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 –
‘the volume of air that
VT 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 –
‘is the highest level of
P ap
pressure applied to the
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
