02 PHYSICS

76. Ventilators
How can ventilators be A question on ventilators will often follow on from a physics question about flow.
classified? The simplest way to address this question is to classify ventilation according to
the Mapleson classification, which separates it into either ‘pressure-generated’
or ‘flow-generated’ ventilation.

A ventilator is a device that delivers gas to the lungs

Pressure Generator Flow Generator

Delivers gas to the patient Delivers gas to patient at a constant
at a constant inspiratory pressure inspiratory flow rate until it has delivered
set by the operator. a pre-set tidal volume.

Usually time cycled Cycles when the set tidal volume

(i.e. the operator sets the pressure,
the number of breaths per minute and the
inspiratory:expiratory time ratio and the
machine will deliver breaths accordingly).
Inspiratory flow rates and tidal volume
achieved will depend on the patient's
lung compliance (i.e. the stiffer the lungs
the lower the resulting tidal volume
delivered).
has been delivered (i.e. the operator sets
the volume to be delivered, the number of
breaths and the I:E ratio).
Inspiratory pressures reached depend
on the patient's lung compliance (i.e. the
lower the compliance, the higher the peak
inspiration pressure).

Risk of barotrauma is low. Higher risk of barotrauma (so set pressure

limits).
Risk of volutrauma is higher Lower risk of volutrauma.
(so set volume limits).

The system has some ability Any leak in the circuit is not compensated
to compensate for leaks, as it always for, as the ventilator will perceive that
acts to deliver a preset pressure the lost volume has been delivered
for a set amount of time. to the patient.

➡Compliance
I E

Pressure Pressure
(cm H2O) (cm H2O)

Time (s) Time (s)

Graphs comparing pressure profiles of the two different ventilation modes

Fig. 76.1  Comparison of pressure vs. flow ventilation

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 VENTILATORS

Pressure generator Flow generator

I E I E

Compliance

Flow Flow Inspired VT

(L/s) (L/s)

Time (s) Time (s)

Expired VT

Fig. 76.2  Comparison of flow profiles for pressure-generated and flow-generated ventilators

A third type of ventilator is called the high-frequency oscillating ventilator

(HFOV).
HFOV employs an ‘open lung’ strategy, using high PEEP and very small tidal
volumes (1–3 mL/kg) at respiratory rates of up to 15 Hz (i.e. 900 breaths per
minute!).
It aims to reduce distending pressures in poorly compliant lungs (e.g. in ARDS)
and is recommended for those patients requiring a high FiO2 > 0.60 and with
high mean airways pressures > 24 cm H2O.
The mechanism of oxygenation with this type of ventilation is not fully
understood, but diffusion, convection and Pendelluft (i.e. movement of gas
between different alveolar units with different time constants) are thought to play
a part.

DEFINITIONS OF VENTILATORY MODES

CPAP – Continuous Positive Airway Pressure

• A positive pressure (cm H2O) is applied to the airway of a
spontaneously breathing patient via a facial or nasal mask. The
pressure is constant through all phases of the ventilatory cycle.
• The positive pressure helps to prevent alveolar and airway closure
during expiration and improves lung compliance by moving the lungs
up the compliance curve.
• This mode of ventilation is used in the treatment of obstructive sleep
apnoea.

PEEP – Positive End Expiratory Pressure

• This is very similar to CPAP, except that it applies to mechanically
ventilated patients.
• PEEP is a set level of pressure (cm H2O) below which the circuit is
not allowed to fall at the end of expiration. It is usually set between
5 and 10 cm H2O.
• It helps to prevent alveolar and airway closure during expiration and
improves lung compliance by moving the lungs up the compliance
curve.

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 02 PHYSICS

BiPAP – Bi-level Positive Airway Pressure

• This is a trade name of a particular make of non-invasive ventilators.
• BiPAP is given via a face mask, usually to a conscious and
spontaneously ventilating patient.
• The operator sets two levels of pressure; the first is effectively the
PEEP, i.e. the level below which the circuit is not allowed to fall.
The second is the positive inspiratory pressure, which the ventilator
delivers to the patient.
• The machine senses when the patient is taking a breath (via a
pressure transducer which senses negative pressure in the system)
and then augments their breath to the set pressure. In most cases,
cycling is controlled by the machine sensing the patient’s respiratory
effort. Some models can deliver time-cycled positive pressure if
the patient fails to make any respiratory effort after a set time has
elapsed.

PC – Pressure Control
• Pressure control is used in a mechanically ventilated patient. It is the
most basic mode of ventilation.
• The operator sets either the desired tidal volume or desired pressure
and the number of breaths per minute, and the ventilator will deliver
these.
• Any respiratory effort that the patient makes is ‘ignored’ by the
ventilator.

PS – Pressure Support
• Pressure support is used for weaning patients from the ventilator.
• As in BiPAP, the ventilator senses the patient’s inspiratory effort and
augments it with a pre-set inspiratory pressure.
• It is usual to set two levels of pressure, the principle being the same
as that described above for BiPAP.

SIMV – Synchronised Intermittent Mandatory Ventilation

• This mode is a ‘half-way house’ between PC and PS.
• The operator sets the desired tidal volume or inspiratory pressure
and the number of breaths per minute. The ventilator will then deliver
these breaths.
• However, if the patient makes an inspiratory effort the machine will
sense this and augment their breath.

PRVC – Pressure Regulated Volume Control

• In this mode, the operator sets the tidal volume and the machine
will deliver this volume in such a way as to give the lowest resultant
inspiratory pressure.
• This mode has been developed to try to reduce the risk of
barotrauma and to address the issue of different areas of the lung
having different compliance in lung diseases such as ARDS.

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