Mechanical Ventilation: Modes and Methods

Criteria for intubation and initiation of mechanical ventilation generally fall into the following
categories: apnea (and/ or need for anesthesia with surgery), severe hypoxemia (PaO≤ 50 mmHg on
room air), progressive or impending respiratory failure (serial arterial blood gases indicating
worsening status with clinical signs and symptoms of fatigue), and acute respiratory failure
(uncompensated respiratory acidosis and hypoxemia on room air). Once the patient is intubated,it is
necessary to select a mechanical ventilator mode and associated parameters. Understanding the
pathology of the condition necessitating mechanical ventilation is essential if the lung is to be
protected while meeting hemodynamic and acid–base management goals.

Microprocessor technology has increased the versatility of traditional modes and has resulted in a
wide variety of new sophisticated mode options. However, despite many available mode options,
there is little scientific evidence supporting the selection of any one mode over another. Instead, the
clinician must carefully apply the options to selected conditions to assure good outcomes. To that
end, a discussion of volume and pressure modes follows. Table 3.2 describes traditional and
common mode parameters found on most ventilators. Table 3.3 describes the parameters required
for selected volume and pressure modes.

What Modes are Best?

Although the new modes of ventilation are attractive because of their sophistication, versatility, and
potential applications,little data exists that demonstrates their superiority. Instead,application,
understanding, and familiarity with the modes are the key to good outcomes. Variation in practice
breeds mistakes and should be decreased when possible. When clinicians do not understand the
modes, the potential for inaccurate and inefficient management exists. This is true throughout the
continuum of ventilation (from the acute stage to the weaning stage). Thus, it is essential that the
ACNP understand the modes, so that they are appropriately applied.

Perhaps the greatest challenge with regard to mechanical ventilation is the management of the most
complex patients. ARDS and acute severe asthma (ASA) are two extreme exam- ples of restrictive
and obstructive pathology. A discussion of the ventilatory management of these conditions follows.

Ventilatory Management of ARDS

Application of Protective Lung Strategies in ARDS.

■ Low lung volume ventilation. Volume modes of ventilation are useful to assure that tidal volumes
of 6 ml/kg (lean body weight) are consistently delivered. To maintain a pH that is within an
acceptable range, fx is generally high (20–30). If this protective strategy results in hypercarbia and
acidosis, it may be necessary to sedate and paralyze the patient to depress respiratory drive.
Permissive hypercarbia is relatively well tolerated in many patients, but it is contraindicated in those
with elevated intracranial pressure and in some with cardiac conditions (Hickling et al., 1990). When
pressure modes are used, constant attention to the delivered volumes is necessary. Furthermore, it
is important to remember that the plateau pressure necessary to prevent lung injury is unknown.
Based on the ARDS network study, the required plateau pressure may be within a 26–30 cm H2O
range; however, plateau pressure is reflective of chest wall as well as lung, thus making it difficult to
determine what the pressure goal should be.
 ■ Lung recruitment is generally accomplished with PEEP.

Unfortunately, it is clinically very difficult to determine what critical opening pressure is required to
uniformly recruit the ARDS lung. Some have used maneuvers such as the “40/40 or 60/60
maneuvers” for lung recruitment (Foti et al., 2000; Fujino et al., 2001). These consist of using critical
opening pressures (PEEP) of 40 or 60 cmH2O for 40–60 seconds. The techniques are difficult to
accomplish and carry the additional risk of barotrauma. Instead, many use high levels of PEEP (e.g.,
14–16 cmH2O) and monitor the effect on PaO. Unfortunately, improved oxygenation may result
from recruitment or may be the result of redistribution of blood flow to aerated areas of the lung.

Definitive methods of assessing lung recruitment are few and include serial CT scan with changes in
PEEP (very unrealistic cost and labor intensive).Another method is to monitor plateau pressure with
increases in PEEP. With this technique,plateau pressure should remain stable or decrease with
increases in PEEP. In contrast,an increase in plateau pressure with the addition of PEEP may be
reflective of overdistention. Prone positioning may also be used to “recruit lung” (Tobin &
Kelly,1999, Albert,Lesa,Sanderson,Robertson,& Hlastala,1987) although definitive data
demonstrating positive effects on mortality secondary to prone positioning are lacking (Gattinoni et
al.,2001;Mancebo et al.,2006). However, subanalyses in the existing studies do suggest that the
technique may result in improved outcomes in those with the most severe ARDS (PaO2/FiO2 ratios
of <100) (Gattinoni et al., 2001; Mancebo et al., 2006). Further studies are necessary to clarify the
use of prone positioning, especially as related to duration, frequency, and timing of the technique.
Regardless of the method used to assure recruitment, it is important to remember that
derecruitment occurs quickly, such as when the ventilator circuit is broken, and is to be avoided