New Modes of Mechanical Ventilation

Mazen Kherallah, MD, FCCP Consultant Intensivist King Faisal Specialist Hospital

Key Ideas for Understanding Mechanical Ventilation

1. Mathematical Models
Equation of motion Time constant Mean airway pressure

2. Control Variables
Pressure, volume, dual

3. Phase Variables
Trigger, Limit and Cycle

4. Breath Types/Patterns 5. Optimum Mode Selection

Lung Mechanics

resistance = (pressure / (flow

flow

transairway pressure transrespiratory pressure volume transthoracic pressure

elastance = (pressure / (volume

Equation of Motion
ventilation pressure =
(to deliver tidal volume)

resistive pressure
(to make air flow through the airways)

elastic pressure
(to inflate lungs and chest wall)

P = Presistive + Pelastance P= RxV + ExV

Phase Variables
Trigger (start)- begins inspiratory flow (start) Cycling (end)- ends inspiratory flow (end) Limiting (continue)- places a maximum value on a control (continue)variable
pressure volume flow time

Trigger VariableVariableStart of a Breath

Time - control ventilation Pressure - patient assisted Flow - patient assisted Volume - patient assisted Manual - operator control

Inspiratory - delivery limits

Maximum value that can be reached but will not end the breathbreath Volume Flow Pressure

End of Inspcycle mechanisms

The phase variable used to terminate inspirationinspiration Volume Pressure Flow Time

Breath Type Only Two (for now)!

Mandatory
Ventilator does the work Ventilator controls start and stop

Spontaneous
Patient takes on work Patient controls start and stop

The Control VariableVariableInspiratory Breath Delivery

Flow (volume) controlled
pressure may vary

Pressure controlled
flow and volume may vary

Time controlled (HFOV)

pressure, flow, volume may vary

Volume/Flow Control
Inspiration
20

Pressure Control
Inspiration
20

Expiration

Expiration

Paw

Pressure
0 20 1

Paw
2 0 0 20 1 2

Volume
0 3 0 1 2 0 3 0 1 2

Flow

Time (s)

Time (s)

-3

-3

Volume Control Breath Types

60

Paw
cmH20 -20 120

SEC

6
INSP

Flow
L/min

SEC

6
EXH

120

If compliance decreases the pressure increases to maintain the same Vt

New Modes of Ventilation

DualDual-Controlled Modes
Type
Dual control within a breath

Manufacturer; ventilator
VIASYS Healthcare; Bird 8400Sti and Tbird VIASYS Healthcare; Bear 1000 Siemens; servo 300 Cardiopulmonary corporation; Venturi Siemens; servo 300 Hamilton; Galileo Drager; Evita 4 Cardiopulmonary corporation; Venturi Hamilton; Galileo

Name
VolumeVolume-assured pressure support Pressure augmentation Volume support Variable pressure support PressurePressure-regulated volume control Adaptive pressure ventilation Autoflow Variable pressure control Adaptive support ventilation

Dual control breath to breath: PressurePressure-limited flow-cycled flowventilation Dual control breath to breath: PressurePressure-limited time-cycled timeventilation

Dual control breath to breath: SIMV

Dual Control within a Breath

volumevolume-assured pressure support
This mode allows a feedback loop based on the volume Switches even within a single breath from pressure control to volume control if minimum tidal volume has not been achieved

Bear 1000

Bird 8400Sti

Tbird

Dual Control within a Breath

volumevolume-assured pressure support The Respiratory Therapist sets :
pressure limit = plateau seen during VC respiratory rate peak flow rate (the flow if TV < target) PEEP FiO2 trigger sensitivity minimum tidal volume

40

Pressure limit overridden Set pressure limit

Paw
cmH20

-20 0.6

Volume
L

Set tidal volume cycle threshold Tidal volume Tidal volume not met met

0 60 Inspiratory flow greater than set flow

Flow cycle

Set flow limit

Inspiratory flow equals set flow

Flow
L/min

60

Switch from Pressure control to Volume/flow control

trigger
Pressure at Pressure support

no
flow= 25% peak

yes

delivered VT set VT

yes
Cycle off inspiration

no
Insp flow > Set flow

yes

no
Switch to flow control at peak flow setting

no yes
delivered VT = set VT

no

PAW <PSV setting

yes

Control logic for volume-assured pressure-support mode

Dual Control within a Breath

volumevolume-assured pressure support If pressure too high, all breaths are pressure-limited. If the peak flow setting is too high , all breaths will be volume-controlled If the pressure is set too high or the minimum tidal volume is set too low; the volume guarantee is negated If peak flow set too low, the switch from pressure to volume is late in the breath, inspiratory time is too long.

Dual Control within a Breath

volumevolume-assured pressure support Amato et al Chest 1992;102: 1225-1234 Compared VAPS to simple AC volume
Lower WOB Lower Raw Less PEEPi

Dual Control Breath-to-Breath Breath-topressure-limited flow-cycled ventilation pressureflowVolume Support Tidal volume is used as feedback control to adjust the pressure support level All breaths are patient triggered, pressure limited, and flow-cycled. flow Automatic weaning of pressure support as long as tidal volume matches minimum required VT (VT set in a feedback loop to adjust pressure).

Dual Control Breath-to-Breath Breath-topressure-limited flow-cycled ventilation pressureflowVolume Support

Servo 300

Maquet Servo-i

VS vs VAPS
How does volume support differ from VAPS ?
In volume support, we are trying to adjust pressure so that, within a few breaths, desired VT is reached. In VAPS, we are aiming for desired VT tacked on to the end of a breath if a pressurelimited breath is going to fail to achieve VT

VS (Volume Support)
Entirely a spontaneous mode Delivers a patient triggered (pressure or flow), pressure targeted, flow cycled breath
Can also be timed cycled (if TI is extended for some reason) or pressure cycled (if pressure rises too high).

Similar to pressure support except VS also targets set VT. It adjusts pressure (up or down) to achieve the set volume (the maximum pressure change is < 3 cm H2O and ranges from 0 cm H2O to 5 cm H2O below the high pressure alarm setting Used for patients ready to be weaned from the ventilator and for patients who cannot do all the WOB but who are breathing spontaneously

VS (Volume Support)

(1), VS test breath (5 cm H2O); (2), pressure is increased slowly until target volume is achieved; (3), maximum available pressure is 5 cm H2O below upper pressure limit; (4), VT higher than set VT delivered results in lower pressure; (5), patient can trigger breath; (6) if apnea alarm is detected, ventilator switches to PRVC

yes

Calculate new Pressure limit

no

Volume from Ventilator= Set tidal volume

calculate compliance

trigger

Pressure limit Based on VT/C

Flow= 5% of Peak flow

yes

cycle off

no

Control logic for volume support mode of the servo 300

Dual Control Breath-to-Breath Breath-topressure-limited flow-cycled ventilation pressureflowVolume Support Little data to show it actually works. If pressure support level increases to maintain TV in pt with increased airways resistance, PEEPi may increase. If minimum TV set too high, weaning may be delayed.

VS (Volume Support)
Indications
Spontaneous breathing patient who require minimum E Patients who have inspiratory effort who need adaptive support Patients who are asynchronous with the ventilator Used for patient who are ready to wean

VS (Volume Support)
Advantages
Guaranteed VT and E Pressure supported breaths using the lowest required pressure Decreases the patients spontaneous respiratory rate Decreases patient WOB Allows patient control of I:E time Breath by breath analysis Variable I to meet the patients demand

VS (Volume Support)
Disadvantages
Spontaneous ventilation required VT selected may be too large or small for patient Varying mean airway pressure Auto-PEEP may affect proper functioning Auto A sudden increase in respiratory rate and demand may result in a decrease in ventilator support

Dual Control Breath-to-Breath Breath-topressure-limited time-cycled ventilation pressuretimePressure Regulated Volume Control

Servo 300

Maquet Servo-i

Dual Control Breath-to-Breath Breath-topressure-limited time-cycled ventilation pressuretimePressure Regulated Volume Control Delivers patient or timed triggered, pressure-targeted pressure(controlled) and time-cycled breaths time Ventilator measures VT delivered with VT set on the controls. If delivered VT is less or more, ventilator increases or decreases pressure delivered until set VT and delivered VT are equal

Dual Control Breath-to-Breath Breath-topressure-limited time-cycled ventilation pressuretimePressure Regulated Volume Control

The ventilator will not allow delivered pressure to rise higher than 5 cm H2O below set upper pressure limit
Example: If upper pressure limit is set to 35 cm H2O and
the ventilator requires more than 30 cm H2O to deliver a targeted VT of 500 mL, an alarm will sound alerting the clinician that too much pressure is being required to deliver set volume (may be due to bronchospasm, secretions, changes in CL, etc.)

PRVC (Pressure Regulated Volume Control)

PRVC. (1), Test breath (5 cm H2O); (2) pressure is increased to deliver set volume; (3), maximum available pressure; (4), breath delivered at preset E, at preset f, and during preset TI; (5), when VT corresponds to set value, pressure remains constant; (6), if preset volume increases, pressure decreases; the ventilator continually monitors and adapts to the patients needs

yes

Calculate new Pressure limit

no

Volume from Ventilator= Set tidal volume

calculate compliance

trigger

Pressure limit Based on VT/C

time= set Inspiratory time

yes

cycle off

no

Control logic for pressure-regulated volume control and autoflow

PRVC (Pressure Regulated Volume Control)

Disadvantages and Risks
Varying mean airway pressure May cause or worsen auto-PEEP auto When patient demand is increased, pressure level may diminish when support is needed May be tolerated poorly in awake non-sedated nonpatients A sudden increase in respiratory rate and demand may result in a decrease in ventilator support

PRVC (Pressure Regulated Volume Control)

Indications
Patient who require the lowest possible pressure and a guaranteed consistent VT ALI/ARDS Patients requiring high and/or variable I Patient with the possibility of CL or Raw changes

PRVC (Pressure Regulated Volume Control)

Advantages
Maintains a minimum PIP Guaranteed VT and E Patient has very little WOB requirement Allows patient control of respiratory rate and Variable E to meet patient demand Decelerating flow waveform for improved gas distribution Breath by breath analysis

A New Twist Volume Targeted

60

Paw
cmH20 -20 120

SEC

6
INSP

Flow
L/min

SEC

6
EXH

120

Many Dual Modes start out looking like PCV

Volume Targeted (Pressure Controlled)

60

Paw
cmH20 -20 120

SEC

6
INSP

Flow
L/min

SEC

6
EXH

120

As compliance changes - flow and volumes change

New Volume Targeted Breath Pressure Variability is Controlled

60

Paw
cmH20 -20 120

SEC

6
INSP

Flow
L/min

SEC

6
EXH

120

Pressure then raises to assure that the set tidal volume is delivered

Dual Control Breath-to-Breath Breath-toadaptive support ventilation

ASV (Adaptive Support Ventilation)

A dual control mode that uses pressure ventilation (both PC and PSV) to maintain a set minimum E (volume target) using the least required settings for minimal WOB depending on the patients condition and effort
It automatically adapts to patient demand by increasing or decreasing support, depending on the patients elastic and resistive loads

ASV (Adaptive Support Ventilation)

The clinician enters the patients IBW, which allows the ventilators algorithm to choose a required E. The ventilator then delivers 100 mL/min/kg. A series of test breaths measures the system C, resistance and autoauto-PEEP If no spontaneous effort occurs, the ventilator determines the appropriate respiratory rate, VT, and pressure limit delivered for the mandatory breaths I:E ratio and TI of the mandatory breaths are continually being optimized by the ventilator to prevent auto-PEEP autoIf the patient begins having spontaneous breaths, the number of mandatory breaths decrease and the ventilator switches to PS at the same pressure level Pressure limits for both mandatory and spontaneous breaths are always being automatically adjusted to meet the E target

ASV (Adaptive Support Ventilation)

Indications
Full or partial ventilatory support Patients requiring a lowest possible PIP and a guaranteed VT ALI/ARDS Patient requiring high and/or variable Patients not breathing spontaneously and not triggering the ventilator Patient with the possibility of work land changes (CL and Raw) Facilitates weaning

ASV (Adaptive Support Ventilation)

Advantages
Guaranteed VT and E Minimal patient WOB Ventilator adapts to the patient Weaning is done automatically and continuously Variable to meet patient demand Decelerating flow waveform for improved gas distribution Breath by breath analysis

ASV (Adaptive Support Ventilation)

Disadvantages and Risks
Inability to recognize and adjust to changes in alveolar VD Possible respiratory muscle atrophy Varying mean airway pressure In patients with COPD, a longer TE may be required A sudden increase in respiratory rate and demand may result in a decrease in ventilator support

Automode
The ventilator switch between mandatory and spontaneous breathing modes Combines volume support (VS) and pressure-regulated pressurevolume control (PRVC) If patient is paralyzed; the ventilator will provide PRVC. All breaths are mandatory that are ventilator triggered, pressure controlled and time cycled; the pressure is adjusted to maintain the set tidal volume. If the patient breathes spontaneously for two consecutive breaths, the ventilator switches to VS. All breaths are patient triggered, pressure limited, and flow cycled. If the patient becomes apneic for 12 seconds; the ventilator switches back to PRVC

MMV (Mandatory Minute Ventilation)

AKA: Minimum Minute Ventilation or Augmented minute ventilation Operator sets a minimum E which usually is 70% 90% of patients current E. The ventilator provides whatever part of the E that the patient is unable to accomplish. This accomplished by increasing the breath rate or the preset pressure. It is a form of PSV where the PS level is not set, but rather variable according to the patients need

MMV (Mandatory Minute Ventilation)

Indications
Any patient who is spontaneously and is deemed ready to wean Patients with unstable ventilatory drive

Advantages
Full to partial ventilatory support Allows spontaneous ventilation with safety net Patients E remains stable Prevents hypoventilation

MMV (Mandatory Minute Ventilation)

Disadvantages
An adequate E may not equal sufficient A (e.g., rapid shallow breathing) The high rate alarm must be set low enough to alert clinician of rapid shallow breathing Variable mean airway pressure An inadequate set E (>spontaneous E) can lead to inadequate support and patient fatigue An excessive set E (>spontaneous E) with no spontaneous breathing can lead to total support

PAV (Proportional Assist Ventilation)

Provides pressure, flow assist, and volume assist in proportion to the patients spontaneous effort, the greater the patients effort, the higher the flow, volume, and pressure
The operator sets the ventilators volume and flow assist at approximately 80% of patients elastance and resistance. The ventilator then generates proportional flow and volume assist to augment the patients own effort
Drager Evita 4

PAV (Proportional Assist Ventilation)

Indications
Patients who have WOB problems associated with worsening lung characteristics Asynchronous patients who are stable and have an inspiratory effort Ventilator-dependent patients with COPD VentilatorDrager Evita 4

PAV (Proportional Assist Ventilation)

Advantages
The patient controls the ventilatory variables ( I, PIP, TI, TE, VT) Trends the changes of ventilatory effort over time When used with CPAP, inspiratory muscle work is near that of a normal subject and may decrease or prevent muscle atrophy Lowers airway pressure

Drager Evita 4

PAV (Proportional Assist Ventilation)

Disadvantages
Patient must have an adequate spontaneous respiratory drive Variable VT and/or PIP Correct determination of CL and Raw is essential (difficult). Both under and over estimates of CL and Raw during ventilator setup may significantly impair proper patientpatientventilator interaction, which may cause excessive assist (Runaway) the pressure output from the ventilator can exceed the pressure needed to overcome the system impedance (CL and Raw) Air leak could cause excessive assist or automatic cycling Trigger effort may increase with auto-PEEP auto-

BiLevels

What is BiLevel Ventilation?

Is a spontaneous breathing mode in which two levels of pressure and hi/low are set Enabled utilizing an active exhalation valve Substantial improvements for spontaneous breathing
better synchronization, more options for supporting spontaneous breathing, and potential for improved monitoring

BiLevel Ventilation
Spontaneous Breaths 60 Spontaneous Breaths Synchronized Transitions

Paw
cmH20

1
-20

What is BiLevel Ventilation?

At either pressure level the patient can breathe spontaneously
spontaneous breaths may be supported by PS if PS is set higher than PEEPH, PS supports spontaneous breath at upper pressure

BiLevel Ventilation
PEEPHigh + PS Pressure Support

60

PEEPH

Paw
cmH20

PEEPL

1
-20

Then What Is APRV?

Is a Bi-level form of ventilation with sudden short Bireleases in pressure to rapidly reduce FRC and allow for ventilation Can work in spontaneous or apneic patients APRV is similar but utilizes a very short expiratory time for PRESSURE RELEASE
this short time at low pressure allows for ventilation

APRV always implies an inverse I:E ratio All spontaneous breathing is done at upper pressure level

APRV (Airway Pressure Release Ventilation)

Provides two levels of CPAP and allows spontaneous breathing at both levels when spontaneous effort is present Both pressure levels are time triggered and time cycled

APRV (Airway Pressure Release Ventilation)

Allows spontaneously breathing patients to breathe at a high CPAP level, but drops briefly (approximately 1 second) and periodically to allow CPAP level for extra CO2 elimination (airway pressure release) Mandatory breaths occur when the pressure limit rises from the lower CPAP to the higher CPAP level

APRV (Airway Pressure Release Ventilation)

Indications
Partial to full ventilatory support Patients with ALI/ARDS Patients with refractory hypoxemia due to collapsed alveoli Patients with massive atelectasis May use with mild or no lung disease

APRV (Airway Pressure Release Ventilation)

Advantages
Allows inverse ratio ventilation (IRV) with or without spontaneous breathing (less need for sedation or paralysis) Improves patient-ventilator synchrony if spontaneous patientbreathing is present Improves mean airway pressure Improves oxygenation by stabilizing collapsed alveoli Allows patients to breath spontaneously while continuing lung recruitment Lowers PIP May decrease physiologic deadspace

APRV (Airway Pressure Release Ventilation)

Disadvantages and Risks
Variable VT Could be harmful to patients with high expiratory resistance (i.e., COPD or asthma) Auto-PEEP is usually present Auto Caution should be used with hemodynamically unstable patients Asynchrony can occur is spontaneous breaths are out of sync with release time Requires the presence of an active exhalation valve

Airway Pressure Release Ventilation

Spontaneous Breaths 60

Paw
cmH20

Releases

1
-20

Modes of Ventilation
Questions?