VENTILATION – THE BASICS
AND BEYOND
C H R I S C R O P S E Y, M D
OVERVIEW
• Modes of Ventilation
• VC, PC, PRVC, BiVent
• Control of ventilation (SIMV PS vs. A/C)
• Cases
Please feel free to ask questions any time!!
WHY DO WE CARE?
• Ventilators save lives! But…
• Ventilators are bad!
• Barotrauma
• Volutrauma
• Atelectrauma
What pressures are we interested in?
Dynamic pressure
Pressure Pressure
OR
Peak pressure
Static pressure
Pressure OR
Plateau pressure
• Normally Pplat = Ppeak – 5to10 cm H2O
– In what situations isn’t that the case?
• Why are we more interested clinically in Pplat?
Ppeak Pplat
Puts a pause in the Inspiratory Cycle – no flow – measures pressure
• Estimates alveolar pressure at end-inspiration
• Indirect indicator of alveolar distension
• Goal is PIP <40, Pplat <30
BASIC VENTILATOR SETTINGS
Ventilation (Clear CO2) Oxygenation (O2 sats)
• TIDAL VOLUME • FiO2
• RESPIRATORY RATE • PEEP
• MINUTE VENTILATION • MEAN AIRWAY PRESSURE
SCHEMATIC OF BASIC MODES
PC PRVC VC
BiVent
VOLUME CONTROL
You set:
Volume Controlled Tidal volume
Peak flow (or I:E)
Rate
BASIC VC SETTINGS
• Tidal volume (Vt) – volume to be given with
each breath (usually in mL)
• Peak flow (VMAX) – rate at which volume is
delivered (in L/min) – controls the I:E
• Alternately, set I:E directly
• Rate - Breaths/minute
VC BASIC PROPERTIES
• Preset rate and tidal volume at the set interval
• Full mechanical breath delivered.
• Uses: weak respiratory effort, allows
synchrony with the patient. Not a weaning
mode
ADVANTAGES
•Consistent TV
• changing impedance
• Auto-PEEP
•Minimum minute ventilation guaranteed (R x
TV)
•Variety of flow waves
•But usually square wave
DISADVANTAGES
•Variable pressures
• airway
• alveolar
•Fixed flow pattern
•Compressible volume
•Circuit leaks = volume loss
•Tachypnea leads to excess MV
FLOW/PRESSURE TRACINGS - VC
Pressure
Flow
Note that pressure is variable (and has plateau); flow
is constant
PRESSURE CONTROL
You set:
Pressure Controlled Pressure limit
Time spent in inspiration
Rate
PRESSURE CONTROL BASIC SETTINGS
• Inspiratory pressure is the target – tells
ventilator max pressure each breath (note that
PIP = Pinspiratory + Ppeep)
• Inspiratory time (I-time) is set and constant
• Note that I:E ratio is affected by I-time
• Rate in breaths/min
ADVANTAGES - PC
• For given PIP, the TV will be higher in PC than
VC
• Put another way, the “cost” of TV is lower in
PC
• More physiologic – decelerating flow
DISADVANTAGES - PC
• No guaranteed tidal volume/minute ventilation
• Can lead to extreme under- or over-ventilation
FLOW/PRESSURE TRACINGS - PC
Note that flow is variable; pressure is constant
COMPARISON – VC VS. PC
Volume Control
Pressure Control
PRESSURE REGULATED VOLUME CONTROL
You set:
TARGET TV
PRVC
Regulation Pressure
Rate
PRESSURE REGULATED VOLUME CONTROL
• Combines positives from VC and PC
• Set TV is “targeted”
• Ventilator estimates vol./press. relationship each
breath
• Ventilator adjusts level of pressure control breath by
breath
PRVC
• First breath = Volume Control
• V/P relationship measured
• Next Breath = PC at Pplateau
• Then up to +/- 3 cm H2O changes per breath
• Time ends inspiration (like PC)
• If PIP reaches regulation minus 5, breath stops
and ventilator alarms
PRESSURE REGULATED VOLUME CONTROL -
CONSIDERATIONS
• Constant pressure during each breath - variable
pressure from breath to breath
• Time cycled
• Delivered TV can vary from set TV breath to
breath
FLOW/PRESSURE WAVEFORM - PRVC
Note 1st breath is VC; 2nd breath is “PC” with Pplat as
PIP
ADVANTAGES
• Decelerating flow pattern
• Pressure automatically adjusted for changes in
compliance and resistance within a set range
– Tidal volume “guaranteed”
– Limits volutrauma/barotrauma
– Prevents hypoventilation
DISADVANTAGES
• Pressure delivered is dependent on tidal volume
achieved on last breath
• Intermittent patient effort → variable tidal volumes
• Asynchrony with variable patient effort
Richard et al. Resp Care 2005 Dec
• Less suitable for patients with asthma or COPD
If in assisted breaths the Pt's demand ↑
pressure level ↓ at a time when support is most necessary
mean airway pressure will ↓
hypoxemia
BIVENT (BILEVEL, APRV)
You set:
Phigh
Plow (i.e. PEEP)
BiVent
Thigh
Tlow
Pressure support
BIVENT BASICS
• Think of it as glorified BiPAP
• Ventilator cycles between high pressure and low
pressure based on set time intervals
• Thigh is usually [much] longer than Tlow
• Tlow allows time for release
• Patient can (and should!) breath spontaneously
throughout pressure cycle
• This differentiates between inverse ratio PC
Spontaneous Breaths
Synchronized Transitions
Spontaneous Breaths
P
T
BIVENT - ADVANTAGES
• Allows for high mean airway pressure relative
to peak airway pressure
• Sustained recruitment of alveoli over time
• Possibly more comfortable – patient can
breathe whenever s/he wants
BIVENT - DISADVANTAGES
• High intrathoracic pressures can lead to
decreased venous return and blood pressure
• Often leads to hypercapnia
• In practice – anecdotally seems to be
uncomfortable
• Really requires spontaneous ventilation (so
shouldn’t paralyze)
WHAT ABOUT PATIENT EFFORT?
• When patient does nothing, things are pretty
simple
• When patient wants to breathe, ventilator has to
figure out what to do
• Patient “triggers” vent:
• Flow – easier, more sensitive in general
• Pressure – tougher to trigger but less accidental breaths
PRESSURE SUPPORT
• We set:
• Pressure support
• PEEP
• Flow % cutoff
• When patient triggers a breath ventilator bumps up
inspiratory pressure to PS level
• Pressure support continues until flow drops to set
percent of maximum
PRESSURE/VOLUME WAVEFORM - PS
Note that every breath has pink “trigger” marking
on upslope
ASSIST CONTROL
• Not a mode on its own, but a way to describe patient-
ventilator interaction
• In A/C, every patient trigger results in full tidal volume
breath
• Advantages:
• Reliable TV
• Decreases patient work
• Disadvantages:
• Can lead to severe hyperventilation
• Possibility of breath stacking / auto-PEEP
ASSIST CONTROL (A/C)
Patient efforts recognized by ventilator
– notice breath time reset every cycle
WHAT IS “AUTO-PEEP”?
INSP
FLOW
EXP
Expiratory flow ends Next breath begins
before next breath before exhalation
ends
Obstructive lung disease
Rapid breathing
Forced exhalation
SIMV
• SIMV is like a hybrid of A/C and PS
• Like A/C, not a mode itself but way of patient-vent
interaction
• SIMV divides Tb into Mandatory periods (Tm) and
Spontaneous periods (Ts)
SIMV
If patient tries to breathe during Tm, the ventilator gives a
FULLY ASSISTED BREATH – the SAME TIDAL
VOLUME IS ACHIEVED
SIMV
If patient tries to breathe during Ts, the ventilator allows the patient to
take the breath.
Assistance provided with PRESSURE (PRESSURE SUPPORT)
TIDAL VOLUME depends on patients effort and pressure support
PRESSURE/FLOW WAVEFORM – SIMV VC
Notice that first breath is VC, next two are PS
CASE 1
• 52 y/o F, 70 kg with aspiration pneumonia, gets
intubated on floor and sent to unit
• Initial settings: VC A/C, Rate 12, TV 700, FiO2
100%, PEEP 6
• Sats 88%
• Ventilator alarm going off for high Peak Pressures
(50 cm H2O)
• What do you do?
CASE 1 (CONT’D)
• Consider hand bagging patient (but be careful!)
• Drop TV – goal 6-8 ml/kg
• Increase PEEP
• Change modes – PC or PRVC (or BiVent)
CASE 2
• 62 y/o F, 52 kg, intubated for exacerbation of severe COPD
• Initial vent settings: SIMV VC, R 12, TV 400, FiO2 50%, PEEP 5
• Total respiratory rate: 16, Sats 100%
• ABG: pH 7.35, PCO2 65, PO2 180
• Vent is alarming because of high PIP – what do you do?
CASE 2 – CONT’D
• Disconnect and hand bag – allow for expiration
• Decrease I:E ratio – allow more time to exhale
• Treat underlying problem (bronchodilators)
• Take into account pt’s chronic compensation
SUMMARY
• Major modes of ventilation: VC, PC, PRVC, BiVent,
PS
• VC, PC, PRVC can be either A/C or SIMV
• Pressure controlled breaths offer smaller PIP for
same TV but no guarantee of TV
• VC breaths guarantee TV but at expense of PIP
• The sooner you can extubate, the better!
