Classification of Mechanical Ventilation

Ventilator Terminology & Classification of Mechanical Ventilation Medical University of South Carolina Division of Neonatology
Modes of Ventilation Mode of ventilation: Refers to the pattern of breaths and its relationship to patient breaths High Frequency Ventilation: Rates significantly above physiological respiratory rate Intermittent Mandatory Ventilation / Synchronized IMV (SIMV) Ventilation at a specified rate that approximates physiological rates May be synchronized to patients inspiration May be synchronized to patients inspiratory time Assist Control Ventilation (AC) Initiation of each breath synchronized to patients respiratory pattern; Every patient breath is assisted to the same degree Pressure Support Ventilation (PS) Initiation of each breath synchronized to patients respiratory pattern; Every breath is assisted, though not necessarily to the same degree May be combined with SIMV or CPAP Usually flow cycled (see: Other Controls below) Airway Pressure Release Ventilation Pressure is maintained at a peak above FRC Very short intermittent releases allow ventilation Spontaneous breaths occur around a high MAP Biphasic Ventilation Utilizes alternating high and low MAPs in various ratios Spontaneous breathing (may be pressure supported) occurs around both high and low MAPs Longer duration of low MAP distinguishes biphasic from pressure release ventilation Mechanical Control of Ventilation Control: (Breath Control) Refers to the mechanism the ventilator uses to adjust the amount of gas delivered Volume Control: Ventilator delivers a preset volume Pressure varies as required to deliver the volume Pressure Control Ventilator delivers a preset peak pressure (PIP) Volume varies Mixed (Dual) Attempt to deliver specified volume using a pressure control Mechanism (and therefore effect) varies significantly between ventilators Includes (among others): PRVC: Tidal Volume is ordered Ventilator calculates anticipated pressure required to deliver ordered volume Pressure is recalculated each breath based on last several breaths and VTs Although volume is ordered, breath delivered is a pressure breath Results in fluctuations in PIP as might VT, to a degree Volume Guarantee Pressure control ventilation with a minimum volume delivery Pressure breath is delivered but may switch to volume breath if needed to ordered VT Both PIP and Minimum VT (volume guarantee) are ordered MUSC Ventilator VIP Bird & Avea VIP Bird & Avea MUSC Ventilator Jet Oscillator VIP Bird Avea VIP Bird Avea
Avea
NA: Supported by Avea but not used in our unit NA: Supported by Avea but not used in our unit
Servo (by internal convention, limited use in NICU) Supported in adult mode on Avea Avea (dual mode ventilator of choice in our NICU)
Revised 12/2006
Modes are sometimes listed as including breath control. For example, the Avea lists 6 neonatal modes of ventilation on its display, which are essentially 2 modes each with 3 breath type controls: Volume Assist Control Volume SIMV Volume Time Cycled Pressure Limited Pressure Assist Control Pressure SIMV Pressure Time Cycled Pressure Limited Other Controls: I. Cycling (how the cycle time is determined; how the breath is terminated) a. Time cycled (respiratory cycle duration is determined by time) b. Volume cycled (respiratory cycle duration determined by delivered volume) c. Flow Cycled (respiratory cycle duration is determined by gas flow) II. Triggering (how a patient effort is detected) a. Time b. Pressure c. Flow d. Temperature flux III. Various controls that change the shape of the ventilator curve (rise time, inspiratory time, flow, etc) Time Cycled Pressure Limited (TCPL) vs Pressure Control (PC) Ventilation In general, all mechanical breaths are characterized by several variables: Trigger: what tells the ventilator to fire Control: determines the characteristics of the breath Cycle: primary mechanism determining how the breath is ended Limit: secondary mechanism of breath termination The major difference between TCPL and PC ventilation is how the breath is delivered gas flow is constant in TCPL, which allows limited gas flow on demand breaths (unassisted patient breaths). In PC ventilation, gas flow is decelerating / variable, which allows for fluctuation in flow according to patient demand. Because of this, PC might have adverse effects on volume delivery (shorter inspiratory plateau) but might also reduce barotrauma and need for sedation.
Revised 12/2006
Terminology Terminology is not standardized between manufacturers and might differ between institutions By convention at MUSC, we use classical descriptors of the respiratory cycle rather than manufacturer specific terminology. I. Pressures a. Positive End Expiratory Pressure i. Avea and VIP Bird ii. Pressure maintained during expiration b. PIP (our preferred terminology) i. Maximal pressure generated during inspiratory phase of ventilatory cycle ii. Set directly on VIP Bird iii. Set indirectly in Avea as (PEEP + Inspiratory Pressure) c. Pressure Support (our preferred terminology) i. Pressure (above PEEP) of assisted breaths in Pressure Support Ventilation ii. Entered directly in Avea (PSV) d. Inspiratory Pressure (Not preferred - use PIP to order peak pressure see above) i. Pressure above PEEP generated in machine breaths ii. AKA: P, tidal pressure iii. PIP = PEEP + IP II. Rate a. Machine rate for mandatory breaths in IMV or SIMV b. Back-Up ventilator rate in AC c. Entered directly in Bird and Avea III. Synchronization a. Inspiratory: senses beginning of patient inspiration i. Flow Trigger (Avea) ii. Assist Sensitivity (Bird) b. Expiratory (limits inspiratory time by sensing near complete inflation of lung) i. Termination Sensitivity (VIP Bird) ii. Percent Flow Cycle (Avea) Example: Goal PIP is 18 with PEEP of 4cm and SIMV rate of 45 (and Pressure Support of 6 cm above PIP) Order: PIP=18, PEEP=4, Rate=45, (Pressure Support = 6 cm) Settings: VIP Bird: PIP=18, PEEP=4, Rate=45, (Pressure support is not available on the VIP Bird) Avea: IP=14, PEEP=4, Rate=45, PSV=6
Revised 12/2006

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Ventilator Terminology & Classification of Mechanical Ventilation Medical University of South Carolina Division of Neonatology

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