Newer Modes of
Mechanical Ventilation
Steven M. Donn, M.D.
Director, Neonatal-
Neonatal-Perinatal Medicine
Professor of Pediatrics
C.S. Mott Children’
Children’s Hospital
University of Michigan Health System
Ideal Mode of Ventilation
Delivers a breath that:
ƒ Synchronizes with the patient’
patient’s
spontaneous respiratory effort
ƒ Maintains adequate and consistent tidal
volume and minute ventilation at low
airway pressures
ƒ Responds to rapid changes in pulmonary
mechanics or patient demand
ƒ Provides the lowest possible WOB
Goals of Mechanical
Ventilation
ƒ Achieve and maintain adequate
pulmonary gas exchange
ƒ Minimize the risk of lung injury
ƒ Reduce patient work of breathing
ƒ Optimize patient comfort
Ideal Ventilator Design
ƒ Achieves all the important goals of
mechanical ventilation
ƒ Provides a variety of modes that can
ventilate even the most challenging
pulmonary diseases
ƒ Has monitoring capabilities to adequately
assess ventilator and patient performance
ƒ Has safety features and alarms that offer
lung protective strategies
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 A Brief Review IMV

ƒ How the modes interact with a

patient’
patient’s spontaneous effort:
IMV
SIMV
SIMV & PS
Assist Control
FSV
ƒ Pressure and Volume are no different.

IMV SIMV

IMV

SIMV SIMV & PS

SIMV

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 SIMV & PS Assist/Control

Assist/Control FSV

Flow Cycling or FSV Assist/Control:

Termination Sensitivity “Total Synchrony”
Flow
The patient starts and ends the breath:
Peak Flow (100%) ƒ The FSV breath is:
Flow triggered
Pressure limited
Flow cycled
ƒ Ventilator-
Ventilator- controlled parameters:
TS 5% PEEP, PIP, Flow
Time ƒ Patient-
Patient-determined parameters:
Set Tinsp (max.)
Rate, inspiratory time

Tinsp (eff.)

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 Benefits of FSV IMV vs. FSV

IMV FSV
ƒ Total breath synchronization V V
ƒ Decreased WOB
ƒ Less sedation
ƒ More efficient tidal volume delivery
ƒ Improved gas exchange
ƒ Fewer complications
P
P

Consequences of Classifying Ventilator

Asynchrony Modes

ƒ Fighting the ventilator

ƒ Inconsistent tidal volume delivery
ƒ Increased WOB
ƒ Inefficient gas exchange
ƒ Barotrauma, thoracic air leaks
ƒ Disturbances in cerebral perfusion
(IVH)

Classifying Modes What Starts the Breath?

of Ventilation
Trigger
ƒ A. Start ƒ Time (IMV) Signal
Trigger mechanism:
C ƒ Pressure
What starts the B
breath? ƒ Flow sensitivity

ƒ B. Limits ƒ Chest impedance

What is controlled ƒ Abdominal response time
and what is variable? A movement (trigger delay)
ƒ C. End
Cycle mechanism:
Time
What causes the
breath to end?

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 Which Parameters are What Ends the Breath?
Limited or Controlled? Cycling Mechanisms

ƒ Time
ƒ Pressure limited ƒ Volume
Pressure is controlled, ƒ Pressure
volume is variable ƒ Flow
ƒ Volume limited Assist/Control
Volume is controlled, Pressure support
pressure is variable

Neonatal Ventilation Intermittent Mandatory

Ventilation
„ Pressure Modalities
TCPL
Pressure Control
Pressure Support
„ Volume Modalities
Volume Targeted (Limited)
Volume Guarantee Patient Patient
Pressure Regulated Volume Control ( PRVC )
„ Combined
VAPS

Time-Cycled,
Pressure-Limited Disadvantages of TCPL
Ventilation
ƒ Variable tidal volumes based on lung
ƒ IMV or Assist/Control compliance
Proximal Airway
ƒ Continuous flow ƒ “Plateau” pressure - barotrauma (?)
Alveolar
ƒ Adjustable ( set )
inspiratory time or TS Pressure ƒ Continuous, high expiratory flow
ƒ Constant inspiratory ƒ Intermittent Mandatory Ventilation:
pressure
ƒ Easy to use
Flow
Patient / Ventilator Asynchrony

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 Pressure Control Benefits of Pressure
Ventilation Control Ventilation
ƒ Constant inspiratory ƒ Variable flow capability for patient demand
pressure Pressure
ƒ Decelerating, variable ƒ Reduced patient inspiratory muscle workload
inspiratory flow rate ƒ Lower peak inspiratory pressures
ƒ Better tolerance, less ƒ Adjustable inspiratory time
sedation necessary Flow
ƒ Time cycled: (A)
ƒ Rapid filling of the alveoli
Pressure Control ƒ Improved gas distribution, V/Q matching,
ƒ Flow cycled: (B) and oxygenation
Pressure Support
A B

Disadvantages of Pressure Control

Pressure Control Ventilation Ventilation
Pressure Volume
ƒ Delivered tidal volume is variable
and depends upon the patient’s lung
mechanics including changes in Flow
airway resistance and lung
compliance

ƒ May have adverse effects on volume

delivery A B
Pressure

Pressure Support A Comparison

TCPL PC PS
„ Generally a form of ventilation
that has no set rate and supports Limit P P P
a patient’
patient’s own spontaneous
effort
Flow
„ It is similar to Pressure Control Cont. Set Variable Variable
with the exception that the
breath ends because of a Ends (cycles)
Time Time
decrease in flow (flow cycling)
or Flow
Flow

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 Volume Ventilation Volume Ventilation

ƒ Constant flow rate Pressure

ƒ “Guaranteed” tidal
volume delivery
Leaks
Tubing compliance
Flow
ƒ Not affected by
lung impedance
ƒ Variable pressure

Advantages of Volume Ventilation

Volume Ventilation
Guaranteed tidal volume, not affected by • Stable, consistent tidal volume delivery
rapidly changing pulmonary mechanics: and minute ventilation, which is
↓ Compliance independent of patient’s lung mechanics,
Pressure Ventilation: Volume Ventilation: BUT:
Decreased Tidal Volume Increased Insp. Pressure
• Pressures variable and difficult to control
V V
• Resultant high peak pressure
• Slow rise to peak pressure, distribution of
ventilation may not be optimized
P P

Disadvantages of Flow Starvation

Volume Ventilation

ƒ Set flow rate may not match Pressure

patient’s demand
low set flow rates = small tidal volume
Flow
ƒ Increased muscle workload from
flow asynchrony, may compromise:
patient comfort
gas exchange
cardiac function

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Monitoring Ideal Monitoring Features

Proximal airway monitoring,

real-time pulmonary graphics:

ƒ Waveforms
ƒ Loops
ƒ Mechanics
ƒ Trending

The Importance of Examples

Proximal Monitoring
Infant
Am J Respir Crit Care Med, 162: 2109, 2000 ƒ Tubing compliance
of .75 cc/cm H2O
ƒ With infant circuits, tidal volume measured at ƒ PIP of 20 will lose 15 cc
the airway was only 56% of the tidal volume of tidal volume to the
monitored at the machine, from compressible tubing compliance
volume loss. ƒ If you measure 30 cc in
the system, only 15 cc
ƒ With pediatric circuits, correlation was slightly is actually being
better, as tidal volume measured at the airway delivered to the infant’s
was 73% of the tidal volume monitored at the lungs
machine. ƒ Loss of 50 %
Pediatric
ƒ Tubing compliance of
2.2 cc/cm H2O
ƒ PIP of 20 will lose 44 cc
of tidal volume to the
tubing compliance
ƒ If you measure 150 cc
in the system, 106 cc
is actually being
delivered to the infant’s
lungs
ƒ Loss of 29%

Clinicians Want the Best

of All Possible Worlds

„ Advantages of both pressure and

volume ventilation
„ “You can’
can’t always get what you
want,”
want,” (Rolling Stones), so…
so…get
what you need.
„ What’
What’s new?

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 Some of the Newer
Modalities Volume Guarantee
„ Volume Guarantee
Drä
Dräger Babylog Available on the Dräger Babylog
„ Pressure Regulated Volume ƒ Delivers a pressure targeted breath
Control and Volume Support at set inspiratory flow (fixed, not
Siemens 300 variable flow)
„ Volume Assured Pressure Support ƒ Based on previous breath, pressure
VIP BIRD Gold may increase or decrease to
“guarantee” targeted volume

Volume Guarantee Pressure Regulated

Volume Control
Limitations: Available on the Servo 300
ƒ Cannot increase pressure higher than set
pressure limit ƒ Variable, decelerating flow pattern
ƒ Requires a pressure plateau to guarantee volume, ƒ Breaths are time cycled, assist/control
which may require (wean in Volume Support)
Longer inspiratory time
Higher flows
ƒ Establishes a “learning period” to determine
ƒ Guarantees Expiratory Volume based on 8 breath patient’s compliance, which establishes
average regulation of pressure/volume
Variability in VT with leaks and mechanics ƒ During learning period, 4 test breaths of
changes from “catch up” increasing pressure are delivered.

Pressure Regulated
Volume Control (PRVC) PRVC

Limitations:
ƒ Inspiratory pressure is regulated based on
the Pressure/Volume calculation of the
previous breath, compared to a target ƒ Only an A/C mode and requires a
tidal volume
change to Volume Support for
ƒ The ventilator continuously adapts the
inspiratory pressure in responses to weaning
changing compliance and resistance to
maintain the target tidal volume
ƒ Only guarantees volume distally and
ƒ Results in breath-to-breath variation of
inspiratory pressure not at patient airway

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 Volume Assured
Pressure Support (VAPS)
Available on the VIP Gold
ƒ Ventilator delivers set pressure
ƒ If targeted volume is not delivered at this
pressure, breath continues to guarantee
volume
ƒ PIP and inspiratory time increase
ƒ Guarantees volume on current breath (no
previous breath averaging)
Characteristics of VAPS
ƒ The ventilator continuously measures the
flow and pressure and calculates delivered
volume
ƒ Does not lower pressure to wean patient
ƒ Can be used both in Assist/Control and
SIMV:
Pressure Support available in SIMV
Management of acute and recovering
lung disease
VAPS: Different Waveforms
Pressure
Flow
Volume
Assured
Volume Assured
Pressure Support
ƒ Combines the advantages of
pressure and volume ventilation
breath to breath.
ƒ Variable flow, volume ventilation
Decelerating, non-limited,
variable flow rate
Guaranteed tidal volume delivery
Characteristics of VAPS
Decision point is at the level of set flow:
ƒ If the target tidal volume has been delivered,
inspiration is terminated (flow cycled breath)
ƒ If preset tidal volume has not been achieved,
the set flow will persist until the desired
volume has been reached (volume cycled
breath)
ƒ Safety limits include high pressure and
maximum inspiratory time
ƒ Depending on the actual settings, the breath
may be flow, volume, or time cycled
Benefits of VAPS
ƒ Lower peak airway pressure
ƒ Reduced patient work of breathing
ƒ Improved gas distribution
ƒ Less need for sedation
ƒ Improved patient comfort
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 Applications of VAPS VAPS
ƒ A patient who requires a substantial level Limitations:
of ventilatory support and has a vigorous
ventilatory drive to improve gas
distribution and synchrony ƒ Will only increase pressure, not
lower pressure with changing
ƒ A patient being weaned from the mechanics
ventilator and having an unstable
ventilatory drive to supply a back-up tidal ƒ Increases inspiratory time to assure
volume as a “safety net” in case the volume (Adjustable VAPS time limit
patient’s effort or/and lung mechanics
available)
change

Conclusions Got Surfactant?

ƒ Newer forms of mechanical ventilation
combine the best of volume and pressure
ventilation.
ƒ These forms have been shown to reduce
work of breathing and improve patient
comfort. Long-term outcomes have yet to
be assessed.
ƒ Further studies are required to measure
the cost:benefit ratios, including
decreased ventilator days and decreased
hospital costs.

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