Evolution of ventilation modes

References made to Mosbys Respiratory Care Equipment, 6th Edition, 1999

HAMILTON MEDICAL AG
Switzerland
2000

Early ventilators

Historical account

before 1900: Different whole-body respirators

are being used for research purpose.
1832 Dr. John Dalziel, Scotland
1847 Ignez von Hauke, Austria

~1900
CPAP is invented. Thoracic surgery
demanded a device for lung-inflation purposes
to avoid problems with pneumothorax
~1930
US poliomyelitis causes EMERSON to
develop and produce his Iron Lung
~1940
IPPB devices are used for lung
inflation therapy and short term ventilation
~1950
Danish polio epidemic stimulated
start of more than 20 ventilator companies to
fill market need.

The jungle of today

PSV
PSV

PAV
PAV

PCV
PCV

BIPAP
BIPAP

CMV
CMV

ASB
ASB

VAPS
VAPS

SIMV
SIMV

APRV
APRV

Clinical objectives
Reverse hypoxemia

Reverse acute respiratory acidosis

Relieve respiratory distress
Prevent or reverse atelectasis
Reverse respiratory muscle fatigue
Permit sedation and/or neurom. blockade
Decrease systemic or myocard. O2 consumption
Reduce intracranial pressure
Stabilize chest wall

Physiological objectives
Alveolar ventilation
Arterial oxygenation (FiO2, FRC, V'A)
Respiratory pump support (WOB
manipulation)
Consensus conference on mechanical ventilation, Int Care
Med 1994, 20:64-79

Learning goals

Part 1: Conventional modes. Three (3)

criteria (+PEEP) to understand modes
Part 2: Combination modes and
adaptive modes

Part 1: Conventional modes

Old and new classifications
CMV
PCV
SPONT
SIMV

Old classifications
Based on:
Power source (motor, pneumatic,
circuit, fluidics)
Flow waveform produced (sinerectangular)
Start of inhalation (machine-initiated,
patient-triggered)

Proposed classification
Start of inhalation (triggering mechanism)
Gas delivery principle
Termination of inhalation (cycling
mechanism)
Maintenance of expiratory pressure level

Components of breath delivery

Flow

Time
Triggering Inspiration Cycling Expiration

Start of inhalation: Time trigger

Flow

Ttot

Time

Start of inhalation: Patient trigger

Paw

Pressure trigger

Flow

Time
Flow trigger

Time

Inspiration
Volume breath:

Flow
Ideal

Pressure breath:

Pressure
Pressure
Ideal

Flow

Cycling

Volume (Flow x Ti)

Pressure
Time (Ti)
Flow (ETS).......

Cycling with ETS

Flow

Time

Maintenance of expiratory pressure

Paw
PEEP

Time

Breath delivery principles (repetition)

Start of inhalation (triggering mechanism)
Gas delivery principle (flow/volume or pressure)
Termination of inhalation (cycling mechanism)
Maintenance of expiratory pressure level

CMV
p. 299

CMV

Controlled
ControlledMechanical
MechanicalVentilation
Ventilationor
orContinuous
Continuous
Mandatory
MandatoryVentilation
Ventilation(machine-triggered
(machine-triggeredinspiration).
inspiration).
IfIftriggered
triggeredor
orsynchronized
synchronized(S),
(S),then
thenalso
alsoknown
knownas
as
Assist/Control
Assist/Control(patient-triggered
(patient-triggeredinspiration).
inspiration).

CMV

Machine or patient-triggered
Gas delivery is flow-controlled (square, decelerating, etc.)
Time-cycled
Control settings are: tidal volume, respiratory rate, and I:E ratio. Other controls
include FiO2, PEEP/CPAP, flow pattern, and pause.

CMV
Flow

Pressure

Volume

CMV
Vt
f
I:E
PEEP
Pause

Alveolar ventilation
Alveolar ventilation, Gas trapping
Gas distribution, Gas trapping
FRC, PaO2, Cardiac output
Gas distribution

Flow pattern (square, accelerating, decelerating): ?

Green: Direct proportional effect
Red: Inverse proportional effect

CMV
Good starting point for inactive patients, minute
ventilation is guaranteed.

Uncomfortable for the patient, triggers only additional

mechanical breaths, possible barotrauma, choice of
inspiratory flow is difficult, difficult to set for active
patients, may increase WOB.

P-CMV
p. 301

P-CMV

Pressure
PressureControlled
Controlled(mechanical)
(mechanical)Ventilation
Ventilation

P-CMV

Machine- or patient-triggered (flow or pressure)

Gas delivery is pressure-controlled
Time-cycled
Control settings are: inspiratory pressure, respiratory rate, and I:E ratio.
Other controls include FiO2, PEEP/CPAP, pressure ramp, and trigger
sensitivity.

P-CMV
Flow

Pressure

Volume

vs.

CMV

P-CMV
Pinsp
f
I:E
PEEP

Vt
Alveolar ventilation, AutoPEEP
Gas distribution, AutoPEEP
FRC,PaO2, Cardiac output

Specialty:
PCV + IRV

AutoPEEP, PaO2

Green: Direct proportional effect

Red: Inverse proportional effect

P-CMV
Decreased peak airway pressures, improved alveolar
gas distribution, minimized regional overinflation
(barotrauma), inspiratory flow adapted to patient
demand

Minute ventilation not guaranteed, increased frequency

does not always lead to increased MV, possible hypoventilation and air trapping (IRV), Ti needs to be tuned
to patient's needs.

SPONT
p. 301

SPONT

AApurely
purelyspontaneous
spontaneousmode.
mode.
Also
Alsoknown
knownas
asPressure
PressureSupport
SupportVentilation
Ventilation(PSV),
(PSV),
Continuous
ContinuousSpontaneous
SpontaneousVentilation,
Ventilation,and
andAssisted
Assisted
Spontaneous
SpontaneousBreathing
Breathing(ASB).
(ASB).

SPONT
Patient-triggered (flow or pressure)
Gas delivery is pressure-controlled, with or without
dynamic compensation for pressure drop across the
tubes (ATC)
Flow-cycled (ETS)
Controls include pressure support level, CPAP, FiO2, flow/pressure
trigger, pressure ramp, and expiratory trigger sensitivity.

SPONT

Pinsp
CPAP/PEEP
Trigger sens
Pramp
ETS

Vt, f , WOB
FRC, PaO2, Cardiac output
WOB
WOB, synchronization with patient
Synchronization with patient

Green: Direct proportional effect

Red: Inverse proportional effect

SPONT
Most comfortable mode, easiest for patient to accept,
supports spontaneous activity, improves gas exchange
(V/Q matching).

Does not work in paralyzed patients. Minute ventilation

is not guaranteed! Pinsp needs to be carefully set
(clinically difficult).

SIMV
p. 300

SIMV

Synchronized
SynchronizedIntermittent
IntermittentMandatory
MandatoryVentilation
Ventilation
Triggered
Triggeredvariant
variantofofIntermittent
IntermittentMandatory
MandatoryVentilation.
Ventilation.

SIMV
Machine- and/or patient-triggered.
Gas delivery is flow-controlled (for mandatory
breaths, different waveforms) or pressure-controlled
(for spontaneous breaths).
Mandatory breaths are time-cycled; spontaneous
breaths are flow-cycled.
Control settings are: tidal volume, respiratory rate, I:E ratio, pressure
support, pressure ramp, and expiratory trigger sensitivity. Other
controls include FiO2, PEEP/CPAP, flow pattern, and pause.

SIMV
Vt
f
I:E
PEEP
Pause
Pinsp
Trigger sens
Pramp
ETS

Alveolar ventilation
Alveolar ventilation, AutoPEEP
Gas distribution, AutoPEEP
FRC, PaO2, Cardiac output
Gas distribution
Vt, WOB, f
WOB
WOB
Synchronization with patient

Green: Direct proportional effect

Red: Inverse proportional effect

SIMV
Better synchronized to the patient than CMV,
guarantees minimal minute ventilation.

Mandatory breaths are difficult to fine-tune: possible

barotrauma, choice of inspiratory flow is difficult, may
increase WOB. Complex mode since many parameters
must be set correctly.

FSIMPV

"FSIMPV"

Fully
FullySynchronized
SynchronizedIntermittent
IntermittentMandatory
MandatoryPressure
Pressure
Ventilation
Ventilation

"FSIMPV "
Machine- and/or patient-triggered.
Gas delivery is pressure-controlled for both
mandatory and spontaneous breaths. Pressure
levels are identical.
Mandatory breaths are time-cycled if they were NOT
triggered by the patient; spontaneous breaths are
flow-cycled.
Control settings are: inspiratory pressure, respiratory rate, I:E ratio,
pressure ramp, and expiratory trigger sensitivity. Other controls include
FiO2 and PEEP/CPAP.

"FSIMPV "
Pinsp
f
I:E
PEEP
Trigger sens
Pramp
ETS

Vt, f, WOB
Alveolar ventilation, AutoPEEP
Gas distribution, AutoPEEP
FRC, PaO2, cardiac output
WOB
WOB
Synchronization with patient

Green: Direct proportional effect

Red: Inverse proportional effect

Mode comparison (1)

CMV
SIMV
SPONT
PCV
(P)SIMV
FSIMPV

# Controls
77

# Pros
11

# Cons
66

10
10
66

22
44

44
33

77
10
10

44
44

44
22

88

55

11

Mode comparison (2)

Trigger

Breath delivery

Cycle

CMV (A/C)

t tand
andpp

FF

tt

SIMV

t tand
andpp

FFand
andPP
PP

t tand
andFF

SPONT

pp

PCV

t tand
andpp

(P)SIMV
FSIMPV

FF
tt

t tand
andpp

PP
PP

t tand
andFF

t tororpp

PP

t tororFF

t: time
p: patient

F: Flow
P: Pressure

t: time
F: Flow

Part 2: Combination and adaptive

modes
Pressure Regulated Volume Control
Volume Support
AutoFlow
Adaptive Pressure Ventilation (APV)
CMV+
Adaptive Support Ventilation (ASV)
All are pressure-based modes (gas delivery)

Pressure-controlled ventilation
Pinsp

fmech

Ti

Ventilator

PEEP

FiO2

Pressure-controlled ventilation
Chigh
VT

Flow

Pressure

Clow

Adaptive Pressure Ventilation (APV)

Vt

Vt

Pinsp
Pinsp

fmech

Ti

Ventilator

PEEP

FiO2

Adaptive Pressure Ventilation (APV)

Vt
Vt

Pinsp

fmech

Ti

Ventilator

PEEP

FiO2

Adaptive Pressure Ventilation (APV)

VT

Flow

Pressure

Minimal Minute Ventilation (MMV)

Vt

ftotal

Vt

ftotal

Pinsp
Pinsp

fmech
fmech

Ti

Ventilator

PEEP

FiO2

Minimal Minute Ventilation (MMV)

Vt

ftotal

Vt

ftotal

Pinsp

fmech

Ti

Ventilator

PEEP

FiO2

Adaptive Support Ventilation

%MinVol
Vt

ftotal

Pinsp
Pinsp

fmech
fmech

Ti

Ti

Ventilator

PEEP

FiO2

Adaptive Support Ventilation

%MinVol
Vt

ftotal

Pinsp

fmech

Ti

Ventilator

PEEP

FiO2

Mode comparison (3)

CMV

# Controls
77

# Pros
11

# Cons
66

10
10
66

22
44

44
33

55
55

44
33

44
22

33(4
(4*)*)

55

11

SIMV
SPONT
PCV
APV/MMV
ASV

*Ideal Body Weight

Appendix
Interrelation of timing parameters Ti, Te, Ttot, f, I:E
Flow, pressure, and volume patterns
SIMV
P-SIMV
FSIMPV
Mode comparison

Interrelation of timing variables

See box 9-29, p. 304

SIMV
Flow

Pressure

Volume

SPONT
Flow

Pressure

Volume

P-SIMV

P-SIMV

Pressure-Controlled
Pressure-ControlledSynchronized
SynchronizedIntermittent
Intermittent
Mandatory
MandatoryVentilation.
Ventilation.

P-SIMV
Machine- and/or patient-triggered.
Gas delivery is pressure-controlled for both
mandatory and spontaneous breaths. Pressure levels
can be different.
Mandatory breaths are time-cycled; spontaneous
breaths are flow-cycled.
Control settings are: inspiratory pressure, respiratory rate, I:E ratio,
pressure support, pressure ramp, and expiratory trigger sensitivity. Other
controls include FiO2 and PEEP/CPAP.

P-SIMV
Pinsp
f
I:E
PEEP
Pause
Psupp
Trigger sens
Pramp
ETS

Vt
Alveolar ventilation, AutoPEEP
Gas distribution, AutoPEEP
FRC, PaO2, Cardiac output
?
Vt, f, WOB
WOB
WOB
Synchronization with patient

Green: Direct proportional effect

Red: Inverse proportional effect

P-SIMV
Reduced peak airway pressures, improved alveolar
gas distribution, prevention of barotrauma, inspiratory
flow of mandatory breaths automatically adapted to
patients effort.

No guaranteed minute ventilation; machines

mandatory Ti must be set to coincide with the patients
Ti breath by breath.

P-SIMV
Flow

Pressure

Volume

"FSIMPV"
Flow

Pressure

Volume

"FSIMPV "
Machine perfectly synchronized to patient timing
(decreased WOB), decreased peak airway pressures,
improved alveolar gas distribution, prevention of
barotrauma, inspiratory flow automatically adapted to
patients effort.

No guaranteed minute ventilation.