Bustamante, Anjaneth C.

BSRTp-3A

Modes of Mechanical Ventilation

Continuous Mandatory Ventilation

A minimal rate is set by the clinician with this mode. The patient can trigger the ventilator at a
more rapid rate, but every breath delivered is a mandatory breath type. Note that breaths can be
either volume-controlled or pressured-controlled. CMV is also known as control mode, the
ventilator delivers preset tidal volume at a time triggered respiratory rate. In the control mode, a
patient cannot change the ventilator respiratory rate or breath spontaneously.

The control mode should only be used when the patient is properly medicated with a
medication with a combination of sedatives, respiratory depressants and neuromuscular
blockers. The control mode ventilation should not be instituted by decreasing the ventilator’s
sensitivity to the point that no amount of patient effort can trigger the ventilator into inspiration.
Regardless of how vigorous the patient’s inspiratory flow is, no gas flow would be delivered to
the patient until the ventilator automatically becomes time triggered.

Indications

The control mode is often indicated if the patient “fights” the ventilator in the initial stages of
mechanical ventilator support. “Fighting” or “bucking” the ventilator often means that the patient
is severely distressed and vigorously struggling to breathe.

Other indications of control mode ventilation include (1) tetanus or other seizure
activities that interrupt the delivery of mechanical ventilation, (2) complete rest for the patient
typically for a period of 24 hours (3) patients with a crushed chest injury in which spontaneous
inspiratory efforts produce significant paradoxical chest wall movement.

Complications

The primary hazard associated with the control mode is the potential for apnea and hypoxia if
the patient should become accidentally disconnected from the ventilator or the ventilator should
fail to operate.
Continuous Positive Airway Pressure

This is a spontaneous breathing mode – no mandatory breaths are delivered. A clinician

determined level of positive pressure is maintained throughout the ventilator cycle. However, it
is possible to set CPAP=zero, in which the pressure applied to the airway is ambient. The CPAP
mode is most commonly used to evaluate extubation readiness. Ventilator performance during
CPAP is better with a flow-triggering than with pressure-triggering. Flow-triggering is
recommended when CPAP is used.

Indications

The indications for CPAP are essentially the same as for PEEP with the additional requirement
that the patient must have adequate lung functions that can sustain eucapnic ventilation
documented by the PaCO2. In adults, CPAP may be given via a face mask, nasal mask, or
endotracheal tube. In neonates, nasal CPAP is a method of choice.
Pressure Support Ventilation

With PSV, the patient’s inspiratory effort is assisted by the ventilator at a preset level of
inspiratory pressure. Inspiration is triggered and cycled by a patient’s effort. A pressure-
supported breath is patient triggered, pressure limited and flow cycled. It is pressure limited
because the maximum airway pressure cannot exceed the preset pressure supported level. It is
flow cycles because a pressure-supported breath cycles to expiration when the flow reaches a
minimal level.

During PSV, the patient determines the respiratory rate, inspiratory time and tidal volume.
Current generation ventilators provide back-up ventilation (volume-controlled or pressured-
controlled CMV) should apnea occur during PSV. PSV is normally flow cycled. Secondary
cycling mechanisms with PSV are pressure and time. Newer generation ventilators allow the
clinician to adjust the termination flow at which the ventilator cycles to a level appropriate for the
patient. It also allows adjustment of rise time at the beginning of the pressure support breath.
Rise time refers to the amount of time required to reach the pressure support level at the
beginning of inspiration.

Indications

Pressure support is typically used in the SIMV mode to facilitate weaning in a difficult wean
patient. In this application, pressure support (1) increases the patient’s spontaneous tidal
volume (2) decreases the patient’s spontaneous respiratory rate, and (3) decreases the work of
breathing.
Synchronized Intermittent Mandatory Ventilation

SIMV is a ventilator mode in which mandatory breaths are delivered at set rate with volume-
control or pressure-control. Between the mandatory breaths, the patient is allowed to breathe
spontaneously. Although other SIMV systems have been associated with a high imposed work-
of-breathing, this has improved in the current generation of ventilators. The ventilator delivers
the mandatory breaths in synchrony with the patient’s inspiratory effort. If no inspiratory effort is
detected, the ventilator delivers a mandatory breath at the scheduled time. This is usually
achieved by use of an assist window. This window open at intervals determined by the set SIMV
rate and remains open for a manufacturer-specific period of time. If a patient-generated
breathing effort is detected while this window is open, a mandatory breath is delivered. If no
patient effort is detected in the time that the window is open, the ventilator delivers a mandatory
breath. With SIMV, the spontaneous breaths can be pressure-supported.

Indications

The primary indication of SIMV is to provide partial ventilator support, i.e, a desire to have the
patient actively involved in providing part of the minute volume.

Advantages

Since SIMV promotes breathing and use of respiratory muscles, SIMV (1) maintains respiratory
muscle strength/avoids muscle atrophy, (2) reduces ventilation to perfusion mismatch, (3)
decreases mean airway pressure and (4) facilitates weaning.

Complications

The primary disadvantage associated with SIMV is the desire to wean the patient too rapidly,
leading to first a high work of spontaneous breathing and ultimately to muscle fatigue and
weaning failure. The best way to avoid this is to decrease the SIMV mandatory respiratory rate
slowly and monitor the patient closely to signs of fatigue
Mandatory Minute Ventilation

MMV is a mode intended to guarantee minute ventilation during weaning. If the patient’s
spontaneous ventilation does not match the target minute ventilation set by the clinician, the
ventilator supplies the difference between the patient’s minute ventilation and the target minute
ventilation. If the patient’s spontaneous minute ventilation exceeds the target, no ventilator
support is provided. MMV is thus a form of closed loop ventilation in which the ventilator adjusts
its output according to the patient’s response. MMV is only available on a few ventilator types
used in the US and its value to facilitate weaning is unclear. MMV can be provided by altering
the rate or the tidal volume delivered from the ventilator. Some ventilators increase the
mandatory breath rate if the minute ventilation falls below the target level, whereas others
increase the level of pressure support when the minute ventilation falls below the target level.

MMV is an additional function of the SIMV mode and is intended to prevent hypercapnia
by “automatically” ensuring that the patient receives a minimum preset minute volume. It is
especially useful in preventing hypoventilation and respiratory acidosis in the final stages of
weaning with SIMV when the patient’s spontaneous breathing is assuming a significant portion
of the minute volume.
Positive End-Expiratory Pressure (PEEP)

PEEP increases the end-expiratory or baseline airway pressure to a value greater than
atmospheric pressure (0 cm H2O on the ventilator manometer). It is often used to improve the
patient’s oxygenation status, especially in hypoxemia that is refractory to high level of FiO2.

Indications

Two major indications for PEEP are (1) intrapulmonary shunt and refractory hypoxemia and (2)
decreased functional residual capacity (FRC) and lung compliance.

Complications

Complications and hazards associated with PEEP include (1) decreased venous return and
cardiac output, (2) barotrauma (3) increased intracranial pressure and (4) alterations of renal
functions and water metabolism.
Bilevel Positive Airway Pressure

BiPAP allows the clinician to apply independent positive airway pressures to both inspiration
and expiration. IPAP (inspiratory) and EPAP (expiratory) are used to define when the positive
airway pressure is present. IPAP provides positive pressure breaths and it improves ventilation
and hypoxemia due to hypoventilation. EPAP is in essence CPAP and it improves oxygenation
by increasing the functional residual capacity and enhancing alveolar recruitment.

Indications

BiPAP appears to be of value in preventing intubation of the end-stage COPD patient and in
supporting patients with chronic ventilator failure. Other indications include patients with
restrictive chest wall disease, neuromuscular disease
Assist Control

With the assist/control mode, the patient may increase ventilator respiratory rate (assist) in
addition to the preset mechanical respiratory rate (control). Each control breath provides the
patient with a preset, ventilator delivered tidal volume. Each assist breath also results in a
preset, ventilator delivered tidal volume. The assist-control mode does not allow the patient to
take spontaneous breathing.

Indications

The AC mode is most often used to provide full ventilator support for patients when they are first
placed on mechanical ventilation. The AC mode is typically used for patients who are stable
respiratory drive and can therefore trigger the ventilator into inspiration. The generally accepted
minimum control respiratory rate in the AC mode is 2 to 4 BPM less than the patient’s assist
rate, or a minimum control rate of from 8-10 BPM.

Complications

The potential hazard associated with AC is alveolar hyperventilation (respiratory acidosis).

Intermittent Mandatory Ventilation

IMV is a mode in which the ventilator delivers control (mandatory) breaths and allows the patient
to breathe spontaneously at any tidal volume the patient is capable of in between the mandatory
breaths.

The primary complication associated with IMV was the random chance for breath stacking. This
occurs when the patient is taking a spontaneous breath and the ventilator delivers a time-
triggered mandatory breath at the same time. If this occurs, the patient’s lung volume and
airway pressure could increase significantly. Setting appropriate high pressure limits will reduce
the risk of barotrauma in the event of breath stacking. As long as the breath stacking occurs
occasionally, the IMV mode is an acceptable mode of ventilation with few complications
Pressure Control Ventilation

In PCV, the pressure control breaths are time triggered by a preset respiratory rate. Once
inspiration begins, a pressure plateau is created and maintained for a preset inspiratory time.
Pressure-controlled breaths are therefore time triggered pressure limited and time cycled.

Pressure control is usually indicated for patients with severe ARDS who require extremely high
peak inspiratory pressures during mechanical ventilation in a volume-cycled mode. As a result
of these high airway pressures, they have a higher incidence of barotrauma.
Airway Pressure Release Ventilation

APRV is similar to CPAP in that the patient is allowed to breathe spontaneously without
restriction. During spontaneous exhalation, the peep is dropped to a lower level and this action
stimulates an effective exhalation maneuver. The length of pressure release time is usually
between 1 and 2 sec. When the pressure release time is shorter than the spontaneous effort, it
resembles pressure-controlled breath with an inverse inspiratory-expiratory (I:E) ratio.

Indications

Primary indication for this mode is similar to that of pressure control, namely, as an alternative
to conventional volume-cycled ventilation for patients with significantly decreased lung
compliance such as patient with ARDS.

Complications

Could be harmful to patients with high expiratory resistance

Auto-PEEP is usually present

Caution should be used with hemodynamically unstable patients

Asynchrony can occur if spontaneous breaths are out of sync with release time

Requires the presence of an “active exhalation valve”

New Modes of Mechanical Ventilation

Adaptive Support Ventilation (ASV)

ASV is based on the minimal work-of-breathing concept, which suggests that the patient will
breathe at a tidal volume and respiratory frequency that minimizes the elastic and resistive
loads while maintain oxygenation and acid base balance.

Indications

Full or partial ventilatory support

Patients requiring a lowest possible PIP and a guarantees VT

Patients requiring high and/or variable minute volume

Patients not breathing spontaneously and not triggering the ventilator

Patients with the possibility of work load changes

Facilitates weaning

Automode

Allows the ventilator to switch between mandatory and spontaneous breathing modes. Auto
mode combines volume support (VS) and pressure-regulated volume control (PRVC) into a
single mode. If the patient is paralyzed, the ventilator will provide PRVC
References:

Chapter Four, 4th Edition: Clinical Application of Mechanical Ventilation (page 81-111)

By: David W. Chang

Chapter four and five, 2nd Edition Essentials of Mechanical Ventilation (page 35-53)

By: Dean R. Hess & Robert M. Kacmarek

Clinical Practice in Respiratory Care (page 411-427)

By: James B. Fink & Gerald E. Hunt