Bi-Level Breath Mode on the Puritan Bennett™
840 Ventilator: Definitions, Sample Case Studies and
Selected Protocols
David J. Howell, PhD, RRT
Introduction
In the years since the introduction of the Puritan
Bennett™ MA-1 Ventilator in the late 1960s, clinicians have
longed for ventilatory modalities that more closely mimic
human ventilatory patterns. Intermittent mandatory ven-
tilation (IMV), for example, long ago ceded its position of
clinician preference to synchronized IMV (SIMV). SIMV
remains a favored treatment option for many clinicians.
However, respiratory care practitioners are often eager to
encourage as much synchronized spontaneous breathing as
possible in intubated patients. Continuous positive airway
pressure (CPAP) is one example of ventilation that, strictly
speaking, is not “mandatory” ventilation at all. Another
approach to synchronized spontaneous breathing is through
a new ventilator option known as the breath mode.
The Bi-Level Breath Mode
The Bi-Level option is a feature of the Puritan Bennett™ 840
Ventilator System. This breath mode is a form of augmented
pressure ventilation. It allows unrestricted spontaneous
breathing at any moment of the mandatory breath cycle,
during either the inspiratory or expiratory phase. Use of the
Bi-Level breath mode can result in improved patient-ven-
tilator synchrony, as the case studies included in this paper
help show.
In the Bi-Level breath mode, the patient can breathe at both
lower and upper levels of positive end expiratory pressure
(PEEP). The waveform for the ventilatory option resem-
bles that of pressure control ventilation (PCV). Unlike PCV,
however, the Bi-Level option allows spontaneous breathing
at the upper pressure level (PEEPH) and at the lower pres-
sure level (PEEPL).
Different Approaches in the Bi-Level Breath Mode
The two approaches for Bi-Level breath mode, based on the
desired inspiration to expiration (I:E) ratio and the clinical
needs of the patients, are conventional I:E ratios and inverse
I:E ratios.
Conventional I:E ratios
The first approach is through the use of a normal I:E ratio.
The clinician begins by setting an inspiratory time (TI)—
for example, 0.8 to 1.6 seconds. In this approach with the
Bi-Level breath mode, the Time High and Time Low—TI in
PCV—is not restricted to any specific ratio. When the time
Figure 1. Conventional I:E Ratio Ventilation
1
spent at the upper and lower levels of PEEP is protracted
enough for spontaneous breathing, the breath mode is com-
monly referred to as “biphasic” in the literature. The Bi-Level
term is a trademarked name for breathing in a biphasic
fashion, as well as in another approach described in the fol-
lowing paragraph. Figure 1 shows the ventilatory waveform
of a patient being treated with conventional I:E ratios in the
Bi-Level breath mode.
An alternative strategy using conventional I:E ratios is to
set the desired I:E ratio the clinician desires the patient to
receive, for example, 1:1, 1:2 and so forth. The approach
allows the patient to have a “normal” TI. At least equally
important, it helps the clinician maintain control of the
patient’s mean airway pressure while allowing the patient to
breathe freely during any phase of the breath.
Inverse I:E ratios
The second approach utilizes an inverse I:E ratio. Longer
Time High (TH) periods and concomitantly shorter Time
Low (TL) periods can be helpful in improving gas distribu-
tion and promoting alveolar recruitment while improving
oxygenation by elevating the mean airway pressure. Bi-
Level ventilation uses I:E ratios in which the TL intervals are
too brief to permit complete alveolar emptying.
Clinicians may sometimes refer to two subsets of
inverse I:E ratio use: pressure control inverse ratio
ventilation (PCIRV) and airway pressure release
ventilation (APRV). In PCIRV, the ratio is inverse, but
not decidedly so. In APRV, the I:E ratio can be quite pro-
nounced. Although the definitions may vary from user to
Figure 2. Inverse I:E Ratio Ventilation
2
user, the distinction nevertheless is between conventional
and inverse I:E ratios, regardless of the proportion.
PCIRV and APRV involve an inverse ratio by 1) requir-
ing that all spontaneous breathing takes place during the TH
period and 2) using a TL that is less than one second. APRV
implies a shortened TL, where all spontaneous breathing
takes place at the upper PEEP (PEEPH) level. The pressure
is then “released” to a lower PEEP (PEEPL) level just long
enough for the lung volume to decrease. The objective is to
manage the patient through a short release time (time at
PEEPL) in order to release some trapped gas, but not long
enough to allow de-recruitment of the alveoli. Pressure
immediately returns to the PEEPH level.
The principle of releasing rather than increasing volume to
augment ventilation is a differentiating feature of APRV. The
ventilator cycles between high and low levels, depending on
the TH and TL settings, and synchronizes with the patient’s
own respiratory pattern. Figure 2 shows the ventilatory
waveform of a patient being treated with an inverse I:E ratio
in the Bi-Level breath mode.
Advantages of APRV for certain patients have been doc-
umented in the literature. They include lower airway
pressures, lower minute ventilation, fewer adverse effects on
cardiac function, less sedation and neuromuscular block-
ade and the ability to breathe spontaneously throughout the
entire ventilatory cycle.1
In both conventional I:E ratio and inverse I:E ratio
approaches, ongoing monitoring of total respiratory rate,
tidal volumes and minute volumes in the Puritan Bennett
840 Ventilator allows all spontaneous breaths to be dis-
played and counted—at PEEPH and at PEEPL levels.
Case Studies of Patients Ventilated in the
Bi-Level Breath Mode
The following two case studies offer slightly different ratio-
nales for use and management of the patient in the Bi-Level
breath mode. The first case study describes a patient being
ventilated with conventional I:E ratios; the second case
TABLE 1. Days, Times, Ventilator Settings, ABGs and CI

ABG in
Bi-Level Mode pH PaCO2 (mm Hg) PaO2 (mm Hg) HCO-3 (mEq/L) SaO2 (%) CI
Day 1/ 1110 7.35 49 86 96 5.7
RR 18 bpm
PEEPH 30 cm H2O
PEEPL 16 cm H2O
PSV 16 cm H2O
TI 1.55 sec
I:E 1:1.5
FiO2 0.9

ABG After
Chemical Paralysis
Day 1/ 1215 7.26 62 75 4.3
CI After Chemical
Paralysis Reversal
Day 1/ 1400 5.5
Day 2/ 0500 7.37 44 99
RR 18 bpm
PEEPH 30 cm H2O
PEEPL 16 cm H2O
PSV 16 cm H2O
TI 1.55 sec
I:E 1:1.5
FiO2 0.7

Bi-Level Mode D/Cd

on Day 7

study describes a patient being ventilated with inverse I:E
ratios.
Case Study One:
Perforated Duodenal Ulcer and Sepsis
A 57-year-old male was admitted to the hospital with gas-
trointestinal bleeding. An exploratory laparoscopy revealed
a perforated duodenal ulcer. The patient subsequently
experienced respiratory failure secondary to sepsis. As his
condition worsened, he was intubated and transferred to the
ICU. In the ICU, the clinician placed the patient on ventila-
tion with the Bi-Level breath mode. An hour after the first
arterial blood gas (ABG), the physician administered chem-
ical paralysis with vecuronium to manage the patient’s work
of breathing.
The chemical paralysis had a profound effect on the patient’s
hemodynamic and pulmonary parameters and was reversed
two hours later.
There was also reason to suspect that the loss of spontane-
ous breathing and an inhibitory thoracic pump effect, as a
result of the paralysis, may have contributed to the patient’s
poor cardiac and pulmonary performance. When the paral-
ysis was reversed and the patient was allowed to contribute
to ventilation, his condition improved. Days, Times, Venti-
lator Settings, ABGs and Cardiac Index (CI) are shown in
Table 1.
Comments on Case Study One
In earlier ventilator technology, patients often required con-
siderable amounts of sedation and/or chemical paralysis

3
TABLE 2. Days, Times, Ventilator Settings, ABGs and P/F Ratios

ABG Post-Extubation
(NIV) pH PaCO2 (mm Hg) PaO2 (mm Hg) HCO-3 (mEq/L) SaO2 (%) P/F Ratio
Day 1/ 0400 7.35 49 86 96 5.7

NIV 18/5
FiO2 0.6

ABG After
Reintubation (VC)
Day 1/ 1215 7.26 62 75 4.3
A/C 12
Vt 750 mL
FiO2 0.6
PEEP 5 cm H2O

Day 1/ 1030 7.37 43 91 24 96 130

A/C 12
Vt 750 mL
FiO2 0.7
PEEP 5 cm H2O

ABG 30 Minutes
After Initiation of
Bi-Level Mode
Day 1/ 1100 7.34 46 133 25 98 220
F 10
TH 4.8 sec
TL 1.2 sec
PEEPH 30 cm H2O
PEEPL 10 cm H2O
PSV 5 cm H2O
FiO2 0.6

Day 3/ 0500 7.36 40 106 23 98 265

F 10 bpm
TH 4.8 sec
TL 1.2 sec
PEEPH 28 cm H2O
PEEPL 10 cm H2O
PSV 5 cm H2O
FiO2 0.4

Bi-Level Mode D/Cd

Day 5/ 0500 7.37 43 99 24 97 247

CPAP 7.5 cm H2O
PSV 20 cm H2O
FiO2 0.4

4
for optimal oxygenation and ventilation and for improved
patient-ventilator synchrony. When one is paralyzed during
mechanical ventilation, as in this case, pharmaceutical
management is more likely to reduce patient-ventilator
asynchrony rather than to improve patient-ventilator syn-
chrony. Paralysis requires controlled ventilation.
With newer technology, such as the Bi-Level breath mode,
clinicians have a wider choice of ventilatory options than
were available in the past. In this patient, chemical paral-
ysis was clearly not the best way to manage his ventilatory
course. This is apparent in the reversal of the paralysis and
the nearly immediate improvement in cardiac index and
oxygen saturation parameters.
Using less sedation and chemical paralysis is not only
a welcome change for some patients, it is also financially
beneficial to the institution caring for the patients.
Critical Care Medicine published an article in the mid-1990s
that reported quadrupled healthcare expense in caring for
patients who had suffered from prolonged muscle weakness
after the use of paralyzing agents.2 In this case, for exam-
ple, elimination of the vecuronium regimen resulted in an
estimated savings of approximately $3,500. Depending on
the patient’s respiratory status, use of the Bi-Level mode can
often reduce medication requirements without compromis-
ing oxygenation and ventilation.
Case Study Two:
Altered mental status and substance abuse
A 52-year-old male patient with a history of alcohol abuse
was admitted to the hospital due to an apparent suicide
attempt with amphetamines and then benzodiazepines.
The patient was intubated secondary to a decrease in
mental status and transferred to the ICU, where he was vol-
ume-ventilated by the Puritan Bennett™ 840 Ventilator. He
required considerable sedation during his period of detox-
ification, but was extubated after two days and placed on a
nasal cannula. When oxygen desaturation followed place-
ment on the cannula, the patient was placed on noninvasive
ventilation (NIV).
The patient remained on NIV for three days. He was rein-
tubated on the third day, due to respiratory failure from
aspiration pneumonia, and was once again supported with
volume control ventilation (VCV) for two days. At that
time, clinicians changed from VCV to
Bi-Level breath mode secondary to poor PaO2/FiO2 (P/F)
ratios post extubation and again during reintubation and
VC ventilation. Days, Times, Ventilator Settings, ABGs and
P/F Ratios are shown in Table 2.
Comments on Case Study Two
The decision to use the Bi-Level breath mode was prompted
by decreased P/F ratios with both conventional VC ven-
tilation and noninvasive ventilation. The Bi-Level option
allowed clinicians to increase mean airway pressure and
simultaneously employ lung protective strategies with a pro-
tracted PEEPH and a shortened PEEPL. The patient’s P/F
ratios rose markedly with Bi-Level ventilation. The patient
was extubated without incident and required no further
ventilatory assistance during his course of stay. More-
over, the Bi-Level breath mode improved patient-ventilator
synchrony to the degree that neither deep sedation nor par-
alytic agents were necessary.
5
Bi-Level Basics
In this breath mode, clinicians may select from several • The Bi-Level breath mode counts and measures sponta-
ventilatory strategies, depending on the clinical condition neous breaths taken during either breath phase.
of the patient. These strategies are ventilation with conven-
• Pressure support of 1.5 cm H2O is applied at TH, or can
tional inspiratory to expiratory (I:E) ratios and with inverse
be operator adjusted.
I:E ratios.
• An exhalation synchronization window is present in the
There may be some patients who are not optimal candi-
Bi-Level option, similar to the window in PCV and
dates for ventilation with the Bi-Level breath mode. These
other modes. If the ventilator detects an inspiratory effort
patients may include individuals with increased airway
near the end of the proposed time or ratio, the TI will
resistance that significantly impedes exhalation of all gas
float to help synchronize exhalation.
(AutoPEEP).
A prolonged expiratory time and an audible expiratory
wheeze are two characteristics to consider before utilizing Keeping Up With Best Clinical Practices
the Bi-Level breath mode to a patient. However, clinicians
may elect to use Bi-Level ventilation on their patients on a ARDS Clinical Trials Network
trial basis—contrary to the patient’s airway characteristics—
Clinicians may wish to explore discussions in clinical
before choosing other conventional modes of ventilation.
forums on the Internet. One group that addresses clini-
Characteristics of the Bi-Level Breath Mode
cal care issues in patients with Acute Respiratory Distress
Clinicians should be familiar with several character–istics of
Syndrome (ARDS) is the ARDS Clinical Trials Network.
the Bi-Level mode before selecting it for use
The ARDS Clinical Trials Network is a group of more than
with their patients. These characteristics include the
a dozen clinical centers, created by the National Heart,
following:
Lung and Blood Institute in 1994.3 ARDS Network mem-
• Pressure and TH parameters are set by the operator.
bers help develop and execute multicenter clinical trials of
• Frequency is set by the operator. novel therapeutic agents for ARDS. As part of its mission,
• Volume and flow are variable according to patient the group publishes results from researchers who explore
needs, compliance and resistance. Volume depends the ways to best manage ventilated patients with ARDS.
on compliance and resistance; flow is variable and For example, one article on the website concerns a well-
patient determined. known, large-scale clinical trial of larger versus smaller
tidal volumes in mechanical ventilation.4 ARDS Clini-
• Patients can breathe spontaneously during TL and TH.
cal Trials Network has also recently published an article
• The active expiratory valve is the hardware that
exploring higher versus lower PEEP levels in patients with
allows spontaneous breathing during any phase of breath
ARDS.5 Clinicians can access the ARDS Network online at
delivery.
http://www.ARDSNet.org.

6
Bi-Level Settings Two Sample Protocols Using the Bi-Level
• Mode = Bi-Level Breath Mode
• PEEPH = High PEEP (similar to inspiratory pressure [PI] For purposes of illustration, this paper includes two
in PCV; sets actual peak inspiratory pressure [PIP], not protocols using the Bi-Level option. The protocols repro-
the pressure above PEEP) duced here may be useful to clinicians who are selecting
the Bi-Level mode for the first time as well as to clinicians
• PEEPL = Low PEEP (same as PEEP in PCV)
well-versed in setup of the ventilatory option. Inclusion
• TH = Time at PEEPH (same as inspiratory time in PCV) of the two protocols does not constitute endorsement by
• Clinician can set TL (Time at PEEPL) or TH:TL Ratio Puritan Bennett. The protocols are reprinted as examples
(same as I:E ratio in PCV) of how the Bi-Level option has been used, and is cur-
rently being used, in some ICU environments. (Please
• Frequency = RR
note: These protocols should only be followed if deter-
• Rise Time Percent mined appropriate by a treating clinician.)
• PS = Above PEEP

One Example of a Bi-Level Setting

• Mode Bi-Level

• PEEPH 20 cm H2O

• TH 1.0 sec

• PEEPL 5 cm H2O

• Frequency 15

• PS 20 cm H2O

7
 Protocol One

Standard Protocol for the Postoperative CABG Patient at United Medical Center
(Cheyenne, Wyoming)

Initial Setup If patient meets initial weaning parameters, initiate CPAP wean per guidelines:

Rate 12-14 bpm – CPAP 5 cm H2O

– Pressure support 15 cm H2O
PEEPL 5 cm H2O
– Hemodynamics, RR and SpO2 stable for 30 minutes
PEEPH 22 cm H2O
If the patient does not meet the CPAP guidelines go to Bi-Level SIMV wean:
Titrate PEEPH to maintain a minute ventilation of 1.5 L per
10 kg (± 1 L). PEEPH is not to be set above 32 cm H2O Decrease Bi-Level rate Q 30 minutes, monitor SpO2, RR,
without a physician’s order. minute ventilation, and hemodynamics until stable at
Bi-Level rate of 4 bpm. When the patient is stable, continue
PSV 15 cm H2O
with CPAP.
FiO2 0.8
Document in chart the initial ventilator setup and any changes that are made as a
TH 1.5 seconds protocol order. ABGs can be drawn at any time during the weaning process. ABGs
must also be documented in the chart as a protocol order.
%P 80% (May be patient specific and not dictated by protocol)
ESENS 10%

ABG Guidelines

pH 7.35 to 7.50

PaCO2 <45 mm Hg

PaO2 >60 mm Hg (FiO2 <0.55)

SaO2 >88% (FiO2 <0.55)

Weaning Parameters

NIF >20 cm H2O

Vt >4 mL/kg

RR <35 bpm

VC >10 mL/kg

Protocol courtesy of Steve Carlson, RRT, Cardiopulmonary Education, United Medical Center, Cheyenne, Wyoming

8
Protocol Two

Bi-Level Lung Protection Ventilator Management

Determine Critical Opening Pressure of Lung by Doing Slow Flow Inflection Maneuver

Initial ventilator setup criteria • Set rate 10 bpm

• Set Pressure Support so sum of PEEPL and PSV does not exceed PEEPH
• Adjust PEEPL 2 cm H2O above lower inflection point (Caution above 15 H2O)
• Adjust FiO2 to achieve saturation of 92% or PaO2 of 65 mm Hg
• Adjust PEEPH to achieve Vt of 7 cc/kg IBW
• Reduce sedation to allow spontaneous breathing
Maximum PEEPH 40 cm H2O
• Set TimeH 1.5 seconds

Determine if AutoPEEP is present as indicated by expiratory flow trace not returning to zero
YES Decrease rate to 8
NO

Obtain ABG NO AutoPEEP present

YES
PaO2 >65 mm Hg PCO2 <35 mm Hg
Decrease rate to 6
NO YES YES NO

pH <7.20
Increase FiO2 Titrate FiO2 to maintain Decrease rate
NO YES
SpO2 >92% but <96%
Increase timeH in increments
of 0.25 seconds. Observe
for AutoPEEP. Maintain Increase rate
settings but prevent
If AutoPEEP develops, regardless AutoPEEP.
decrease rate so long as of elevated
pH >7.25 Decrease
PCO2
timeH if
oxygenation
adequate
(Minimum
1.5 sec)

Ventilator Maintenance

• Continually adjust PEEPH to maintain Vt of 7 cc/kg IBW • Q72hr if PO2/FiO2 >200

• Perform inflection maneuver based on PaO2/FiO2 or acute change in patient status • Reduce FiO2 as tolerated to keep SpO2 >92%
• Daily if PO2/FiO2 <100 • When FiO2 <0.4, decrease TimeH if > than 1.5 sec; otherwise, decrease rate.
• Q48hr if PO2/FiO2 100-200 • Maintain PSV to deliver Vt 7 cc/kg

Protocol courtesy of Ken Hargett, RRT, Director of Respiratory Care Services, The Methodist Hospital, Texas Medical Center, Houston, Texas

9
Summary
Newer breath modes and ventilatory strategies are per-
tinent to conversations about EBM. In a recent issue of
Respiratory Care, Branson and Johannigman observe that
ventilator technology “advances at an alarming rate.” They
7
add that a thorough understanding by the clinician of how
each ventilator mode functions is essential to good practice.
Moreover, they encourage clinicians to be “good con-
sumers,” using EBM to make the best-informed decisions
possible. Ongoing conversations among clinicians will help
identify the best uses—and modes—of mechanical ventila-
tion.
One option for clinicians is the Bi-Level breath mode, a fea-
ture in the Puritan Bennett™ 840 Ventilator. The
Bi-Level option allows clinicians to select from two ventila-
tory strategies: Conventional I:E ratio ventilation to simplify
the patient’s transition from controlled to spontaneous
breathing and inverse I:E ratio to support therapeutic goals
for the patient living with ARDS.
10
Several types of patients for whom the Bi-Level breath
mode is a welcome ventilatory option are described in the
cases studies and the protocols contained within this paper.
These are intended only as sample applications of the Bi-Level
breath mode on the Puritan Bennett 840 Ventilator. There
are in all likelihood many other patients with different dis-
ease processes who may also benefit from this breath mode.
There are probably other protocols as well, developed based
on clinician preferences at the particular healthcare institu-
tion. There may even be approaches in the Bi-Level breath
mode that have yet to be identified. Clinicians will undoubt-
edly confer with their attending physicians to determine
which patients are good candidates for ventilation in the Bi-
Level breath mode.
 Keeping Up With Best Clinical Practices

Respiratory Care

Evidence-based medicine (EBM) is a growing topic of inter-

est for clinicians throughout the country. A range
of EBM topics is covered in the July 2004 issue of
Respiratory Care.6 In the issue’s foreword, Dr. Dean Hess
explores knowledge tree development and the clinical
practice paths that most clinicians have historically trod.
The issue includes, among others, articles on the definition
of EBM, a review of “newer” ventilation modes,
EBM and respiratory care protocols, EBM and ventilator
weaning and the 2003 Donald F. Egan Scientific Lecture on
clinical research and clinical practice in respiratory inten-
sive care.

About the author

Dr. Howell is a registered respiratory therapist and a freelance medical writer in the
Bay Area, with a particular interest in biomedical devices. He has received financial
support from Covidien in preparation of this manuscript.

11
References

1. Frawley PM, Habashi NM. Airway pressure release ventilation: Theory and practice. AACN Clinical Issues.
2001;12(2):234-236.

2. Rudis MI, Guslits BJ, Peterson EL, et al. Economic impact of prolonged motor weakness complicating neuro-
muscular blockade in the intensive care unit. Crit Care Med. 1996; 24:1749-1756.

3. http://www.ARDSNet.org

4. The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with
traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med.
2000;342:1301-1308.

5. The National Heart, Lung and Blood Institute ARDS Clinical Trials Network. Higher versus lower posi-
tive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med.
2004;351:327-36.

6. Hess DR, ed. 19th Annual New Horizons Symposium: Integrating evidence-based respiratory care into clini-
cal practice. Respir Care. 2003;49(7).

7. Branson RD, Johannigman JA. What is the evidence for newer ventilation modes? Respir Care.
2003;49(7):742-760.

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