DUAL CONTROLLED MODES OF

MECHANICAL VENTILATION

PROF DR UUR KOCA

Advantage of Volume control modes:

- Guarantee a preset tidal volume and minute ventilation

Advantage of Pressure control modes:

- The abilitiy to determine and maintain peak airway pressure and inspiratory
time

- The variable and decelerating inspiratory flow pattern

Dual control modes have been developed to provide the benefits of both volume
control and pressure control ventilation
Dual control modes are closed-loop systems that switch between pressure
control and volume control in a single breath or breath to breath on
measured patient characteristics

Dual control modes change the output (pressure) based on a measured input
(volume)

The dual-control modes can be patient-triggered or time-triggered, and flow-

cycled or time-cycled
I. Dual control within a breath modes
Volume-assured PS (VAPS): Bird 8400 STi, TBird, Avea
Pressure Augmentation (PA): Bear 1000
II. Dual control breath to breath modes
Pressure limited, Flow cycled:
Volume support (VSV): Servo 300
Variable PS: Venturi
Pressure limited, Time cycled :
Pressure Regulated Volume Control (PRVC): Servo 300
Autoflow: Evita 4
Variable Pressure Control: Venturi
Volume Control Plus: Puritan Bennett 840
Adaptive PS: Gallileo

III. Combination Modes

Adaptive Support ventilation: Gallileo
Automode: Servo 300
 Dual control within a breath
- Volume assured pressure support (VAPS)
- Pressure augmentation (PA)

The ventilator switches from PC or PS to VC during the inspiratory

phase of individual breaths based on the patients inspiratory effort
and ability to achieve the clinican set minimum tidal volume

This technique combines the high initial flow of pressure limited

breath with possibility of switching to constant flow (volume limited
breath).

The advantage of dual control with in a breath is reduced work of

breathing while maintaining a minimum guaranteed tidal volume and
minute ventilation.
 Dual control within a breath

Once the breath triggered (patient or time) the ventilator attempts to reach the
pressure support setting as quickly as possible. This portion of breath is the
pressure limited portion and associated with a high variable flow.

As the pressure support level is reached, the ventilator measures delivered flow and
volume and starts a continuous comparison between the volume that has been
delivered and the desired tidal volume.

If the delivered tidal volume and set tidal volume are equal, the breath is a pressure
support breath

If the delivered tidal volume remains greater than the set minimum, the ventilator
operates in the pressure support mode and makes no maniplations.
 Dual control within a breath

If the micropressor finds that the measured flow is inadequte to achieve the
set tidal volume in the set inspiratory time, inspiration continues according to
the peak flow setting until the set minimum tidal volume has been delivered;
that is the breath changes from pressure limited to volume limited.

In this situation, airway pressure will rise above the set pressure support level.
If inspiratory time longer than 3 seconds, breath will be automatically time
cycled.

Because of the airway pressure may rise above the set pressure support setting
during the volume limited portion of the breath, the high pressure alarm is
important.
 Dual control within a breath

Choosing the appropriate pressure and flow settings is critical

- If the pressure is set too high and minimum tidal volume is set low
all breaths will be pressure support breaths and minimum tidal
volume guarantee will be provided without any feedback operation.

- If the peak flow is set too low, the switch from pressure to volume
will occur late and inspiratory time may be prolonged.
 Dual control within a breath

PS setting

PS setting at a level equivalant to the plateau pressure obtained

during a volume control breath at a desired tidal volume can be
used

Peak flow setting

Peak flow should be adjusted to allow for the appropriate

inspiratory time and inspiratory to expiratory ratio required by
the patient
 Volum Assured PS
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Dual control breath to breath modes
Pressure limited, Flow cycled: Volume support (VSV),Variable PS

These modes are closed loop control of pressure support ventilation.

Tidal volume is used as a feedback control for continiously
adjusting the pressure support level.

The peak pressure is adjusted to ensure delivery of the target tidal

volume based on the compliance measured during the previous
breath.
 Dual control breath to breath modes ;Pressure limited, Flow cycled

VSV

A test breath is delivered with an inspiratory pressure of 10 cmH 2O above

PEEP and ventilator measures delivered tidal volume and calculates the
total system compliance. The following three breaths are delivered at a
peak pressure of 75% of the pressure that calculated to deliver the
minimum set tidal volume.

All breaths are patient triggered, pressure limited and flow cycled pressure
support breaths

The maximum pressure change breath to breath is 3 cmH2O and can range
from 0 cmH2O above PEEP to 5 cmH2O below high pressure alarm setting.
 Dual control breath to breath modes ;Pressure limited, Flow cycled

Respiratory frequency, inspiratory time and flow are determines by

the patient.

If inspiratory time exceeds 80% of the total cycle time a secondary

cycling mechanism is activated.

Decrease in patient respiratory frequency causes automatically

increase in the tidal volume target to maintain the minute volume
constant
 Dual control breath to breath modes ;Pressure limited, Flow cycled

Setting alarms for minute ventilation, high pressure and respiratory rate is

important for safely using these modes

Increases in pressure level to maintain the tidal volume may increase autoPEEP at

the patients who has airflow obstruction.

As the autoPEEP increases the same pressure results in a smaller tidal volume. In

this situation, the algorithym increases the pressure limit, increasing the

pressure worsens air trapping.

This vicious circle of increasing pressure support, worsening air trapping causes to

inability to trigger the ventilator. Decreasing in respiratory rate results in

further increase in tidal volume to maintain the same minute volume.

Dual control breath to breath modes ;Pressure limited, Flow cycled

In cases of hyperpnea ventialtor decreases pressure support. If

the cause of hyperpnea is increase in metabolic demand,
decreasing the pressure support level is opposite response.

The inability of all dual modes to distinguish between improved

pulmonary compliance abd increased patient effort (increased
metabolic demand)
Dual control breath to breath modes ;Pressure limited, Flow cycled

These modes allow automatic reduction of pressure support as lung

mechanics improve and patient effort increases

These modes can be used as a weaning mode by clinician reduction

of the target tidal volume

If the clinician sets minimum tidal volume greater than the patient
demand, the patient may remain at that level of support and
weaning may be delayed.
Dual control breath to breath modes: Pressure limited, Time cycled
Pressure Regulated Volume Control, Autoflow, Variable Pressure Control, Volume
Control Plus, Adaptive PS

These modes are closed loop control of pressure control ventilation.

The pressure limit is adjusted using the clinician set desired tidal
volum as the negative feedback control.

The primary advantage of these modes is reduction in peak

inspiratory pressure associated with a declerating flow pattern,
combined with the guaranteed delivery of minute volum.

These modes enable the ventilator to adjust inspiratory flow

according to patient flow demand combined with maintenance of
constant tidal volum.
 Dual control breath to breath modes: Pressure limited, Time cycled

All breaths in these modes are time or patient triggered, pressure

limited and time cycled.

These modes allow dual control breath to breath by using either

continuous mandatory ventilation or SIMV except PRVC that allows
continuous mandatory ventilation.

During SIMV the mandatory breaths are the dual control breaths
 Dual control breath to breath modes: Pressure limited, Time cycled

PRVC

The pressure limit fluctuates between 0 cmH2O above PEEP level to

5 cmH2O below the upper pressure alarm limit.

Upper pressure alarm limit is critic. If the desired tidal volum is not

delivered with the pressure of 5 cmH2O below the upper pressure

alarm limit, the ventilator will alarm.

Hipoventilation may occur if the desired tidal volume and maximum

pressure alarm limit settings are incompatible

Combination Modes
Adaptive Support ventilation, Automode

Automode

Automode designed for automated weaning from pressure control to

pressure support and for automated escalation of support if
patient efort diminishes below a selected threshold.

It combines volume support ventilation and PRVC into a single mode;

This mode provides a continuous weaning from pressure control to
pressure support or from volume control to volume support with
guaranteed tidal volum
 Combination Modes

Automode

The ventilator provides PRVC breaths if the patient is paralyzed. All breaths
are mandatory, time triggered, pressure limited and time cycled. The
pressure limit increases or decreases to maintain the desired tidal volum.

If the patient triggers 2 consecutive breaths, the ventilator switches to

volume support. In this case, all breaths are patient triggered, pressure
limited and flow cycled.

If the patient becomes apneic for 12 seconds (8 seconds for pediatric, 5

seconds for neonatal patient) the ventilator switches to PRVC.

The switches PRVC to VS are accomplished at equivalant peak pressure.

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