Basic Mode

Maryana Binte Mohamed

Registered Nurse, BSc (Nursing)
Alexandra Campus

Slides courtesy of:

Lily Lai,
Clinical Specialist, Malaysia

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Objectives
•Define what is mode of ventilation

•State the breath characteristics and breath type

•Discuss the relationship between ventilation parameters

•Explain the basic modes of ventilation

•Summarise the advantages and disadvantages of each mode

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What is a Mode?
A ventilator mode is delivery a sequence of breath types and timing of
breath

▪ Breath sequence
➢ Mandatory
➢ Intermittent mandatory
➢ Spontaneous

▪ Breath type
Pressure or volume

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Breath characteristics

A. Trigger .......
What initiates a breath

B. Limit ......
What controls/limits it

C. Cycle.......
What ends a breath

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A. Trigger
What the ventilator senses to initiate a breath…

➢ Patient (Flow, Pressure)

➢ Machine (Time based)

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B. Limit
▪ Pressure Limit
• Pressure targeted, pressure limited – Ppeak set (PIP)
• Volume is variable

▪ Volume Limit
• Volume targeted, volume limited (Vt set)
• Pressure is variable

▪ Flow Limit
• Flow targeted, flow limited

▪ Dual Limit
• Volume targeted (guaranteed) and pressure limited

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Cycle
Determines the end of inspiration and the switch to expiration

▪ Machine cycling
• Time
• Pressure
• Volume

▪ Patient cycling
• Flow

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Breath type waveforms

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Relationship Between Parameters

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Modes of Ventilation

Mode of ventilation Breath types available

Volume Assist Control Volume Control, Volume Assist
Pressure Assist Control Pressure Control, Pressure Assist

Volume SIMV Volume Control, Volume Assist,

Pressure Support
Pressure SIMV Pressure Control, Pressure Assist,
Pressure Support
Pressure Support Pressure support

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 Volume Controlled Ventilation
▪ Machine delivers pre-set volume of gas into patient’s lungs

▪ Time/patient-triggered

▪ Flow-limited

▪ Volume-cycled

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Volume Control Ventilation
A. The increase airway
resistance causes the
PIP to increase

B. Decrease in lung
compliance (too stiff)
causes the entire
waveform to increase in
size

C. Increase lung
compliance (too flexible)
causes the peak
pressures to fall

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 Volume Cycle
Changes in pressure that occur in lung when using volume-cycled machine.
(A) ↓ compliance or ↑ airway resistance
(B) Normal compliance & airway resistance
(C) ↑ compliance or ↓ airway resistance

C B A
500
Volume in ml

20 25 30
Pressure in cm H2O
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Volume Control Breaths
How does Volume Control work?
Flow delivery is
determined by user
Flow

settings
Pressure
Airway

Pressure is generated by the

ventilator to push the set Tidal
Volume
PEEP
into the patient

Breath ends when the Inspiratory Time elapses/Tidal Volume has been delivered.

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Pressure Controlled Ventilation
▪ Delivers a pre-set pressure to the lungs

▪ Time/patient-triggered

▪ Pressure-limited

▪ Time-cycled

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 Pressure Control Breaths
How does Pressure Control work?
Flow delivery is a result of:
• Pressure change needed,
Flow

• Slope Rise setting,

• Patient effort,
• And patient pulmonary
mechanics.
Pressure
Airway

Pressure delivery is determined

by pressure change needed
PEEP
(difference between PC setting
and PEEP).
The PC setting is the pressure
change (above PEEP)

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 Rise Time /Slope Rise
▪ The rise time % setting allows you to adjust how quickly the ventilator
generates inspiratory pressure for pressure-based breaths that is,
spontaneous breaths with PS, PC mandatory

▪ The higher the value of rise time %, the more aggressive (and hence,
the more rapid) the rise of inspiratory pressure to the target.

▪ The rise time % setting only appears when pressure-based breaths are
available.

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 Pressure Control Breaths – Slope Rise

• The Slope Rise setting determines the rate of pressure rise to

the Pressure Control level.

PC setting
Pressure
Airway

PEEP

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Pressure Control Breaths – Slope Rise
Work of • A faster Slope-Rise with a squared pressure
Breathing waveform delivers a higher peak-flow and
higher machine assistance for the patient
at the onset of the breath.

• A slower Slope-Rise with a slanted

pressure waveform delivers a lower
peak-flow and less machine assistance
for the patient at the onset of the
breath.

Target
Pressure
Airway

Pressure

PEEP

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Slope Rise

Transient overshoot
Transient overshoot

Slow rise Moderate rise Fast rise

Pressure relief
Pressure relief

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 Pressure Control Breaths
How does a Pressure Control breath end?
Flow
Pressure
Airway

PEEP

The user set Inspiratory Time determines the duration of the breath

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Pressure Control :Inspiratory Time
Normal is about 0.8 – 1.2 secs in adults

▪ With lung pathology, different portions of the lung may take different
amounts of time to inflate;

➢ Setting a longer inspiratory time may help ensure all parts of the
lung ventilate adequately

➢ Must always allow sufficient time for exhalation to prevent gas

from being trapped inside the lung

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Setting inspiratory time

A longer inspiratory time

acts as a breath hold.

May be uncomfortable if it
happens on every breath

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Pressure Control Ventilation

A. Normal

B. Increase airway resistance

as marked by the decreased
expiratory flow rate and
increases expiratory time

C. Decrease compliance
marked by the high peak
expiratory flow and shortened
expiratory time due to greater
elastic recoil

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 VOLUME VS PRESSURE

Types Volume Control Pressure Control

Trigger Patient/machine Patient/machine
Limit Flow Pressure
Cycle Volume Time

Tidal Volume Constant Variable

Ppeak Variable Constant
Modes ACV/SIMV PCV/PSV/SIMV

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VOLUME VS PRESSURE
Vt

V'

0
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Pressure Support Ventilation
▪ Pressure support is defined as the application of a pre-set positive pressure
to a spontaneous inspiratory effort

▪ Patient-triggered

▪ Pressure-limited

▪ Flow-cycled

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 Pressure Support Breaths
How does Pressure Support work?
Delivery Flow delivery is a result of:
• Amount of pressure change needed
which is determined by the PS set
• Slope Rise setting,
Flow

• Expiratory Threshold setting,

• Patient effort

The amount of pressure change

Pressure
Airway

needed is determined by:

• The Pressure Support setting
(change = Pressure Support
PEEP
setting).

The Pressure Support setting is the

pressure change (above PEEP).

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Pressure Support Breaths
How does Pressure Support work?
100% of Peak End
Flow It ends by one of three
mechanisms:
Set from 5-85% of
Peak Flow 1. Flow delivery drops
Flow

to a user-set percent
of the peak flow.
Target Pressure + 3 cmH2O 2. Pressure rises 3
Target cmH2O/mbar above
Airway Pressure

Pressure
PS setting + the target pressure.
PEEP

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Pressure support ventilation
Patient trigger，flow cycle, pressure support
Flow Esens
L/m

Pressure
support
Pressure
cm H2O

Volum
e
mL Time (sec)
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Settings for PSV
Pressure support level

ESENS
The ESENS setting defines the percentage of the projected peak
inspiratory flow at which the ventilator cycles from inspiration to
exhalation.
When inspiratory flow falls to the level defined by ESENS,
exhalation begins. ESENS is active during every spontaneous
breath.

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Pressure Support – Esensitivity

The maximum flow delivered during the breath is

called the “Peak Flow”
Peak Flow
Expiratory Threshold = a % of Peak Flow
Flow

Inspiration Exhalation

When flow drops from the peak flow

to the % of peak flow set as the Time
Expiratory Threshold, the breath
cycles from inspiration to exhalation
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Pressure Support Breaths – Esens
If the Peak Flow is 100 L/min Example
Peak Flow = 100 L/min
Expiratory Threshold = 33%
Flow = 33 L/min
Flow

Inspiration Exhalation
And Expiratory Threshold is set at 33%

The breath will change from the inspiratory phase to

the expiratory phase when flow delivery to the patient
drops from 100 L/min down to 33 L/min

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 Definition of SIMV
Synchronised Intermittent Mandatory Ventilation

▪ Breath – Spontaneous, Assisted,

Mandatory

▪ Trigger – Patient, Time

▪ Limit – Volume, Flow, Pressure

▪ Cycle – Volume, Flow, Time

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SIMV
Volume Control

Flow
L/m

Pressure
cm H2O

Volum
e
mL
Spontaneous Breath

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SIMV
Pressure Control

Flow
(L/mi
n)
Set PC level
Pressure
(cm
H2O)

Volum
e Time
(ml) Spontaneous Breath (sec)

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Mode
Assist Control
Volume Control Ventilation
Pressure Control Ventilation
Pressure Support Ventilation
Synchronized Intermittent
Mandatory Ventilation
Summary
Advantages
Reduced work of breathing compared to
spontaneous breathing
Constant tidal volume (Vt)
Type of ventilation familiar to most clinician
Allows limitation of peak inspiratory pressures
Variable flow improves synchrony in
some patients
Variable flow may improve synchrony in some
Patients
Prevents respiratory muscle atrophy
Patient comfort, improved patient ventilator
interaction
Less interference with normal cardiovascular
function
Prevents respiratory muscle atrophy
Disadvantages
Potential adverse hemodynamic effects,
may lead to inappropriate hyperventilation
May lead to excessive inspiratory
pressures
Fixed inspiratory flow may cause
asynchrony
Potential hyper- or hypoventilation with
lung resistance/compliance changes
Requires spontaneous respiratory effort
Fatigue and tachypnea with PSV too low
Activation of expiratory muscles with PSV
too high
Asynchrony if rate set too low
Increased work of breathing compared to
AC
Summary

▪Knowledge of ventilation modes is only part of the management of

critically ill or injured patients.

▪Solid patient assessment, an understanding of the patient’s clinical

presentation, together with the appropriate mechanical ventilation, are
required to evaluate the effectiveness of each mode

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maryana_binte_mohamed@nuhs.edu.sg

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