Modes of

Ventilation
 Aims

 To be able to demonstrate essential

knowledge of the care and management of
the patient requiring mechanical ventilation
 Objectives

 Explore the indications and contra-indications

 Overview of the modes of ventilation
 Be familiar with normal parameters of
ventilation
 Discuss the indications for weaning and
extubation
 Indications

 Respiratory Failure
 Cardiopulmonary arrest
 Trauma Events
 Cardiovascular impairment
 Neurological impairment
 Pulmonary impairment
 Procedures requiring sedation/paralysis
 Goals

 Treat hypoxemia/hypercapnia
 Relieve respiratory distress/reverse
fatigue
 Decrease Myocardial O2 demand
 Prevention or reversal of atelectasis
 Breath for the sedated/paralysed
patient
 Stabilise the chest wall
 Contra-Indications

 Risks outweigh benefits, for example

Neutropenia
 Non-invasive deemed preferable to invasive
ventilation
 Invasive ventilation considered medically futile
 Contrary to the expressed wishes of the patient
Ventilation
 Ventilators

A machine that generates a controlled

flow of blended air and oxygen into a
patient’s airway.
 Ventilation

Two categories Volume or Pressure

This refers to the mode of breath delivery

rather than the mode itself
 Volume

In volume category modes of ventilation the machine

generates flow to achieve a set volume known as

TIDAL VOLUME
 Tidal Volume

Definition –

VT
‘the volume of air that
is inspired or expired
in a single breath
during regular
breathing’
 Volume Modes

Advantages Disadvantages

Guaranteed Minute Increased monitoring

Ventilation (Mv). of airway pressures.
Airway pressures will
increase if lung
compliance decreases.
Risk of barotrauma.
Minute Ventilation

Definition –

M V
‘the total volume of gas
in litres expelled from
the lungs per minute’
 Pressure

In pressure modes of ventilation a pressure limit is set,

the machine generates flow until the peak pressure
limit is achieved-

PAP or PIP
Peak Airway
(inspiratory) Pressures
Peak Airway (Inspiratory)
Pressures

P ip Definition –

P
‘is the highest level of
pressure applied to the
ap lungs during inhalation
expressed in cmh2o’

P peak
 Pressure Modes

Advantages Disadvantages

Greater control of No guaranteed minute

airway pressure. ventilation.
Less risk of Increased monitoring of
barotrauma. VT required.
Rapid changes in the
compliance can cause
hypoventilation/hypoxia.
 Inspiration

FLOW TRIGGER - a breath is generated when the patient’s

respiratory effort causes flow to reach a set level.
PRESSURE TRIGGER - a breath is generated by measuring
pressure and starting assisted ventilation when pressure
reaches a given level.
TIME TRIGGER - a breath is generated by measuring
frequency of respirations and starting ventilation when
respirations frequency is at a given.
 Expiration

 TIME CYCLED - such in in pressure controlled ventilation

 FLOW CYCLED - such as in pressure support

 VOLUME CYCLED - the ventilator cycles to expiration once a

set tidal volume has been delivered: this occurs in volume
controlled ventilation.
Mandatory Modes of
Ventilation
Intermittent Positive Pressure
Ventilation

IPPV
 IPPV

Set: TV, rate, Fi02, PEEP,

No capacity for the patient
to trigger a breath
Uncomfortable if patient
not fully sedated &/
paralysed
Suitable only for patients
who have no ability to
breathe spontaneously
Mandatory Assist Modes of
Ventilation
 SIMV

Synchronized Intermittent Mandatory Ventilation

 SIMV

 Provides a set TIDAL VOLUME at a set RATE (F)

 Patient can breathe in-between mandatory ventilation
 Spontaneous breaths are supported with pressure
support
 Ventilator synchronises mandatory breaths and
spontaneous breaths for increased patient comfort
NB
Usually volume targeted but some machines offer SIMV(pc)
 SIMV

Advantages Disadvantages

 Guaranteed Minute  Increased monitoring of

Ventilation airway pressures.
 Airway pressures will
increase if lung
compliance decreases.
 Risk of barotrauma.
Bilevel Positive Airway Pressure

BiPAP
 BiPAP

 Provides a set P-insp at a set RATE (F)

 Patient can breathe in-between mandatory ventilation

 Spontaneous breaths are supported with pressure support

 Pt can breathe at any point of respiratory cycle, not just

between breaths

 Breathing takes between two levels Pinsp and PEEP

 BiPAP

Advantages Disadvantages

Increased patient comfort No guaranteed Minute

Ventilation
Can limit high airway Increased monitoring of Tidal
pressures Volumes
Patient may hypo-ventilate
and become hypoxic if lung
Reduce risk of barotrauma
compliance changes suddenly
Spontaneous Modes of
Ventilation
 Spontaneous Modes of
Ventilation

Spontaneous modes
are-
Triggered
Cycled

-By the patient

 Pressure Support or ASB

The patient triggers the ventilator and receives a

supported breath at a pre-set pressure.

This helps overcome the increased work of breathing

or resistance of breathing through an endotracheal
tube.
 Complications of invasive ventilation

 Airway:
 Aspiration pneumonia
 Trauma to trachea during
intubation
 Hypoxia prior to / during
intubation
 Laryngeal oedema
 Occlusion of blood supply to
trachea (if cuff pressures to
high)
 Sinus infection
 Complications of invasive ventilation

 Mechanical:

 Ventilator malfunction.
 Ventilator circuit: occlusion,
kinks, bronchospasm,
disconnection & biting.
 Barotrauma / Volutrauma
can rupture alveoli, causing
pneumothorax.
 Complications of invasive ventilation

 Decreased cardiac output:

 Induction agents
 Changes intrathoracic
pressure & reduces venous
return
 Cardiac output falls, BP
drops
 CVP and LV preload rise
 This has implications for the
perfusion of all vital organs:
brain, kidneys, GI tract
Complications
 PEEP

 Maintains pressure within the

breathing circuit at a pre-set
level at the end of expiration

 When used during

spontaneous respiration it is
called CPAP

 A degree of PEEP should be

applied on all ventilation modes
to minimise risk of atelectasis
Other settings to consider:
Inspiration time : Expiration time

 I:E ratio is 1:2

 Can be reversed – 1:1 or less:

2:1

 Some machines automatically

alter I:E ratios when the set
resp rate is altered.
 Reversing the I:E Ratio
Disadvantages Advantages
Air trapping from  Advantages or
increased reversing the I:E ratio:
intrathoracic pressure  Alveolar recruitment
Hypercarbia ( Î C02)  Reduced alveolar
Breath stacking collapse due to shorter
Extreme discomfort expiratory times
for the pt  Increased mean airway
Reduction in cardiac pressure without
return increasing PAP