Pressure support ventilation

Oxford Textbook of Critical Care (2 ed.)

Edited by Andrew Webb, Derek Angus, Simon Finfer,
Luciano Gattinoni, and Mervyn Singer

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Critical Care.

Publisher: Oxford University Press Print Publication Date: Apr 2016

Print ISBN-13: 9780199600830 Published online: Apr 2016
DOI: 10.1093/med/
9780199600830.001.0001

Pressure support ventilation  

Chapter: Pressure support ventilation

Author(s): Hérnan Aguirre-Bermeo and Jordi Mancebo

DOI: 10.1093/med/9780199600830.003.0097

Key points

◆ Pressure support ventilation (PSV) is an assisted ventilatory

mode that is patient-triggered, pressure-limited, and flow cycled.
During PSV, airway pressure is maintained nearly constant during
the entire inspiration.
◆ PSV allows the patient to maintain a certain degree of control
over respiratory rate and tidal volume.
◆ The main use of the modality is in withdrawal from mechanical
ventilation because it unloads respiratory muscles and allows a
gradual reduction of support until extubation.

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Pressure support ventilation

◆ If not properly used (usually due to excessive levels of support),

this modality generates high and abnormal tidal volumes, and
wasted inspiratory efforts.
◆ The closed-loop modality could have important clinical
implications in withdrawal of mechanical ventilation in specific
groups of patients. It appears to be as good as usual care
performed by experts and skilled teams.

Definition

Pressure support ventilation (PSV) is an assisted ventilatory mode

that is patient-triggered (by pressure, airflow, or both), pressure-limited,
and flow cycled. In this modality, the airway pressure is maintained
almost constant during the entire inspiration. The ventilator provides
assistance when the patient makes a breathing effort, and then, when
inspiratory flow reaches a certain threshold level, cycling to exhalation
occurs. The use of PSV is common in all intensive care units (ICUs), and it
is the most commonly used method to wean patients from mechanical
ventilation [1].

Mode characteristics

Trigger

In PSV, the clinician decides whether to use pressure or flow triggers to

initiate ventilatory assist. The recommended pressure and flow triggers
are, respectively, from –0.5 to –2.0 cmH2O, and from 1 to 2 L/min [2].

Several studies have compared the use of pressure versus flow triggers,
without finding any significant differences between the triggers.
However, Aslanian et al. [2] found that the flow trigger was more effective
in reducing breathing effort when used in PSV versus volume-controlled
modality. In patients with intrinsic positive end-expiratory pressure
(PEEPi), the flow trigger can decrease inspiratory effort; moreover, low
levels of external positive end-expiratory pressure (PEEP) are
recommended to compensate for this PEEPi, the dynamic flow limitation
and for decrease the work of breathing [3].

Flow delivery

Once the ventilator is triggered, the machine provides an inspiratory flow

(via a servo regulatory mechanism) to maintain the preset level of airway
pressure (pressure support setting) nearly constant throughout the
inspiration. The velocity of pressurization, which depends on the shape of
the inspiratory flow waveform, is the time required for the ventilator to
reach the pressure support setting at the onset of inspiration (rise time).
Different pressurization rates have a profound effect on effort. Low
pressurization rates produce a high inspiratory muscle effort, while high
pressurization rates lower inspiratory muscle effort [4]. Visual inspection
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Pressure support ventilation

of the ventilator waveforms may be used to guide this setting. Tidal

volume depends on the preset level of pressure support, the inspiratory
effort of the patient, the cycling-off threshold level, and the mechanical
characteristics (resistance and compliance) of the patient’s respiratory
system.

Cycling of expiration

During PSV, cycling from inspiration to expiration is triggered when the

inspiratory airflow reaches a certain threshold value. The threshold value
coincides, theoretically, with the end of inspiratory muscle effort. This
flow value could be a percentage of peak flow (i.e. 25% of peak flow) or a
fixed level (i.e. 5 L/min). The latest generation of ventilators allow the
physician to set this flow threshold value [5]. Modification of the cycling-
off criteria can influence inspiratory effort and patient–ventilator
synchrony. In patients with chronic obstructive pulmonary disease
(COPD), setting the cycling-off at higher percentages of peak inspiratory
flow can improve patient–ventilator synchrony and reduce inspiratory
muscle effort [6]. Thille et al. [7] have described a similar phenomenon in
COPD and non-COPD patients. Tracings obtained during pressure support
ventilation are shown in Fig. 97.1.

Fig. 97.1
From top to bottom: tracings of airflow (flow), oesophageal pressure (Pes),
airway pressure (Paw), gastric pressure (Pga), and tidal volume (Volume)
recorded in a patient breathing in PSV mode.

Physiological effects

Breathing pattern and respiratory effort

PSV allows the patient to retain control over the respiratory rate and tidal
volume, a process referred to as physiological ventilation. PSV induces
changes in the breathing pattern that affect tidal volume and respiratory

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Pressure support ventilation

rate, without, however, inducing major changes in minute ventilation. As

a result, in most patients, tidal volume rises and the ventilator respiratory
rate decreases as the level of support is increased. Inappropriate low
levels of support can generate low tidal volumes and a high respiratory
rate, resulting in patient discomfort and hypercapnia; on the other hand,
excessive levels of support may produce hyperinflation, the appearance of
wasted inspiratory efforts, respiratory alkalosis, and even periods of
apnoea.

Patient ventilator synchrony during PSV

Asynchronies can be present in all ventilator modalities and inappropriate

ventilator settings can aggravate the frequency and severity of these
asynchronies.

The patient–ventilatory synchrony achieved with PSV is good because it is

able to recognize the beginning and the end of each spontaneous effort.
However, asynchronies occur during PSV. Often, but not always, these
asynchronies during PSV can be detected at the bedside by examining
ventilator waveforms.

Thille et al. [8] found that assisted control modalities are associated with
a higher prevalence of asynchronies compared with PSV. In their study,
the most common asynchronies were ineffective triggering and double-
triggering.

A study by Leung et al. [9] showed that high levels of support (above 60–
70% of full support) generated wasted inspiratory efforts. A more recent
study [7] found that the frequency of asynchronies can be decreased by
lowering pressure-support levels.

Clinical usefulness and applications

Withdrawal of mechanical ventilation

In the process of withdrawal of mechanical ventilation, the support level

should be reduced as quickly as the patient’s clinical tolerance will
permit. This reduction, therefore, must be made on an individual basis.
The support levels are usually lowered by one or two steps per day
(between 2 and 4 cmH2O per step). A spontaneous breathing trial (SBT)
should be conducted as soon as the physician suspects that weaning may
be possible and the patient appears to be ready to breathe without
ventilatory assistance. This trial can be performed by disconnecting the
patient from the ventilator and attaching a T-piece to the endotracheal
tube or, alternatively, the SBT can be performed by administering low
levels of PSV with or without PEEP. Esteban et al. [10] showed that both
methods (pressure support or a T-piece) are suitable for successful
discontinuation of ventilator support. However, a recent study by Cabello
and colleagues [11], showed that, in difficult to wean patients (those who
had failed at least one SBT), the use of pressure support and PEEP
modifies the breathing pattern, inspiratory muscle effort, and
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Pressure support ventilation

cardiovascular response when compared with the T-piece trial. In fact, of

the 100% of difficult to wean patients who failed a T-piece trial, 79 and
57%, respectively, successfully completed subsequent PSV with PEEP and
PSV without PEEP trials. For these reasons, it is still unclear as to which
SBT is best to predict successful extubation, and therefore weaning
strategies must be individualized.

Initial suggested settings

As occurs in other ventilation modalities, all PSV settings must be

adjusted individually in each patient. However, we can provide some
suggestions for the initial PSV settings. These settings should be checked
several times during the day and/or whenever the patient requires an
adjustment.

First, the pressurization rate should be fast (short rise time), and the
support level should be adjusted to produce a respiratory rate of
approximately 25–30 breaths/min depending on the patient’s comfort.
Cycling off should be approximately 25% of peak inspiratory flow (a
higher percentage is recommended in COPD patients). The FiO2 and
PEEP must be adjusted according to gas exchange and PEEPi.

Closed-loop modality

A closed-loop, knowledge-based system has been designed to help in

withdrawal from mechanical ventilation. The system continuously
analyses physiological data (respiratory rate, tidal volume, and end-tidal
CO2 level) and adapts the level of pressure support to keep the patient
within a ‘comfort zone’. This comfort zone is defined as a respiratory rate
that can vary freely from 15 to 30 breaths/min (up to 34 breaths in
patients with neurological disease). The tidal volume should be above a
minimum threshold and an end-tidal CO2 level below a maximum
threshold [12]. The level of pressure support is periodically adapted by
the system in steps of 2–4 cmH2O. The system automatically tries to
reduce the pressure level to a minimal value, at which time a
‘spontaneous breathing trial’ with the minimal low-pressure support is
performed by the system. Upon successful completion of this trial, a
message on the screen recommends separation from the ventilator.

Lellouche et al. [12], showed that this system reduces the duration of
mechanical ventilation and ICU stay compared with the usual intensive
care weaning procedures. However, two recent studies have failed to fully
confirm these results [13,14]. Rose et al. [13] reported that the
automated system did not reduce weaning time in their study, in contrast
to the positive findings of Lellouche and colleagues. However, this may be
due to differences between the two studies, particularly in terms of
patient severity, duration of ventilation, the patient–nurse ratio, and in
ICU staffing levels. The study performed by Schadler et al. [14] also had
several difference with the Lellouche et al. study. One important
difference is that the Schadler study was performed in post-operative

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Pressure support ventilation

patients with nursing and medical staff who were skilled in the
management of mechanical ventilation. The authors found that overall
weaning times did not differ significantly between the control group and
the experimental group, with the exception of a subgroup of 132 patients
who had undergone cardiac surgery (24 hours in closed-loop versus 35
hours in control group, p = 0.035). Given the findings published to date,
we can conclude that this closed-loop modality performs at least as well
as experienced medical staff in weaning patients from mechanical
ventilation.

References
1. Esteban A, Ferguson ND, Meade MO, et al. (2008). Evolution of
mechanical ventilation in response to clinical research. American Journal
of Respiratory and Critical Care Medicine, 177(2), 170–7.

2. Aslanian P, El Atrous S, Isabey D, et al. (1998). Effects of flow

triggering on breathing effort during partial ventilatory support.
American Journal of Respiratory and Critical Care Medicine, 157(1), 135–
43.

3. Mancebo J, Albaladejo P, Touchard D, et al. (2000). Airway occlusion

pressure to titrate positive end-expiratory pressure in patients with
dynamic hyperinflation. Anesthesiology, 93(1), 81–90.

4. Chiumello D, Pelosi P, Croci M, Bigatello LM, and Gattinoni L. (2001).

The effects of pressurization rate on breathing pattern, work of
breathing, gas exchange and patient comfort in pressure support
ventilation. European Respiratory Journal, 18(1), 107–14.

5. Brochard L and Lellouche F. (2006). Pressure support ventilation. In:

Tobin MJ (ed.) Principles and Practice of Mechanical Ventilation, 2nd edn,
pp. 221–50. New York, NY: McGraw-Hill Medical Publishing Division.

6. Tassaux D, Gainnier M, Battisti A, and Jolliet P. (2005). Impact of

expiratory trigger setting on delayed cycling and inspiratory muscle
workload. American Journal of Respiratory and Critical Care Medicine,
172(10), 1283–9.

7. Thille AW, Cabello B, Galia F, Lyazidi A, and Brochard L. (2008).

Reduction of patient–ventilator asynchrony by reducing tidal volume
during pressure-support ventilation. Intensive Care Medicine, 34(8),
1477–86.

8. Thille AW, Rodriguez P, Cabello B, Lellouche F, and Brochard L. (2006).

Patient–ventilator asynchrony during assisted mechanical ventilation.
Intensive Care Medicine, 32(10), 1515–22.

9. Leung P, Jubran A, and Tobin MJ. (1997). Comparison of assisted

ventilator modes on triggering, patient effort, and dyspnea. American
Journal of Respiratory and Critical Care Medicine, 155(6), 1940–8.

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Pressure support ventilation

10. Esteban A, Alia I, Gordo F, et al. (1997). Extubation outcome after

spontaneous breathing trials with T-tube or pressure support ventilation.
The Spanish Lung Failure Collaborative Group. American Journal of
Respiratory and Critical Care Medicine, 156(2 Pt 1), 459–65.

11. Cabello B, Thille AW, Roche-Campo F, Brochard L, Gomez FJ, and

Mancebo J. (2010). Physiological comparison of three spontaneous
breathing trials in difficult-to-wean patients. Intensive Care Medicine,
36(7), 1171–9.

12. Lellouche F, Mancebo J, Jolliet P, et al. (2006). A multicenter

randomized trial of computer-driven protocolized weaning from
mechanical ventilation. American Journal of Respiratory and Critical Care
Medicine, 174(8), 894–900.

13. Rose L, Presneill JJ, Johnston L, and Cade JF. (2008). A randomised,
controlled trial of conventional versus automated weaning from
mechanical ventilation using SmartCare/PS. Intensive Care Medicine,
34(10), 1788–95.

14. Schadler D, Engel C, Elke G, et al. (2012). Automatic control of

pressure support for ventilator weaning in surgical intensive care
patients. American Journal of Respiratory and Critical Care Medicine,
185(6), 637–44.

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