Conquering the jungle of

ventilation modes

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

HAMILTON MEDICAL AG
Switzerland
2000
Early ventilators
The jungle of today

PSV
PAV
PCV

VAPS ASB
BIPAP
CMV SIMV 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. 3 (+PEEP)

criteria 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 (sine-
rectangular)
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

Time
Ttot
Start of inhalation: Patient trigger

Paw

Pressure trigger

Time
Flow Flow trigger

Time
Inspiration
Volume breath: Flow
Ideal

Pressure
Pressure breath: 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 Mechanical Ventilation or Continuous

Mandatory Ventilation (machine-triggered inspiration).

If triggered or synchronized (S), then also known as

Assist/Control (patient-triggered 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 Alveolar ventilation
f Alveolar ventilation, Gas trapping
I:E Gas distribution, Gas trapping
PEEP FRC, PaO2, Cardiac output
Pause 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 Controlled (mechanical) 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 vs. CMV

Flow

Pressure

Volume
 P-CMV

Pinsp Vt
f Alveolar ventilation, AutoPEEP
I:E Gas distribution, AutoPEEP
PEEP 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 hypo-
ventilation and air trapping (IRV), Ti needs to be tuned
to patient's needs.
SPONT
p. 301
 SPONT

A purely spontaneous mode.

Also known as Pressure Support Ventilation (PSV),

Continuous Spontaneous Ventilation, and Assisted
Spontaneous Breathing (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 Vt, f , WOB

CPAP/PEEP FRC, PaO2, Cardiac output
Trigger sens WOB
Pramp WOB, synchronization with patient
ETS 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).
Mode comparison summary

Trigger Breath delivery Cycle

CMV (A/C) t and p F t
SIMV t and p F and P t and F
SPONT p P F
PCV t and p P t

t: time F: Flow t: time

p: patient P: Pressure 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 PEEP FiO2

Ventilator
 Pressure-controlled ventilation
Chigh Clow
VT

Flow

Pressure
Adaptive Pressure Ventilation (APV)

Vt

Vt

Pinsp fmech Ti PEEP FiO2

Pinsp

Ventilator
Adaptive Pressure Ventilation (APV)

Vt

Vt

Pinsp fmech Ti PEEP FiO2

Ventilator
 Adaptive Pressure Ventilation (APV)

VT

Flow

Pressure
Minimal Minute Ventilation (MMV)

Vt ftotal

Vt ftotal

Pinsp fmech Ti PEEP FiO2

Pinsp fmech

Ventilator
Minimal Minute Ventilation (MMV)

Vt ftotal

Vt ftotal

Pinsp fmech Ti PEEP FiO2

Ventilator
Adaptive Support Ventilation

%MinVol

Vt ftotal

Pinsp fmech Ti PEEP FiO2

Pinsp fmech Ti

Ventilator
Adaptive Support Ventilation

%MinVol

Vt ftotal

Pinsp fmech Ti PEEP FiO2

Ventilator
Mode comparison (2)

# Controls # Pros # Cons

CMV 7 1 6
SIMV 10 2 4
SPONT 6 4 3
PCV 5 4 4
APV/MMV 5 3 2
ASV 3 (4*) 5 1

*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
p. 300
 SIMV

Synchronized Intermittent Mandatory Ventilation

Triggered variant of Intermittent Mandatory 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 Alveolar ventilation
f Alveolar ventilation, AutoPEEP
I:E Gas distribution, AutoPEEP
PEEP FRC, PaO2, Cardiac output
Pause Gas distribution
Pinsp Vt, WOB, f
Trigger sens WOB
Pramp WOB
ETS 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.
SIMV

Flow

Pressure

Volume
SPONT

Flow

Pressure

Volume
P-SIMV
 P-SIMV

Pressure-Controlled Synchronized Intermittent

Mandatory 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

Flow

Pressure

Volume
 P-SIMV

Pinsp Vt
f Alveolar ventilation, AutoPEEP
I:E Gas distribution, AutoPEEP
PEEP FRC, PaO2, Cardiac output
Pause ?
Psupp Vt, f, WOB
Trigger sens WOB
Pramp WOB
ETS 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.
FSIMPV
 "FSIMPV"

Fully Synchronized Intermittent Mandatory Pressure

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"

Flow

Pressure

Volume
 "FSIMPV "

Pinsp Vt, f, WOB

f Alveolar ventilation, AutoPEEP
I:E Gas distribution, AutoPEEP
PEEP FRC, PaO2, cardiac output
Trigger sens WOB
Pramp WOB
ETS Synchronization with patient

Green: Direct proportional effect

Red: Inverse proportional effect
 "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.

Mode comparison (1)

# Controls # Pros # Cons

CMV 7 1 6
SIMV 10 2 4
SPONT 6 4 3
PCV 7 4 4
(P)SIMV 10 4 2
FSIMPV 8 5 1
Mode comparison (2)
Trigger Breath delivery Cycle
CMV (A/C) t and p F t
SIMV t and p F and P t and F
SPONT p P F
PCV t and p P t
(P)SIMV t and p P t and F
FSIMPV t or p P t or F

t: time F: Flow t: time

p: patient P: Pressure F: Flow