“Assist-Control

Ventilation versus
Pressure Support
Ventilation on Sleep
Quality in Mechanically
Ventilated Patients”

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Abstract

A retrospective research was conducted with the title of, “Assist-

Control Ventilation versus Pressure Support Ventilation on Sleep Quality in
Mechanically Ventilated Patients”. This is to compare the influence of 2
Ventilatory Modes for the increased understanding of the role of patient-
ventilator asynchrony in the etiology of sleep disruption. Furthermore, this
determines whether
optimizing patient-ventilator interactions by using proportional
assist ventilation improves sleep.

Introduction

Mechanical ventilation is used primarily to improve gas exchange and

achieve respiratory muscle rest. To achieve this goal, it is important that a patient
does not make respiratory efforts out of synchrony with the cycling of the
ventilator. Since a behavioural stimulus is decreased during sleep,
respiratory muscle rest might be greater during sleep as compared with
wakefulness. The operation of a ventilator, however, including its alarms, may
disrupt sleep. Although disruptions of sleep may adversely affect critically ill
patients, little information is available about the interplay between patient–
ventilator synchrony and sleep. Studies of healthy volunteers and animals
suggest that sleep disruption could result in negative energy balance, reduced
host immunity, and decreased ventilatory responses to hypoxemia and
hypercapnia. These deleterious effects might prolong the duration of mechanical
ventilation in critically ill patients.

Mechanically ventilated patients arouse repeatedly from sleep. In patients

free of critical illness, arousals can result from a derangement of arterial blood
gases or an increase in respiratory effort, and both are common occurrences in
critically ill patients. Patient–ventilator dysynchrony or a particular ventilator mode
might also lead to sleep disruption. Pressure support predisposes to an abnormal
breathing pattern, specifically central apneas with consequent hyperpnea.
Healthy subjects develop central apneas during pressure support when their
carbon dioxide tension (PCO2) decreases by a few torr below the apnea
threshold. Whether pressure support causes apneas in critically ill patients and
whether the apneas lead to disruption of sleep are unknown. Disruption of
sleep secondary to central apneas, however, can cause

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cardiopulmonary abnormalities in ambulatory patients, and these effects may be
magnified in critically ill patients.

Pressure Support Ventilation (PSV). When a patient attempts to breathe

spontaneously through an endotracheal tube, the narrowed diameter of the
airway results in higher resistance to airflow, and thus a higher work of breathing.

Assist Control (AC) is the mode wherein the ventilator provides a

mechanical breath with either a pre-set tidal volume or peak pressure every time
the patient initiates a breath. Traditional assist-control used only a pre-set tidal
volume—when a preset peak pressure is used this is also sometimes termed
Intermittent Positive Pressure Ventilation or IPPV. However, the initiation timing
is the same—both provide a ventilator breath with every patient effort. In most
ventilators a back-up minimum breath rate can be set in the event that the patient
becomes apnoeic. Although a maximum rate is not usually set, an alarm can be
set if the ventilator cycles too frequently. This can alert that the patient is
tachypneic or that the ventilator may be auto-cycling (a problem that results when
the ventilator interprets fluctuations in the circuit due to the last breath
termination as a new breath initiation attempt).

Unlike pressure support, assist-control ventilation delivers a fixed tidal

volume on every breath, and it can be set to deliver breaths when a patient fails
to make an effort. The backup rate will prevent the development of apneas, and
perhaps decrease arousals. If pressure support causes central apneas by
lowering arterial PCO2 below the apnea threshold.

Statement of the Problem

This study will determine and evaluate the sleep quality of the patients
mechanically ventilated and sought to answer the following:

1. What is the demographical data of the respondents of the study?

1.1 Diagnosis
1.2 Gender
1.3 Age
1.4 Days of ventilatory support

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 2. What are sleep qualities of patients in each ventilatory mode?
2.1 Apneas
2.2 Sleep fragmentation
2.3 Minute ventilation while awake and asleep
3. What is the duration of hours of sleep of each patient in each ventilatory
mode?
Significance of the Study
The findings of the study may be helpful and will be significant to the following:

Nursing students. This may help the students to cope with the procedures
specifically in the ICU Concept and in the mechanical ventilators, which is the
main focus of the study.

Future Researchers. This study will serve as a reference for the future
researchers who want to focus on the study of the Assist-control ventilation
ventilation pressure support ventilation on sleep quality in mechanically ventilated
patient

Nurses. This may help the nurses to cope with situational cases especially in
relation to the Assist-control ventilation and pressure support ventilation on sleep
quality in mechanically ventilated patient. It would enhance the nurse’s capability
of giving quality care to patients as well.

Methods and Procedure

This chapter describes the method of research used in the study, subjects
to be observed, sources of data, data gathering procedures that are necessary to
complete the study and the instruments used to gather necessary information.
This will enable researchers to establish order in the conduct of research.

Research Methodology

The researchers used the retrospective method. The purpose of research is to

evaluate the reasonableness of past economic activities, to examine the validity
of existing decisions. Analysis of the past is the construction of a better future.

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 In quantitative research your aim is to determine the relationship between one
thing (an independent variable) and another (a dependent or outcome variable)
in a population. Quantitative research designs are either descriptive (subjects
usually measured once) or experimental (subjects measured before and after a
treatment). In our research it is experimental, because it is a collection of
research designs which use manipulation and controlled testing to understand
causal processes. Generally, one or more variables are manipulated to
determine their effect on a dependent variable.

Experimental Research is often used where:

1. There is time priority in a causal relationship (cause precedes effect)

2. There is consistency in a causal relationship (a cause will always lead to
the same effect)
3. The magnitude of the correlation is great.

This is an experiment where the researcher manipulates one variable,

and control/randomizes the rest of the variables. It has a control group,
the subjects have been randomly assigned between the groups, and the
researcher only tests one effect at a time. It is also important to know what
variable(s) you want to test and measure.

Subjects of the Study

The subjects of the study were the 11 mechanically ventilated male

patients.

Sampling Technique

The respondents were gathered through purposive sampling technique.

It is used in determining the target population, or those involved in the study. The
respondents chosen were the 11 mechanically ventilated male patients.

Procedure of Data Gathering

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 Information was gathered through previous studies and literature that was
related to the study proper. This therefore aided the research study to its
conclusions.

Presentation, Analysis, and Interpretation of Data

Presentation of Data

TABLE 1: Demographical Data of the Respondents of the study

Patient No. Diagnosis Age Days of

Ventilator
Support
1 ARDS, CHF 90 26
2 ARDS, CHF 65 7
3 ARDS 75 16
4 ARDS 54 31
5 CHF 67 3
6 CHF 49 4
7 CHF 72 50
8 Pneumonia 66 7
9 Pneumonia 59 2
10 Pneumonia, 85 34
CHF
11 Pulmonary 58 4
Hemorrhage

ARDS – Adult Respiratory Distress Syndrome; CHF – Congestive Heart Failure

All patients were male and were receiving sedatives.

INTERPRETATION

There were 11 mechanically ventilated patient, most of them have the

diagnosis of CHF followed by ARDS, Pneumonia and lastly Pulmonary
Hemorrhage. Most of them are young old (late 50’s through mid 70’s). Patient no.
7 has the highest days of ventilator support (50) and the least is patient no. 6 and
11 which is 4.

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ANALYSIS

Eleven mechanically ventilated patients were recruited, after obtaining

informed consent from surrogates. Patients were excluded if they were
comatose; receiving vasopressors; recovering from general anesthesia, drug
overdose, or alcohol intoxication; or were considered unstable by their primary
physician.

TABLE 2: Sleep qualities of patients in each ventilatory mode

FIGURE 2.1

INTERPRETATION

Based on the details shown, 55% of them developed apneas during

pressure support while 45% is Assist-Control ventilation, Individual and group
mean values are shown.

ANALYSIS

Six of the 11 patients developed apneas during pressure support as

compared with assist-control ventilation by virtue of back up rate. )

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 Sleep Fragmentation

45% Pressure Support

55% Assist-Control ventilation

FIGURE 2.2

INTERPRETATION

There were a 45:55 ratio regarding the sleep fragmentation of

Pressure support and Assist-Control ventilation.

ANALYSIS

In the 11 patients, the frequency of arousals was an almost equivalent

during pressure support and assist-control ventilation. Total sleep fragmentation
was measured as the sum of arousals and awakenings.

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 Minuteventilation (Awake)

45% Apneas
55% No apneas

FIGURE 2.3.1

Minuteventilation (Asleep)

45% Apneas
55% No apneas

FIGURE 2.3.2

INTERPRETATION

In figure 2.3.1 55% or 6 of the respondents experienced apneas

while awake and 45% 0r 5 out of the 11 mechanically ventilated did not.

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 In figure 2.3.2 minute ventilation when asleep 45% experienced
apneas while 55% did not.

ANALYSIS

Minute ventilation during sleep was greater in patients who did not
develop apneas than in patients who developed apneas, suggesting that
increased respiratory drive protects against the development of central apneas.

TABLE 3: The duration of hours of sleep of each patient in each ventilatory

mode
Duration of hours of sleep
Pressure Support 75 minutes
Assist-Control ventilation 90 minutes

INTERPRETATION

All 11 patients achieved sleep while receiving each mode of ventilation.

Total durations of sleep were as follows: 90 minutes during assist-control
ventilation and 75 minutes during pressure support

ANALYSIS

It depicts that the duration of hours of sleep is mostly viable to Assist-

Control ventilation rather than Pressure support. Sleep is a heightened anabolic
state, accentuating the growth and rejuvenation of the immune, nervous, skeletal
and muscular system and often thought to help conserve energy.

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Endnotes

Literature

1
“Sleep in Critically Ill Patients Requiring Mechanical Ventilation”

Andrew B. Cooper, MD, Kristine S. Thornley, BSc, RPSGT,G. Bryan Young,

MD, Arthur S. Slutsky, MD, FCCP, Thomas E. Stewart, MD and Patrick J.
Hanly, MD. 138(6). Current issue December, 2010 from
http://www.med.yale.edu/library/nursing/education/apa.html

2
Effect of Ventilator Mode on Sleep Quality in Critically Ill Patients, Pathasary,
Sairam and Martin J. Tobin

3
Sleep in mechanically ventilated patients. Reishtein, Judith L

4
Patient-ventilator interaction and sleep in mechanically ventilated patients:
pressure support versus proportional assist ventilation. Bosma, Karen, Gabriela
Ferreyra, Cristina Ambrogio, Daniela Pasero and Lucia Mirabella.

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“Mechanical ventilation: let us minimize sleep disturbances” Cabello, Belen;
Parthasarathy, Sairam; Mancebo, Jordi

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Effects of Different Ventilator Settings on Sleep and Inspiratory Effort in Patients
with Neuromuscular Disease, Fanfulla, Francesco, Monica
Delmastro, Angela Berardinelli,Nadia D'Artavilla Lupo and Stefano
Nava. Critical Care Medicine Vol 172. pp. 619-624, (2005). Published
ahead of print on June 16, 2005

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Sleep during mechanical ventilation.Parthasarathy, Sairam

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