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Ventilators for NIV: how to choose, matching to patient, basic set-up

Dr Bernd Schönhofer
Respiratory and Critical Care Medicine
Klinikum Hannover
Podbielskistrasse 380
30659 Hannover, Germany
Bernd_Schoenhofer@yahoo.com

Aims
Dealing with NIV, the aim of this presentation is to characterize different types of ventilators and to
illustrate criteria how to choose ventilators. Additionally matching the respirator to patient and the
basic set-up in acute and chronic respiratory failure will be focused on.

Summary
Non-invasive mechanical ventilation (NIV) has a long tradition for the treatment of chronic respiratory
failure and more recently has also been applied in acute respiratory failure (ARF). Based on this
experience, negative pressure and positive pressure, critical care ventilators and portable, volume
targeted and pressure targeted ventilators in spontaneous (i.e. assist), spontaneous/timed
(i.e.assist/controlled) and timed (i.e. controlled) modes are used to perform NIV. The individual choice
of ventilator type should depend on the patient’s condition, but also on the expertise of attending staff,
the therapeutic requirements and finally on the location of care.
Many years volume targeted ventilators predominantly were applied to treat CRF; in the past decade
pressure targeted ventilators are surpassing the former. The majority of studies dealing with ARF have
used pressure targeted ventilation in the assist mode. Positive qualities of pressure support ventilation
(PSV) are leak compensation, good patient-ventilator synchrony and the option of integrated positive
end expiratory pressure to counteract the effect of dynamic hyperinflation. In this article some crucial
issues concerning PSV (i.e. triggering into inspiration, pressurisation, cycling into expiration and
CO2-rebreathing) and some corrective measures are discussed. The parameters which should be
monitored during NIV are presented.

How to choose the ventilator


In general many factors determine the choice of the ventilator type (table 1). When initiating home
(also called “long term mechanical ventilation”, LTMV), one main aim is to choose the simplest
technology. However, modern home ventilators offer a broad array of sophisticated operations. The
choice of type of the home ventilator should involve the patient’s participation as well as including the
practitioner experience.
Two different types of ventilators are mainly used: volume targeted ventilators (VTV) and pressure
targeted ventilators (PTV). In home mechanical ventilation PTV has been increasingly used from the
late 1980s on, and in the passed decade even surpassed VTV as a treatment of chronic respiratory
failure (CRF).
Two different types of ventilators are used to perform NIV in acute respiratory failure (ARF) (table
2): Critical care (CC) ventilators, which are characterised by high technical quality and elaborated
monitoring, but also much simpler, smaller and less expensive portable ventilators, which often are
used in home mechanical ventilation. In a French epidemiologic survey 76% CC ventilators and 24%
portable ventilators were used to apply NIV in the treatment of ARF 1. The technical performance
regarding 7 variables of 9 portable home pressure ventilators in a lung model was compared to a CC
ventilator 2. It was found that most pressure ventilators evaluated were able to respond to high
ventilatory demands and even outperformed the CC device.

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Ventilator modes
Pressure targeted ventilation
Patients with ARF are often characterised by agitation, irregular breathing pattern and often
tachypnoea. They prefer ventilation modes which support spontaneous breathing. Compared to VTV
due to several significant advantages PTV are the preferred NIV devices in the treatment of ARF
(table 3). Accordingly, in the French epidemiologic survey ARF was treated in 67% with PSV with or
without positive endexpiratory pressure (PEEP), whereas in only 15% assist-control VTV were used 1.
PSV allows the patient to control inspiratory and expiratory times while providing a set pressure
which along with patient effort and respiratory mechanics determines the inspiratory flow and tidal
volume. Another positive quality of PSV is the improved patient-ventilator synchrony in terms of
triggering and cycle functions.
In order to compensate a significant leak a ventilator needs high flows. PTV have leak compensating
abilities with peak inspiratory flow rates of 120 – 180 L/min. However, based on a test lung model
recently it was found that leak compensating capabilities between six different devices differed
markedly 3. In volume targeted ventilators leak compensation is much more limited. Adding a leak to
the circuit of these ventilators caused a fall in tidal volume of more than 50% 4. Moderate leaks can be
compensated by increasing tidal volume.
The new generation of pressure targeted ventilators include higher maximal inspiratory pressure (up to
40 cm water), adjustable pressure rise time, adjustable minimum and maximum inspiratory times and
sophisticated monitoring and alarm systems. Especially in terms of efficacy and safety this new
generation has overcome the most concerns about the application of portable pressure ventilators as an
intervention in ARF. Some crucial issues of PSV and corrective measure are given in table 4. Failures
in the ventilator settings or other shortcomings may be perceived already during the adaptation period
in terms of insufficient improvement of gas exchange or adverse effects. During ventilation typical
problems may be persistent hypercapnia, hyoxemia, hypocapnia and air leaks. Table 5 deal with
possible causes and indicates some solutions.
COPD is characterised by dynamic hyperinflation and intrinsic PEEP which may cause patient-
ventilator asynchrony 5, 6 and consequent increase of work of breathing. PEEP, which is an integrated
option of PTV, is set to counteract the effect of intrinsic PEEP on ventilator triggering and therefore
increases the effect of the intervention and patient’s comfort. PEEP may also stabilize the upper
airway function during sleep, increase functional residual capacity or decrease micro- and
macroatelectasis.

Proportional assist ventilation (PAV)


PAV has recently be proposed as a mode of synchronized partial ventilatory support in which the
ventilator pressure output is proportional to instantaneous patient effort 7. In patients with ARF due to
COPD, it has been shown that PAV decreases the resistive load of breathing proportionally to the
degree of inspiratory muscle effort 8. Compared to PSV, the effect of PAV was equal in terms of
improvement in physiologic parameters, with even higher levels of comfort 9.

Volume targeted ventilation


During VTV the ventilator delivers a set tidal volume for each breath and inflation pressures may
vary. VTV may be preferred in patients with changing respiratory impedance in order to ensure a
certain tidal volume. The ventilators have a more elaborated alarm system, the capability to generate
higher positive pressures, and built-in backup batteries that power the ventilator for at least one hour.
Ideally, the volume provided by the ventilators should be constant. However, Lofaso et al found that
some volume targeted home ventilators are inaccurate in delivering the preset tidal volume, especially
when a high airway resistance was simulated 10. VTV have no integrated PEEP but interchangeable
PEEP valves can be added to the exhalation port.
Compared to PSV volume targeted ventilators are rarely used in ARF due to some important
disadvantages (table 3) and were only in one study exclusively applied 11. Mainly caused by high peak
mask pressures volume targeted modes cause more discomfort in terms of leaks, gastric distension,
pressure sores and skin necrosis.

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Control and assist-control mode
The combination of triggering spontaneous breathing and controlled mechanical ventilation is
available in volume targeted ventilators as the assist-control (A/C) mode, which is called
“spontaneous-timed” (ST) mode in pressure targeted ventilators. Here the ventilator setting allows for
spontaneous patient triggering and improves the patient-ventilator synchrony. The backup rate is
usually set at slightly below the spontaneous breathing rate.
Patients with CRF, who mostly are cooperative and often start NIV with an elective indication, are
optionally offered controlled ventilation modes, which has been rarely studied 12. In ARF the pure
control modes have been rarely applied. However, if they are used, the breathing frequency of the
ventilator must be set higher than the spontaneous breathing frequency to avoid spontaneous efforts.
Furthermore inspiratory and expiratory times are set. Volume or pressure targeted controlled modes
may be preferred in patients with unreliable respiratory effort, unstable ventilatory drive or mechanics,
apnoea and hypopneas, massive overloaded respiratory muscles and failure of pressure support modes
augmenting spontaneous breathing before endotracheal intubation.

Studies comparing ventilator modes


Comparisons between different modes in NIV are rarely done. However, studies have compared PSV
with VTV in A/C mode in patients with ARF. Table 6 highlights major points of these studies in
terms of patients’ comfort, and the efficacy of the intervention. No difference between modes were
found with respect to short-term physiologic end-points (i.e., gas exchange) 13-16. The A/C mode
resulted in a higher respiratory muscle rest. PSV was more comfortable and showed better leak
compensation 16.
In the chronic setting, several studies have been done to compare ventilator modes. In a short-term
study, Restrick et al found no difference in overnight oxygenation when patients with CRF used VTV
versus PTV, each for one night 17. Smith and Shneerson reported an improvement in diurnal blood gas
tensions compared to daytime in patients who switched from VTV to a PTV4. In a long-term case
series study we found that in a subpopulation of patients with clinically stable CRF, VTV may be
superior to PTV 12.

Ventilators with mixed volume and pressure targeted modes


In order to reach a greater variability of pressure and volume targeted modes, to bridge the distance
between them and to compensate for their specific limitations, recently new ventilators which combine
the 2 modes have been released 18. These respirators are similar to CC ventilators and may be useful
for difficult to adapt patients. Furthermore patients with rapidly changing breathing pattern and
breathing mechanics (such as intrinsic lung disease) may benefit from this kind of ventilators.
However, the clinical impact of these “dual ventilators” has not been well explored regarding the
treatment of ARF and therefore it is unknown if they offer important advantages to other respirators.

Synchronized intermittent mandatory ventilation (SIMV)


SIMV is still available in most VTV models. In SIMV, spontaneous breathing is possible in addition
to mandatory ventilation. Apart from recently developed ventilators in the older machines neither
demand nor continuous gas flow systems are available, i.e. the associated WOB during spontaneous
breathing is high 19. SIMV delivered by the latter should not be used any longer as a mode in LTMV.

How to adapt to and to set the ventilator

Practical Issues
In this chapter only respirator associated issues will be dealt with. Both in ARF and CRF adaptation to
NIV means to match the machine to the patient’s own pattern of breathing. Therefore asking the
following simple questions may be helpful: Are you getting a big enough breath ? Does the breath
lasts long enough ? Are the breaths coming too quickly ? Do you have enough time to breathe out ? Is
there enough time between the breaths ? Is the number of breaths adequate ?
Therefore in simple words every step should be explained to the patient in a calming manner. In order
to realize the most possible comfort and to reduce the probability of aspiration and gastro-esophageal
reflux the patient should be seated in an upright position (e.g., 45-60°). The duration of the first

27
continuous period of NIV depends on the well being and tolerance of the patient. Often it may be
helpful to interrupt the first period of NIV already after some minutes in order to get some feedback
and not to provoke an aversion against NIV. In case of dys-synchrony between patient and ventilator,
a short-term manual mask ventilation trial according to patients’ ventilator needs using an ambu-bag
may be helpful to induce acclimatization.

When NIV is started, the major aims are to reduce WOB and dyspnea. Regarding effectiveness of
mechanical ventilation, the physician must ensure an adequate inspiration in terms of pressure, volume
and timing. Normal tidal volume (VT) is about 5-9 mL/kg. Performing NIV with VTV the difference
compared to invasive mechanical ventilation is that a leak may cause a significant decrease in VT.
Therefore VT is set higher. VT about 10-15 mL/kg are large enough to compensate for leaks, resulting
in an effective, “leak compensated” VT of 5-9 mL/kg 20. With VTV in the controlled mode, the
inspiratory time is set directly (usually between 0.7 - 1.0 sec), or indirectly via peak inspiratory flow
rate which should be 40-60 L/min.

No scientific based data are available investigating the ideal peak inspiratory pressure. Concerning the
recommended pressure levels there is a tendency to set higher levels in some European countries
compared to USA. The fact that no patient could tolerate inspiratory pressures of higher than 15 cm
H2O in several US studies 21, 22 is in contrast to other studies, where pressures between 18 and 40 H2O
were applied 23-25. Also Bott et al used VTV in AC mode to treat ARF with peak inspiratory pressures
in excess of 30 cm H2O mostly without irritating patients 11. Independent of the applied time frame and
ventilator type compared to patients with neuromuscular diseases, in patients with chest wall disorders
and obesity hypoventilation (OHS) high levels of inspiratory pressure are chosen (up to 30 cm H2O
and sometimes even higher).

In more recently developed PTV respirators pressure rise time (i.e., the time to reach the preset
inspiratory pressure) can be set, in order to enhance patients’ comfort. In COPD, patients require a
rapid pressure rise time, e.g. 0.1 – 0.2 sec may be preferred. A relaxed patient, e.g. with NM, without
high ventilatory drive of breathing feels convenient with a slower rise time, e.g. 0.3-0.5 sec.

Monitoring during adaptation and follow up


What physiologic parameters should be monitored during both the acute adaptation to NIV ? In the
initial adaptation period, close observation of MV, synchrony between the ventilator and patient and
degree of activation of the accessory muscles is needed in order to correct shortcomings. The quality
of MV should be evaluated by blood gas analysis. The appropriate ventilator settings are based on the
PaCO2 and pH values as a surrogate of ventilation which should be measured about one hour after a
continuous period of NIV. During this initial period, effective MV should translate into a decrease of
PaCO2 by 5-10 mm Hg and associated increase of pH.

References

1. Carlucci A, Richard JC, Wysocki M et al. Noninvasive Versus Conventional Mechanical


Ventilation. An epidemiologic survey. Am. J. Respir. Crit. Care Med. 2001; 163:874-880
2. Bunburaphong T, Imanaka H, Nishimura M et al. Performance characteristics of bilevel
pressure ventilators: a lung model study. Chest 1997; 111:1050-1060
3. Mehta S, McCool FD, Hill NS. Leak compensation in positive pressure ventilators: a lung
model study. Eur Respir J 2001; 17:259-267
4. Smith IE, Shneerson J. Secondary failure of nasal intermittent positive pressure ventilation
using the Monnal D: Effects of changing ventilator. Thorax 1997; 52:89-91
5. Elliott MW, Mulvey DA, Moxham J et al. Inspiratory muscle effort during nasal intermittent
positive pressure ventilation in patients with chronic obstructive airways disease. Anaesthesia
1993; 48:8-13

28
6. Nava S, Bruschi C, Fracchia C et al. Patient-ventilator interaction and inspiratory effort during
pressure support ventilation in patients with different pathologies. Eur. Respir. J. 1997;
10:177-183
7. Younes M. Proportional assist ventilation, a new approach to ventilatory support. Theory. Am.
Rev. Respir. Dis. 1992; 145:114-120
8. Ranieri VM, Grasso S, Mascia L et al. Effects of proportional assist ventilation on inspiratory
muscle effort in patients with chronic obstructive pulmonary disease and acute respiratory
failure. Anesthesiology 1997; 86:79-91
9. Wysocki M, Richard JC, Meshaka MD. Nonivasive proportional assist ventilation compared
with noninvasive pressure support ventilation in hypercapnic acute respiratory failure. Crit.
Care Med. 2002; 30:323-329
10. Lofaso F, Fodil R, Lorino H et al. Inaccuracy of tidal volume delivered by home mechanical
ventilators. Eur Respir J 2000; 15:338-341
11. Bott J, Carroll MP, Conway JH et al. Randomised controlled trial of nasal ventilation in acute
ventilatory failure due to chronic obstructive airways disease. Lancet 1993; 341:1555-1557
12. Schonhofer B, Sonneborn M, Haidl P et al. Comparison of two different modes for
noninvasive mechanical ventilation in chronic respiratory failure: volume versus pressure
controlled device. Eur. Respir. J. 1997; 10:184-191
13. Meecham Jones DJ, Paul EA, Grahame-Clarke C et al. Nasal ventilation in acute
exacerbations of chronic obstructive pulmonary disease: effect of ventilator mode on arterial
blood gas tensions. Thorax 1994; 49:1222-1224
14. Navalesi P, Fanfulla F, Firgerio P et al. Physiologic evaluation of noninvasive mechanical
ventilation delivered with three types of masks in patients with chronic hypercapnic
respiratory failure. Crit. Care Med. 2000; 28:1785-1790
15. Vitacca M, Rubini F, Foglio K et al. Non-invasive modalities of positive pressure ventilation
improve the outcome of acute exacerbations in COLD patients. Intensive Care Med. 1993;
19:450-455
16. Girault C, Richard JC, Chevron V et al. Comparative physiologic effects of noninvasive
assist-control and pressure support ventilation in acute hypercapnic respiratory failure. Chest
1997; 111:1639-1648
17. Restrick LJ, Fox NC, Braid G et al. Comparison of nasal pressure support ventilation with
nasal intermittent positive pressure ventilation in patients with nocturnal hypovention. Eur
Respir J 1993; 6:364-370
18. Kacmarek RM, Hill NS. Ventilators for noninvasive positive pressure ventilation: technical
aspects. In: Muir JF, Ambrosino N, Simon AK, eds. Noninvasive mechanical ventilation. Vol.
6. Sheffield: European Respiratory Monograph, 2001; 76-105
19. Kacmarek RM, Stanek KS, McMahon KM. Imposed work of breathing during synchronized
intermittent mandatory ventilation provided by five home care ventilators. Respir care 1990;
35:405-414
20. Leger P, Jennequin J, Gerard M et al. Home positive pressure ventilation via nasal mask for
patients with neuromuscular weakness or restrictive lung and chest wall deformities. Respir
Care 1989; 34:73-77
21. Casanova C, Bartolome R, Celli R et al. Long-term controlled trial of nocturnal nasal postive
pressure ventilation in patients with severe COPD. Chest 2000:1582-1590
22. Lin CC. Comparison between nocturnal nasal positive pressure ventilation combined with
oxygen therapy and oxygen monotherapy in patients with severe COPD. Am. J. Respir. Crit.
Care Med. 1996; 154:353-358
23. Elliott MW, Simmonds AK, Carroll MP et al. Domicilliary nocturnal nasal intermittent
positive pressure ventilation in hypercapnic respiratory failure due to chronic obstructive lung
disease: effects on sleep and quality of life. Thorax 1992; 47:342-348
24. Meecham Jones DJ, Paul EA, Jones PW et al. Nasal pressure support ventilation plus oxygen
compared with oxygen therapy alone in hypercapnic COPD. Am. J. Respir. Crit. Care Med.
1995; 152:538-544
25. Ambrosino N, Nava S, Bertone P et al. Physiologic evaluation of pressure support ventilation
by nasal mask in patients with stable COPD. Chest 1992; 101:385-391

29
Additional references dealing with technical issues

Schönhofer B. Choice of ventilator types, modes, and settings for long-term ventilation. Respir Care
Clin 2002; 8: 419-445

Schönhofer B and Sorter-Leger, S: Equipment needs for non-invasive mechanical ventilation 2002,
Eur Respir J 2002; 20:1029-36

****

Underlying pathophysiology
Invasiveness and degree of ventilator dependency
Convenience
Comfort
Individual needs and preference of the patient
Presence of artificial airway
Age and compliance of the patient
External PEEP
Leak
Portability
Necessary supplies
Economy
Reliability
Local expertise
Staff familiarity

Tab. 1: Some important factors which influence the decision what kind of ventilator is chosen

Issues CC ventilator Portable ventilator

Technical aspects Higher technical quality Simpler technique


Monitoring, alarms Elaborated No
Specific issue Not all ventilators useful PSV responds to high ventilatory demands
in treatment of ARF See table 2

Table 2: Critical care (CC) ventilators versus portable ventilators, PSV: Pressure support
ventilation

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Issue PTV VTV
Level of applied volume medium high
Level of applied pressure Medium/high high
Noise low low
Weight medium high
Alarm rare yes
Handling easy medium
Price medium medium/ high
Internal battery rare usual
Comfort high medium
Amount of reduced WOB medium high
Amount of leak compensation high medium
Mucosal dryness medium low
CO2 rebreathing low no
Trigger sensitivity high medium
EPAP (external PEEP) option yes optional
Tachypnoe tolerance high low
Effect on progressing illness low medium
Table 3: Pressure targeted ventilators (PTV) versus volume targeted ventilators (VTV),
WOB: Work of breathing, PEEP: Positive endexpiratory pressure

Problem Potential cause Corrective measure


Inspiratory trigger 1. Air leak 1. Face mask
2. Autocycling, since trigger is 2. Reduction of trigger
set too sensitive sensitivity
3. Increased work of breathing 3. Flow trigger
due to pressure trigger
Pressurisation 1. Increase of inspiratory
1. Pressure rise time is too long
pressure
2. Pressure support too low 2. Reduction of pressure rise
time
Expiratory trigger 1. Air leak 1. Face mask
2. High endinspiratory flow 2.1. Increase of
endinspiratory flow threshold
2.2. Preset time limit of the
inspiration
CO2-rebreathing 1. Single circuit 2. Two lines
(No true exhalation valve) (Exhalation valve)
2. High respiratory rate 2. Lower respiratory rate
3. No PEEP 3. PEEP
Table 4: Some problems when PSV is applied and corrective measures

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Crucial issue Potential cause Troubleshooting
Hypercapnia* Pressure support, Vt, Increase one of more of theses
fb or volume is too parameters
low
Air leak# Change mask type
VTV: increase Vt
Change from VTV to PTV
CO2 - rebreathing CO2 - rebreathing valve,
external PEEP
Low compliance Increase care and education
Hypocapnia Vt, fb, minute Reduce one of more of theses
ventilation and/ or parameters
IPAP too high
Air leak Nasal mask, open See Air leak#
mouth
Hypoxemia With hypercapnia See Hypercapnia*
Without Hypercapnia:
Atelectasis or
Intrinsic lung disorder Increase of external PEEP O2
(gas exchange) supplemantation

Table 5: Troubleshooting of crucial issues of pressure support ventilation (PSV), tidal


volume (Vt), breathing frequency (fb)

A/C mode PSV


Comfort medium high
Gas exchange improved improved
Muscle rest high low
Leak compensation low high

Table 6: Comparison between A/C mode and PSV

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Slide 1 ___________________________________
Ventilators for NIV
How to choose, matching to patient, ___________________________________
basic set up
Bernd Schönhofer, MD, PhD
___________________________________
Respiratory and Critical Care Medicine
Klinikum Hannover ___________________________________
Germany

ERS school course ___________________________________


Noninvasive positive pressure ventilation: State of the art
Pisa, 10. June 2004
___________________________________
___________________________________

Slide 2 ___________________________________
Ventilators for NIV
___________________________________
How to choose ? ___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 3 The choice of NIV-ventilators depends on: ___________________________________


Diagnosis
Underlying pathophysiology ___________________________________
Acute respiratory failure
Weaning from respirator
Chronic respiratory failure ___________________________________
Dependency
Convenience ___________________________________
Comfort
Autonomy
Perceived benefit ___________________________________
Individual needs and preference of the
patient
Age and compliance of the patient
___________________________________
___________________________________

33
Slide 4 The choice of NIV-ventilators depends on (2): ___________________________________
Location
Local expertise ___________________________________
Staff familiarity
Training
Impact on nurse workload
___________________________________
Technical issues
External PEEP ___________________________________
Leak
Necessary supplies ___________________________________
Needs to follow-up
Handling
Portability ___________________________________
___________________________________

Slide 5 The choice of NIV-ventilators depends on (3): ___________________________________


Security issues
Alarms (on pressure, volume, frequency…) ___________________________________
Monitoring (TV, leak volume, frequency…)
Patient-circuit detection by ventilator ___________________________________
Battery supply

Kind of „arbitrary“ issues


___________________________________
Home-care provider
Hospital policy of technical department ___________________________________
Insurance politics
Availability
___________________________________
___________________________________

Slide 6 ___________________________________
Different techniques in NIV
___________________________________
• Negative and positive pressure
• Volume and pressure targeted ventilation ___________________________________
• Assisted and controlled mode
___________________________________
• Intensive care and home ventilators
___________________________________
___________________________________
___________________________________

34
Slide 7 Negative pressure ventilation ___________________________________
unloads respiratory muscles
___________________________________
___________________________________
Pes ___________________________________
Pmask

RC
___________________________________
EMG dia
Carrey, Chest 1990; 97: 150
___________________________________
___________________________________

Slide 8 Negative as effective as positive pressure ___________________________________


in teatment of acute on chronic respiratory
failure (CRF) in COPD patients ___________________________________
Corrado et al, Chest 2001; 121: 189
___________________________________
Group Patients Failure Deaths Intubation
NPV 53 11 (21%) 8 (15%) 5 (9,4%)
PPV 53 13 (25%) 9 (17%) 7 (13.2) ___________________________________
NPV: Negative pressure ventilation
PPV: Positive pressure ventilation
___________________________________
___________________________________
___________________________________

Slide 9 Volume (VTV) ___________________________________


and pressure targeted ventilation (PTV)
___________________________________
flow

___________________________________
___________________________________
volume

___________________________________

VTV PTV
___________________________________
___________________________________

35
Slide 10 VTV in CRF ___________________________________
First author, journal, year Diagnosis
Ellis et al, ARRD, 1987, Chest, 1988
Kerby et al, ARRD, 1987
RTD
RTD
___________________________________
Leger et al, Respir Care, 1989 RTD
Carroll et al, Thorax, 1988 RTD, COPD
Bach et al, Chest, 1987, 1990 NM ___________________________________
Heckmatt et al, Lancet 1990 RTD
Gay et al, Mayo Clin Proc, 1991 RTD, COPD
Goldstein et al, Chest 1991 RTD ___________________________________
Elliott et al, Thorax 1992 Miscell.
Piper, Sullivan, ERS, 1996 NM
Muir et al, AJRCCM, 1999 COPD ___________________________________
Restrictive thoracic disease: RTD
Neuromuscular disease: NM
Chronic obstructive disease: COPD
___________________________________
___________________________________

Slide 11 VTV in long term ventilation ___________________________________


in neuromuscular disorders
___________________________________
Taking into account that experience with
recently released pressure targeted
ventilation (PTV) continues to be limited, and
___________________________________
that only volume targeted ventilation VTV are
readily available for home mechanical ___________________________________
ventilation, there was consensus on generally
recommending the use of VTV in the assist ___________________________________
control and control mode.
Robert et al, Consensus conference, ERJ, 1993 ___________________________________
___________________________________

Slide 12 PTV surpasses VTV in home ventilation ___________________________________


Schönhofer, ERS Monograph, 2001, 259-273

100
[%]
___________________________________
90
80
70
60
___________________________________
50
40
30 ___________________________________
20
10
0 ___________________________________
1990 1992 1994 1996 1998 2000
Volume targeted ventilators
Pressure targeted ventilators (PTV) in spontaneous mode
PTV in controlled or assist-controlled mode
___________________________________
___________________________________

36
Slide 13 VTV vs PTV – advantages/disadvantages
___________________________________
Issue Pressure Volume ___________________________________
Amount of leak compensation high low
Trigger sensitivity high low/medium
EPAP (PEEP) option yes rare ___________________________________
Volume constance medium high
Level of applied pressure medium/high high
Comfort high low/medium ___________________________________
Amount of reduced WOB medium high
Long duration batteries rare yes
Alarms rare yes ___________________________________
Air stacking no yes
High breathing drive +++ +
___________________________________
___________________________________

Slide 14 VTV and PTV ___________________________________


according to diagnosis
___________________________________
Pressure Volume ___________________________________
COPD Neuromuscular
Obesity-Hypoventilation Chest wall deform
Hypovent. + OSA COPD
___________________________________
Neuromuscular OHS
Chest wall deform
___________________________________
___________________________________
___________________________________

Slide 15 Capacity to compensate for leak ___________________________________


Metha et al, ERJ, 2001: 17: 259

Leak +
___________________________________
VT % baseline

Leak +++ ___________________________________


___________________________________
___________________________________
___________________________________
___________________________________

37
Slide 16 In a subgroup of patients with CRF ___________________________________
VTV may be more effective than PTV
___________________________________
[mmHg]
PCO2
70

60
___________________________________
50

40
___________________________________
30
4 weeks VTV 4 months VTV ___________________________________
4 weeks PTV
Schönhofer et al, ERJ, 1997; 10: 184 ___________________________________
___________________________________

Slide 17 Assisted and controlled mode ___________________________________


• Spontaneous mode (S) ___________________________________
–Triggered by patient

• Spontaneous/ timed (S/T) ___________________________________


= Assist/control (A/C)
–Triggered by patient - or ventilator
___________________________________
• Timed (T) ___________________________________
= Controlled
–Triggered by ventilator ___________________________________
___________________________________

Slide 18 ___________________________________
A/C vs PSV
Girault C, et.al: Chest 111:1639, 1997 ___________________________________
ACV SB PSV
Paw, cmH2O 6.9 0.4 4.6
___________________________________
∆Pes, cmH2O 6.0 21.4 9.8
pEMGdi 60.5 100 67.5 ___________________________________
WOBinsp,J 0.38 0.85 0.52
Comfort, VAS (0-100) 57 75 82 ___________________________________
Acute on chronic RF, Nasal mask, n=15
___________________________________
___________________________________

38
Slide 19 ___________________________________
Portable- vs ICU- ventilators
Results from bench studies: ___________________________________
Comparative or even better bench study
triggering, pressurization, and cycling ___________________________________
between home ventilators and ICU
ventilators ___________________________________
Bunburaphong et al, Chest 1997;111:1050
Patel and Petrini, Chest. 1998;114:1390-6
___________________________________
Tassaux et al, Intensive Care Med. 2002; 28: 1254-61
Richard et al, ICM, 2002; 28: 1049 - 1057 ___________________________________
___________________________________

Slide 20 ___________________________________
ICU- versus portable ventilators
Portable ICU ventilators ___________________________________
Leak compensation +++ +
Inspiratory trigger +++ less sophisticated
Expiratory trigger problem
Alarms
seldom
vital indication
often
disturbing
___________________________________
Monitoring no (yes) yes
Oxygen blender
Handling
seldom
simple
yes
complex
___________________________________
Compactness yes no
Hosts
CO2 rebreathing
light
potentially
heavy
no
___________________________________
Helmet compatible difficult yes
___________________________________
___________________________________

Slide 21 ICU ventilators ___________________________________


22-bed MICU, University hospital, 1997-8
___________________________________
• Hypercapnic (41%); hypoxemic (29%);
weaning/post-extubation (29%); n = 143
• PSV 15 + 3 (69%) or A/CV 500cc + 5 (31%) ___________________________________
– Mode changed in 20% first 24h, saved ETT in
19/20
• Mask according to best fit: 81% oronasal
___________________________________
– Mask changed in 18% at some time
• Success: 64% ___________________________________
Girault C, et.al: Crit Care Med 31:552, 2003 ___________________________________
___________________________________

39
Slide 22 Bi-level portable ventilators
___________________________________

Technical options
___________________________________
Trigger ___________________________________
– Flow
– Pressure

Pressurization ___________________________________
Rise time
___________________________________
Inspiratory time
___________________________________
___________________________________

Slide 23 “Modern Bi-level” ventilation ___________________________________


Characterisation
___________________________________
Technical options
Flow trigger, more sensitive ___________________________________
Expiratory trigger
“Intelligent” alarms ___________________________________
Easy to handle
Monitoring capabilities
___________________________________
High FiO2
___________________________________
___________________________________

Slide 24 ___________________________________
What settings ?
___________________________________
___________________________________
___________________________________
Inspiration Switching Expiration
___________________________________
___________________________________
___________________________________

40
Slide 25 Flow vs Pressure trigger ___________________________________
- a matter of work of breathing
___________________________________

PTPes total (cm H2O x s)


20

15 ___________________________________
10
___________________________________
5

___________________________________
A/C PSV PSV
pressure Flow trigger Flow trigger
trigger at 1L/min at 5L/min
Nava et al, Thorax, 1997: 52: 249
___________________________________
___________________________________

Slide 26 Why not triggering ? ___________________________________


• Patient
– Reduced respiratory efforts
___________________________________
– Dynamic hyperinflation
– UAO ___________________________________
• Circuit
– Obstructed, e.g. HMEs ___________________________________
• Mask
– Leak ___________________________________
• Ventilator
– Trigger sensitivity is reduced ___________________________________
___________________________________

Slide 27 Effect of Inspiratory Positive Airway


___________________________________
Pressure (IPAP) ___________________________________
Pressure support = IPAP minus EPAP ___________________________________
Decreased WOB
Improved ventilation
___________________________________
Increased tidal volume
Decreased CO2 ___________________________________
Increased O2
___________________________________
___________________________________

41
Slide 28 Effect of Expiratory Positive Airway
___________________________________
Pressure (EPAP) ___________________________________
Counter autoPEEP ___________________________________
Raise FRC, recruit lung
___________________________________
Reduce preload and afterload
Limit dynamic airway collapse ___________________________________
___________________________________
___________________________________

Slide 29 NIV with PSV in ARF ___________________________________


How to set ?
___________________________________
• Meduri PEEP + PSV 10-20; full face
• Vitacca PEEP 5 + A/CV VT 12mL/kg; RR 15;
or PEEP 5 + PSV 14-22; full face
___________________________________
• Brochard PEEP 0 + PSV 20; full face
• Kramer PEEP 2.6 + PSV 11 (8 to start); nasal ___________________________________
• Antonelli PEEP 5.1+ PSV (to VT 8-10cc/kg)
___________________________________
• or fixed pressures (e.g. IPAP: 20, EPAP: 4), Plant
___________________________________
___________________________________

Slide 30 Set inspiratory pressure ___________________________________


Airway pressure [cm H2O]
IPAP: Peak inspiratory pressure ___________________________________
30 More rest ? Leak ?
Better ventilation quality ?
___________________________________
20

Slow increase up to 15-20


___________________________________
cmH2O (in most studies)
10
___________________________________
External PEEP, EPAP
___________________________________
___________________________________

42
Slide 31 ___________________________________
Inspiratory pressure reduces WOB
___________________________________
Inspiratory PSV [cm H2O] 12 20 p
Decrease of RR [1/min] 3 16 <0.05
___________________________________
Decrease of pCO2 4 21 <0.05
Decrease of Pdi 7.2 11.2 0.08 ___________________________________
Brochard L, et al, NEJM, 1990; 323: 1523-30
___________________________________
___________________________________
___________________________________

Slide 32 PEEP reduces WOB (PTPdi) in ___________________________________


patients with intrinsic PEEP
___________________________________
PTPdi (% of control)

80

60
___________________________________
40 ___________________________________
20

PS10 PS10 PS20 PS20


___________________________________
PEEP5 PEEP5

Nava et al, Chest, 1993; 103: 143 ___________________________________


___________________________________

Slide 33 Pressure rise time (PRT) ___________________________________


IPAP ___________________________________
___________________________________
EPAP
300 ms ___________________________________
• COPD patient need short PRT
___________________________________
• In patients with neuromuscular diseases or Obesity
Hypoventilation PRT tends to be longer
___________________________________
___________________________________

43
Slide 34 ___________________________________
Inspiratory time (Ti)
• Set by operator ___________________________________
– Based on respiratory rate during spontaneous
breathing ___________________________________
– Select I:E ratio
• In COPD: short inspiration (I:E, e.g. 1: 2.5)
• In Restriction: longer inspiration (I:E, e.g. 1:1.5) ___________________________________
• Calculation serve as guides
• Based on expiratory trigger ___________________________________
– Detect deceleration of flow at end of inspiration
___________________________________
___________________________________

Slide 35 ___________________________________
Set inspiratory time= time cycled
___________________________________
In case of cycling – problems
– Leakage
___________________________________
– Increased airway resistance
___________________________________
• Set inspiratory time window (“min/max”)
• Improves ventilator efficacy ___________________________________
___________________________________
___________________________________

Slide 36 Leakage causes failure of cycling into expiration ___________________________________


Time- vs Flow - Cycling
Flow cycled pressure support High flow due to leak ___________________________________
Timed
Flow
___________________________________
Timed
Pressure
___________________________________
Timed cycled ventilation

___________________________________
Calderini et al, ICM, 1999; 25: 662
___________________________________
___________________________________

44
Slide 37 Back–up frequency
___________________________________
___________________________________
• Set in ST- or A/C mode
• Indications ___________________________________
–Central apneas
___________________________________
–Low spontaneous fb during sleep

–Max muscle rest


___________________________________
___________________________________
___________________________________

Slide 38 Timed mode ___________________________________

• Set frequency slightly higher than ___________________________________


spontaneous breathing frequency
• Set I:E ratio
___________________________________
___________________________________
• Indications
– Ineffective triggering ___________________________________
– Max muscle rest
___________________________________
___________________________________

Slide 39 ___________________________________
Many open questions
RE technical issues ___________________________________
___________________________________

?
___________________________________
___________________________________
___________________________________
___________________________________

45
Slide 40 Impact of home ventilator failure
___________________________________
Srinivasan S.et al. Chest 1998;114:1363-67
87/150 patients required assistance
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 41 Performance issues ___________________________________


(Bench vs bed)
___________________________________
• Blower or piston efficiency
• Triggering optimum sensitivity ___________________________________
• Trigger delay
• CO2 rebreathing ___________________________________
• Humidification
• O2 entrainment ___________________________________
• Valve or outlet
• Tubing ___________________________________
___________________________________

Slide 42 Home care ventilators ___________________________________


• Inspiratory and expiratory tubing ___________________________________
• Inspiratory tube + expiratoty valves:
- diaphragm
- balloon
___________________________________
• Inspiratory tubes + “non-rebreathing” valves:
- Whisper Swivel®
___________________________________
- Plateau valve ®
- mask holes
___________________________________
___________________________________
___________________________________

46
Slide 43 ___________________________________
How To Start ?
___________________________________
Matching, Basic setting ___________________________________
___________________________________
Some practical issues
___________________________________
___________________________________
___________________________________

Slide 44 ___________________________________
Elective initiation of NIV
___________________________________
• Patient seated at about 45 degrees
• Apply mask briefly to face; reassure ___________________________________
• Then affix headgear
___________________________________
RE Interfaces, see separate presentation
___________________________________
___________________________________
___________________________________

Slide 45 Initiation of NIV in CRF ___________________________________


• Alarms off ___________________________________
• Low pressures
• Adjust PTV or VTV according to comfort
muscle rest and quality of ventilation ___________________________________
• Seek and correct leaks
• Assure patient-ventilator synchrony ___________________________________
• Sedate judiciously
___________________________________
___________________________________
___________________________________

47
Slide 46 Ask simple questions ___________________________________
• Tidal volumen
– Not enough, sufficient, too much ? ___________________________________
• Speed of air flow ___________________________________
– Too slow, adequate, too fast ?
___________________________________
• Breathing frequency
– Too low, adequate, too high ___________________________________
• Time to expiration
– Too short, adequate, too long
___________________________________
___________________________________

Slide 47 How to set the ventilator ? ___________________________________


Vitacca et al, Chest 2000
___________________________________
• Usual setting:
Maximal support, reducing PaCO2 < 5%
ePEEP progressively increased by 1 cmH2O at ___________________________________
patient’s comfort (</= 6 cm H2O)
___________________________________
• Physiologic setting
Decrease of transdiaphragmatic pressure (Pdi)
(i.e. 40-90% of spontaneous breathing)
___________________________________
Decrease iPEEP by ePEEP
(i.e. 50% of spontaneous breathing) ___________________________________
___________________________________

Slide 48 „Usual“ vs physiological setting ___________________________________


Vitacca et al, Chest, 2000; 118: 1286
___________________________________
Prevalence of
Reduction ineffective efforts,
[%]
0
of PEEPi Reduction of PTP i.e. triggering ___________________________________
-20

Physiol
___________________________________
-40

-60 Usual ___________________________________


-80

Compared with spontaneous breathing


___________________________________
___________________________________

48
Slide 49 ___________________________________
Initiation of NIV in ARF
___________________________________
• Inspiratory pressure: 20-30 mbar
• Expiratory pressure: 5-8 mbar ___________________________________
• Tidal volume: 5-7 ml/kg
– Aim at adequate ventilation ___________________________________
• Breathing frequency : Close to
spontaneous fb
___________________________________
• FiO2: SaO2 guided

___________________________________
___________________________________

Slide 50 Adjustment to the ventilator ___________________________________


Evaluation and monitoring
No single parameter, but the time course
___________________________________
of the diagnostic package determines the
decision: NIV or intubation ___________________________________
Comfort SaO2 PCO2 pH fb Vt Leak

___________________________________
___________________________________

Re- evaluation after 1-2 hours


___________________________________
___________________________________

Slide 51 NIV in ARF


___________________________________
– early failure and success
___________________________________
PCO2
[mmHg]
90
Non-
Responder ___________________________________
80

70 ___________________________________
60 Responder

___________________________________
Baseline 2 hr

Meduri et al, Chest, 1996 ___________________________________


___________________________________

49
Slide 52 ___________________________________
Troubleshooting (1)
Change
___________________________________
–Ventilator ___________________________________
–Mode
–Inspiratory pressure ___________________________________
–Breathing frequency
–I:E ratio ___________________________________
–In- expiratory trigger
___________________________________
___________________________________

Slide 53 Troubleshooting (2) ___________________________________


• Do not hyperventilate ___________________________________
– IPAP too high
• Aerophagia ___________________________________
• Glottis closure
• Expiratory muscle active during inspiration
• Asynchrony ___________________________________
• CO2 rebreathing ___________________________________
– EPAP too low
– Missing expiratory valve, outlet ___________________________________
___________________________________

50