Disclaimer:

Medicine and respiratory therapy are continuously changing

practices. The author and publisher have reviewed all information
in this report with resources believed to be reliable and accurate
and have made every effort to provide information that is up to
date with the best practices at the time of publication. Despite our
best efforts we cannot disregard the possibility of human error
and continual changes in best practices the author, publisher, and
any other party involved in the production of this work can
warrant that the information contained herein is complete or fully
accurate. The author, publisher, and all other parties involved in
this work disclaim all responsibility from any errors contained
within this work and from the results from the use of this
information. Readers are encouraged to check all information in
this publication with institutional guidelines, other sources, and up
to date information. Respiratory Therapy Zone is not affiliated with
the NBRC®, AARC®, or any other group at the time of this
publication.

Copyright ã Respiratory Therapy Zone

2
Table of Contents
Introduction ……………………………………………………………..…………………………………...……..4
Ventilator Modes …………………………………….……………..…………….…………………..….……..5
Primary Ventilator Modes …………………………………….………..………………….…….……..7
Spontaneous Ventilator Modes …………………………………….………..……….…….……..9
Other Ventilator Modes …………………………………….………………....…………..….…….…...11
Ventilator Settings …………………………………….………………………………….……………..…..17
TMC Practice Questions …………………………………….…………………………..…….…...…..23
Practice Questions …………………………………….………………………………….…………….…..28
Conclusion …………………………………………………………..…..………………………………….....…..47
References …………………………………………………….….……..…………………………………....…..48

Copyright ã Respiratory Therapy Zone

3
Introduction

Are you ready to learn about the modes and settings of

mechanical ventilation? I sure hope so because that is what this
study guide is all about.

Inside of this cheat sheet, we’ve listed out all the different
ventilator modes and settings that you need to know as a
Respiratory Therapist or student.

Not to mention, we’ve also included some helpful practice

questions as well.

So if you’re ready to get started, let’s go ahead and dive right in. J

Copyright ã Respiratory Therapy Zone

4
Ventilator Modes

First and foremost, let’s talk about the ins and outs of ventilator
modes and cover all the basics.

What is a Ventilator Mode?

A ventilator mode is a way of describing how the mechanical
ventilator assists the patient with inspiration. The characteristics of
a particular mode controls how the ventilator functions.

Understanding the different ventilator modes is one of the most

important aspects of mechanical ventilation.

Primary Control Variables:

In mechanical ventilation, there are two primary control variables:

1. Volume Control
2. Pressure Control

Volume Control
Volume Control means that you can set (or control) the patient’s
tidal volume.

So with a set tidal volume and a set respiratory rate, this means
that there is a known minute ventilation. This is good when it
comes to making adjustments to achieve a desired PaCO2.

One of the negative aspects of using Volume Control is that, since

the tidal volume is preset, if the patients lung compliance were to
decrease, this could result in high peak pressures.

5
Another drawback of Volume Control is patient-ventilator
dyssynchrony.

Pressure Control
Pressure Control means that you can set (or control) the patient’s
pressure in order to achieve a desired tidal volume.

As with Volume Control, a Pressure-Controlled tidal volume and

set rate can help you reach a desired PaCO2.

The main disadvantage of using Pressure Control is the patient’s

tidal volume can potentially be unstable if there are changes in
the patient’s lung compliance or airway resistance.

So again, Volume Control and Pressure Control — those are the

two control variables.

When initiating mechanical ventilation on a patient, once you

select the control variable, now you can choose the actual
operational mode that determines the pattern of breathing for the
patient.

6
Primary Ventilator Modes

In mechanical ventilation, there are two primary ventilator modes:

1. Assist/Control (A/C) Mode

2. Synchronous Intermittent Mandatory Ventilation (SIMV)
Mode

Assist/Control (A/C) Mode

In this mode, a minimum number of preset mandatory breaths
are delivered by the ventilator but the patient can also trigger
assisted breaths. The patient makes an effort to breathe and the
ventilator assists in delivering the breath.

With that said, this mode of ventilation does not allow the patient
to take spontaneous breaths. In this mode, the operator can set
either a controlled pressure or a controlled volume.

The sensitivity control can be adjusted to make it easier or harder

for the patient to initiate a breath.

When to Use Assist/Control?

This mode is most often used when mechanical ventilation is first

initiated for a patient because this mode provides full ventilatory
support.

That is also one of the advantages of using Assist/Control because

it keeps the patient’s work of breathing requirement very low.

One of the major complications of Assist/Control is

hyperventilation, which results in respiratory alkalosis. This is the
result of too many breaths given to the patient, whether patient-
triggered or machine-triggered.

7
Synchronous Intermittent Mandatory Ventilation
(SIMV) Mode
In this mode, the ventilator delivers a preset minimum number of
mandatory breaths. However, it also allows the patient to initiate
spontaneous breaths in between the mandatory breaths.

This mode also allows the operator to set either a controlled

pressure or a controlled volume.

When to Use SIMV?

The primary indication for SIMV is when a patient needs partial

ventilatory support. That is because, since the patient can takes
spontaneous breaths, that means they can contribute to some of
their minute ventilation.

SIMV is a mode that is used for weaning as well.

Advantages of Using SIMV:

• Since the patient is able to take spontaneous breaths, it helps

to maintain their respiratory muscle strength and avoid
muscular atrophy.
• It distributes tidal volumes evenly throughout the lung fields,
which reduces V/Q mismatching.
• It helps to decrease the patient’s mean airway pressure.

As a Respiratory Therapist (or student), SIMV and Assist/Control

are the two ventilator modes that you should be most familiar
with.

However, it’s also important to develop an understanding of the

spontaneous modes and the secondary modes of mechanical
ventilation as well.

8
Spontaneous Ventilator Modes

Keep in mind that, in order to use any of the following modes, the
patient must be breathing spontaneously.

Continuous Positive Airway Pressure (CPAP)

In CPAP, or continuous positive airway pressure, a continuous
pressure that is above atmospheric pressure is maintained
throughout the breathing cycle.

The patient must be breathing spontaneously to be in this mode

because no mandatory breaths are given. This is a useful mode for
weaning patients off of the ventilator.

Pressure Support Ventilation (PSV)

A mode of mechanical ventilation in which the patient’s
spontaneous breaths are supported by the ventilator during the
inspiratory phase of breathing. As the patient triggers a breath,
the ventilator assists by adding pressure to make breathing easier.

The level of pressure is preset by the operator, so you have control

over how much support you give the patient. For example, the
higher the level of pressure support that is set, the easier it will be
for the patient to take a breath.

In PSV, the breaths are time-cycled and pressure-limited.

PSV is often used to help the patient overcome the airway

resistance that is caused by the endotracheal tube.

9
For example, let’s say there is a patient who needs to be weaned
from the ventilator that is in the SIMV mode. If their endotracheal
tube size is too small, the airway resistance would be increased
which would make weaning difficult.

That’s when PSV would come in handy to help the patient

overcome the airway resistance so that they can be extubated.

Volume Support (VS)

A mode of mechanical ventilation in which the ventilator delivers a
supported breath to help the patient reach a set tidal volume. This
mode is totally dependent on the patient’s effort, meaning that,
the machine varies the inspiratory pressure support level with
each breath in order to achieve the target volume.

This mode is not quite as common as some of the others, but it’s
often used to wean patients from anesthesia.

10
Other Ventilator Modes

Now that we’ve covered the primary and spontaneous modes of

ventilation, now let’s go through the unconventional ventilator
modes. These are sometimes referred to as the secondary modes
of ventilation.

1. Control Mode Ventilation (CMV)

2. Airway Pressure Release Ventilation (APRV)
3. Mandatory Minute Ventilation (MMV)
4. Inverse Ratio Ventilation (IRV)
5. Pressure Regulated Volume Control (PRVC)
6. Proportional Assist Ventilation (PAV)
7. Adaptive Support Ventilation (ASV)
8. Adaptive Pressure Control (APC)
9. Volume-Assured Pressure Support (VAPS)
10. Neurally Adjusted Ventilatory Assist (NAVA)
11. Automatic Tube Compensation (ATC)
12. High-Frequency Oscillatory Ventilation (HFOV)

Control Mode Ventilation (CMV)

It’s a mode where the ventilator delivers a preset tidal volume at a
set time-triggered frequency. Basically, the ventilator controls
both the rate and tidal volume which means that it’s in total
control of the minute ventilation.

This mode should only be used on patients who are fully sedated
and have been administered neuromuscular blocking agents.

That is also the biggest hazard of using this mode because, since
the patient is fully dependent on the machine for ventilation and
oxygenation, it could be devastating if they were to become
disconnected.

11
Airway Pressure Release Ventilation (APRV)
A mode of mechanical ventilation in which two levels of
continuous positive airway pressure are applied with an
intermittent release phase for spontaneous breaths. This mode is
often recommended to improve oxygenation and treat refractory
hypoxemia.

Other indications for APRV include an Acute Lung Injury (ALI),

Acute Respiratory Distress Syndrome (ARDS), and Severe
Atelectasis.

Settings for APRV:

• High Pressure
• Low Pressure
• High Time
• Low Time

Mandatory Minute Ventilation (MMV)

This is a feature of some ventilators that causes an increase in the
mandatory breaths that are delivered when the patient’s
spontaneous breathing level becomes inadequate.

So basically, if the patient’s spontaneous breathing decreases, the

ventilator compensates in order to make sure that a safe minimal
minute ventilation is delivered.

MMV is often an additional function of the SIMV mode and is

intended to prevent hypercapnia.

12
Inverse Ratio Ventilation (IRV)
This is a mode that uses an inverse I:E ratio to improve
oxygenation and gas exchange. It’s been shown to decrease
shunting, improve V/Q mismatching, and decrease deadspace
ventilation.

IRV is commonly recommended for patients with Acute

Respiratory Distress Syndrome (ARDS).

This mode causes auto-PEEP (intrinsic PEEP) which is actually

what helps improve the patient’s oxygenation and reduce
shunting.

Pressure Regulated Volume Control (PRVC)

A mode of mechanical ventilation that provides volume-controlled
breaths with the lowest pressure possible. It does so by altering
the flow and inspiratory time. This mode is used to keep the peak
airway pressure at the lowest possible level.

This mode is volume-cycled and can be patient triggered-or time-

triggered.

Proportional Assist Ventilation (PAV)

This is a mode of mechanical ventilation where the machine uses
variable pressure to provide pressure support for a patient’s
spontaneous breaths. The level of pressure support is adjusted
depending on the patient’s work of breathing.

13
PAV is either pressure-triggered or flow-triggered, and the
breathing cycle ends once the patient’s volume or flow demands
are met.

One thing to keep in mind about this mode is that, if the patient’s
lungs show rapid improvement, overdistention or barotrauma
could occur because too much pressure would be delivered.

Adaptive Support Ventilation (ASV)

A mode of ventilation that changes the number of mandatory
breaths and pressure support level according to the patient’s
breathing pattern.

Adaptive Pressure Control (APC)

A pressure-controlled mode that utilizes a closed-loop control of
the pressure setting in order to maintain a minimum delivered
tidal volume.

With that said, in this mode, the delivered tidal volume will vary
depending on the patient’s lung compliance.

Volume-Assured Pressure Support (VAPS)

A mode of ventilation that provides a stable tidal volume by
incorporating inspiratory pressure support ventilation along with
conventional volume-assisted cycles. It’s only available on certain
ventilators.

14
This mode can cause a prolonged inspiratory time, so patients
with an obstructive disease should be monitored closely in order
to prevent air trapping or other cardiovascular effects.

Neurally Adjusted Ventilatory Assist (NAVA)

A ventilator mode that uses the patient’s electrical activity of the
diaphragm to guide the functionality of the ventilator.

A catheter with electrodes is positioned in the patient’s esophagus

at the level of the diaphragm, and that is how the electrical activity
is picked up from the phrenic nerves. Then, the ventilator uses this
information to ventilate the patient.

Automatic Tube Compensation (ATC)

While not technically a ventilator mode, this is a setting on some
ventilators that offsets and compensates for the airflow resistance
that is imposed by the endotracheal tube or artificial airway.

High-Frequency Oscillatory Ventilation (HFOV)

A type of mechanical ventilation that delivers very small tidal
volumes at an extremely fast rate which minimizes the chances of
a lung injury.

This mode has been shown to improve oxygenation in severe

cases, such as with refractory hypoxemia.

15
Adjusting the Setting in HFOV:

• Ventilation – can be increased by increasing the Amplitude

(Power) or by decreasing the frequency.
• Ventilation – can be decreased by decreasing the Amplitude
(Power) or by increasing the frequency.
• Oxygenation – can be increased by increasing the Mean
Airway Pressure setting or by increasing the FiO2.
• Oxygenation – can be decreased by decreasing the Mean
Airway Pressure setting or by decreasing the FiO2.

This mode is also indicated to provide mechanical ventilatory

support in neonates with conditions such as congenital
diaphragmatic hernia, diffuse alveolar disease, and pulmonary
hypoplasia.

Copyright ã Respiratory Therapy Zone

16
Ventilator Settings

Now that we’ve covered all the modes of mechanical ventilation,

let’s dive deeper into the settings that can be controlled by you
(the Respiratory Therapist) or the doctor.

What are Ventilator Settings?

To give a brief definition, ventilator settings are the controls on a
mechanical ventilator that can be set or adjusted in order to
determine the amount of support that is delivered to the patient.

Support can be provided in the form of ventilation and

oxygenation. You must develop an understanding of how each
setting can be adjusted in order to provide more or less of each
type of support for the patient. The good news is, that is exactly
what we’re going to cover in this article.

Examples of the Basic Ventilator Settings:

• Mode
• Tidal Volume
• Frequency (Rate)
• FiO2
• Flow Rate
• I:E Ratio
• Sensitivity
• PEEP
• Alarms

Keep reading if you want to learn more about each of the basic
ventilator settings. Below, we’re going to provide a detailed
overview of each.

17
Basic Ventilator Settings Explained:
In this section, we’re going to break down each ventilator setting,
one by one. Each setting can be controlled or adjusted depending
on the patient’s condition and needs.

Tidal Volume

Tidal Volume refers to the volume of air that is inhaled and

exhaled from the lungs during normal breathing. The tidal volume
setting on the ventilator determines how much air is delivered to
the lungs by the machine.

Frequency (Respiratory Rate)

The respiratory rate, also referred to as the breathing rate, is

simply the rate at which breathing occurs. It typically refers to the
number of breaths that are taken per minute and the normal
range is 10-20 breaths/minute.

The frequency setting on the ventilator determines how many

breaths are delivered to the patient by the machine.

Fraction of Inspired Oxygen (FiO2)

The FiO2, or fraction of inspired oxygen, is the concentration of

oxygen that is being inhaled by the patient.

For patient with severe hypoxemia, an FiO2 of 100% may be

required when mechanical ventilation is initiated. But you goal
should be to wean the FiO2 down to the lowest possible level that
provides adequate oxygenation.

If a patient receives an FiO2 > 60% for a prolonged period of time,

it increased their chances of oxygen toxicity.

18
Flow Rate

The inspiratory flow rate is a rate that controls how fast a tidal
volume is delivered by the ventilator. The setting can be adjusted
depending on the patient’s inspiratory demands.

The normal inspiratory flow rate should be set at around 60 L/min.

With that said, most ventilators can deliver up to 120 L/min if a
patient needs a prolonged expiratory which is necessary when
obstructive diseases are present.

If the flow rate is set too low, it could result in patient-ventilator

dyssynchrony and an increased work of breathing. If the flow rate
is set too high, it could result in decreased mean airway pressures.

Inspiratory-to-Expiratory Ratio (I:E Ratio)

The I:E ratio refers to a ratio of the inspiratory portion compared to

the expiratory portion of the breathing cycle.

For patients on the ventilator, the normal I:E ratio is between 1:2
and 1:4. A larger I:E ratio may be delivered if a patient is in need of
a longer expiratory time due to the possibility of air trapping.

The I:E ratio can be adjusted by making changes to the flow rate,
inspiratory time, expiratory time, tidal volume, and frequency
settings.

Trigger Sensitivity

The sensitivity control is what determines how much effort

(negative pressure) the patient must generate in order to trigger a
breath from the machine.

The normal sensitivity setting should be set between -1 and -2

cmH2O. If the sensitivity is set too high, it will cause the ventilator

19
to initiate auto-triggering and increase the total frequency of
breaths. If it’s set too low, the patient could have a difficult time
initiating a breath.

Positive End Expiratory Pressure (PEEP)

PEEP is a positive pressure that is delivered during the expiratory

phase of the breathing cycle in order to prevent the closure of
alveoli and allow increased time for oxygen exchange to occur.

It’s typically indicated in patients with refractory hypoxemia and

those who have not responded well to a high FiO2.

Ventilator Alarms

A ventilator alarm is a safety mechanism on a mechanical

ventilator that uses set parameters to provide alerts whenever
there is a potential problem related to the patient-ventilator
interaction.

Common Ventilator Alarms Include:

• High Pressure
• Low Pressure
• Low Expired Volume
• High Frequency
• Apnea
• High PEEP
• Low PEEP

20
Initial Ventilator Settings
Once it has been determined that mechanical ventilation is
indicated for a patient who needs help with oxygenation and/or
ventilation, then you must know how to properly input the initial
settings.

Each mechanical ventilator machine is different, so be sure to

abide by the guidelines provided by the manufacturer. However,
here are some general guidelines that you can use when
determining the initial ventilator settings.

Mode

Any operational mode will work when setting up the initial

ventilator settings! Don’t get too caught up on deciding on the
right mode, especially for the TMC Exam. With that said, just as a
reminder, you can select A/C in the patient needs full support or
SIMV if they only need partial support.

Tidal Volume

The initial tidal volume setting should be 5 – 10 mL/kg of the

patient’s ideal body weight (IBW).

Frequency

The initial frequency setting should be 10 – 20 breaths/min.

FiO2

The initial FiO2 setting should be 30 – 60% unless the patient was
previously receiving an higher percentage of oxygen before
intubation. Then you would use that previous FiO2. Strive to
provide the lowest concentration of oxygen that’s possible to

21
maintain a normal PaO2. An FiO2 up to 100% as an initial setting is
appropriate for patients with severe oxygenation issues.

Flow Rate

The initial flow setting should be 40 – 60 L/min.

I:E Ratio

The initial I:E ratio setting should be 1:2 – 1:4.

Sensitivity

The initial sensitivity setting should be between -1 and -2.

PEEP

The initial PEEP setting should be 4 – 6 cmH2O

How to Read Ventilator Settings?

Being able to read and understand the settings on a ventilator is a
highly valuable skill set that is usually only performed by doctors
and Respiratory Therapists.

Registered Nurses, however, do receive some limited training on

reviewing the basic ventilator settings. But their license does not
allow them to adjust or make changes to the settings. Again, this
is something that must be performed by the Respiratory Therapist
or physician.

22
TMC Practice Questions:

As a bonus, we wanted to give you access to a few sample TMC

Practice Questions on the topic of mechanical ventilation. These
are some of our premium practice questions, so read through
them and see what you think.

1. A 63-year-old female patient is intubated and receiving

mechanical ventilation in the pressure controlled A/C mode. If
the patient’s compliance were to decrease, which of the
following would you expect to occur?
A. Her delivered volume will decrease
B. Her peak pressure will increase
C. Her inspiratory time will increase
D. Her PEEP level will decrease

To get this one correct, you must have a basic understanding of

lung compliance. You also have to take into account that the
ventilator is in the pressure control mode, which means that the
pressure is pre-set.

If there is a decrease in lung compliance when the ventilator is

operating in the pressure control mode, the machine will continue
delivering a constant pressure. But, since the lungs don’t expand
as much when there is decreased compliance, it reaches the set
pressure limit much faster. That means that there will be a
decrease in the delivered tidal volume.

In this case, the inspiratory time will decrease and the PEEP levels
should not be affected.

The correct answer is: A. Her delivered volume will decrease

23
2. A 176 lb male patient is intubated and receiving volume control
A/C ventilation with the following settings: FiO2 of 40%, Rate of
12/min, and Tidal Volume of 550 mL. An ABG was analyzed and
the following results were obtained:
ABG Results Ventilator Settings
pH 7.39 Spontaneous Tidal Volume 180 mL
PaCO2 37 mmHg Spontaneous Rate 37/min
HCO3- 23 mEq/L Vital Capacity 550 mL
PaO2 107 mmHg MIP/NIF -12 cm H2O
Which of the following would you recommend?
A. Place the patient on a 40% T-piece and monitor closely
B. Switch the patient to SIMV at a rate of 5/minute
C. Place the patient CPAP and monitor closely
D. Maintain the current ventilator settings and re-evaluate
later

To get this one right, you must be able to interpret the patient’s
ABG results and make the appropriate changes to the ventilator
settings. You will likely see several questions in this format on the
TMC Exam.

The first thing you should note is that the values of the ABG results
are all within the normal ranges. Then you can look at the bedside
measurements.

The patient has a fast spontaneous breathing rate, a low

spontaneous tidal volume, a low vital capacity, and a low MIP/NIF.
All of these findings indicate that this patient is not ready for a
spontaneous breathing trial and should not yet be weaned. So it’s
best to maintain the current setting and re-evaluate the patient at
a later time.

All of the other answer choices demonstrate some type of

weaning, so we can rule them out right away.

24
The correct answer is: D. Maintain the current ventilator settings
and re-evaluate later

3. A 68-year-old male patient with COPD is receiving volume

control SIMV with the following settings:
Tidal volume 480 mL
Rate 12/min
Pressure support 10 cm H2O
PEEP 5 cm H2O
During a spontaneous breathing trial via T-tube, the patient’s
breathing rate increased drastically which required that he be
placed back on the ventilator. Which of the following would
you recommend during the next breathing trial?
A. Increase the sedation dosage
B. CPAP with pressure support via ET tube
C. CPAP without pressure support via ET tube
D. Extubate and provide BiPAP via full face mask

To get this one correct, you needed to be familiar with SBTs and
the process of weaning from mechanical ventilation.

There are 3 primary ways to perform an SBT:

• Simple T-piece without ventilatory support

• CPAP mode without pressure support
• CPAP mode with pressure support

Using CPAP with pressure support during an SBT can help the
patient overcome the extra work of breathing that is imposed by
the ET tube. It also helps to increase tidal volumes and prevent
tachypnea. None of the other answer choices are indicated in this
case, so you know that the correct answer has to be B.

The correct answer is: B. CPAP with pressure support via ET tube

25
Well, How’d You Do?
These were just a few example practice questions so that you can
get an idea of what to expect on the TMC Exam.

Mechanical Ventilation is definitely the most important section of

the exam, which means that it’s important to spend a lot of time
mastering this topic. Going through practice questions is a great
way to do just that!

The practice questions that we provided for you here were actually
taken straight from our TMC Test Bank.

It’s one of our bestselling products where we break down

hundreds of practice questions that cover every topic you need to
know for the TMC Exam.

Each question comes with a detailed rationale that explains

exactly why the answer is correct. Thousands of students have
already used it to pass the TMC Exam. Are you next?

If you thought the practice questions above were helpful,

definitely consider checking it out.

Click Here to Learn More

26
One More Thing!
Before you go, I just wanted to remind you about our Practice
Questions Pro membership.

As you can most likely already tell, our practice questions are
loaded with helpful tidbits of information that can help you
prepare for (and) pass the TMC Exam.

Now, you can get these TMC Practice Questions sent to your inbox
on a daily basis.

And the more practice questions you see, the better.

This way, over time, you can master every single topic that you
need to know to increase your chances of passing the exam on
your first (or next) attempt.

For many students, it’s very convenient to wake up each day and
have a new TMC Practice Question in the inbox waiting for you.

If this is something that sounds interesting to you, definitely

consider signing up.

Click Here to Get Daily Practice Questions via Email

27
Practice Questions:

To help you develop a better understanding of ventilator settings

and modes, we have listed out even more practice questions.

1. What is the definition of ventilator settings?

The controls on a mechanical ventilator that can be set or
adjusted in order to determine the amount of support that is
delivered to the patient.

2. If you have a patient with chest trauma, what would you want
the set flow to be above and what would you do to minimize the
chances of barotrauma?
The flow should be set above 60 LPM. This patient needs lower
volumes and a higher respiratory rate in order to minimize the
chances of barotrauma.

3. What ventilator setting makes it easier for a patient to initiate a

breath?
Sensitivity

4. What flow pattern is used in pressure-controlled mode and

what type of patients typically like this pattern?
Descending; and COPD patients.

5. If you have a patient with a set tidal volume of 600 mL but they
are getting 850 mL, what would you adjust and why?
In this case, you would need to decrease the pressure setting
because the normal tidal volume is 250 mL above the set tidal
volume.

6. What would be the normal ventilator settings for an adult

postoperative patient?

28
Mode: SIMV, Tidal volume: 5-10 mL/kg, Rate: 10-12 bpm, i-Time: 1
second, Flow: 40-60 LPM, PEEP: 5, FiO2: start at 100% and titrate to
keep their saturation > 90%.

7. If you have a patient with a closed head injury, what mode

would you choose for this patient?
Volume-controlled ventilation. Don’t use PEEP if a patient has
increased intracranial pressure.

8. You have a patient who was admitted for COPD exacerbation.

Which ventilator mode would you choose?
Pressure control

9. What is the normal range for trigger sensitivity?

The normal range is -1 to -2 cm H2O.

10. What type of ventilation would we use for normal lungs when
other systems are shutting down?
Volume ventilation

11. For a patient with a CHF exacerbation, when would you NOT
want to use volume ventilation?
You would not want to use volume ventilation if the PIP is high.
Also, you would want to consider using NIV first unless it is
contraindicated.

12. If there is a leak in the patient circuit, which alarm would likely
sound?
The Low-pressure alarm.

13. What is trigger sensitivity?

It is the setting that determines how easy it if for the patient to
initiate a breath.

14. What is the normal high minute ventilation alarm?

29
It should be set 10 L/min above the patient’s resting minute
ventilation.

15. Which type of ventilator mode would you use for an ARDS
patient?
Pressure Controlled Ventilation

16. Which type of ventilator mode would you use for a closed head
injury patient if there are no lung injuries?
Volume Controlled Ventilation

17. What type of flow pattern would you see when using a volume-
controlled mode?
Square

18. What I-time would you use for a patient with a CHF
exacerbation?
You would want to use an I-time of 1 to 1.5 seconds. The reason we
want a longer I-time is to use the pressure as a way to decrease
the edema associated with their CHF exacerbation.

19. You have a patient who was found unconscious and you do not
have any other information about the patient. What would the
initial ventilator settings need to be?
Mode: Volume-controlled, Tidal volume: 5-10 mL/kg, Respiratory
Rate: 10-20 bpm, I-time: 1 second, PEEP: 5 cmH2O, and FiO2: 100%.

20. Your patient’s high-pressure ventilator alarm is sounding.

What are the specific causes of this alarm?
Coughing, kinking in the circuit or ET tube, secretions, decreased
compliance, increased Raw, and mucous plugging.

21. What would the normal flow setting be for a postoperative hip
surgery patient?
40 – 60 L/min

30
22. An adult male patient presents to the ER after a motor vehicle
accident. He has an increased ICP and needs to be placed on the
ventilator. Which type of mode would you select for this patient?
Volume-controlled ventilation

23. What is the purpose of permissive hypercapnia?

It is used to decrease the PIP and the likelihood of barotrauma.

24. What is the term for when a COPD patient needs to be

mechanically ventilated while they also have acute respiratory
failure?
Acute-on-chronic respiratory failure

25. What mode should you set for a patient that has chest
damage from a motor vehicle accident?
Pressure-controlled mode.

26. What are the levels of alarms during mechanical ventilation?

Level 1: Immediately life-threatening (includes the failure of
electrical power, exhalation valve, or timing). There can be
excessive or no gas delivery to the patient. The remaining 2 levels
are potentially life-threatening and non-life threatening.

27. What alarm cannot be silenced if gas is critical to the ventilator

operation?
The low-source gas alarm

28. What is permissive hypercapnia?

The process of allowing the PaCO2 to rise slightly in order to give
small tidal volumes and a higher respiratory rate which can
decrease the chances of barotrauma.

29. Which alarm cannot be silenced?

The high-pressure alarm.

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30. A child arrives in ER with an acute asthma attack and needs to
be mechanically ventilated. Which type of ventilation would you
select?
Pressure-controlled ventilation

31. If a patient is in a volume-controlled mode and the high-

pressure alarm is going off, what is likely the problem?
The patient’s lung compliance has decreased which is causing an
increase in PIP.

32. Why do we allow for larger tidal volumes for patients with
neuromuscular diseases?
It allows for the patient to meet their “air hunger” needs.

33. What types of patients can benefit from permissive

hypercapnia?
ARDS patients. It uses a high respiratory rate and a low tidal
volume to prevent a high PIP (barotrauma).

34. If the flow setting is increased on a mechanical ventilator, what

setting may also need to be adjusted?
You may need to change the trigger from flow to pressure.

35. What are the two methods of setting a trigger?

Flow and Pressure.

36. Which flow patterns are the most common on a ventilator?

Square – often seen in volume controlled modes. Descending –
often seen in pressure controlled modes.

37. Which type of ventilation should be used for a patient with an

acute lung injury?
Pressure-controlled ventilation

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38. For an adult patient with ARDS who weighs 70 kg, which type
of ventilation would you select and what tidal volume would you
aim for?
You should select pressure-controlled ventilation and tidal volume
should be set at 280-560 mL. Patients with ARDS require a smaller
tidal volume than normal.

39. What happens to a mechanically delivered breath if the high-

pressure alarm is reached?
The alarm will sound and the breath will be terminated.

40. Which alarm settings can be triggered by a leak?

The low pressure, low tidal volume, and low minute ventilation
alarms.

41. If your patient has a tidal volume of 4-8 mL/kg and a respiratory
rate of 15-25 bpm, what disease process does this patient likely
have?
They likely have ARDS. A smaller tidal volume and higher
respiratory rate will decrease the chances of barotrauma and
minimize the PIP.

42. What are the various factors used to trigger ventilator breaths?
Pressure and Flow (from the patient), Timed (from the ventilator),
or Manual (from the operator)

43. What is the mean airway pressure?

It is the pressure maintained in the airways throughout an entire
respiratory cycle.

44. Which blood gas value is the primary indicator of adequate

ventilation?
PaCO2

45. What are the various ways you can adjust the I:E ratio on a
volume-cycled ventilator?

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By adjusting the flow, I-time, tidal volume, or the respiratory rate.

46. What FiO2 limit is considered dangerous in regards to possible

oxygen toxicity?
Greater than 60%.

47. What settings on a ventilator are used to increase or decrease

the PaO2?
FiO2 and PEEP

48. How does PEEP increase the blood oxygenation?

It increases alveoli recruitment by allowing positive pressure at the
end of expiration before inhalation, which restores the functional
residual capacity.

49. How can the inspiratory time improve blood oxygenation?

It allows for a longer inhalation time, which provides a longer
contact time for diffusion to take place.

50. What is the appropriate action for any ventilator problem that
is not immediately identified and corrected?
Remove the patient from the ventilator and begin manually
ventilating the patient with a bag-valve mask.

51. What ventilator changes could be made to correct respiratory

acidosis?
Increase the tidal volume or respiratory rate in order to blow off
more CO2. Adjust the tidal volume first, but if the tidal volume is
already in the ideal range, then adjust the respiratory rate.

52. What ventilator changes could be made to correct a

respiratory alkalosis?
Decrease the tidal volume or respiratory rate.

53. What changes could be made to correct a high PaO2?

Decrease the FiO2 or PEEP.

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54. What is the goal for the PaCO2 and pH when mechanically
ventilating a COPD patient with chronic hypercapnia?
The goal is to get them to their baseline because their PaCO2 and
pH are usually always acidic.

55. What is the normal tidal volume range?

The normal range is 5-10 mL/kg of ideal body weight.

56. What is the most common setting for the initiation of apnea
ventilation?
The most common settings is 20 seconds.

57. What techniques can be used to monitor the possible cardiac

effects of positive pressure ventilation?
An arterial-line, continuous blood pressure monitor, and a Swan-
Ganz catheter.

58. What is an advantage of pressure control ventilation over

volume control ventilation?
It helps to prevent barotrauma.

59. What is the pressure trigger?

The patient generates an inspiratory effort that drops the pressure
in the system, therefore, triggering the machine into inspiration.

60. What is a time trigger?

The machine begins inspiration as a result of a predetermined
time.

61. What is a flow trigger?

The patient generates an inspiratory effort that changes the flow
in the system, therefore, triggering the machine into inspiration.

62. What is an advantage of a flow vs pressure trigger?

Flow is more sensitive to the patient’s effort.

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63. What is a pressure limit?
It sets a maximum inspiratory pressure that can be delivered to
the patient. Basically, it stops inspiration.

64. What is the pressure-limiting relief valve?

It is basically the high-pressure alarm. It releases any pressure in
the system by venting any volume that is remaining. In other
words, it allows the volume to escape.

65. How does PEEP work?

It works by increasing the functional residual capacity. On
expiration, the pressure is held at an elevated baseline above the
atmospheric pressure.

66. What is CPAP in mechanical ventilation?

When used on a ventilator, CPAP is essentially the same thing as
PEEP except that the patient must be taking spontaneous
breaths.

67. How does PEEP contribute in removing CO2?

It doesn’t. PEEP only affects oxygenation, not ventilation.

68. What are patient triggered modes?

They are modes where the patient determines their respiratory
rate, inspiratory flow rate, and volume of breaths.

69. What basic parameters must be set on a ventilator?

Volume, rate, mode, and the initial FiO2.

70. What should be the initial ventilator setting for FiO2?

The initial FiO2 should be 30 – 60% unless the patient was
previously receiving an higher percentage of oxygen before
intubation. Then you would use that previous FiO2.

71. What are 5 examples of ventilator modes?

CMV, A/C, IMV, SIMV, and CPAP

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72. What type of pressure ventilation involves normal respirations,
chest cuirass, and an iron lung?
Negative pressure

73. Positive pressure ventilators can be ____ or ____ controlled.

Pressure, Volume

74. What are 2 examples of nonconventional ventilator modes?

HFOV and APRV

75. How does positive pressure ventilation create transairway

pressure?
By increasing the airway opening pressure above the alveolar
pressure.

76. List the modes of positive pressure ventilation from the most
support to the least support:
CMV, A/C, IMV, SIMV, CPAP

77. What is an advantage of a volume-controlled mode?

It ensures minimal minute ventilation.

78. What are some disadvantages of a volume-controlled mode?

The pressure is variable, there is a possibility of barotrauma or
volutrauma, and the volume is limited by the high pressure alarm.

79. What is an advantage of a pressure-limited mode?

There is less risk of barotrauma.

80. What are some disadvantages of pressure-controlled modes?

This type of mode doesn’t ensure minute ventilation, and the tidal
volume is variable.

81. What two things are variable in pressure-controlled modes?

The volume, which is dependent on a set pressure, and the flow.

37
82. What are the four types of triggers?
Time, Patient, Pressure, and Flow.

83. What control is used to adjust the patient’s inspiratory effort?

Sensitivity

84. What are the two types of sensitivity controls?

Pressure and Flow

85. How does a pressure trigger work?

The ventilator senses a drop in pressure below the baseline and
senses the patient’s negative inspiratory effort.

86. Which trigger type is more sensitive, pressure or flow?

Flow

87. How does a flow trigger work?

When a patient initiates a breath, the base flow returning to the
ventilator is reduced which triggers an inspiration.

88. What is Controlled Mandatory Ventilation?

A mode that is time-triggered, gives machine breaths, and is
volume or pressure cycled.

89. What are the indications for CMV?

The need to control minute ventilation completely. Also, the need
to control chest expansion completely. For example, it would be
helpful for a patient with a flail chest.

90. What are some complications of CMV?

The patient is totally ventilator dependent, alarms are essential,
you may be unable to assess weaning, and seizures may interrupt
the delivery of a breath.

91. What are some indications for the A/C mode?

38
The patient needs full ventilatory support, the need to support a
high minute ventilation with low oxygen consumption, and the
need for sedation after intubation.

92. What is an advantage of the A/C mode?

It keeps the patient’s work of breathing requirement low.

93. What is the IMV mode?

It was the first widely used mode that allowed partial ventilatory
support, facilitates weaning, and increases respiratory muscle
strength. It is not widely used today.

94. What are some complications of the IMV mode?

Breath stacking, which is a spontaneous effort immediately
followed by a mechanical breath. It leads to an increased PIP,
barotrauma, and cardiac compromise.

95. What is the synchronization window?

It is the time interval just prior to time triggering in which the
ventilator is responsive to the patient’s spontaneous breath.

96. What are some indications for the SIMV mode?

It is indicated for a patient who needs partial ventilatory support,
and if the patient can actively contribute to their minute
ventilation.

97. What happens if the rate is set high in the SIMV mode?
This would provide total ventilatory support. SIMV with no
spontaneous rate is essentially the same as A/C.

98. What happens if the rate is set low in the SIMV mode?
It facilitates weaning, strengthens the respiratory muscles, and
decreases the mean airway pressure making spontaneous breaths
have a lower peak pressure than mandatory breaths.

99. What are some complications of the SIMV mode?

39
A low rate can increase the patient’s work of breathing causing
respiratory muscle fatigue.

100. What mode has a positive baseline pressure continuously

applied to the circuit and airway during both inspiration and
expiration?
CPAP

101. In this mode, the ventilator delivers a time-triggered breath

and allows the patient to breathe at their own tidal volume
between mechanical breaths?
SIMV

102. In this mode, the ventilator delivers a set tidal volume or

pressure at a time-triggered rate but the patient can trigger a
mechanical breath above the preset rate?
Assist/Control

103. In this mode of ventilation, the patient cannot trigger a

mechanical or spontaneous breath so there is no negative
deflection on graphics?
Controlled Mandatory Ventilation (CMV). The patient must be
sedated or paralyzed. It is not as commonly used.

104. In order for this mode to be used, the patient must be

spontaneously breathing, have adequate lung function to
maintain normal PaCO2, and not be at risk for hypoventilation?
CPAP

105. What does pressure support do?

It augments spontaneous tidal volume, decreases spontaneous
respiratory rate, and reduces the patient’s work of breathing.

106. How does pressure support decrease the patient’s

spontaneous respiratory rate?

40
An increased volume decreases the need for a high respiratory
rate in order to achieve the required minute ventilation. Also, it
decreases deadspace ventilation.

107. What is the desired respiratory rate during mechanical

ventilation?
Less than 25.

108. What is tidal volume dependent upon with a pressure

support mode?
It is dependent on the set inspiratory pressure, lung compliance,
and airway resistance.

109. What makes flow variable in pressure support?

It’s dependent upon the flow needed to maintain the plateau
pressure.

110. What would be considered CPAP with pressure support?

BiPAP

111. How do you manage pressure support?

Begin with 5-10 and increase in increments of 3-5.

112. You should titrate pressure support according to what 3

things?
(1) Spontaneous tidal volume of 5 – 10 mL/kg of IBW. (2)
Respiratory rate of less than 25. (3) A decrease in work of
breathing.

113. Is PEEP considered a standalone mode on ventilation?

No, no it is not.

114. What are some positive effects of PEEP?

It helps recruit alveoli, increases the FRC, increases the alveolar
surface area, and increases oxygenation.

41
115. What are some complications of PEEP?
Cardiac compromise, increased intrathoracic pressure, decreased
venous return, decreased cardiac output, and decreased blood
pressure.

116. What is an indication for PEEP?

Refractory hypoxemia

117. How do you manage proper levels of PEEP?

The physiologic normal setting of PEEP is 5 cmH2O. You can
increase the setting in increments of 3 – 5 while watching the
patient’s blood pressure. You should strive to titrate to the
previous level or zero in order to lower blood pressure. You can
treat low blood pressure with volume expansion or vasopressors,
then increase the PEEP setting again while continuing to monitor.

118. Is Inverse Ratio Ventilation (IRV) a volume controlled or

pressure controlled mode?
IRV is a pressure controlled mode.

119. During mechanical ventilation, a long inspiration and a short

expiration causes what?
It causes air trapping, auto-PEEP, and prevents alveolar collapse.

120. What is auto-PEEP?

Air trapping that occurs when there is an incomplete expiration.

121. How does IRV prevent alveolar collapse?

The critical opening pressure is reduced, the pressure needed for
ventilation is less, and it improves ventilation.

122. What are some complications of IRV?

Barotrauma, requires paralysis sedation, and cardiovascular
compromise.

123. When is Mandatory Minute Ventilation activated?

42
MMV is activated when the patient’s spontaneous breathing is less
than the minimum set minute ventilation. When this occurs, the
ventilator increases ventilation.

124. The method of increased ventilation with MMV varies upon

what?
It depends on the ventilator model. Some ventilators increase the
respiratory rate, some increase the tidal volume, and some
increase the level of pressure support.

125. In mechanical ventilation, what should the minute ventilation

be set to achieve?
It should be set to achieve a satisfactory PaCO2.

126. What are some advantages of MMV?

It promotes spontaneous breathing, it requires minimal support
but protects against hypoventilation and respiratory acidosis, and
it permits weaning but compensates for apnea.

127. What does Pressure Control generate?

It generates a flow in order to increase the airway pressure to a
preset pressure limit.

128. What are some indications for pressure control?

It is indicated for patients with a low lung compliance, patients
with a high PIP during volume controlled ventilation, and in
patients with ARDS.

129. What are some advantages of Pressure Control Ventilation?

The PIP is reduced while maintaining adequate oxygenation and
ventilation. Also, there is a reduced risk of barotraumas.

130. How do you manage pressure control?

The PIP is set to achieve a desired tidal volume unless the patient
is allowed to become hypercapnic in the interest of limiting the

43
PIP. Tidal volume and minute ventilation must be carefully
monitored in this mode.

131. What APRV stand for?

It is a mode of ventilation that stands for Airway Pressure Release
Ventilation.

132. APRV is inappropriate for what kind of patients?

Those at risk for an inadequate spontaneous respiratory rate.

133. When does APRV resemble IRV?

APRV resembles IRV when the expiratory pressure release time is
less than the spontaneous effort.

134. Why is APRV a beneficial alternative to IRV?

Because it does not require paralytic medications.

135. What is the description of the APRV mode?

It is time-triggered but the patient is allowed to breathe
spontaneously at any time. It is mandatory and spontaneous
pressure limited and it is time-cycled with a preset I-time.

136. What is HFOV?

It is a mode of ventilation that stands for High-Frequency
Oscillatory Ventilation. It reduces the risk of lung destruction by
keeping alveoli open at a constant pressure. It oscillates very
rapidly and provides a high respiratory rate at very small tidal
volumes.

137. What is amplitude in HFOV?

It is the change in stroke volume and the force delivered by the
piston. Adjusting the amplitude setting helps control the patient’s
ventilation.

138. What are the trigger variables for VC/SIMV?

Time, volume, and pressure.

44
139. What is the limit variable for VC/SIMV?
Volume

140. What is the definition of Controlled Mandatory Ventilation

(CMV)?
It is a ventilator mode that is used in sedated, apneic, or paralyzed
patients. All breaths are triggered, limited, and cycled by the
ventilator. The patient has no ability to initiate their own breaths.

141. What is the definition of Synchronized Intermittent Mandatory

Ventilation (SIMV)?
It is a ventilator mode that provides assisted mechanical
ventilation synchronized with the patient’s breathing. The
ventilator senses the patient taking a breath then delivers the
breath. Spontaneous breathing by patient occurs between the
assisted mechanical breaths which occurs at preset intervals. If the
patient fails to take a breath, the ventilator will provide a
mechanical breath.

142. When is the SIMV mode preferred?

When the patient has an intact respiratory drive.

143. How is SIMV is similar to CPAP and BIPAP?

SIMV, BiPAP, and CPAP are all spontaneously triggered by patient.

144. How does the trigger in Assist/Control ventilation work?

The trigger for delivery of a breath can be either by the patient or
by elapsed time.

145. What is the preferred mode for patients with respiratory

distress?
Assist/Control

146. This mode can be used in ARDS, paralyzed, or sedated

patients?

45
Assist/Control Ventilation

147. During Assist/Control ventilation, what can happen to an

anxious patient?
They can trigger the ventilator to hyperventilate which leads to
breath stacking or auto-PEEP.

148. Which mode of mechanical ventilation can provide a precise

I:E ratio?
Control Mode Ventilation (CMV)

149. What mode can make it easier for the patient to overcome
the resistance of the ET tube and is often used during weaning
because it reduces the work of breathing?
Pressure Support Ventilation

150. What is the definition of Pressure Support Ventilation?

It is a ventilator mode that supports ventilation during inspiration.
The patient determines the tidal volume, rate, and minute volume.
It requires consistent respiratory effort by the patient.

46
Conclusion

So there you have it!

You now have access to everything you need to know about the
settings and modes of mechanical ventilation.

Now it’s up to you to learn this information.

I definitely recommend that you read through this stuff several

times until the information sticks. Your future self will thank you,
especially once it’s time to take the board exams.

No worries, I have total faith that you can do it!

Keep working and studying hard and you will be just fine. Thank
you so much for reading all the way to the end.

I wish you the best of luck on your journey, and as always, breathe
easy my friend. J

Copyright ã Respiratory Therapy Zone

47
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2. Egan’s Fundamentals of Respiratory Care. (2010) 11th Edition.

Kacmarek, RM, Stoller, JK, Heur, AH. Elsevier.

3. Mosby’s Respiratory Care Equipment. Cairo, JM. (2014) 9th

Edition. Elsevier.

4. Pilbeam’s Mechanical Ventilation. (2012) Cairo, JM. Physiological

and Clinical Applications. 5th Edition. Saunders, Elsevier.

5. Ruppel’s Manual of Pulmonary Function Testing. (2013) Mottram,

C. 10th Edition. Elsevier.

6. Rau’s Respiratory Care Pharmacology. (2012) Gardenhire, DS. 8th

Edition. Elsevier.

7. Perinatal and Pediatric Respiratory Care. (2010) Walsh, BK,

Czervinske, MP, DiBlasi, RM. 3rd Edition. Saunders.

8. Wilkins’ Clinical Assessment in Respiratory Care (2013) Heuer, Al.

7th Edition. Saunders. Elsevier.

9. Clinical Manifestations and Assessment of Respiratory Disease.

(2010) Des Jardins, T, & Burton, GG. 6th edition. Elsevier.

10. Neonatal and Pediatric Respiratory Care. (2014) Walsh, Brian K.

4th edition. RRT. Elsevier.

11. Clinical Application of Mechanical Ventilation (2013) Chang,

David W. 4th edition. Cengage Learning.

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