Mechanicalventilation

mode
Faundra arieza Firdaus
Dep anasthesiologi
Rs Hermina tangkubanprahu
WHAT ARE
VENTILATORS ?

▶ A machine that generates a controlled flow of gas into a patient’s airways

▶ Supportive role to buy time

MECHANICAL
VENTILATION

▶ Several models have evolved over time-

▶ Negative pressure ventilation

▶ Positive pressure ventilation

▶ Simple pneumatic system
▶ New generation microprocessor controlled
systems.

▶ The basic function and applica-

tions remain common.
BASIC VENTILATOR
PARAMETERS

▶ Tidal volume
▶ Frequency
▶ PIP
▶ Plateau Pressure
▶ PEEP
▶ Inspiratory Time
▶ Expiratory time
▶ I:E Ratio
BASIC VENTILATOR
PARAMETERS

▶ Mode
▶ Tidal volume
▶ Frequency
▶ PIP
▶ Plateau Pressure
▶ PEEP
▶ Inspiratory Time
▶ Expiratory time
▶ I:E Ratio
STARTING A VENTILATOR:
MODE

▶ Mode denotes interplay b/w patient and the ven-

tilator
▶ Describes the style of breath support based on rela-
tionship between the various possible types of breath
and inspiratory – phase variables
WHERE TO START ?

▶ CPAP, IPAP, EPAP, NIV

▶ Pressure control, Volume control
▶ CMV, Assist Control, IMV, SIMV,
▶ PSV, ASV, MMV,
▶ APRV
▶ PCV, PRVC, PSV, VCIRV, Volume
Support,
▶ Auto Mode,
▶ BiLevel, Bi-
PAP,
▶ HFJV,
HFOV
Objective FROM
OBJECTIVE To
OBJECTIVES

▶ Understand how ventilators control breath delivery, phase and con-

trol variables.

▶ Understand the basic modes of ventilation.

▶ Combinations, tailor-making, mix and match…

THE VENTILATOR
CIRCUIT
THE VENTILATOR
CIRCUIT

Blender
Air-O2 mixture
of desired FiO2
50 psi air
at 50 psi
50 psi O2

Stepped down
pressure

Pressure
Flow regulating
regulator valve
Exp limb

Insp limb T-piece & ETT

tube
FLOW
REGULATORS / PEEP
Flow in
ventilator
circuit-
constant
T-connection

ET
T

Flow in ET & patient Flow

airway- sensor
keeps changing in Baby’s
magnitude & di- airway
rection !!
 WHAT DOES FLOW
SENSOR DO?
Flow in
ventilator
circuit-
constant
T-connection

E Flow
sensor
Insp flow T Exp flow
 T - insp flow
RR
= peri-tube leak
= tidal vol
 VENTILATORY
PHASES
• Inspiration: Inspiratory valve opens and
expiratory valve is closed
• Inspiratory pause: inspiratory valve and
expiratory valve closed
• Expiration: Inspiratory valve closed and 0
expiratory valve open
Ti Te
• Expiratory pause: Inspiratory valve and
expiratory (or PEEP) valve closed at end
of expiration
PHASE VARIABLES: TRIGGER, LIMIT
AND CYCLING
PHASE
VARIABLES

▶ Trigger : ventilator (time)- triggered or patient (pressure or flow) trig-

gered
▶ Limit: flow-limited or pressure-limited
▶ Cycling: volume, time, flow or pressure cycled.
PHASE VARIABLES:
TRIGGER

▶ What causes the breath to begin (signal to open the in-

spiratory valve)
▶ Machine (controlled): the ventilator will trigger regular breaths at a frequency
which will depend on the set respiratory rate, ie, they will be ventilator time
triggered.

▶ Patient (assisted): If the patient does make an effort to breathe and the ventila-
tor can sense it (by either sensing a negative inspiratory pressure or an inspi-
ratory flow) and deliver a breath, it will be called a patient- triggered breath.
PHASE VARIABLES: TRIGGER
PHASE VARIABLES: TRIGGER
PHASE VARIABLES: LIMIT

Factor which controls the inspiration inflow

▶ Flow Limited: a fixed flow rate and pattern is set and maintained throughout inspiration.
▶ An adequate tidal volume (Ti dependent)
▶ Pressure will be variable (comp and resistance dependent)
▶ Pressure limited: the pressure is not allowed to go above a preset limit.
▶ The tidal volume will be variable (comp and resistance dependent)
PHASE VARIABLES:
CYCLING

▶ Signal that stops the inspiration and starts the expiration.

▶ Without inspiratory pause: one signal
▶ With inspiratory pause: two cycling signals (one to close inspiratory valve and
the second to open the expiratory valve)

▶ Volume
▶ Time
▶ Flow
▶ Pressure : back-up form of cycling when the airway pressure reaches the set
high-pressure alarm level
 THE VENTILATORY
CYCLE

PIP

PEEP

Ti Te

0.35 sec 0.65

sec

1 resp cycle= Ti + Te
 BREATH TYPE: SPONTANEOUS VS
Mechanical vs assisted

Assisted
Mechanical

Inspiration

Paw Spontaneous
(cm H2O)
Expiration
Expiration

Inspiration
Time (sec)
CONTROL
VARIABLES

▶ Pressure: Pressure signal is the feedback signal (Pressure Preset)

▶ Volume: Volume signal is the feedback signal. usually measure the flow and
turn it into volume signal electronically. (volume preset)

▶ Time
▶ Flow

▶ Combinations
VOLUME CONTROL
VENTILATION

Preset Peak Flow Flow

Dependent on
Cl & Raw Pressure

Preset Vt
Volume

Time (sec)
PRESSURE CONTROL
VENTILATION

Flow

Set PC Pressure
level

Cl Cl
Volume

Time (sec)
BASIC MODES OF VENTILATION

▶ Controlled Mechanical Ventilation

▶ Assist Control Ventilation
▶ Intermittent Mandatory Ventilation
▶ Synchronized Intermittent Mandatory Ventilation

▶ Pressure Support
▶ Combinations
 CONTROLLED MANDATORY
VENTILATION
(CMV
) The ventilator delivers
▶ Preset tidal volume (or pressure) at a time triggered (preset) respiratory rate.
▶ As the ventilator controls both tidal volume (pressure) and respiratory rate, the
ventilator “controls” the patients minute volume.
Pressure
CONTROLLED MANDATORY
VENTILATION
(CMV)
Volume controlled Pressure controlled
CONTROLLED MANDATORY
VENTILATION
Tar-
(VOLUME-
geted) Time triggered, Flow limited, Volume cycled Ventilation
Preset Peak
Flow
Flow
(L/m)

Dependent on
Pressure CL & Raw
(cm
H2O)
Preset VT
Volume Volume Cy-
cling
(mL)

Time (sec)
CONTROLLED MANDATORY
VENTILATION
Targeted) (PRESSURE-
Time Triggered, Pressure Limited, Time Cycled Ventilation

Time-Cycled
Flow
(L/min)

Set PC level
Pressure
(cm H2O)

Volume
(ml)
Time (sec)
CONTROLLED MANDATORY
VENTILATION
(CMV)
▶ Patient can not breath spontaneously
▶ Patient can not change the ventilator respiratory rate

▶ Suitable only when patient has no breathing efforts

▶ Disease or
▶ Under heavy sedation and muscle relaxants
CONTROLLED MANDATORY
VENTILATION
(CMV)
▶ Asynchrony and increased work of breathing.

▶ Not suitable for patient who is awake or has own respiratory efforts

▶ Can not be used during weaning

ASSIST CONTROL
VENTILATION
 ASSIST CONTROL
VENTILATION

Control ventilation (CMV) Assist / control ventilation

Control Control Assisted

Pressure

Time (sec)
 ASSIST CONTROL
VENTILATION

▶ A set tidal volume (volume control) or a set pressure and time (pressure
control) is delivered at a minimum rate
▶ Additional ventilator breaths are given if triggered by the patient
▶ Mandatory breaths: Ventilator delivers preset volume and preset flow rate at a
set back-up rate
▶ Spontaneous breaths: Additional cycles can be triggered by the patient but other-
wise are identical to the mandatory breath.
Pressure

Assist / control ventilation

Control ventilation (CMV)
 ASSIST CONTROL
VENTILATION

▶ Tidal volume (VT) of each delivered breath is the same, whether it is

assisted breath or controlled breath
▶ Minimum breath rate is guaranteed (controlled breaths with set VT)
Pressure

Assist / control ventilation

Control ventilation (CMV)
ASSIST CONTROL
VENTILATION
(volume) Assist Control (Pressure) Assist Control
Ventilation Ventilation
 ASSIST CONTROL
VENTILATION (PRESSURE)
Patient / TimeTriggered, Pressure Limited, Time Cycled Ventilation

Time-Cycled
Flow

Set PC level
Pressure

Pt triggered Time triggered

Volume

Time (sec)
 ASSIST CONTROL
VENTILATION (VOLUME)
Patient / Time triggered, Flow limited, Volume cycled Ventilation

Flow

Pressure

Preset VT
Volume Volume Cycling

Time (sec)
 ASSIST CONTROL
VENTILATION

▶ Asynchrony taken care of to some extent ▶ Hyperventilation

▶ Low work of breathing, as every breath is ▶ Respiratory alkalosis.
Pressure

Assist / control ventilation

Control ventilation (CMV)
 ASSIST CONTROL
VENTILATION

🞄 Hyperventilation and breath stacking can usually be

overcome by choosing optimal ventilator settings and ap-
propriate sedation.
Pressure

Assist / control ventilation

Control ventilation (CMV)
 (IMV
) 🞄 Machine breaths are delivered at a set rate (volume or pressure
limit)
Pressure

Time (sec)
 (IMV
) 🞄 Machine breaths are delivered at a set rate (volume or pressure
limit)
🞄 Patient is allowed to breath spontaneously from either a demand
valve or a continuous flow of gases but not offering any inspira-
Pressure

tory assistance.

Time (sec)
 (IMV
) 🞄 Patient’s capability determines Tidal volume of spontaneously
breaths
🞄 Some freedom to breath naturally even on mechanical ventilator
Pressure

Time (sec)
 (IMV
) 🞄 Random chance of breath stacking and asynchrony: Increased
WOB
🞄 Uncomfortable feeling
Pressure

Time (sec)
(IMV)
Pressure controlled IMV Volume controlled IMV
 (IMV
) Cons:
▶ Freedom for natural spontaneous ▶ Asynchrony
Pros:
breaths even on machine
▶ Random chance of breath stacking.
▶ Lesser chances of hyperventilation
▶ Increase work of breathing
▶ Random high airway pressure
(barotrauma) and lung volume
(volutrauma)

Setting appropriate pressure limit is important to reduce the risk of barotrauma

CAN WE
SYNCHRONIZE
it?
SYNCHRONIZED INTERMITTENT
MANDATORY
Ventilation
▶ Ventilator delivers either patient triggered assisted breaths or time trig-
gered mandatory breath in a synchronized fashion so as to avoid breath
stacking

▶ If the patient breathes between mandatory breaths, the ventilator will allow
the patient to breathe a normal breath by opening the demand (inspiratory)
valve but not offering any inspiratory assistance.
 SYNCHRONIZATION WINDOW

🞄 Time interval just prior to time triggering in which the ventilator is

responsive to the patient’s inspiratory effort.
Pressure

Time trigerring

Time (sec)
 SIMV

If the patient makes a spontaneous inspiratory effort that falls in sync window, the
ventilator is patient triggered to deliver an assisted breath and will count it as manda-
tory breath
Patient trigerred
synchronized breath
Pressure

Time trigerred
mandatory breath
 SIMV

if patient does not make an inspiratory effort then ventilator will deliver a time
triggered mandatory breath.

Patient trigerred
synchronized breath
Pressure

Time trigerred
mandatory breath
 SIMV

if patient does not make an inspiratory effort then ventilator will deliver a time
triggered mandatory breath.

Patient trigerred
synchronized breath
Pressure

Time trigerred
mandatory breath
If the pt triggers outside this window, vent will allow this spontaneous breath to occur by opening the demand
(inspiratory) valve but does not offer any inspiratory assistance.
 SYNCHRONIZED INTERMITTENT
MANDATORY
Ventilation
3 types of breathing:

1. Patient initiated assisted ventilation,

2. Ventilator generated controlled ventilation,
3. Unassisted spontaneous breath.
Pressure
SYNCHRONIZED INTERMITTENT
MANDATORY
Ventilation
P-SIMV V-
SIMV
SYNCHRONIZED INTERMITTENT
MANDATORY
Ventilation (SIMV)
⚫ It
allows patients to assume a portion of their ventilatory drive:
Weaning is possible
⚫ Greater work of breathing than AC ventilation and therefore some may
not consider it as the initial ventilator mode
⚫ Friendlycardiopulmonary interaction: Negative inspiratory pressure
generated by spontaneous breathing leads to increased venous return,
which theoretically may help cardiac output and function
PRESSURE SUPPORT VENTILATION

▶ Pressure (or Pressure above PEEP) is the setting variable

▶ No mandatory breaths
▶ Applicable on Spontaneous breaths: a preset pressure assist,
▶ Flow cycling: terminates when flow drops to a specified fraction
(typically 25%) of its maximum.
▶ Patient effort determines size of breath and flow rate.
PRESSURE SUPPORT VENTILATION

▶ Pressure (or Pressure above PEEP) is the setting variable

▶ No mandatory breaths
▶ Applicable on Spontaneous breaths: a preset pressure assist,
▶ Flow cycling: terminates when flow drops to a specified fraction (typically
25%) of its maximum.
▶ Patient effort determines size of breath and flow rate
PRESSURE SUPPORT VENTILATION

▶ Pressure (or Pressure above PEEP) is the setting variable

▶ No mandatory breaths
▶ Applicable on Spontaneous breaths: a preset pressure assist,
▶ Flow cycling: terminates when flow drops to a specified fraction (typically
25%) of its maximum.
▶ Patient effort determines size of breath and flow rate.
PRESSURE SUPPORT VENTILATION

▶ It augments spontaneous VT decreases spontaneous rates and WOB

▶ Used in conjunction with spontaneous breaths in any mode of ventilation.
▶ No guarantee of tidal volume with changing respiratory mechanics,
▶ No back up ventilation in the event of apnea.
PRESSURE SUPPORT VENTILATION

▶ Provides pressure support to overcome the increased work of breathing

imposed by the disease process, the endotracheal tube, the inspiratory
valves and other mechanical aspects of ventilatory support
▶ Allows for titration of patient effort during weaning.
▶ Helpful in assessing extubation readiness
 SIMV + PS
VENTILATION

Spontaneous breath with PS

Pressure
SUMMA
RY
 Control ventilation (CMV) Assist / control ventilation
Control Control
Pressure

Assisted

Time (sec)
Pressure
Pressure
Thank you!! YOU HAVE DONE IT!!!