Modes of Mechanical Ventilation POINTS OF DISCUSSIONS Advanced

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Modes of Mechanical Ventilation

Modes of Mechanical Ventilation

POINTS OF DISCUSSIONS Advanced Basics: Flow and Time Limit and cycling Rise Time Volume

POINTS OF DISCUSSIONS 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)

CPAP and PSVV TRIGGERED MODES OF VENTILATION

CPAP and PSVV TRIGGERED MODES OF VENTILATION

SPONTANEOUS BREATHING Pressure (cm H 2 O) Flow (L/m) Volume (m. L) Time (sec)

SPONTANEOUS BREATHING Pressure (cm H 2 O) Flow (L/m) Volume (m. L) Time (sec)

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) Pressure (cm H 2 O) CPAP Level Flow (L/m)

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) Pressure (cm H 2 O) CPAP Level Flow (L/m) Volume (m. L) Time (sec)

PRESSURE SUPPORT VENTILATION (PSV) Longer Inspiration Pressure (cm H 2 O) Set PS Level

PRESSURE SUPPORT VENTILATION (PSV) Longer Inspiration Pressure (cm H 2 O) Set PS Level Better Efforts Flow Cycling Flow (L/m) Volume (m. L) Time (sec) Patient Triggered, Flow Cycled, Pressure limited Mode

CPAP+PSV Pressure (cm H 2 O) Set PS Level CPAP Level Flow Cycling Flow

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

TRIGGERED MODES OF VENTILATION PRESSURE SUPPORT VENTILATION Control Trigger Limit Pressure Patient Pressure Target

TRIGGERED MODES OF VENTILATION PRESSURE SUPPORT VENTILATION Control Trigger Limit Pressure Patient Pressure Target Patient Triggered Flow Cycled Ventilation Cycle Flow

CMV or IPPV MANDATORY MODES OF VENTILATION

CMV or IPPV MANDATORY MODES OF VENTILATION

MANDATORY MODES OF VENTILATION CMV Control Trigger Pressure Or Volume Time Limit Target Time

MANDATORY MODES OF VENTILATION CMV Control Trigger Pressure Or Volume Time Limit Target Time Triggered Time Cycled Ventilation Cycle Time

CONTROL MODE (PRESSURE-TARGETED VENTILATION) Set PC Level Time Cycling Pressure (cm H 2 O)

CONTROL MODE (PRESSURE-TARGETED VENTILATION) Set PC Level Time Cycling Pressure (cm H 2 O) Flow (L/m) Volume (m. L) Time (sec) Time Triggered, Pressure Limited, Time Cycled Ventilation

CONTROL MODE (VOLUME-TARGETED VENTILATION) Time Cycling Pressure (cm H 2 O) Dependent on CL

CONTROL MODE (VOLUME-TARGETED VENTILATION) Time Cycling Pressure (cm H 2 O) Dependent on CL & Raw Flow (L/m) Preset VT Volume Cycling Volume (m. L) Time (sec) Time Triggered, Flow Limited, Volume Cycled Ventilation

SIMV and A/C HYBRID MODES OF VENTILATION

SIMV and A/C HYBRID MODES OF VENTILATION

HYBRID MODES OF VENTILATION A/C Control Trigger Pressure Or Volume Time Or Patient Limit

HYBRID MODES OF VENTILATION A/C Control Trigger Pressure Or Volume Time Or Patient Limit Target Time or Patient. Triggered Time Cycled Ventilation Cycle Time

ASSISTED MODE (VOLUME-TARGETED VENTILATION) Time Cycling Pressure (cm H 2 O) Preset peak Flow

ASSISTED MODE (VOLUME-TARGETED VENTILATION) Time Cycling Pressure (cm H 2 O) Preset peak Flow (L/m) Volume (m. L) Time (sec) Patient Triggered, Flow limited, Volume Cycled Ventilation

ASSISTED MODE (PRESSURE-TARGETED VENTILATION) Set PC Level Time Cycling Pressure (cm H 2 O)

ASSISTED MODE (PRESSURE-TARGETED VENTILATION) Set PC Level Time Cycling Pressure (cm H 2 O) Flow (L/m) Volume (m. L) Time (sec) Patient Triggered, Pressure Limited, Time Cycled Ventilation

HYBRID MODES OF VENTILATION SIMV/PS Breath Type Control Trigger Mandatory Pressure Or Volume Time

HYBRID MODES OF VENTILATION SIMV/PS Breath Type Control Trigger Mandatory Pressure Or Volume Time Or Patient Spontaneous Pressure Patient Limit Cycle Time Pressure Flow

SIMV (VOLUME TARGETED VENTILATION) Pressure (cm H 2 O) M M M Spontaneous Breaths

SIMV (VOLUME TARGETED VENTILATION) Pressure (cm H 2 O) M M M Spontaneous Breaths Flow (L/m) Volume (m. L) Time (sec)

SIMV+PS (VOLUME TARGETED VENTILATION) Set PS Level Pressure (cm H 2 O) Tsynch Tsupp

SIMV+PS (VOLUME TARGETED VENTILATION) Set PS Level Pressure (cm H 2 O) Tsynch Tsupp M Flow-cycled Flow (L/m) Volume (m. L) Time (sec)

SIMV + PS (PRESSURE-TARGETED VENTILATION) Tsynch Pressure (cm H 2 O) Tsynch Tsupp Set

SIMV + PS (PRESSURE-TARGETED VENTILATION) Tsynch Pressure (cm H 2 O) Tsynch Tsupp Set PC Level Time Cycled Set PS Level Flow-cycled Flow (L/m) Volume (m. L) Time (sec)

HYBRID MODE VENTILATION: SYNCHRONIZATION (SIMV+PSV) M Tsupp Tsynch Pressure (cm H 2 O) Flow

HYBRID MODE VENTILATION: SYNCHRONIZATION (SIMV+PSV) M Tsupp Tsynch Pressure (cm H 2 O) Flow (L/m) Cycles Mandatory Cycle Time Triggered window for supported breaths synchronized breaths Time (sec) M Tsynch Tsupp

ADVANCED MODES OF MECHANICAL VENTILATION

ADVANCED MODES OF MECHANICAL VENTILATION

POINTS OF DISCUSSION Triggered Modes of Ventilation Volume Support (VS) Proportional Assist Ventilation (PAV

POINTS OF DISCUSSION Triggered Modes of Ventilation Volume Support (VS) Proportional Assist Ventilation (PAV or PPS) Hybrid Modes of Ventilation Volume Assured Pressure Support Pressure Regulated Volume Control (PRVC) Auto mode: VS and PRVC Adaptive Support Ventilation: ASV Bi-level Ventilation (APRV and Bi-vent) Mandatory Minute Ventilation (MMV)

DUAL CONTROL BREATH-TO-BREATH PRESSURE-LIMITED FLOW-CYCLED VENTILATION VOLUME SUPPORT Control Trigger Limit Target Cycle Pressure

DUAL CONTROL BREATH-TO-BREATH PRESSURE-LIMITED FLOW-CYCLED VENTILATION VOLUME SUPPORT Control Trigger Limit Target Cycle Pressure Patient Pressure Volume Flow Pressure Limited Flow Cycled Ventilation

VS (VOLUME SUPPORT) Apnea Upper Pressure limit Pressure 5 cm H 2 O 1

VS (VOLUME SUPPORT) Apnea Upper Pressure limit Pressure 5 cm H 2 O 1 2 3 4 6 5 Flow Constant exp. Flow (1), VS test breath (5 cm H 2 O); (2), pressure is increased slowly until target volume is achieved; ( 3), maximum available pressure is 5 cm H 2 O below upper pressure limit; ( 4), VT higher than set VT delivered results in lower pressure; (5), patient can trigger breath; (6) if apnea alarm is detected, ventilator switches to PRVC

yes Calculate new Pressure limit Trigger n o Pressure limit Based on VT/C Volume

yes Calculate new Pressure limit Trigger n o Pressure limit Based on VT/C Volume from Ventilator= Set tidal volume Flow= 5% of Peak flow Calculate compliance yes Cycle off no Control logic for volume support mode of the servo 300

DUAL CONTROL BREATH TO BREATH: PROPORTIONAL ASSIST VENTILATION(PAS)/PROPORTIONAL PRESSURE SUPPORT (PPS) Control Trigger Limit

DUAL CONTROL BREATH TO BREATH: PROPORTIONAL ASSIST VENTILATION(PAS)/PROPORTIONAL PRESSURE SUPPORT (PPS) Control Trigger Limit Target Cycle Pressure Patient Pressure Volume Flow Pressure Limited Flow Cycled Ventilation

PROPORTIONAL ASSIST VENTILATION (PAV) Changing pressure support based on patient’s efforts Pressure Flow Time

PROPORTIONAL ASSIST VENTILATION (PAV) Changing pressure support based on patient’s efforts Pressure Flow Time Rregulates the pressure output of the ventilator moment by moment in accord with the patient’s demands for flow and volume. Thus, when the patient wants more, (s)he gets more help; when less, (s)he gets less. The timing and power synchrony are therefore nearly optimal—at least in concept.

PROPORTIONAL ASSIST AMPLIFIES MUSCULAR EFFORT Muscular effort (Pmus) and airway pressure assistance (Paw) are

PROPORTIONAL ASSIST AMPLIFIES MUSCULAR EFFORT Muscular effort (Pmus) and airway pressure assistance (Paw) are better matched for Proportional Assist (PAV) than for Pressure Support (PSV).

DUAL CONTROL WITHIN A BREATH VOLUME-ASSURED PRESSURE SUPPORT Control Trigger Limit Target Cycle Dual

DUAL CONTROL WITHIN A BREATH VOLUME-ASSURED PRESSURE SUPPORT Control Trigger Limit Target Cycle Dual Pressure/ Volume Patient Pressure Volume Flow or volume Volume Assured Pressure Support Ventilation

Pressure limit overridden 40 Set pressure limit Paw cm. H 20 -20 0. 6

Pressure limit overridden 40 Set pressure limit Paw cm. H 20 -20 0. 6 Volume Set tidal volume cycle threshold Tidal volume met Tidal volume not met L 0 60 Inspiratory flow greater than set flow Flow cycle Set flow Inspiratory flow equals set flow Flow L/min 60 Switch from Pressure control to Volume/flow control

Trigger Pressure at Pressure support no flow= 25% peak yes delivered VT ≥ set

Trigger Pressure at Pressure support no flow= 25% peak yes delivered VT ≥ set VT yes no Cycle off inspiration Insp flow > Set flow yes no no yes delivered VT = set VT Switch to flow control at peak flow setting no PAW <PSV setting yes Control logic for volume-assured pressure-support mode

DUAL CONTROL BREATH-TO-BREATH PRESSURE REGULATED VOLUME CONTROL Control Trigger Limit Target Cycle Volume Patient

DUAL CONTROL BREATH-TO-BREATH PRESSURE REGULATED VOLUME CONTROL Control Trigger Limit Target Cycle Volume Patient or Time Pressure Lowest pressure for set volume Time Pressure-limited Time-cycled Ventilation

PRVC (PRESSURE REGULATED VOLUME CONTROL) Upper Pressure Limit Pressure Floe 1 5 cm H

PRVC (PRESSURE REGULATED VOLUME CONTROL) Upper Pressure Limit Pressure Floe 1 5 cm H 2 O 2 3 4 5 6 Time PRVC. (1), Test breath (5 cm H 2 O); (2) pressure is increased to deliver set volume; (3), maximum available pressure; (4), breath delivered at preset E, at preset f, and during preset TI; (5), when VT corresponds to set value, pressure remains constant; (6), if preset volume increases, pressure decreases; the ventilator continually monitors and adapts to the patient’s needs

PRVC AUTOMATICALLY ADJUSTS TO COMPLIANCE CHANGES Pressure control Ventilation PRVC

PRVC AUTOMATICALLY ADJUSTS TO COMPLIANCE CHANGES Pressure control Ventilation PRVC

yes n Calculate new o Pressure limit Trigger Pressure limit Based on VT/C Volume

yes n Calculate new o Pressure limit Trigger Pressure limit Based on VT/C Volume from Ventilator= Set tidal volume Time= set Inspiratory time Calculate compliance yes Cycle off no Control logic for pressure-regulated volume control and autoflow

AUTOMODE Mandatory Spontaneous PRVC VS Ventilator triggered, pressure controlled and time cycled; the pressure

AUTOMODE Mandatory Spontaneous PRVC VS Ventilator triggered, pressure controlled and time cycled; the pressure is adjusted to maintain the set tidal volume Patient triggered, pressure limited, and flow cycled. Apnea for 12 seconds Two consecutive breaths

DUAL CONTROL BREATH-TO-BREATH ADAPTIVE SUPPORT VENTILATION

DUAL CONTROL BREATH-TO-BREATH ADAPTIVE SUPPORT VENTILATION

ASV (ADAPTIVE SUPPORT VENTILATION) A dual control mode that uses pressure ventilation (both PC

ASV (ADAPTIVE SUPPORT VENTILATION) A dual control mode that uses pressure ventilation (both PC and PSV) to maintain a set minimum E (volume target) using the least required settings for minimal WOB depending on the patient’s condition and effort It automatically adapts to patient demand by increasing or decreasing support, depending on the patient’s elastic and resistive loads

ASV (ADAPTIVE SUPPORT VENTILATION) The clinician enters the patient’s IBW, which allows the ventilator’s

ASV (ADAPTIVE SUPPORT VENTILATION) The clinician enters the patient’s IBW, which allows the ventilator’s algorithm to choose a required E. The ventilator then delivers 100 m. L/min/kg. A series of test breaths measures the system C, resistance and auto. PEEP If no spontaneous effort occurs, the ventilator determines the appropriate respiratory rate, VT, and pressure limit delivered for the mandatory breaths I: E ratio and TI of the mandatory breaths are continually being “optimized” by the ventilator to prevent auto-PEEP If the patient begins having spontaneous breaths, the number of mandatory breaths decrease and the ventilator switches to PS at the same pressure level Pressure limits for both mandatory and spontaneous breaths are always being automatically adjusted to meet the E target

THE SAFETY WINDOW: LOW RATE/VOLUME LIMITS V m. L + 800 Target Current (Pmax-PEEP)*Cdyn

THE SAFETY WINDOW: LOW RATE/VOLUME LIMITS V m. L + 800 Target Current (Pmax-PEEP)*Cdyn 600 5 b/min Min. Vol 7. 0 L/min + 400 f=60/[1 RCinsp+2 RCexp] 2 * Vd 200 f b/min 10 20 30 f. Spont 0 b/min 40 50 60 f. Control Pinsp 11 b/min 18 cm. H 2 O

MANDATORY MINUTE VENTILATION A minimum minute ventilation is set by the operator The ventilator

MANDATORY MINUTE VENTILATION A minimum minute ventilation is set by the operator The ventilator monitors the spontaneous MV The part of the pre-selected MV that the patient is not able to accomplish is provided by the ventilator to make up the difference by automatically changing the breath rate

MMV Min. Vent. MMV SMV time

MMV Min. Vent. MMV SMV time

MMV SETTINGS MMV = 70 -90% of SMV Min. Vent. MMV SMV time

MMV SETTINGS MMV = 70 -90% of SMV Min. Vent. MMV SMV time

BILEVEL VENTILATION 60 PEEPHigh + PS PEEPH Paw PEEPL cm. H 20 -20 Pressure

BILEVEL VENTILATION 60 PEEPHigh + PS PEEPH Paw PEEPL cm. H 20 -20 Pressure Support 1 2 3 4 5 6 7

Pressure Thigh Phigh Tlow Pressure Time Psupp Time

Pressure Thigh Phigh Tlow Pressure Time Psupp Time

Pressure Thigh Phigh Tlow Pressure Time Phigh Psupp Time

Pressure Thigh Phigh Tlow Pressure Time Phigh Psupp Time

Pressure Thigh Phigh Tlow Pressure Time Phigh Psupp Time Psupp

Pressure Thigh Phigh Tlow Pressure Time Phigh Psupp Time Psupp

AIRWAY PRESSURE RELEASE VENTILATION Control Trigger Limit Cycle Pressure Time Triggered Time-cycled Ventilation

AIRWAY PRESSURE RELEASE VENTILATION Control Trigger Limit Cycle Pressure Time Triggered Time-cycled Ventilation

AIRWAY PRESSURE RELEASE VENTILATION Spontaneous Breaths 60 Paw Releases cm. H 20 -20 1

AIRWAY PRESSURE RELEASE VENTILATION Spontaneous Breaths 60 Paw Releases cm. H 20 -20 1 2 3 4 5 6 7 8

APRV (AIRWAY PRESSURE RELEASE VENTILATION) Spontaneous breaths Airway Pressure CPAP Released CPAP Restored CPAP

APRV (AIRWAY PRESSURE RELEASE VENTILATION) Spontaneous breaths Airway Pressure CPAP Released CPAP Restored CPAP Level 1 CPAP Level 2 Time

QUESTIONS

QUESTIONS