clinician, and the patient is free to breathe
spontaneously between mechanical breaths, supported by PEEP. However, because the patient and
ventilator function independently, there is a significant probability of dyssynchrony [3]. The patient
and ventilator may be out of phase, resulting in an
infant who struggles or fights mechanical ventilation. This can result in inconsistent tidal volume
delivery, increased work of breathing, inefficient
gas exchange, barotrauma and thoracic airleaks [4],
and even disturbances in cerebral perfusion associated with the development of intraventricular
haemorrhage in preterm infants [5].
Newer modes of neonatal mechanical ventilation
have addressed patient-ventilator dyssynchrony
[6,7]. Synchronized intermittent mandatory ventilation (SIMV) attempts to link the onset of mechanically delivered breaths to the onset of spontaneous
breathing by the patient. The ventilator rate is
chosen by the clinician, but mandatory breaths are
held within a timing window until initiation of a
patient breath to which it is then synchronized. As
with IMV or IPPV, the patient is free to breathe
between mechanical breaths and is supported by
PEEP. This mode of ventilation is a major advance
from IMV, but there is still the problem of dyssynchrony if the patients own inspiratory time is
shorter than that chosen by the clinician for the
ventilator. Pressure support ventilation (PSV), a
mode which is flow-cycled and pressure-limited,
can be added to SIMV to support spontaneous
breathing and provide an inspiratory pressure
boost to overcome the imposed work of breathing
created by narrow lumen endotracheal tubes, ventilator circuit dead space, and the demand valve [8].
Pressure support breaths are patient-triggered and
may either be flow- or time-cycled.
The most recent mode of mechanical ventilation
introduced into the neonatal intensive care unit is
assist/control ventilation (A/C), also referred to as
patient-triggered ventilation (PTV) [1,2,7]. In this
ventilatory mode, all spontaneous breaths which

S. M. Donn and S. K. Sinha

reach a trigger threshold result in the delivery of a

mechanical breath which is timed to the onset of
patient inspiration. Thus, each spontaneous breath
is fully or partially supported by a mechanical
breath, which is timed to its onset. However, unless
there is also an expiratory trigger, there can be
some degree of dyssynchrony if the babys inspiratory time is shorter than the inspiratory time
chosen by the clinician. In this scenario, the baby
will end his breath while the ventilator is still
providing positive pressure ventilation. Use of an
expiratory trigger has enabled full synchronization
of the mechanical and spontaneous breaths [3,9].
One means of achieving this is to use changes in
airway flow as a signal of spontaneous breathing. A
small flow change can be used to initiate a mechanical breath, whereas expiration may be triggered
by a decline in inspiratory flow to a fraction of peak
flow. This is described as flow-cycling, in which
each mechanical breath ends as a percentage of
peak inspiratory flow rather than by a fixed time
limit. Using flow-cycled A/C in a pressure-limited
manner, the patient starts and ends the breath by
the use of a flow signal. The breath is flowtriggered, pressure-limited, and flow-cycled. The
clinician chooses the ventilator-controlled parameters, peak inspiratory pressure, positive end
expiratory pressure, and flow, while the patient
determines the respiratory rate and the inspiratory
time. The benefits of flow-cycling include total
breath synchronization, decreased work of breathing, more efficient tidal volume delivery, improved
gas exchange, and fewer acute complications [9].
Because the baby and the ventilator are fully
synchronized, the use of sedative drugs can be
significantly reduced.

Classifying ventilator modes

Classification of a mode or a breath type can be
based on three points in the ventilatory cycle [10].
The first of these is initiation or the trigger mechanism. What starts the breath? Intermittent mandatory ventilation utilized time. The ventilator cycles
according to the rate, which is set by the clinician.
Triggered ventilation begins with detection of a
surrogate for spontaneous breathing. This might be
changes in airway pressure or airway flow, chest
impedance, or abdominal movement. The second
point is the limit variable. That is, what is controlled and what is variable? With pressure-limited

Newer techniques of mechanical ventilation: an overview

ventilation, pressure is controlled and tidal volume

will be variable. With volume-limited ventilation,
volume is controlled and pressure will be variable.
The final point is termination. That is, what is the
cycling mechanism which causes the breath to end?
All modes of ventilation utilize time, although with
the newer modes this is generally a secondary
cycling mechanism. Volume-cycling can be accomplished in adult and paediatric ventilators, although
its use in neonatal ventilators is made difficult by
the use of uncuffed endotracheal tubes. Because
there is always almost some degree of leak around
the endotracheal tube, true volume-cycling is probably impossible. It is preferable in the neonatal
application to refer to this as volume-targeted or
volume-limited ventilation. Pressure may also be a
cycling mechanism and, as mentioned above, the
use of the flow signal may also be applied to
cycling.
Recent advances in ventilator design have produced additional forms of ventilation available to
neonatal patients. The pressure-limited types
include time-cycled, pressure limited ventilation;
pressure control ventilation; and PSV. Volumetargeted types include volume-limited ventilation,
volume guarantee, pressure regulated volume control, and a hybrid type known as volume assured
pressure support (VAPS).
Time-cycled, pressure-limited ventilation
Time-cycled, pressure-limited ventilation may be
applied in either IMV, SIMV, or A/C modes. It is
characterized by continuous flow and adjustable
inspiratory time, and a constant inspiratory pressure. It is easy to use and has been the primary
means of mechanical ventilation in the newborn for
decades. However, it does have a number of
inherent disadvantages. Because it is pressurelimited, there is variability in tidal volume based on
the patients lung compliance. Also, when applied
in the IMV mode, patientventilator dyssynchrony
can be a major problem. Time-cycled, pressurelimited ventilation results in a plateau pressure and
may be associated with barotrauma. The continuous high expiratory flow may create turbulence and
impair gas exchange as well as elevate expiratory
resistance.
Pressure control ventilation
Pressure control ventilation has been recently
introduced into the neonatal intensive care unit.

403

Table 1. Comparison between TCPL, PC AND PS

Limit
Flow
Ends (cycles)

TCPL

PC

PS

Pressure
Continuous set
Set or flow

Pressure
Variable
Set

Pressure
Variable
Flow

TCPL, Time cycled pressure limited; PC, pressure control; PS, pressure
support.

This is a pressure-limited form of ventilation in

which there is constant inspiratory pressure with
each delivered breath, but the flow rate is variable
during inspiration depending upon patient effort.
Flow delivery in pressure control ventilation is
initially rapid, followed by decelerating flow at the
maintenance of peak inspiratory pressure. This
would appear to be advantageous in conditions in
which there is high respiratory resistance. Potential
benefits of pressure control ventilation include
variable flow capability to match patient demand,
reduced patient inspiratory muscle work load,
lower peak inspiratory pressure, and rapid filling
of the alveoli, with improved gas distribution,
ventilation-perfusion matching, and oxygenation.
Potential disadvantages include the fact that the
delivered tidal volume is variable and also
depends on the patients lung mechanics, particularly pulmonary compliance and airway resistance.
This has the potential to adversely effect tidal
volume delivery if patient compliance suddenly
deteriorates. Table 1 compares the features of
time-cycled, pressure-limited ventilation, pressure control ventilation, and pressure support
ventilation.

Volume-targeted ventilation
The development of microprocessor-based ventilator technology and sophisticated neonatal
transducers has enabled the reintroduction of
volume-targeted ventilation in neonatal intensive
care [11,12]. The distinguishing features of pressure
and volume-targeted modes and their perceived
advantages and disadvantages are summarized in
Tables 2 and 3. Volume ventilation involves selecting a targeted tidal volume to be delivered to the
patient while allowing the pressure required to
deliver that volume to be variable. When patient
compliance is low, pressure will be high, but as

404

S. M. Donn and S. K. Sinha

Table 2. Differentiating features of pressure and volume targeted ventilation

Variables

Pressure-limited

Volume-controlled

Control (fixed) variable

Pressure

Volume

Phase (changeable) variable

Inspiratory trigger
Inspiratory limit
Inspiratory cycle
Delivered tidal volume
Recorded peak pressure

Patient or machine
Pressure
Time or flow
Variable
Constant

Patient or machine
Flow
Volume or flow
Constant
Variable

Inspiratory flow wave form

Available modes

Ramp-descending
IMV, SIMV, A/C, PSV

Square
IMV, SIMV, A/C, PSV

IMV, Intermittent mandatory ventilation; SIMV, synchronized intermittent mandatory ventilation; A/C, assist-control; PSV,
pressure support ventilation.

Table 3. Perceived advantages and disadvantages of volume targeted vs pressure-limited ventilation

Pressure-limited

Volume targeted

Advantages

Gas distribution is improved by exposing

the lungs to set PIP throughout inspiratory
cycle.
Reduces work of breathing by providing high
initial flow.
Limits excessive airway pressure and, thus
reduces risk of baro-trauma.

Increase in minute volume delivery as VT is increased.

Auto-weaning of proximal airway pressure as lung
compliance improves.
Constant VT delivery regardless of pulmonary
compliance.

Disadvantages

Variable VT delivery, thus risk of excessive

volume delivery as compliance improves or
inadequate volume deliver if compliance
worsens.
Inconsistent change in VT with change in PIP
and PEEP.

Excessive airway pressure could increase risk of

baro-trauma.
Patient-ventilator asynchrony from fixed inspiratory
flow (flow starvation).

compliance improves, the ventilator will automatically wean peak inspiratory pressure to deliver the
same tidal volume, and thus it may be more
effective in states characterized by rapidly changing compliance such as following the administration of surfactant. Volume ventilation involves
a constant flow rate. It assures a guaranteed tidal
volume delivery, although it is important that the
volume of delivered gas be measured as close to
the airway as possible. It is also important to know
the compliance of the ventilator circuit itself, as
there is compressible volume loss to the circuit
and this will increase as pulmonary compliance
decreases. Volume-targeted ventilation is not
affected by lung impedance nor rapidly changing
pulmonary mechanics. Its major advantage is a

stable and consistent tidal volume delivery and

minute ventilation independent of pulmonary
mechanics, but pressures are variable and can be
difficult to control, and there may be a resultant
high peak pressure when compliance is poor.
During volume ventilation there is also a slow rise
to peak pressure, and therefore the distribution of
ventilation may not be optimized, particularly if
lung disease is heterogeneous. The set flow rate
during volume ventilation may not match the
patients demand, resulting in small tidal volumes
and a condition referred to as flow starvation.
Unless a synchronized mode is chosen, there can be
increased muscle workload, which can compromise
patient comfort, gas exchange and even cardiac
function.

Newer techniques of mechanical ventilation: an overview

Monitoring
In addition to the advances in ventilator and sensor
technology, neonatal clinicians now have the
ability to monitor ventilator performance and ventilator patient interaction on a breath-to-breath
basis, utilizing real-time displays of pulmonary
mechanics, waveforms, or numerical data [13]. An
ideal monitor is one capable of measuring and
displaying airway graphics with a proximal monitor. This should include flow, pressure, and volume
waveforms; pressure-volume and flow-volume
loops; calculation of pulmonary mechanics; and
trending of data. The importance of proximal
monitoring was recently demonstrated. With infant
circuits, tidal volume measurements at the airway
were only 56% of that measured at the machine
because of compressible volume loss [14]. A small
discrepancy in delivered tidal volume could have a
huge impact on an extremely low birth weight
baby.
Monitoring also enables the customization of
ventilator settings based on the response of the
individual patient. It allows for determination of
optimal positive end expiratory pressure, detection
of overinflation, determination of gas trapping,
and many other subtle features which have the
potential for causing injury.

405

up breaths, and early experience demonstrated

difficulty in avoiding hypocapnia with this
technique [16].

Pressure regulated volume control

Pressure regulated volume control is available on a
Servo 300 ventilator [17]. This form of ventilation
produces a variable decelerating flow pattern. The
breaths are time-cycled and delivered in A/C.
Pressure regulated volume control establishes a
learning period to determine the patients compliance, which enables the regulation of pressure
and volume. During the learning period, four test
breaths of increasing pressure are delivered. The
inspiratory pressure is regulated based on the
pressure-volume calculation of the previous breath
and compared to a target tidal volume. The ventilator continuously adapts the inspiratory pressure
in responses to changing compliance and resistance
in order to maintain the targeted tidal volume. This
results in breath-to-breath variation of inspiratory
pressure.
This form of ventilation is limited to the A/C
mode and requires a change to volume support for
weaning. Additionally, tidal volume is measured
distally and not at the patient airway, and thus
there can be differences between actual and
measured delivered tidal volumes.

Newer ventilatory techniques

Volume assured pressure support
Volume guarantee
Volume guarantee is a form of ventilation available
on the Draeger Babylog 8000 infant ventilator.
Volume guarantee delivers a pressure-targeted
breath at a set inspiratory flow which is fixed and
not variable. Based on the previous breath, the
pressure may increase or decrease to guarantee the
targeted volume selected by the clinician [15].
Limitations of volume guarantee include the fact
that it cannot increase pressure higher than the set
pressure limit, it requires a pressure plateau to
guarantee the volume delivery (this may result in
longer inspiratory times and higher flows), and the
guarantee is based on the expired tidal volume of
the preceding eight breaths. There can be variability in tidal volume delivery with leaks and
changes in pulmonary mechanics from these catch

Volume assured pressure support (VAPS) is available on the VIP BIRD Gold Infant/Pediatric ventilator [11]. This is a hybrid mode of ventilation,
which combines the best features of pressurelimited and volume-targeted ventilation. The ventilator delivers a breath to a set pressure limit. If the
targeted volume has not been delivered to the
patient at this pressure, the breath will be prolonged to guarantee delivery of tidal volume. Peak
inspiratory pressure and inspiratory time are
increased and the guaranteed volume is provided
on the current breath without the need for previous
breath averaging. VAPS maybe thought of as
variable flow volume ventilation. It involves a
decelerating but non-limited variable flow rate in
order to achieve guaranteed tidal volume delivery.
The ventilator continuously measures the flow and
pressure, and calculates the delivered volume. It can

406

S. M. Donn and S. K. Sinha

Table 4. Commonly available neonatal ventilators which provide volume targeted modes of ventilation
Ventilator

Available modes

VIP BIRD Gold"

Features

Volume control
Combination modes
VAPS

Volume limited-pressure controlled breaths

Requires properly installed flow sensor

Siemens Servo 300

Volume control
Combination modes
PRVC
Volume support

Flow cycling in all modes

Sensor located in machine
Closed loop feed back technology Automode

Draeger Babylog 8000"

Combination mode
Volume guaranteed pressure-limited

Flow cycling in PSV only with a fixed 15%

termination criteria
Heated wire sensor

Bear Cub 750 PSV"

"

be used in both A/C and SIMV modes, and PSV

may be added to the SIMV mode. During the
VAPS breath, the decision point is made when flow
decelerates to the lowest level set. If the targeted
tidal volume has been delivered, inspiration is
terminated and the breath is flow-cycled. If the
pre-set tidal volume has not been achieved, the set
flow will persist until the desired volume has been
reached. This involves transitioning from a
pressure-limited to a volume-targeted breath. The
flow waveform switches from sinusoidal to square.
Thus the breath changes from being flow-cycled to
being volume-targeted. Safety limits include a
high pressure and maximum inspiratory time.
Depending upon the actual settings, the breath
could therefore be flow-, volume-, or time-cycled.
The potential benefits of VAPS include lower
peak airway pressures, reduced patient work of
breathing, improved gas distribution, less need for
sedation, and improved patient comfort. VAPS
maybe suitable for a patient who requires a substantial level of ventilatory support but has a
vigorous ventilatory drive to improve gas distribution and synchrony, or it may be beneficial for a
patient who has been weaned from the ventilator
but who has unstable ventilatory drive to supply a
back-up tidal volume as a safety net in case the
patients effort and/or pulmonary mechanics
change. The major limitations of VAPS include the
fact that it will only increase pressure and not
lower it with changing mechanics, and it increases
the inspiratory time to assure tidal volume
delivery.

Flow cycling
Variable orifice sensor
Proximal airway sensor
Flow triggering

Proportional assist ventilation (PAV)

Is a ventilatory technique in which the level of
ventilatory support is proportional to patient
effort. It functions on the principle of using combined elastive and resistive unloading of respiratory musculature to achieve gas exchange at lower
mean airway pressure than other forms of conventional mechanical ventilation [18]. So far there has
been one published clinical trial of PAV in newborns. It evaluated PAV, A/C, and IMV in a
cross-over design study of 36 infants weighing
6001200 g with mild to moderate acute respiratory illness. PAV resulted in lower mean airway and
transpulmonary pressures at an equivalent fraction
of inspired oxygen and similar carbon dioxide
removal rate [19]. Further trial of this promising
technique study is needed.
Table 4 shows the commonly available neonatal
ventilators which provide volume targeted modes
of ventilation.

Conclusions
The newer modes in the forms of mechanical
ventilation for the newborn combine the best
features of volume and pressure ventilation. These
modes and forms have been shown to reduce
the work of breathing and to improve patients
synchrony and comfort.
Much more clinical investigation is necessary to
define the best indications and applications of these

Newer techniques of mechanical ventilation: an overview

new forms of ventilation. Clinicians should not be

daunted by the wide array of choices now available, but should concentrate initial efforts on learning a few of the modes and techniques including
their indications and limitations. A thorough understanding of the principles of mechanical ventilation
and interpretation of pulmonary graphics is necessary before attempting to master all of these new
techniques. Nevertheless, the opportunity now
exists for clinicians to design strategies aimed at
the basic pathophysiology and to adapt them in
response to the ventilatorpatient interaction.

407

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References
1 Sinha SK, Donn SM. Advances in neonatal conventional
ventilation. Arch Dis Child 1996; 75: F135140.
2 Donn SM, Sinha SK. Newer modes of mechanical ventilation for the neonate. Curr Opin Pediatr 2001; 13:
99103.
3 Donn SM, Nicks JJ, Becker MA. Flow-synchronized
ventilation of preterm infants with respiratory distress
syndrome. J Perinatol 1994; 14: 9094.
4 Lipscomb AP, Thorburn RJ, Reynolds EO, et al.
Pneumothorax and cerebral hemorrhage in preterm
infants. Lancet 1981; 1: 414416.
5 Perlman JM, Goodman S, Kreusser KL, Volpe JJ.
Reduction in intraventricular hemorrhage by elimination
of fluctuating cerebral blood flow velocity in preterm
infants with respiratory distress syndrome. N Engl J Med
1985; 312: 13531357.
6 Bernstein G, Mannino F, Heldt GP, et al. Randomized
multicenter trial comparing synchronized and conventional intermittent mandatory ventilation in neonates. J
Pediatr 1996; 128: 453463.
7 Greenough A. Update on patient-triggered ventilation.
Clin Perinatol 2001; 28: 533546.
8 Sinha SK, Donn SM. Pressure support ventilation. In:
Sinha SK, Donn SM (eds) Manual of Neonatal Respiratory

14

15

16

17

18
19

Care. Armonk, NY: Futura Publishing Co., 2000; 157

160.
Donn SM, Sinha SK. Controversies in patient-triggered
ventilation. Clin Perinatol 1998; 25: 4961.
Carlo WA, Ambalavanan N, Chatburn RL. Classification
of mechanical ventilation devices. In: Sinha SK, Donn SM
(eds) Manual of Neonatal Respiratory Care. Armonk, NY:
Futura Publishing, 2000; 122127.
Sinha SK, Donn SM. Volume-controlled ventilation.
Variations on a theme. Clin Perinatol 2001; 28: 547560.
Sinha SK, Donn SM, Gavey J, McCarty M. Randomised
trial of volume controlled versus time cycled, pressure
limited ventilation in preterm infants with respiratory
distress syndrome. Arch Dis Child 1997; 77: F202F205.
Sinha SK, Nicks JJ, Donn SM. Graphic analysis of
pulmonary mechanics in neonates receiving assisted ventilation. Arch Dis Child Fetal & Neonatal Edition 1996; 75:
F213F218.
Cannon ML, Cornell J, Tripp-Hamel DS, et al. Tidal
volumes for ventilated infants should be determined with
a pneumotachometer placed at the endotracheal tube. Am
J Respir Care Crit Care Med 2000; 162: 21092112.
Cheema IU, Ahluwailia JS. Feasibility of tidal volumeguided ventilation in newborn infants: a randomized
crossover trial using the volume guarantee modality.
Pediatrics 2001; 107: 13231328.
Mrozek JD, Bendel-Stenzel EM, Meyers PA, et al.
Randomized controlled trial of volume-targeted synchronized ventilation and conventional intermittent mandatory ventilation following initial exogenous surfactant
therapy. Pediatr Pulmonol 2000; 29: 1118.
Piotrowski A, Sobala W, Kawczynski P. Patient-initiated,
pressure-regulated, volume-controlled ventilation compared with intermittent mandatory ventilation in neonates: a prospective, randomized study. Intens Care Med
1997; 23: 975981.
Schulze A, Bancalari E. Proportional assist ventilation.
Clin Perinatol 2001; 28: 56178.
Schulze A, Gerhardt T, Musante G, et al. Proportional
assist ventilation in low birth weight infants with acute
respiratory disease: a comparison to assist/control and
conventional mechanical ventilation. J Pediatr 1999; 135:
339344.