basic ventilator y modes

7/27/2019 Basic Ventilator y Modes

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MODES OF MECHANICAL VENTILATION

Mazen Kherallah, MD, FCCP


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POINTS OF DISCUSSIONS

| Advanced Basics:

y Flow and Time

y Limit and cycling

y Rise Time

y Volume vs Pressure Control

| Mandatory Modes of Ventilation

y Controlled Mandatory Ventilation (CMV or IPPV)

| Triggered Modes of Ventilation

y Continuous Positive Airway Pressure (CPAP)y Pressure Support Ventilation (PSV)

| Hybrid Modes of Ventilation

y Assist Control Mode (A/C)

y Synchronized Intermittent Mandatory Ventilation (SIMV)


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ADVANCED BASICS


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RESPIRATORYCYCLE

Inspiration

Expiration


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ExpInsp

RELATIONSHIP BETWEEN TIDALVOLUME,

INSPIRATORYTIME AND FLOW

VT 1

Ti a

VT 2

VT 3

Time

Volume

Flow= 30 L/min

Flow= 15 L/min

Flow= 37.5 L/min


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ExpExpInspInspInsp

RELATIONSHIP BETWEEN TIDALVOLUME,

INSPIRATORYTIME AND FLOW

VT 1

Ti a

Time

Volume

Ti b Ti c

Flow= 30 L/min

Flow= 20 L/min

Flow= 60 L/min


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PRESSURE LIMITED BREATH

Time

Volume

Pressure Limit


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EXPIRATORYFLOW CYCLING

Time

Flow

50%

100%

Flow Cycling


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RISE TIME

Time

Flow

Pressure

Volume

TI TE


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MANDATORY, SPONTANEOUS AND TRIGGERED

INSPIRATORYCYCLINGM

S

Tsynch

M M

M

MM

M

M

S

M

Tsupp Tsupp

Tsupp Tsupp

Tsupp

Tsupp

S


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VOLUME CONTROLLED INFLATION

Time

Flow

Pressure

Volume

TI TE

Tidal Volume


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If compliance decreases the pressure increases tomaintain the same Vt

1 2 3 4 5 6

SEC

1 2 3 4 5 6

PawcmH20

50

-20

120

120

SEC

INSP

EXH

FlowL/min

VOLUME CONTROL BREATHS

Decreased Compliance


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VOLUME CONTROL WITH END-INSPIRATORY

PAUSE

Time

Flow

Pressure

Volume

TI TE

Tidal Volume

End Inspiratory Pause


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PRESSURE CONTROLLED INFLATION

Time

Flow

Pressure

Volume

TI TE

Tidal Volume

Rise Time

Peak Inspiratory Flow


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Inspiration Expiration

0 1

20

00 1 2

3

-3

0

20

0 21

20

00 1 2

3

-3

0

20

0 2

Inspiration Expiration

Volume/Flow Control Pressure Control

Time (s) Time (s)

Paw

Paw

Pressure

Volume

Flow


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TRIGGERED MODES OF

VENTILATIONCPAP and PSVV


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SPONTANEOUS BREATHING

Time (sec)

Flow

(L/m)

Pressure(cm H2O)

Volume

(mL)


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PRESSURE SUPPORTVENTILATION

(PSV)

Time (sec)

Flow

(L/m)

Pressure(cm H2O)

Volume

(mL)

Set PS

Level

Flow

Cycling

Better Efforts

Longer Inspiration

Patient Triggered, Flow Cycled, Pressure limited Mode


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CPAP+PSV

Time (sec)

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

Set PS

Level

Flow

Cycling

Patient Triggered, Flow Cycled, Pressure limited Mode

CPAP Level


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TRIGGERED MODES OFVENTILATION

PRESSURE SUPPORTVENTILATION

Control Trigger Limit Target Cycle

Pressure Patient Pressure Flow

Patient Triggered Flow Cycled Ventilation


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PRESSURE ORVOLUME-TARGETED

VENTILATION

| Full to partial ventilatory support

| Augments the patients spontaneous VT

| Decreases the patients spontaneous

respiratory rate

| Decreases patient WOB by overcomingthe 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 VE

| Fatigue and tachypnea if PS

level is set too low

Advantages Disadvantages


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MANDATORY MODES OF

VENTILATIONCMV or IPPV


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MANDATORYMODES OFVENTILATION

CMV


Pressure

Or

Volume

Time Time

Time Triggered Time Cycled Ventilation


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CONTROL MODE

(PRESSURE-TARGETEDVENTILATION)

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

Time Triggered, Pressure Limited, Time Cycled Ventilation

Time (sec)

Time CyclingSet PC Level


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CONTROL MODE

(VOLUME-TARGETEDVENTILATION)

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

Time Triggered, Flow Limited, Volume Cycled Ventilation

Time (sec)

Preset VTVolume Cycling

Time Cycling

Dependent on

CL& Raw


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VENTILATION

| Decreases the

work of breathing

(WOB)

| Helps maintain a

normal PaCO2

| Not able to assist the

ventilator



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HYBRID MODES OF

VENTILATIONSIMV and A/C


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HYBRID MODES OFVENTILATION

A/C


Pressure

Or

Volume

Time

Or

Patient

Time

Time or PatientTriggered Time Cycled

Ventilation


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ASSISTED MODE

(VOLUME-TARGETEDVENTILATION)

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

Patient Triggered, Flow limited, Volume Cycled Ventilation

Time (sec)

Preset peak Flow

Time Cycling


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ASSISTED MODE

(PRESSURE-TARGETEDVENTILATION)

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

Patient Triggered, Pressure Limited, Time Cycled Ventilation

Time (sec)

Time CyclingSet PC Level


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VENTILATION

| Decreases the

work of breathing

(WOB)

| Allows patients to

regulate

respiratory rate

| Helps maintain anormal PaCO2

|Alveolar

hyperventilation



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HYBRID MODES OFVENTILATION

SIMV/PS

Breath

Type

Control Trigger Limit Cycle

Mandatory Pressure

Or

Volume

Time

Or

Patient

Time

Spontaneous Pressure Patient Pressure Flow


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SIMV

(VOLUME

TARGETED

VENTILATION

)

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

Spontaneous Breaths

M M M

Time (sec)


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SIMV+PS

(VOLUME

TARGETED

VENTILATION

)

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

MTsuppTsynch

Set PS Level

Flow-cycled

Time (sec)


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SIMV + PS

(PRESSURE

-TARGETED

VENTILATION

)

Flow

(L/m)

Pressure

(cm H2O)

Volume

(mL)

Tsupp

Tsynch

Time CycledFlow-cycled

Tsynch

Set PC Level Set PS Level

Time (sec)


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HYBRID MODEVENTILATION: SUPPRESSION

Time (sec)

Flow

(L/m)

Pres

sure

(cmH2O)

Cycles

M Tsupp MMTsupp

M M

Tsupp Tsupp


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HYBRID MODEVENTILATION: SYNCHRONIZATION

(SIMV+PSV)

Time (sec)

Flow

(L/m)

Pressure

(cm H2O)

Cycles

Triggered window for

supported breaths

Triggered window for

synchronized breaths

Mandatory Cycle Time

M Tsupp Tsynch M Tsynch Tsupp


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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

stackingy May cause

barotrauma or

volutrauma



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ALL MODES TABLES

Mandatory Modes of Ventilations


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Mandatory Modes of Ventilations

Mandatory breaths

Inspiratory cycling Time Time Time Time

Control Volume Volume Volume (Pressure)

Target/Limit - Pressure-limited Volume-targeted

Feeadback - - Intra-breath Inter-breath

Expiratory cycling Time Time Time Time

Triggered Breaths

Types None None None None

Supported Breaths

Control - - - -

Target - - - -

Feedback - - - -

Expiratory Cycling - - - -

Spontaneous Breaths

During mandatory inspirationNot

accommodated

Not

accommodated

Not

accommodatedAccommodated

OtherwiseNot


Not


Synonyms

IPPV (Draeger)

ControlledMandatory

Ventilation

IntermittentMandatory

Ventilation

IPPV (Draeger):trigger off,

autoflow off

IPPV (Draeger):trigger off,

autoflow on

Triggered Modes of Ventilations


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Triggered Modes of Ventilations

Mandatory breaths

Inspiratory cycling - - -

Control - - -

Target/Limit - - -

Feeadback - - -

Expiratory cycling - - -

Triggered Breaths

Types Supported breaths Supported breaths Supported breaths

Supported Breaths

Control Pressure (Pressure) (Pressure)

Target -- Volume-targeted Flow and Volume

Feedback -- Inter-breath Intra-breath

Expiratory Cycling Flow Flow Flow

Spontaneous Breaths

During mandatory inspiration - - -

Otherwise - - -

Synonyms

Assisted Spontaneus Breathing

(Draeger)

Spontaneous Mode (Hamilton,

Puritan Bennet)

Pressure Support (MaquetPressure Support Ventilation

(Viasys)

CPAP (Respironics)

Volume Support

(Maquet, Puritan-

Bennett)

Propotional Assist

Ventilation,

Proportional Pressure

Suport (Draeger)

Propotional AssistVentilation Plus

(Puritan-Bennet)

Hybrid Mode: Assist Control


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Hybrid Mode: Assist Control

Mandatory breaths

Inspiratory cycling Time or trigger Time or trigger Time or trigger

Control Volume Pressure (Pressure)

Target/Limit - - Volume-targeted

Feeadback - - Inter-breath

Expiratory cycling Time Time Time

Triggered Breaths

Types Mandatory pattern Mandatory pattern Mandatory pattern

Supported Breaths

Control - - -

Target - - -

Feedback - - -

Expiratory Cycling - - -

Spontaneous Breaths

During mandatory inspiration Not accommodated Accommodated Accommodated

Otherwise - - -

Synonyms

IPPVASSIST (Draeger)

Synchronized cCntrolled

Mandatory Ventilation

(Hamilton)

Volume Control (Maquet)VCV-A/C (Puritan-Bennett,

Respironics)

Volume A/C (Viasys)

BIPAPASSIST (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)

Hybrid Mode: Synchronized Intermittent Mandatory Ventilation


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Hybrid Mode: Synchronized Intermittent Mandatory Ventilation

Mandatory breaths

Inspiratory cycling Time or trigger Time or trigger Time or trigger

Control Volume Pressure (Pressure)

Target/Limit - - Volume-targeted

Feeadback - - Inter-breath

Expiratory cycling Time Time Time

Triggered Breaths

TypesMandatory and

supported pattern

Mandatory and supported

pattern

Mandatory and

supported pattern

Supported Breaths

Control Pressure Pressure Pressure

Target - - -

Feedback - - -

Expiratory Cycling Flow Flow Flow

Spontaneous Breaths

During mandatory inspiration Not accommodated Accommodated Accommodated

Otherwise Only if support is off Only if support is off Only 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)

Hybrid Mode: Bi-Level Ventilatio


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Mandatory breaths

Inspiratory cycling Time or trigger Time or trigger Time or trigger Time or trigger

Control Pressure Pressure Pressure Pressure

Target/Limit - - - -

Feeadback - - - -

Expiratory cycling Time or trigger Time or trigger Time or trigger Time or trigger

Triggered Breaths

InteractionMandatory andsupported

Mandatory pattern andsupported

Mandatory andsupported

Mandatory andsupported

Supported Breaths

Control Pressure Pressure Pressure Pressure

Target - - - -

Feedback - - - -

Expiratory Cycling Flow Flow Flow Flow

Spontaneous Breaths

During mandatoryinspiration

Accommodated

Trigers suuport to PEEP+Psupport If

this>Phigh (Hamilton DuoPAP)

Plow+Psupport If this>Phigh (Hamilton

APRV)

PEEPL+PsuppIf this>PEEPH(Puritan-Bennett)

Triggers support toPRES HIGH + PSV if

Thigh PSV is activated

Tigger support to

PSV above PHigh

Otherwise Triggers support

Triggers support to PEEP+Psupport(Hamilton) DuoPAP)

Plow+Psupport (Hamilton APRV)

PEEPL+Psupp (Puritan-Bennett)

Triggers support to

PREDSLOW=PSV

Triggers support to

PSV above PEEP

SynonymsBIPAP

(Draeger)

DuoPAP/APRV (Hamilton)

BiLevel (Puritan-Bennet)

APRV/Bi-phasic

(Viasys)Bi-vent (Maquet)


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YOU

basic ventilator y modes

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