1. Modes of Mechanical Ventilation

2. P OINTS OF D ISCUSSIONS Advanced Basics: Flow and Time Limit and cycling Rise Time Volume vs Pressure Control Mandatory Modes of Ventilation Controlled Mandatory Ventilation (CMV or IPPV) Triggered Modes of Ventilation Continuous Positive Airway Pressure (CPAP) Pressure Support Ventilation (PSV) Hybrid Modes of Ventilation Assist Control Mode (A/C) Synchronized Intermittent Mandatory Ventilation (SIMV)

3. R ESPIRATORY C YCLE Transition=Inspiratory Cycling Transition=Expiratory Cycling Inspiration Expiration

4. M ANDATORY, S PONTANEOUS AND T RIGGERED I NSPIRATORY C YCLING M S T synch M M M M M M M S M T supp S

5. P RESSURE L IMITED B REATH Time Volume Pressure Limit

6. E XPIRATORY F LOW C YCLING Time Flow 50% 100% Flow Cycling

7. V OLUME C ONTROLLED I NFLATION Time Flow Pressure Volume TITI TETE Tidal Volume

8. If compliance decreases the pressure increases to maintain the same Vt 12 3 4 56 SEC 12 3 4 56Paw cmH 2 0 50 -20 120 120 SEC INSP EXH Flow L/min V OLUME C ONTROL B REATHS Decreased Compliance

9. P RESSURE C ONTROLLED I NFLATION Time Flow Pressure Volume TITI TETE Tidal Volume Rise Time Peak Inspiratory Flow

10. InspirationExpiration 01 20 0 01 2 3 -3 0 20 0 2 1 0 01 2 3 -3 0 20 0 2 InspirationExpiration Volume/Flow Control Pressure Control Time (s) Paw Pressure Volume Flow

11. R ISE T IME Time Flow Pressure Volume TITI TETE

12. V OLUME C ONTROL WITH E ND -I NSPIRATORY P AUSE Time Flow Pressure Volume TITI TETE Tidal Volume End Inspiratory Pause

13. Exp Insp R ELATIONSHIP BETWEEN T IDAL V OLUME, I NSPIRATORY T IME AND F LOW V T 1 T i a V T 2 V T 3 Time Volume Flow= 30 L/min Flow= 15 L/min Flow= 37.5 L/min

14. Exp Insp R ELATIONSHIP BETWEEN T IDAL V OLUME, I NSPIRATORY T IME AND F LOW V T 1 T i a Time Volume T i bT i c Flow= 30 L/min Flow= 20 L/min Flow= 60 L/min

15. TRIGGERED MODES OF VENTILATION CPAP and PSVV

16. S PONTANEOUS B REATHING Time (sec) Flow (L/m) Pressure (cm H 2 O) Volume (mL)

17. C ONTINUOUS P OSITIVE A IRWAY P RESSURE (CPAP) Time (sec) Flow (L/m) Pressure (cm H 2 O) Volume (mL) CPAP Level

18. P RESSURE S UPPORT V ENTILATION (PSV) Time (sec) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Set PS Level Flow Cycling Better Efforts Longer Inspiration Patient Triggered, Flow Cycled, Pressure limited Mode

19. CPAP+PSV Time (sec) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Set PS Level Flow Cycling Patient Triggered, Flow Cycled, Pressure limited Mode CPAP Level

20. T RIGGERED M ODES OF V ENTILATION P RESSURE S UPPORT V ENTILATION ControlTriggerLimitTargetCycle PressurePatientPressureFlow Patient Triggered Flow Cycled Ventilation

21. P RESSURE O R V OLUME -T ARGETED V ENTILATION Full to partial ventilatory support Augments the patients spontaneous VT Decreases the patient’s spontaneous respiratory rate Decreases patient WOB by overcoming the resistance of the artificial airway, vent circuit and demand valves Allows patient control of TI, Vm I, f and VT Set peak pressure Prevents respiratory muscle atrophy Facilitates weaning Improves patient comfort and reduces need for sedation May be applied in any mode that allows spontaneous breathing, e.g., VC-SIMV, PC-SIMV Requires consistent spontaneous ventilation Patients in stand-alone mode should have back-up ventilation VT variable and dependant on lung characteristics and synchrony Low exhaled V E Fatigue and tachypnea if PS level is set too low Advantages Disadvantages

22. MANDATORY MODES OF VENTILATION CMV or IPPV

23. M ANDATORY M ODES OF V ENTILATION CMV ControlTriggerLimitTargetCycle Pressure Or Volume Time Time Triggered Time Cycled Ventilation

24. C ONTROL M ODE (P RESSURE -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Time Triggered, Pressure Limited, Time Cycled Ventilation Time (sec) Time Cycling Set PC Level

25. C ONTROL M ODE (V OLUME -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Time Triggered, Flow Limited, Volume Cycled Ventilation Time (sec) Preset V T Volume Cycling Time Cycling Dependent on C L & R aw

26. P RESSURE O R V OLUME -T ARGETED V ENTILATION Decreases the work of breathing (WOB) Helps maintain a normal PaCO2 Not able to assist the ventilator Advantages Disadvantages

28. HYBRID MODES OF VENTILATION SIMV and A/C

29. H YBRID M ODES OF V ENTILATION A/C ControlTriggerLimitTargetCycle Pressure Or Volume Time Or Patient Time Time or PatientTriggered Time Cycled Ventilation

30. A SSISTED M ODE (V OLUME -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Patient Triggered, Flow limited, Volume Cycled Ventilation Time (sec) Preset peak Flow Time Cycling

31. A SSISTED M ODE (P RESSURE -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Patient Triggered, Pressure Limited, Time Cycled Ventilation Time (sec) Time Cycling Set PC Level

32. P RESSURE O R V OLUME -T ARGETED V ENTILATION Decreases the work of breathing (WOB) Allows patients to regulate respiratory rate Helps maintain a normal PaCO2 Alveolar hyperventilation Advantages Disadvantages

33. H YBRID M ODES OF V ENTILATION SIMV/PS Breath Type ControlTriggerLimitCycle MandatoryPressure Or Volume Time Or Patient Time SpontaneousPressurePatientPressureFlow

34. SIMV (V OLUME T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) Spontaneous Breaths M MM Time (sec)

35. SIMV+PS (V OLUME T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) M T supp T synch Set PS Level Flow-cycled Time (sec)

36. SIMV + PS (P RESSURE -T ARGETED V ENTILATION ) Flow (L/m) Pressure (cm H 2 O) Volume (mL) T supp T synch Time Cycled Flow-cycled T synch Set PC Level Set PS Level Time (sec)

37. H YBRID M ODE V ENTILATION : S UPPRESSION Time (sec) Flow (L/m) Pressure (cm H 2 O) Cycles M T supp M M M M

38. H YBRID M ODE V ENTILATION : S YNCHRONIZATION (SIMV+PSV) Time (sec) Flow (L/m) Pressure (cm H 2 O) Cycles Triggered window for supported breaths Triggered window for synchronized breaths Mandatory Cycle Time M T supp T synch M T supp

39. SIMV Maintains respiratory muscle strength by avoiding muscle atrophy Decreases mean airway pressure Facilitates ventilator discontinuation – “weaning”! When used for weaning, may be done too quickly and cause muscle fatigue Mechanical rate and spontaneous rate may asynchronous causing “stacking” May cause barotrauma or volutrauma Advantages Disadvantages

40. ALL MODES TABLES

41. Mandatory Modes of Ventilations Mandatory breaths Inspiratory cyclingTime ControlVolume (Pressure) Target/Limit-Pressure-limitedVolume-targeted Feeadback--Intra-breathInter-breath Expiratory cyclingTime Triggered Breaths TypesNone Supported Breaths Control---- Target---- Feedback---- Expiratory Cycling---- Spontaneous Breaths During mandatory inspiration Not accommodated Accommodated Otherwise Not accommodated Accommodated Not accommodated Accommodated Synonyms IPPV (Draeger) Controlled Mandatory Ventilation Intermittent Mandatory Ventilation IPPV (Draeger): trigger off, autoflow off IPPV (Draeger): trigger off, autoflow on

42. Triggered Modes of Ventilations Mandatory breaths Inspiratory cycling--- Control--- Target/Limit--- Feeadback--- Expiratory cycling--- Triggered Breaths TypesSupported breaths Supported Breaths ControlPressure(Pressure) Target--Volume-targetedFlow and Volume Feedback--Inter-breathIntra-breath Expiratory CyclingFlow Spontaneous Breaths During mandatory inspiration--- Otherwise--- Synonyms Assisted Spontaneus Breathing (Draeger) Spontaneous Mode (Hamilton, Puritan Bennet) Pressure Support (Maquet Pressure Support Ventilation (Viasys) CPAP (Respironics) Volume Support (Maquet, Puritan- Bennett) Propotional Assist Ventilation, Proportional Pressure Suport (Draeger) Propotional Assist Ventilation Plus (Puritan-Bennet)

43. Hybrid Mode: Assist Control Mandatory breaths Inspiratory cyclingTime or trigger ControlVolumePressure(Pressure) Target/Limit--Volume-targeted Feeadback--Inter-breath Expiratory cyclingTime Triggered Breaths TypesMandatory pattern Supported Breaths Control--- Target--- Feedback--- Expiratory Cycling--- Spontaneous Breaths During mandatory inspirationNot accommodatedAccommodated Otherwise--- Synonyms IPPV ASSIST (Draeger) Synchronized cCntrolled Mandatory Ventilation (Hamilton) Volume Control (Maquet) VCV-A/C (Puritan-Bennett, Respironics) Volume A/C (Viasys) BIPAP ASSIST (Draeger) P-CMV (Hamilton) Pressure Control (Maquet) PCV-A/C (Puritan- Bennett, Respironics) Pressure A/C (Viasys) Adaptive Pressure Ventilation CMV PRVC (Maquet) VC+A/C (Puritan- Bennet) PRVC A/C (Viasys) IPPV Assist Autoflow (Draeger)

44. Hybrid Mode: Synchronized Intermittent Mandatory Ventilation Mandatory breaths Inspiratory cyclingTime or trigger ControlVolumePressure(Pressure) Target/Limit--Volume-targeted Feeadback--Inter-breath Expiratory cyclingTime Triggered Breaths Types Mandatory and supported pattern Supported Breaths ControlPressure Target--- Feedback--- Expiratory CyclingFlow Spontaneous Breaths During mandatory inspirationNot accommodatedAccommodated OtherwiseOnly if support is off Synonyms SIMV (Draeger, Hamilton) SIMV (VC)+PS (Maquet) VCV-SIMV (Puritan- Bennett, Respironics) Volume SIMV (Viasys) P-SIMV (Hamilton) SIMV(PC)+PS (Maquet) PCV-SIMV (Puritan- Bennett, Respironics) Pressure SIMV (Viasys) SIMV+Autoflow Adaptive Pressure Ventilation SIMV (Hamilton) SIMV (PRVC)+PS (Puritan-Bennett) PRVC SIMV (Viasys)

45. Hybrid Mode: Bi-Level Ventilatio Mandatory breaths Inspiratory cyclingTime or trigger ControlPressure Target/Limit---- Feeadback---- Expiratory cyclingTime or trigger Triggered Breaths Interaction Mandatory and supported Mandatory pattern and supported Mandatory and supported Supported Breaths ControlPressure Target---- Feedback---- Expiratory CyclingFlow Spontaneous Breaths During mandatory inspiration Accommodated Trigers suuport to PEEP+P support If this>P high (Hamilton DuoPAP) P low +P support If this>P high (Hamilton APRV) PEEP L +P supp If this>PEEP H (Puritan- Bennett) Triggers support to PRES HIGH + PSV if T high PSV is activated Tigger support to PSV above P High Otherwise Triggers support Triggers support to PEEP+P support (Hamilton) DuoPAP) P low +P support (Hamilton APRV) PEEPL+P supp (Puritan-Bennett) Triggers support to PREDSLOW=PSV Triggers support to PSV above PEEP Synonyms BIPAP (Draeger) DuoPAP/APRV (Hamilton) BiLevel (Puritan-Bennet) APRV/Bi-phasic (Viasys) Bi-vent (Maquet)

46. THANK YOU