Mechanical Ventilation Course

From Basic Knowledge To Advanced Care

Modes of Mechanical Ventilation

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 Regardless of which operating mode is selected, it should
achieve four main goals: provide adequate ventilation and
oxygenation, avoid ventilator-induced lung injury, provide
patient-ventilator synchrony, and allow successful weaning
from mechanical ventilation

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Ask Yourself

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Patient has to adapt to MV
No FB from patient to MV

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 MV adapts to the patient
FB data from patient to MV

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The clinician  monitor, analyze, Smart MV  monitor, analyze,
then act and adjust then act and adjust

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Delayed triggering or cycling Smart breath adjustment
Asynchrony needing sedation Better awake synchrony
Inadequate variables and VQ Adequate variables and VQ

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MODE

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Breath Type Trigger Target Cycle
V-control Time Flow Volume
V-assist Patient Flow Volume
P-control Time Pressure Time
P-assist Patient Pressure Time
P-support Patient Pressure Flow

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 The patient can breath
spontaneously without any
support or augmentation.
It can used for T-piece method
for SBT during weaning.
it can be used with PEEP.
It is associated with increased
WOB.

Apnea Backup ventilation

In the event of apnea, backup ventilation is recalled (set range
15-20 seconds), it deliver predetermined values according to
mode VC or PC

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 It maintains a continuous level of
positive airway pressure PAP in
a spontaneous breathing.
Expiratory PAP > inspiratory PAP
> zero baseline.

Recruitment and Oxygenation

It may be helpful in refractory hypoxia and atelectasis;
preservation of FRC and reduction of WOB

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 It applies a preset pressure
plateau to airways for the
duration of spontaneous breath.
Starting spontaneous breath, it is
augmented by preset limited
pressure, and ends the breath
when flow is reduced when
reduction by 10-25% of PIFR.

Importance
PSV augments patient’s inspiratory efforts, increasing tidal volume and
reduction of WOB

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 Importance
PSV needs a competent drive and
adequate efforts.
It can not be used in deeply
sedated nor paralyzed patients,
and in ARDS/shocked patients.
It is commonly used as a recovery
mode; with SIMV and mode of
weaning.

PSV level is titrated until spontaneous tidal volume 10 ml/kg and frequency
less than 25 b/m; add-on PEEP.
Once PSV level is less than 10 cmH2O with adequate effort; it is time for
weaning SBT.

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VOLUME control PRESSURE control

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VOLUME control PRESSURE control

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 Mandatory solo MV doses all of
the work; preset start of breath ,
target variables (VC or PC), and
end of breath, without any
patient effort

Patient Criteria
The patient is properly medicated with sedation and NMBAs

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 Indications
CMV (with sedation and
NMBAs) is indicated for patients
fighting the MV.
Also in status epilepticus with
complete anesthesia/anti-
epileptic infusions, or in cases of
crushed chest injury or impaired
ventilatory drive or pump.

Complications
As the patient is totally dependent on MV; there is apnea and hypoxia when
accidently MV-patient disconnection, and prolonged difficult weaning due to
diaphragmatic disuse atrophy and oxidative injury.

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The patient may increase MV assisted frequency (patient triggered) in
addition to the preset MV controlled frequency (time triggered).
AC dose not allow the patient to take the whole spontaneous alone

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 The patient starts breath, then
the MV delivers the breath
achieving preset targets
variables, and breath ends by MV
preset data.
With adequate patient
ventilatory drive of 12/min,
minimum control frequency is
10/min.

Indications
As a resting mode, MV provides full ventilatory support while permits the
patient (when able) to trigger MV into inspiration; used in ARDS, ACPO,
shock, and multisystem trauma, or impaired ventilatory drive or pump.

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 Advantages
Reduction WOB, and the patient
is allowed to control RR and
minute volume according to his
demand and efforts.

Disadvantages
With patient rapid breathing, it causes alveolar hyperventilation with
alkalosis, and hyperinflation with auto-PEEP.

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 Intermitting Pattern
periodic VC/PC mandatory
breaths and PSV supported
spontaneous breaths in between.
It is not continuous mandatory
nor spontaneous breathing

The patient can decide his own

frequency of supported breaths, in
addition MV gives a set number
of mandatory breaths to
supplement patients won efforts

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 The mandatory AC breaths are synchronized with the spontaneous
breaths efforts to avoid breath-stacking double-triggering (associated
with high alveolar volume and overdistension-volutrauma, or high
AW pressure and barotrauma)

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 Synchronization Window

During this window

If there is patient inspiratory effort, the
MV is patient-triggered to deliver
assisted mandatory breath.
If there is no patient inspiratory effort,
the MV is time-triggered to deliver
controlled mandatory breath.

In-between these windows

The patient is permitted to take
supported spontaneous breaths,
depending on his demand/effort

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 VC-SIMV with PSV PC-SIMV with PSV

Indications
The primary indication for SIMV is to provide partial ventilatory
support; keeping the patient actively involved in providing part of the
minute volume. It was introduced as a method for weaning.

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 Advantages
It maintains respiratory muscles
strength by avoiding their
atrophy, and it decreases mean
AW pressure, plus it facilitates
weaning.

Disadvantages
Early use of SIMV can lead to
increased WOB of spontaneous
breaths, and muscle fatigue with
weaning failure.

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Conventional modes
Variables are affected by Variables with dual control
patient effort and demand
plus ventilatory drive and
mechanics
To be adjusted, they need
input from the clinician
The ventilator dose not
adapt to dynamic changes
Smart modes
change in proportion to
patient effort and demand
plus ventilatory drive and
mechanics
Automatic and adaptive
achievement of preset
targets and limits
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Guaranteed Adequate MV Computerized FB
with Limited Safe Pressures systems make online
smart automatic
adjustments in tidal
volume, frequency,
airway pressures, and
timing of the
respiratory cycle

Improved
Patient-Ventilator Synchrony

Limited
VILI and HD instability

Improved
VQ matching and Vent-Oxyg

Reduced
WOB and sedation
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 Pressure-limited Time-cycled breath-to-breath
PC-ACV  VC-ACV
Smart ventilator compares the delivered Vt/MV with the
preset Vt/MV
The physician presets Vt target, and the ventilator delivers a
pressure-limited breath, until that preset Vt is achieved
The ventilator adjusts Vt target , and Ti/I:E values, plus limit
of IP, with RR according to patient-A or MV-C
The IP is automatically adjusted  or  to deliver a preset Vt;
according to change of mechanics R/C
If delivered Vt is equal, there is no action
If delivered Vt is low, it increases IP on the next breath
If delivered Vt is high, it decreases IP on the next breath

PRVC – APV – VC+

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 Pressure-limited Flow-cycled breath-to-breath
PSV  VC-SIMV
Smart ventilator compares the delivered Vt/MV with the
preset Vt/MV
The physician presets Vt target, and the ventilator is triggered
to a pressure-limited breath according to patient spontaneous
effort, until that preset Vt is achieved
The ventilator adjusts Vt target plus limit of IP, and RR plus
Ti/I:E values according to patient spontaneous effort
The PS is automatically adjusted  or  to deliver a preset Vt;
according to change of mechanics R/C
If delivered Vt is equal, there is no action
If delivered Vt is low, it increases PS on the next breath
If delivered Vt is high, it decreases PS on the next breath

VSV – MMV
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 Pressure-limited Flow-cycled within-breath
PSV  VC-ACV
Smart ventilator compares the delivered Vt with the preset Vt
The physician presets Vt target, and the ventilator is triggered
to a pressure-limited breath according to patient spontaneous
effort, until that preset Vt is achieved
The ventilator adjusts Vt target, plus limit of IP, and RR plus
Ti/I:E values according to patient spontaneous effort
Each breath is automatically shifted to and from VC-ACV
If delivered Vt is equal, there is no action
If delivered Vt is low, it forms constant inspiratory flow to
reach preset Vt

VAPS

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Variable Support-Control Automode/Adaptive
PSV/PC-ACV  VC-SIMV/ACV
Automatic shift from supported to assisted breaths of dual-
control nature, plus Adaptive manner to meet needed MV
If there is no spontaneous effort, the ventilator is set up in
PRVC mode (time-cycle)
If there are adequate spontaneous breaths, the ventilator
shifts to VSV mode (flow-cycle)

Proportional Assist Ventilation PAV

No preset limits or targets
This mode supports patient spontaneous breathing in
proportion to his effort/demand and change in mechanics
Constant WOB regardless changing effort/demand

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Guaranteed Adequate MV with Limited Safe Pressures

Dual control with Time-cycling

Depends on ventilator delivery/triggering
Not for weaning

Dual control with Flow-cycling

Depends on adequate patient spontaneous efforts
Self weaning mode

Variable support-control
Automatic weaning from ventilator delivery/triggering to adequate
patient spontaneous effort

Proportional support
Depends on adequate patient spontaneous efforts
Variables are delivered in proportion to effort/demand

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 PC-ACV  VC-ACV

The lowest possible IP is

used to deliver preset Vt/MV
With PC-ACV
If delivered Vt is equal, there is
no action.
If delivered Vt is low, it increases
IP on the next breath; to achieve
preset Vt
If delivered Vt is high, it
decreases IP on the next breath;
to achieve preset Vt

Automatic adjusting IP for VC breath by

altering PIFR and Ti; in response to
mechanical AW and lung changes R/C

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 Test for
compliance and
set IP limit

Delivery at
previous measured
values

Modify PIFR
and Ti to deliver
target Vt and
under-limit IP

Disadvantages Indications
Guaranteed Vt with preset lowest
It may result in air-trapping and
PIP in ARDS or asthma and
auto-PEEP, and it may be poorly
COPD; allowing adequate alveolar
tolerated in non-sedated patients.
ventilation plus oxygenation.
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 PSV  VC-SIMV

Compare delivered Vt with

desired preset Vt
No set for RR or Ti
If delivered Vt is equal, there is
no action.
If delivered Vt is low, it increases
PS on the next breath; to achieve
preset Vt
If delivered Vt is high, it
decreases PS on the next breath;
to achieve preset Vt
If apnea, it is shifted to PRVC

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 PSV  SIMV

Compare actual patient effort

MV with desired preset MV
With PSV actual MV ≥ preset
MV; no action.
With PSV actual MV < preset
MV; activation of MMV,
operating with SIMV with
adjusted AC Vt and frequency
to reach preset MV.
Once adequate recovery of
spontaneous drive; return to
baseline PSV.
Partial  Full  Partial

Automatic smartly ensuring adequate preset MV; preventing hypoventilation

and hypercapnia

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 PSV  VC-ACV

Compare delivered Vt with

desired preset Vt
With PSV delivered Vt ≥ preset
Vt; no action.
With PSV delivered Vt < preset
Vt; activation of VAPS,
operating with VC-AC to adjust
inspiratory flow and time; to
reach preset Vt.
Partial  Full  Partial

Providing optimal inspiratory flow and

tidal volume with targeted pressure;
reducing WOB and adequate ventilation.
It may prolong inspiratory time,
resulting in air-trapping in COPD 40
 PSV  SIMV or PC-ACV  VC-ACV

Compare delivered effort

MV with desired preset MV
Passive patients; the ventilator
adjusts the appropriate values
of Vt/RR/Ti/I:E plus limited IP;
to maintain preset MV; PC-
ACV plus guaranteed MV
Active patients trigger
ventilator to decrease PC
breaths, and to increase PSV
level until preset Vt/RR;
maintaining preset MV

Excellent mode for ventilation Initiation ----- Support ----- Weaning

ASV is adaptive to patient demand/effort and dynamic mechanics/drive
More PSV breathing ----------------- Less PC-ACV breathing
Guaranteed minute volume with Limited safe inspiratory pressure 41
 Clinician Input
Limit of IP/PEEP/FiO2 ,and
patient IBW, plus desired
target MV (100 ml/kg/min)

Ventilator Analysis
Dynamic compliance

Ventilator Adjustment
Vt/RR and Ti/I:E plus limit
of IP

Final Adaptation
Reach to guaranteed MV
with PC or PSV

Used as full support in

ARDS/COPD, and for
facilitated weaning
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 VSV  PRVC

Automatic shift from

supported to assisted breaths
of dual-control nature, plus
Adaptive manner to meet
needed MV
If there is no spontaneous
effort, the ventilator is set up in
PRVC mode (time-cycle)
If there are adequate
spontaneous breaths, the
ventilator shifts to VSV mode
(flow-cycle)

Excellent mode for ventilation Initiation ----- Support ----- Weaning

It is adaptive to patient demand/effort and dynamic mechanics/drive
More PSV breathing ----------------- Less PC-ACV breathing
Guaranteed minute volume with Limited safe inspiratory pressure 44
 Amplification of patient
effort, without preset
limits or targets, with
constant WOB
Measurement of flow/Vt pulled
by the patient

Calculation of respiratory
elastance and resistance

Determination of proportional
support to overcome E/R

Delivery the needed pressure

This mode supports patient

spontaneous breathing in
proportion to his effort/demand
and change in lung mechanics
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IRV and APRV APRV and BIPAP

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 PC-IRV  Bi-CPAP

PC-IVR allowing biphasic

spontaneous CPAP
Inhalation phase high pressure and
time is more than exhalation phase
low pressure and time.
High period is for constant alveolar
recruitment and oxygenation.
Low period is for release and
ventilation; avoided derecruitment as
it is short period.

During high and low phases

If there is enough effort, it allows
Bi-CPAP spontaneous breathing.
If there is no respiratory effort, it
becomes a form of inversed ratio
pressure limited ventilation.
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 It allows lung protective strategy,
alveolar recruitment, and improves
oxygenation and hemodynamics in
ARDS, plus allowing spontaneous
breathing and patient-ventilator
synchrony, so less sedation/NMBAs.
It may be complicated with potential
volutrauma due to dynamic
hyperinflation, and increased WOB.

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 PC-AC  CPAP/PSV

PC-AC allowing biphasic

spontaneous CPAP or PSV
Inhalation phase high pressure and
time is and exhalation phase low
pressure and time.
High period is for constant alveolar
recruitment and oxygenation.
Low period is for release and
ventilation.

During high and low phases

If there is enough effort, it allows
Bi-CPAP or Bi-PSV spontaneous
breathing.
If there is no respiratory effort, it
becomes a pressure limited
ventilation.
Bi-level
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 APRV
PC-IRV  Bi-CPAP
The patient spends most of time
at level of high pressure.

BIPAP
PC-AC  Bi-CPAP or bi-PSV
The patient spends most of time
at level of low pressure.

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 IRV mode I:E > 1:1 (2:1 – 4:1)

Improved oxygenation
Prolonged inspiration allows
alveolar recruitment, and
shortened expiration allows for
auto-PEEP and prevention of
decruitment.
Constant volume alveoli
Improved VQ plus reduced
shunt.

Disadvantages
Overdistension and barotrauma,
Indication
and increased trans-vascular fluid
In ARDS with sedation/NMBAs
shift with APO, and it needs
sedation with NMBAs
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 PC-IRV
Increasing Ti  increasing
inspiration  time-cycling

VC-IRV
Slowing PIFR  increasing
inspiratory time  flow-cycling
Inspiratory pause  increasing
inspiratory time  time-cycling

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 Neuro-Ventilatory Integration

Inspiratory neural drive  electrical activity of diaphragm  processed

signal  ventilator triggering  mechanical inflation  reduced signal
intensity  ventilator cycling  mechanical deflation

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 Clinical impact of
diaphragmatic injury

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 CPAP with a wiggle

Time-cycled very high rate breaths with

small Vt, oscillating around a steady AW
pressure
No overdistension Nor derecruitment
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 Advantages
Uniform Steady AW and
alveolar inflation pressures,
with constant recruitment and
prevented decruitment.
Reduced risk of Volutrauma,
Barotrauma, Biotrauma, and
Atelectrauma.
Improved VQ and gas exchange.

Disadvantages
Hemodynamic instability, and Indication
increased ICP, need for As a rescue treatment in ARDS
sedation/NMBAs, and frequent refractory to ventilation and prone
suctioning of AW to reduce position; when ECMO is not
obstruction. available nor suitable
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Thank you
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