Modes of mechanical ventilation

Modes of mechanical ventilation are one of the most important aspects of the usage of mechanical ventilation. The mode refers to the method of inspiratory support. In general, mode selection is based on clinician familiarity and institutional preferences, since there is a paucity of evidence indicating that the mode affects clinical outcome. The most frequently used forms of volume-limited mechanical ventilation are intermittent mandatory ventilation (IMV) and continuous mandatory ventilation (CMV).^[1]

Terminology

There have been substantial changes in the nomenclature of mechanical ventilation over the years, but more recently it has become standardized by many respirology and pulmonology groups.^[2][3]

Writing a mode is most proper in all capital letters with a dash between the control variable and the strategy (i.e. PC-IMV, or VC-MMV etc.).^{[citation needed]}

Taxonomy for mechanical ventilation

The taxonomy is a logical classification system based on 10 maxims of ventilator design:^[4]

10 maxims

How modes are classified

Step 1: Identify the primary breath control variable. If inspiration starts with a preset inspiratory pressure, or if pressure is proportional to inspiratory effort, then the control variable is pressure. If inspiration starts with a preset tidal volume and inspiratory flow, then the control variable is volume. If neither is true, the control variable is time.

Step 2: Identify the breath sequence. Determine whether trigger and cycle events are patient or machine determined. Then, use this information to determine the breath sequence.

Step 3: Identify the targeting schemes for the primary breaths and (if applicable) secondary breaths.

Example mode classification is given below

Mode Name: A/C Volume Control (Covidien PB 840):^{[citation needed]}

1. Inspiratory volume and flow are preset, so the control variable is volume.
2. Every breath is volume cycled, which is a form of machine cycling. Any breath for which inspiration is machine cycled is classified as a mandatory breath. Hence, the breath sequence is continuous mandatory ventilation.
3. The operator sets all the parameters of the volume and flow waveforms so the targeting scheme is set-point. Thus, the mode is classified as volume control continuous mandatory ventilation with set-point targeting (VC-CMVs).

Mode Name: SIMV Volume Control Plus (Covidien PB 840):^{[citation needed]}

1. The operator sets the tidal volume but not the inspiratory flow. Because setting volume alone (like setting flow alone) is a necessary but not sufficient criterion for volume control, the control variable is pressure.
2. Spontaneous breaths are allowed between mandatory breaths so the breath sequence is IMV^{[clarification needed]}.
3. The ventilator adjusts inspiratory pressure between breaths to achieve an average preset tidal volume, so the targeting scheme is adaptive. The mode tag is PC-IMVa,s.

Descriptions of common modes

Mechanical ventilation machines are available with both invasive modes (such as intubation) and non-invasive modes (such as BPAP). Invasive has to do with the insertion of medical devices or tubes internal to the patient, while non-invasive is completely external to the patient, as for example in using a tightly fitting mask or other device that covers the patient's nose and mouth.

Assist mode, control mode, and assist-control mode

A basic distinction in mechanical ventilation is whether each breath is initiated by the patient (assist mode) or by the machine (control mode).^{[citation needed]} Dynamic hybrids of the two (assist-control modes) are also possible, and control mode without assist is now mostly obsolete.^{[citation needed]}

Airway pressure release ventilation

Airway pressure release ventilation graph

Airway pressure release ventilation is a time-cycled alternant between two levels of positive airway pressure, with the main time on the high level and a brief expiratory release to facilitate ventilation.^{[5][6][7][needs update?]}

Airway pressure release ventilation is a very versatile mode of ventilation. Like other modes, it needs to be well understood to use it effectively.^[8] The exhalation time (T_low) is shortened to usually less than one second to maintain alveoli inflation. In the basic sense, this is a continuous pressure with a brief release.

Different perceptions of this mode may exist around the globe. While 'APRV' is common to users in North America, a very similar mode, biphasic positive airway pressure (BIPAP), was introduced in Europe.^{[9][needs update?]} The term APRV has also been used in American journals where, from the ventilation characteristics, BIPAP would have been perfectly good terminology.^{[10][needs update?]} But BiPAP(tm) is a trademark for a noninvasive ventilation mode in a specific ventilator (Respironics Inc.).

Other manufacturers have followed with their own brand names (BILEVEL, DUOPAP, BIVENT). Although similar in modality, these terms describe how a mode is intended to inflate the lung, rather than defining the characteristics of synchronization or the way spontaneous breathing efforts are supported.

Intermittent mandatory ventilation has not always had the synchronized feature, so the division of modes were understood to be SIMV (synchronized) vs IMV (not-synchronized). Since the American Association for Respiratory Care established a nomenclature of mechanical ventilation the "synchronized" part of the title has been dropped and now there is only IMV.

Mandatory minute ventilation

Mandatory minute ventilation (MMV) allows spontaneous breathing with automatic adjustments of mandatory ventilation to the meet the patient's preset minimum minute volume requirement. If the patient maintains the minute volume settings for V_T x f, no mandatory breaths are delivered.^{[citation needed]}

If the patient's minute volume is insufficient, mandatory delivery of the preset tidal volume will occur until the minute volume is achieved. The method for monitoring whether or not the patient is meeting the required minute ventilation (V_E) differs by ventilator brand and model, but, in general, there is a window of monitored time, and a smaller window checked against the larger window (i.e., in the Dräger Evita® line of mechanical ventilators there is a moving 20-second window, and every 7 seconds the current tidal volume and rate are measured) to decide whether a mechanical breath is needed to maintain the minute ventilation.^{[citation needed]}

MMV is an optimal mode for weaning in neonatal and pediatric populations and has been shown to reduce long-term complications related to mechanical ventilation.^{[11][needs update?]}

Pressure-regulated volume control

Pressure-regulated volume control is an Assist Controlled Ventilation (ACV) based mode. Pressure-regulated volume control utilizes pressure-limited, volume-targeted, time-cycled breaths that can be either ventilator- or patient-initiated.^{[citation needed]}

The peak inspiratory pressure delivered by the ventilator is varied on a breath-to-breath basis to achieve a target tidal volume that is set by the clinician.

For example, if a target tidal volume of 500 mL is set but the ventilator delivers 600 mL, the next breath will be delivered with a lower inspiratory pressure to achieve a lower tidal volume. Though PRVC is regarded as a hybrid mode because of its tidal-volume (VC) settings and pressure-limiting (PC) settings fundamentally PRVC is a pressure-control mode with adaptive targeting.

Continuous positive airway pressure

Continuous positive airway pressure (CPAP) is a non-invasive positive pressure mode of respiratory support. CPAP is a continuous pressure applied to keep the alveoli open and not fully deflate. This mechanism for maintaining inflated alveoli helps increase partial pressure of oxygen in arterial blood, an appropriate increase in CPAP increases the PaO₂.^{[citation needed]}

Automatic positive airway pressure

Automatic positive airway pressure (APAP) is a form of CPAP that automatically tunes the amount of pressure delivered to the patient to the minimum required to maintain an unobstructed airway on a breath-by-breath basis by measuring the resistance in the patient's breathing.^{[citation needed]}

Bilevel positive airway pressure

Bilevel positive airway pressure (BPAP) is a mode used during non-invasive ventilation (NIV). First used in 1988 by Professor Benzer in Austria,^[12] it delivers a preset inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP). BPAP can be described as a Continuous Positive Airway Pressure system with a time-cycle change of the applied CPAP level.^{[13][needs update?]}

CPAP/APAP, BPAP, and other non-invasive ventilation modes have been shown to be effective management tools for chronic obstructive pulmonary disease, acute respiratory failure, sleep apnea, etc.^{[14][needs update?]}

Often BPAP is incorrectly referred to as "BiPAP". BiPAP is the name of a portable ventilator manufactured by Respironics Corporation; it is just one of many ventilators that can deliver BPAP.^{[citation needed]}

Medical uses

BPAP has been shown to be useful in reducing mortality and reducing the need for endotracheal intubation when used in people with chronic obstructive pulmonary disease (COPD).^[15]

High-frequency ventilation (Active)

The term active refers to the ventilator's forced expiratory system. In a HFV-A scenario, the ventilator uses pressure to apply an inspiratory breath and then applies an opposite pressure to force an expiratory breath. In high-frequency oscillatory ventilation (sometimes abbreviated HFOV) the oscillation bellows and piston force positive pressure in and apply negative pressure to force an expiration.^{[16][needs update?]}

High-frequency ventilation (Passive)

The term passive refers to the ventilator's non-forced expiratory system. In a HFV-P scenario, the ventilator uses pressure to apply an inspiratory breath and then returns to atmospheric pressure to allow for a passive expiration.^{[citation needed]}

This is seen in High-Frequency Jet Ventilation, sometimes abbreviated HFJV. Also categorized under High Frequency Ventilation is High Frequency Percussive Ventilation, sometimes abbreviated HFPV. With HFPV it utilizes an open circuit to deliver its subtidal volumes by way of the patient interface known as the Phasitron.^{[citation needed]}

Volume guarantee

Volume guarantee an additional parameter available in many types of ventilators that allows the ventilator to change its inspiratory pressure setting to achieve a minimum tidal volume.^{[citation needed]} This is utilized most often in neonatal patients who need a pressure controlled mode with a consideration for volume control to minimize volutrauma.

Spontaneous breathing and support settings

Positive end-expiratory pressure

Positive end expiratory pressure (PEEP) is pressure applied upon expiration. PEEP is applied using either a valve that is connected to the expiratory port and set manually or a valve managed internally by a mechanical ventilator.

PEEP is a pressure that an exhalation has to bypass, in effect causing alveoli to remain open and not fully deflate. This mechanism for maintaining inflated alveoli helps increase partial pressure of oxygen in arterial blood, and an increase in PEEP increases the PaO₂.^{[17][needs update?]}

Pressure support

Pressure support is a spontaneous mode of ventilation also named Pressure Support Ventilation (PSV). The patient initiates every breath and the ventilator delivers support with the preset pressure value. With support from the ventilator, the patient also regulates their own respiratory rate and their tidal volume.

In Pressure Support, the set inspiratory pressure support level is kept constant and there is a decelerating flow. The patient triggers all breaths. If there is a change in the mechanical properties of the lung/thorax and patient effort, the delivered tidal volume will be affected. The user must then regulate the pressure support level to obtain desired ventilation.^[18][19]

Pressure support improves oxygenation,^{[20][needs update?]} ventilation and decreases work of breathing.

Also see adaptive support ventilation.

Other ventilation modes and strategies

Flow-controlled ventilation

Flow-controlled ventilation (FCV) is an entirely dynamic ventilation mode, without pauses, with continuous and stable gas flows during both inspiration and expiration, aiming for linear changes in both volume and pressure.^[21] FCV is an invasive ventilation mode but, unlike Volume- and pressure controlled modes, it does not rely on a passive expiration created by collapse of the thoracic wall and elastic recoil of the lungs. A high resistant breathing circuit inhibits a passive expiration and therewith allows to fully control and stabilize the expiration flow. FCV creates an inspiration by generating a stable flow from a set End-expiratory pressure (EEP) to a set Peak pressure. Then a stable expiratory flow is created by suctioning.^{[22][needs update?]} This expiratory flow rate is preferably similar to the inspiratory flow, aiming for an I:E ratio of 1:1.0, to minimize energy dissipation in the lungs.^{[23][medical citation needed][24]} FCV is a more efficient ventilation as compared to conventional modes,^{[25][26][non-primary source needed]} allows ventilation through even small lumens (~2 – 10 mm ID)^{[27][28][non-primary source needed]} and results in less applied mechanical power.^[25] FCV was invented by Professor Dr. med. Dietmar Enk.^{[21][non-primary source needed]}

Negative pressure ventilation

Main article: Negative pressure ventilator

Negative-pressure ventilation stimulates (or forces) breathing by periodic application of partial vacuum (air pressure reduced below ambient pressure), applied externally to the patient's torso—specifically, chest and abdomen—to assist (or force) the chest to expand, expanding the lungs, resulting in voluntary (or involuntary) inhalation through the patient's airway.^[29][30][31]

Various "negative pressure ventilators" (NPVs) have been developed to serve this function—most famously the "Iron lung," a tank in which the patient lays, with only their head exposed to ambient air, while air pressure on the remainder of their body, inside the tank, is varied by pumping, to stimulate chest and lung expansion and contraction. Though not in wide use today, NPVs were the principal forms of hospital and long-term mechanical ventilation in the first half of the 20th century, and remain in limited use today.^[29][30][31]

Closed loop systems

Adaptive Support Ventilation

Adaptive Support Ventilation (ASV) is the only commercially available mode that uses optimal targeting. This technology was patented in 1991^[32][33][34] In this positive pressure mode of ventilation, the frequency and tidal volume of breaths of a patient on the ventilator are automatically adjusted and optimized to mimic natural breathing, stimulate spontaneous breathing, and reduce weaning time. In the ASV mode, every breath is synchronized with patient effort if such an effort exists, and otherwise, full mechanical ventilation is provided to the patient.^[35][36]

Automatic Tube Compensation

Automatic Tube Compensation (ATC) is the simplest example of a computer-controlled targeting system on a ventilator. It is a form of servo targeting.^{[citation needed]}

The goal of ATC is to support the resistive work of breathing through the artificial airway.

Neurally Adjusted Ventilatory Assist

Neurally Adjusted Ventilatory Assist (NAVA) is adjusted by a computer (servo) and is similar to ATC but with more complex requirements for implementation.^{[citation needed]}

In terms of patient-ventilator synchrony, NAVA supports both resistive and elastic work of breathing in proportion to the patient's inspiratory effort

Proportional Assist Ventilation

Proportional assist ventilation (PAV) is another servo targeting based mode in which the ventilator guarantees the percentage of work regardless of changes in pulmonary compliance and resistance.^{[37][needs update?]}

The ventilator varies the tidal volume and pressure based on the patient's work of breathing. The amount it delivers is proportional to the percentage of assistance it is set to give.

PAV, like NAVA, supports both restrictive and elastic work of breathing in proportion to the patient's inspiratory effort.

Liquid ventilation

Liquid ventilation is a technique of mechanical ventilation in which the lungs are insufflated with an oxygenated perfluorochemical liquid rather than an oxygen-containing gas mixture. The use of perfluorochemicals, rather than nitrogen, as the inert carrier of oxygen and carbon dioxide offers a number of theoretical advantages for the treatment of acute lung injury, including:

• Reducing surface tension by maintaining a fluid interface with alveoli
• Opening of collapsed alveoli by hydraulic pressure with a lower risk of barotrauma
• Providing a reservoir in which oxygen and carbon dioxide can be exchanged with pulmonary capillary blood
• Functioning as a high-efficiency heat exchanger

Despite its theoretical advantages, efficacy studies have been disappointing and the optimal clinical use of LV has yet to be defined.^{[38][needs update?]}

Total liquid ventilation

In total liquid ventilation (TLV), the entire lung is filled with an oxygenated PFC liquid, and a liquid tidal volume of PFC is actively pumped into and out of the lungs. A specialized apparatus is required to deliver and remove the relatively dense, viscous PFC tidal volumes, and to extracorporeally oxygenate and remove carbon dioxide from the liquid.^{[39][40][41][needs update?]}

Partial liquid ventilation

In partial liquid ventilation (PLV), the lungs are slowly filled with a volume of PFC equivalent or close to the FRC during gas ventilation. The PFC within the lungs is oxygenated and carbon dioxide is removed by means of gas breaths cycling in the lungs by a conventional gas ventilator.^{[42][needs update?]}

See also

• Medicine portal

• Table of modes of mechanical ventilation
• Mechanical ventilation – Method to mechanically assist or replace spontaneous breathing
• Prone ventilation
• Respiratory therapist – Practitioner in cardio-pulmonary medicine
• Bubble CPAP – Noninvasive form of ventilation for newborns