Standardized

Vocabulary for
Mechanical Ventilation
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Active exhalation valve

A mechanism for holding pressure in the breathing circuit by delivering the flow
required to allow the patient breathe spontaneously. This feature is especially
prominent in modes like Airway Pressure Release Ventilation that are intended to
allow unrestricted spontaneous breathing during a prolonged mandatory (i.e., time
triggered and time cycled) pressure controlled breath.

Asynchrony (dyssynchrony)
Regarding the timing of a breath, asynchrony means triggering or cycling of an
assisted breath that either leads or lags the patient’s inspiratory effort. Regarding
the size of a breath, asynchrony means the inspiratory flow or tidal volume does
not match the patient’s demand. Also, some ventilators allow a patient to inhale
freely during a pressure controlled mandatory breath but not to exhale, thus
inducing asynchrony. Asynchrony may lead to increased work of breathing and
discomfort.

Adaptive targeting scheme

A control system that allows the ventilator to automatically set some (or
conceivably all) of the targets between breaths to achieve other preset targets. One
common example is adaptive pressure targeting (e.g., Pressure Regulated Volume
Control mode on the Maquet Servo-i ventilator) where a static inspiratory pressure
is targeted within a breath (i.e., pressure controlled inspiration) but this target is
automatically adjusted by the ventilator between breaths to achieve an operator
set tidal volume target.

Airway pressure
The pressure at the airway opening measured relative to atmospheric pressure
during mechanical ventilation.
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Airway pressure release

ventilation (APRV)
A form of pressure control intermittent mandatory ventilation that is designed
to allow unrestricted spontaneous breathing throughout the breath cycle. APRV
is applied using I:E ratios much greater than 1:1 and usually relying on short
expiratory times and gas trapping to maintain end expiratory lung volume rather
than a preset PEEP. This is in contrast to Bilevel Positive Airway Pressure (BIPAP)
which is also pressure control intermittent mandatory ventilation but with I:E ratios
closer to 1:1, expiratory times that do not create significant gas tapping and preset
PEEP levels above zero.

Assisted breath
A breath during which all or part of inspiratory (or expiratory) flow is generated by
the ventilator doing work on the patient. In simple terms, if the airway pressure
rises above end expiratory pressure during inspiration, the breath is assisted
(as in the Pressure Support mode). It is also possible to assist expiration by
dropping airway pressure below end expiratory pressure (such as Automatic Tube
Compensation on the Dräger Evita 4 ventilator). In contrast, spontaneous breaths
during CPAP are unassisted because the ventilator attempts to maintain a constant
airway pressure during inspiration.

autoPEEP
The positive difference between end-expiratory alveolar pressure (total or
intrinsic PEEP) and the end-expiratory airway pressure (set or extrinsic PEEP;
Am J Respir Crit Care Med 2011;184:756-762). When autoPEEP exists, a positive
pressure difference drives flow throughout exhalation until the subsequent breath
interrupts deflation. AutoPEEP is caused when expiratory time (either set by the
patient’s brain or a ventilator) is short relative to the expiratory time constant of the
respiratory system (possibly including the expiratory resistance of the breathing
circuit).
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Automatic tube
compensation
A feature that allows the operator to enter the size of the patient’s endotracheal
tube and have the ventilator calculate the tube’s resistance and then generate just
enough pressure (in proportion to inspiratory or expiratory flow) to compensate
for the added resistive load. (See servo control.)

Autotrigger
A condition in which the ventilator repeatedly triggers itself because the sensitivity
is set too high(sometimes called “autocycling”). For pressure triggering, the
ventilator may autotrigger due to a leak in the system dropping airway pressure
below a pressure trigger threshold. When sensitivity is set too high, even the
heartbeat can cause inadvertent triggering. Autotriggering is a form of patient-
ventilator asynchrony.

Bio-variable targeting scheme

A control system that allows the ventilator to automatically set the inspiratory
pressure or tidal volume randomly to mimic the variability observed during normal
breathing. Currently this “biologically variable” targeting scheme is only available in
one mode, Variable Pressure Support, on the Dräger V500 ventilator. The operator
sets a target inspiratory pressure and a percent variability from 0% to 100%.
A setting 0% means the preset inspiratory pressure will be delivered for every
breath. A 100 % variability setting means that the actual inspiratory pressure varies
randomly from PEEP/CPAP level to double the preset pressure support level.

Blower
A blower is a machine for generating relatively large flows of gas as the direct
ventilator output with a relatively moderate increase of pressure (e.g., 2 psi).
Blowers are used on home care and transport ventilators. (see compressor).
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Breath
A positive change in airway flow (inspiration) paired with a negative change in
airway flow (expiration), associated with ventilation of the lungs. This definition
excludes flow changes caused by hiccups or cardiogenic oscillations. However, it
allows the superimposition of, for example, a spontaneous breath on a mandatory
breath or vice versa. The flows are paired by size, not necessarily by timing.
For example, in Airway Pressure Release Ventilation there is a large inspiration
(transition from low pressure to high pressure) possibly followed by a few small
inspirations and expirations, followed finally by a large expiration (transition from
high pressure to low pressure). These comprise several small spontaneous breaths
superimposed on one large mandatory breath. In contrast, during High Frequency
Oscillatory Ventilation, small mandatory breaths are superimposed on larger
spontaneous breaths.

Breathing circuit
System of tubing connecting the patient to the ventilator.

Breath sequence
A particular pattern of spontaneous and/or mandatory breaths. The 3 possible
breath sequences are: continuous mandatory ventilation, (CMV), intermittent
mandatory ventilation (IMV), and continuous spontaneous ventilation (CSV).

Compliance
A mechanical property of a structure such as the respiratory system; a parameter
of a lung model, or setting of a lung simulator; defined as the ratio of the change
in volume to the associated change in the pressure difference across the system.
Compliance is the reciprocal of elastance.
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Compressor
A compressor is a machine for moving a relatively low flow of gas to a storage
container at a higher level of pressure (e.g, 20 psi). Compressors are generally
found on intensive care ventilators whereas blowers are used on home care and
transport ventilators. Compressors are typically larger and consume more electrical
power than blowers, hence the use of the latter on small, portable devices. (see
blower) CMV See continuous mandatory ventilation.

Continuous mandatory ventilation

Commonly known as “Assist/Control”; CMV is a breath sequence for which
spontaneous breaths are not possible between mandatory breaths because every
patient trigger signal in the trigger window produces a machine cycled inspiration
(ie, a mandatory breath). Machine triggered mandatory breaths may be delivered at
a preset rate. Therefore, in contrast to IMV, the mandatory breath frequency may
be higher than the set frequency but never below it. In some pressure controlled
modes on ventilators with an active exhalation valve, spontaneous breaths
may occur during mandatory breaths, but the defining characteristic of CMV is
that spontaneous breaths are not permitted between mandatory breaths. See
mandatory breath, intermittent mandatory ventilation, trigger window.

Continuous spontaneous ventilation

A breath sequence for which all breaths are spontaneous.

Control variable
The variable (ie, pressure or volume in the equation of motion) that the ventilator
uses as a feedback signal to manipulate inspiration. For simple set-point targeting,
the control variable can be identified as follows: If the peak inspiratory pressure
remains constant as the load experienced by the ventilator changes, then the
control variable is pressure. If the peak pressure changes as the load changes but
tidal volume remains constant, then the control variable is volume.
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Volume control implies flow control and vice versa, but it is possible to distinguish
the two on the basis of which signal is used for feedback control. Some primitive
ventilators cannot maintain either constant peak pressure or tidal volume and
thus control only inspiratory and expiratory times (ie, they may be called time
controllers).

Continuous mandatory ventilation

Commonly known as “Assist/Control”; CMV is a breath sequence for which
spontaneous breaths are not possible between mandatory breaths because every
patient trigger signal in the trigger window produces a machine cycled inspiration
(ie, a mandatory breath). Machine triggered mandatory breaths may be delivered at
a preset rate. Therefore, in contrast to IMV, the mandatory breath frequency may
be higher than the set frequency but never below it. In some pressure controlled
modes on ventilators with an active exhalation valve, spontaneous breaths
may occur during mandatory breaths, but the defining characteristic of CMV is
that spontaneous breaths are not permitted between mandatory breaths. See
mandatory breath, intermittent mandatory ventilation, trigger window.

Continuous spontaneous ventilation

A breath sequence for which all breaths are spontaneous.

Control variable
The variable (ie, pressure or volume in the equation of motion) that the ventilator
uses as a feedback signal to manipulate inspiration. For simple set-point targeting,
the control variable can be identified as follows: If the peak inspiratory pressure
remains constant as the load experienced by the ventilator changes, then the
control variable is pressure. If the peak pressure changes as the load changes but
tidal volume remains constant, then the control variable is volume.
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CPAP
Continuous positive airway pressure; the set or measured mean value of
transrespiratory system pressure during unassisted breathing or between
assisted breaths. While this term is sometimes used synonymously for PEEP,
historically, PEEP came first. PEEP mechanisms originally required the patient to
drop transrespiratory system pressure to below atmospheric pressure to inhale,
imposing a load and causing an increased work of breathing. CPAP mechanisms
were developed so that the patient only had to drop pressure below the set CPAP
level to inhale, thus decreasing the imposed load. See PEEP.

CSV
See continuous spontaneous ventilation; all breaths are spontaneous. See
spontaneous breath.

Cycle (cycling)
To end the inspiratory time (and begin expiratory flow).

Cycle variable
The variable (usually pressure, volume, flow, or time) that is used to end inspiratory
time (and begin expiratory flow).

Driving pressure
The pressure causing delivery of the tidal volume during pressure control modes
(ie the change in transrespiratory pressure associated with tidal volume delivery).
Driving pressure may be estimated either from ventilator settings (ie, driving
pressure = set inspiratory pressure above total PEEP) or from the airway pressure
waveform (ie, driving pressure = end inspiratory pressure above total PEEP). See
airway pressure, inspiratory pressure, peak inspiratory pressure.
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Dual targeting scheme

A control system that allows the ventilator to switch between volume control and
pressure control during a single inspiration. Dual targeting is a more advanced
version of set-point targeting. It gives the ventilator the decision of whether
the breath will be volume or pressure controlled according to the operator set
priorities. The breath may start out in pressure control and automatically switch
to volume control, as in the Bird “VAPS” mode or, the reverse, as in the Dräger
“Pressure Limited” mode feature. The Maquet Servo-i ventilator has a mode called
“Volume Control” and the operator presets both inspiratory time and tidal volume
as would be expected with any conventional volume control mode. However, if
the patient makes an inspiratory effort that decreases inspiratory pressure by 3
cm H2O, the ventilator switches to pressure control and, if the effort lasts long
enough, flow cycles the breath. Indeed, if the tidal volume and inspiratory time are
set relatively low and the inspiratory effort is relatively large, the resultant breath
delivery is indistinguishable from Pressure Support. As a result, the tidal volume
may be much larger than the expected, preset value. This highlights the need to
understand dual targeting. Because both pressure and volume are the control
variables during dual targeting, we identify the control variable as the one with
which the breath initiates. This is because the alternate control variable may never
be implemented during the breath, depending on the other factors in the targeting
scheme.

Dynamic compliance
The slope of the pressure-volume curve drawn between two points of zero flow
(eg, at the start and end of inspiration).

Dynamic hyperinflation
The increase in lung volume that occurs whenever insufficient exhalation time
prevents the respiratory system from returning to its normal resting end-expiratory
equilibrium volume between breath cycles. Inappropriate operator set expiratory
time may lead to dynamic hyperinflation, inability of the patient to trigger breaths,
and an increased work of breathing.
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Elastance
A mechanical property of a structure such as the respiratory system; a parameter
of a lung model, or setting of a lung simulator; defined as the ratio of the change
in the pressure difference across the system to the associated change in volume.
Elastance is the reciprocal of compliance.

Elastic load
The pressure difference applied across a system (e.g., a container) that sustains
the system’s volume relative to some reference volume, and/or the amount of its
compressible contents relative to some reference amount. (For a linear system:
elastance x volume, or, volume/compliance; for a container, the overall effective
elastance (compliance) includes the elastances (compliances) of its structural
components and the compressibility of the fluid [gas or liquid] within it.)

Equation of motion for the

respiratory system
A relation among pressure difference, volume, and flow (as variable functions of
time) that describes the mechanics of the respiratory system. The simplest and
most useful form is a differential equation with constant coefficients describing the
respiratory system as a single deformable compartment including the lungs and
chest wall connected in series to a single flow conducting tube:

PTR (t) + pmus (t) = EV (t) + RV (t) + autoPEEP

where
PTR (t) = The change in transrespiratory pressure difference (i.e., airway
opening pressure minus body surface pressure) as a function of time
(t), measured relative to end expiratory airway pressure. This is the
pressure generated by a ventilator, Pvent(t), during an assisted breath.
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pmus (t) = Ventilatory muscle pressure difference as a function of time

(t); the theoretical chestwall transmural pressure difference that would
produce movements identical to those produced by the ventilatory
muscles during breathing maneuvers (positive during inspiratory effort,
negative during expiratory effort).

V (t) = Volume change relative to end expiratory volume as a function

of time (t).
V (t) = Flow as a function of time (t), the first derivative of volume with
respect to time.

E = Elastance (inverse of compliance; E = 1/C).

R = Resistance.

autoPEEP = End expiratory alveolar pressure above end expiratory

airway pressure.

For the purposes of classifying modes of mechanical ventilation the equation is

often simplified to:

Pvent = EV + RV
Where
Pvent = The transrespiratory pressure difference (ie, “airway pressure”)
generated by the ventilator during an assisted breath.

Expiratory flow time

The period from the start of expiratory flow to the instant when expiratory flow
stops. By convention, expiratory flow is in the negative direction (below zero) in
graphs.

Expiratory pause time

The period from cessation of expiratory flow to the start of inspiratory flow.
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Expiratory time
The period from the start of expiratory flow to the start of inspiratory flow;
expiratory time equals expiratory flow time plus expiratory pause time.

Feedback control
Closed loop control accomplished by using the output as a signal that is fed back
(compared) to the operator-set input. The difference between the two is used to
drive the system toward the desired output (ie, negative feedback control). For
example, pressure controlled modes use airway pressure as the feedback signal
to manipulate gas flow from the ventilator to maintain an inspiratory pressure
setpoint.

Flow control
A breath sequence for which all breaths are spontaneous.

Flow triggering
The starting of inspiratory flow due to a patient inspiratory effort that generates
inspiratory flow above a preset threshold (ie, the trigger sensitivity setting).

Flow target
Inspiratory flow reaches a preset value that may be maintained before inspiration
cycles off.

Flow cycling
The ending of inspiratory time due to inspiratory flow decay below a preset
threshold (aka, the cycle sensitivity).
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IMV
See intermittent mandatory ventilation.

Inspiratory flow
The flow into the airway opening during the inspiratory time. By convention,
inspiratory flow is in the positive direction (above zero) in graphs.

Inspiratory flow time

The period from the start of inspiratory flow (into the airway opening) to the
cessation of inspiratory flow.

Inspiratory hold
An intentional maneuver during mechanical ventilation whereby exhalation is
delayed for a preset time (inspiratory hold time) after an assisted breath. This
maneuver is used to assess static respiratory system mechanics and also to
increase mean airway pressure during volume control ventilation in an attempt to
improve gas exchange.

Inspiratory hold (pause) time

The period from the cessation of inspiratory flow (into the airway opening) to the
start of expiratory flow during mechanical ventilation.

Inspiratory pressure
General term for the pressure at the patient connection during the inspiratory
phase.
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Inspiratory pressure change

The change in transrespiratory system pressure associated with delivery of the
tidal volume as described in the equation of motion for the respiratory system.
For pressure control modes, if inspiratory pressure is set relative to atmospheric
pressure, the term “peak inspiratory pressure” is used to describe the setting.
If inspiratory pressure is set relative to PEEP, the term “inspiratory pressure
change” is used. See equation of motion for the respiratory system, peak
inspiratory pressure

Inspiratory time
The period from the start of inspiratory flow to the start of expiratory flow.
Inspiratory time equals inspiratory flow time plus inspiratory pause time.

Intelligent targeting scheme

A ventilator control system that uses artificial intelligence programs such as
fuzzy logic, rule based expert systems, and artificial neural networks. Examples
include the rule based system used by SmartCare (Dräger Evita XL ventilator) and
IntelliVent-ASV (Hamilton S1 ventilator).

Intermittent mandatory ventilation

Breath sequence for which spontaneous breaths are permitted between
mandatory breaths. For most ventilators, a short “window” is opened before the
scheduled machine triggering of mandatory breaths to allow synchronization with
any detected inspiratory effort on the part of the patient. This is referred to as
synchronized IMV (or SIMV).

Three common variations of IMV are: (1) Mandatory breaths are always delivered at
the set frequency; (2) Mandatory breaths are delivered only when the spontaneous
breath frequency falls below the set frequency; (3) Mandatory breaths are
delivered only when the spontaneous minute ventilation
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(ie, product of spontaneous breath frequency and spontaneous breath tidal

volume) drops below a preset or computed threshold (aka Mandatory Minute
Ventilation). Therefore, in contrast to CMV, with IMV the mandatory breath
frequency can never be higher than the set rate but it may be lower.

For some modes (eg, Airway Pressure Release Ventilation), a short window is
also opened at the end of the inspiratory time. Because spontaneous breaths
are allowed during the mandatory pressure controlled breath, this window
synchronizes the end of the mandatory inspiratory time with the start of
spontaneous expiratory flow, if detected.
With these technological developments, potential confusion arises as to whether
inspiration that is synchronized (either start or stop) is considered patient
triggered/cycled or machine triggered/cycled. If we say synchronized breaths are
patient triggered and cycled, we have the awkward possibility of a spontaneous
breath occurring during another spontaneous breath. This is avoided by
distinguishing between a trigger window and a synchronization window.

There are some modes where the idea of IMV may be vague: With Airway
Pressure Release Ventilation, relatively high frequency spontaneous breaths are
superimposed on low frequency mandatory breaths. However, the expiratory
time between mandatory breaths is often set so short that a spontaneous breath
is unlikely to occur between them. Other ambiguous modes are High Frequency
Oscillation, High Frequency Jet Ventilation, Intrapulmonary Percussive Ventilation
and Volumetric Diffusive Respiration. With these modes, high frequency mandatory
breaths are superimposed on low frequency spontaneous breaths and again, there
is no possibility of a spontaneous breath actually occurring between mandatory
breaths. Nevertheless, we classify all these modes as forms of IMV because
spontaneous breaths can occur along with mandatory breaths and because
spontaneous efforts do not affect the mandatory breath frequency. See machine
triggering, patient triggering, synchronization window, trigger window,
continuous mandatory ventilation.

Load
The pressure required to generate inspiration (see elastic load and resistive load).
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Machine cycling
Ending inspiratory time independent of signals representing the patient
determined components of the equation of motion (Pmus, elastance, or
resistance). Common examples are cycling due to a preset tidal volume or
inspiratory time. If a patient signal (indicating expiration) occurs during an
inspiratory time synchronization window, inspiration stops and is defined as a
machine cycled event that ends a mandatory breath. See machine triggering,
patient triggering, synchronization window, trigger window, continuous
mandatory ventilation, intermittent mandatory ventilation.

Machine triggering
Starting inspiratory flow based on a signal (usually time) from the ventilator,
independent of a patient trigger signal. Examples include triggering based on
a preset frequency (which sets the ventilatory period), or based on a preset
minimum minute ventilation (determined by tidal volume divided by the ventilatory
period). If a signal from the patient (indicating an inspiratory effort) occurs within
a synchronization window, the start of inspiration is defined as a machine trigger
event that begins a mandatory breath. See machine cycling, patient triggering,
synchronization window, trigger window, continuous mandatory
ventilation, intermittent mandatory ventilation.

Mandatory breath
A breath for which the patient has lost control over timing. This means a breath
for which the start or end of inspiration (or both) is determined by the ventilator,
independent of the patient. That is, the machine triggers and/or cycles the breath.
A mandatory breath can occur during a spontaneous breath (eg, High Frequency
Jet Ventilation). A mandatory breath is, by definition, assisted. See assisted
breath, spontaneous breath.
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Mandatory minute ventilation

A form of intermittent mandatory ventilation (IMV) in which the ventilator monitors
the exhaled minute ventilation as a target variable. If the exhaled minute ventilation
falls below the operator set value, the ventilator will trigger mandatory breaths or
increase the inspiratory pressure until the target is reached.

Mechanical ventilator
An automatic machine designed to provide all or part of the work required to
generate enough breaths to satisfy the body’s respiratory needs.

Mode of ventilation
A predetermined pattern of interaction between a patient and a ventilator,
specified as a particular combination of control variable, breath sequence, and
targeting schemes for primary and secondary breaths.

Negative pressure ventilation

A type of assisted breathing for which transrespiratory pressure difference is
generated by keeping airway pressure equal to atmospheric pressure and making
body surface pressure less than atmospheric pressure. Examples would be
ventilation with an “iron lung” or “chest cuirass”.

Neurally Adjusted Ventilatory Assist

The name of a mode using a servo targeting scheme in which the controller sets
airway pressure to be proportional to patient effort based on the voltage recorded
from diaphragmatic activity from sensors embedded in an orogastric tube:

P(t) = KEdi (t)

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where P(t) is inspiratory pressure relative to end expiratory pressure as a function

of time, t, K is the NAVA support level (an amplification factor), Edi (t) is the electrical
signal from the diaphragm as a function of time. The operator inputs the constant
of proportionality between voltage and pressure (gain). Then the controller sets
airway pressure to equal the product of gain and the Edi.

Optimal targeting scheme

A ventilator control system that automatically adjusts the targets of the ventilatory
pattern to either minimize or maximize some overall performance characteristic.
One example is Adaptive Support Ventilation (Hamilton Medical G5 ventilator)
in which the ventilator adjusts the mandatory tidal volume and frequency (for a
passive patient) is such a way as to minimize the work rate of ventilation.

Partial ventilatory support

The ventilator and the respiratory muscles each provide some of the work of
breathing; muscle pressure adds to ventilator pressure in the equation of motion.

Patient cycling
Ending inspiratory time based on signals representing the patient determined
components of the equation of motion, (Pmus , elastance, or resistance).
Common examples of cycling variables are peak inspiratory pressure and percent
inspiratory flow. See machine triggering, machine cycling, patient triggering,
synchronization window, trigger window, continuous mandatory
ventilation, intermittent mandatory ventilation.

Patient triggering
Starting inspiration based on a patient signal occurring in a trigger window,
independent of a machine trigger signal. The signal is related to one of the
patient determined components of the equation of motion (Pmus, elastance, or
resistance). Common examples of patient trigger variables are airway pressure
drop below baseline and inspiratory flow due to patient effort.
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See machine triggering, machine cycling, synchronization window, trigger

window, continuous mandatory ventilation, intermittent mandatory
ventilation.

PC-CMV : Pressure controlled continuous mandatory ventilation.

PC-IMV : Pressure controlled intermittent mandatory ventilation.
PC-CSV : Pressure controlled continuous spontaneous ventilation.

Peak airway pressure

The maximum airway pressure during a mechanically assisted inspiration,
measured relative to atmospheric pressure.

Peak inspiratory pressure

The inspiratory pressure change that is set relative to atmospheric pressure during
pressure control modes. See inspiratory pressure change.

PEEP
Positive end expiratory pressure; the value of transrespiratory system pressure at
end expiration. See CPAP.

Positive pressure ventilation

A type of assisted breathing for which transrespiratory pressure difference is
generated by raising airway pressure above body surface pressure (usually equal
to atmospheric pressure). Examples would be ventilation with intensive care or
transport ventilators.

Pressure
A measure of force per unit of area at a particular point in space.
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Pressure change
The difference between pressure (or pressure gradient) measured at one point in
time and the same pressure measured at a previous point in time.

Pressure gradient
The difference between pressure measured at one point in space and another
point in space. Examples include the pressure difference across a cell membrane
causing gas diffusion into the cell and the pressure difference across the
respiratory system causing flow into the lungs. See transairway pressure,
transalveolar pressure, transchestwall pressure, transpulmonary
pressure, transrespiratory pressure, transthoracic pressure.

Pressure control
A general category of ventilator modes for which pressure delivery is
predetermined by a targeting scheme such that inspiratory pressure is either
proportional to patient effort or has a particular waveform regardless of respiratory
system mechanics. When inspiratory pressure is preset, we further specify that
inspiration must start out with the preset pressure to avoid confusion with dual
targeting that may switch from a preset flow to a preset pressure (eg, Pmax feature
used with volume control modes on the Dräger Evita Infinity V500 ventilator). See
dual targeting scheme. According to the equation of motion, pressure control
means that inspiratory pressure is predetermined as the independent variable so
that volume and flow become the dependent variables. See volume control and
equation of motion.

Pressure cycling
Inspiration ends (ie, expiratory flow starts) when airway pressure reaches a preset
threshold.
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Ramp
A mathematical function whose value rises or falls at a constant rate. Ascending
(rising) or descending (falling) functions are sometimes used for inspiratory flow in
volume control modes.

Resistance
A mechanical property of a structure such as the respiratory system; a parameter
of a lung model, or setting of a lung simulator; defined as the ratio of the change in
the pressure difference across the system to the associated change in flow.

Resistive load
The pressure difference applied across a system (e.g., a container) that is related to
a rate of change of the system’s volume and/or the flow of fluid within or through
the system. (For a linear system: resistance x flow, or, resistance x rate of change
of volume; for a container, the effective resistance includes the mechanical (usually
viscous) resistances of its structural components and the flow resistance of the
fluid [gas or liquid] within it.)

Secondary breaths
Spontaneous breaths during IMV.

Sensitivity
The sensitivity setting of the ventilator is a threshold value for the trigger variable
which, when met, starts inspiration. In other words, the sensitivity is the amount
the trigger variable must change to start inspiratory flow. Sensitivity is sometimes
used to refer to the cycle threshold.
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Pressure Support
The name of a mode using a set-point targeting scheme in which all breaths are
pressure or flow triggered, pressure targeted, and flow cycled.

Pressure triggering
The starting of inspiratory flow due to a patient inspiratory effort that generates an
airway pressure drop below end expiratory pressure larger than a preset threshold
(ie, the trigger sensitivity setting).

Pressure target
Inspiratory pressure reaches a preset value before inspiration cycles off.

Primary breaths
Mandatory breaths during CMV or IMV or spontaneous breaths during CSV.

Proportional Assist Ventilation (PAV)

The name of a mode using a servo targeting scheme based on the equation of
motion for the respiratory system in the form:

P (t) = K1V (t) + K2V (t)

where inspiratory pressure relative to end expiratory pressure as a function of time
P(t) is the sum of two components. The first is the “volume assist” or the amount
of elastic load supported, ie, K1 times volume as a function of time V(t). The second
component is the “flow assist” or the amount of resistive load supported, ie, K2,
times flow as a function of
time, V (t). The values of K1 and K2 are preset by the operator and represent the
supported elastance and resistance, respectively, whereas volume and flow are
generated by the patient. Because volume and flow are initiated by the patient’s
inspiratory effort created by muscle pressure, Pmus, the pressure generated by PAV
can be thought of as an amplifier of Pmus.
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Servo targeting
A control system for which the output of the ventilator automatically follows a
varying input. For example, the Automatic Tube Compensation feature on the
Dräger Evita 4 ventilator tracks flow and forces pressure to be equal to flow
squared and multiplied by a constant (representing endotracheal tube resistance).
Other examples include Proportional Assist Ventilation (Covidien PB 840
ventilator; pressure is proportional to spontaneous volume and flow) and Neurally
Adjusted Ventilatory Assist (Maquet Servo-i ventilator; pressure is proportional
to diaphragmatic electrical activity). For all three of these example modes airway
pressure is effectively proportional to the patient’s inspiratory effort.

Set-point targeting
A control system for which the operator sets all the parameters of the pressure
waveform (pressure control modes) or volume and flow waveforms (volume
control modes). Advanced volume control modes actually allow the ventilator to
make small adjustments to the set inspiratory flow to compensate for such factors
as patient circuit compliance. From an engineering point of view, this is adaptive
feedback control, but from a ventilator mode taxonomy point of view, such
adjustments are better seen as a way of implementing operator preset values, and
thus classified as set-point targeting.

Sinusoid
A mathematical function having a magnitude that varies as the sine of an
independent variable (eg time). A sinusoidal function is sometimes used for
inspiratory flow in volume control modes.

Sinusoid
A breath for which the patient retains substantial control over timing. This means
the start and end of inspiration may be determined by the patient, independent of
any machine settings for inspiratory time and expiratory time. That is, the patient
both triggers and cycles the breath. Note that use of this definition for determining
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the breath sequence (ie, CMV, IMV, CSV) assumes normal ventilator operation.
For example, coughing during VC-CMV may result in patient cycling for a patient
triggered breath due to the pressure alarm limit. While inspiration for that breath
is both patient triggered and patient cycled, this is not normal operation and
the sequence does not turn into IMV. A spontaneous breath may occur during a
mandatory breath (eg Airway Pressure Release Ventilation). A spontaneous breath
may be assisted or unassisted. See assisted breath, mandatory breath.

Synchronized IMV (SIMV)

A form of IMV in which mandatory breath delivery is coordinated with patient
effort. A synchronized breath is considered to be machine triggered. See
intermittent mandatory ventilation.

Synchronization window
A mathematical function having a magnitude that varies as the sine of an
independent variable (eg time). A sinusoidal function is sometimes used for
inspiratory flow in volume control modes. A short period, at the end of a preset
expiratory time or at the end of a preset inspiratory time, during which a patient
signal may be used to synchronize a mandatory breath trigger or cycle event
to a spontaneous breath. If the patient signal occurs during an expiratory time
synchronization window, inspiration starts

and is defined as a machine triggered event. This is because the mandatory

breath would have been time triggered regardless of whether the patient signal
had appeared or not and because the distinction is necessary to avoid logical
inconsistencies in defining mandatory and spontaneous breaths which are the
foundation of the mode taxonomy. If inspiration is triggered in a synchronization
window, the actual ventilatory period for the previous breath will be shorter than
the set ventilatory period (determined by the set mandatory breath frequency).
Some ventilators add the lost time to the next mandatory breath period to
maintain the set frequency. Sometimes a synchronization window is used at the
end of the inspiratory time of a pressure controlled, time cycled breath. If the
patient signal occurs during such an inspiratory time synchronization window,
expiration starts and is defined as a machine cycled event. Some ventilators offer
the mode called Airway Pressure Release Ventilation (or something similar with a
different name) that makes use of both expiratory and inspiratory synchronization
windows. See intermittent mandatory ventilation, machine triggering, patient
triggering, trigger window.
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Tag
A mode classification. A tag can be an acronym. For example the mode named
Volume A/C is classified as volume control (VC) continuous mandatory ventilation
(CMV) with set-point targeting (s) and can be represented as VC-CMVs. Another
example (using both primary and secondary breaths) would be PRVC SIMV
classified as PC-IMVa,s, where the primary breath uses adaptive targeting (a) and
the secondary breath uses set-point targeting (s). The mode named Adaptive
Support Ventilation has multiple targeting for each type of breath (ie, both optimal,
o, and intelligent, i). It is classified as PC-IMVoi,oi.

Target
A predetermined goal of ventilator output. Targets can be viewed as the goals of
the targeting scheme. Within-breath targets are the parameters of the pressure,
volume, or flow waveform. Examples of within-breath targets include inspiratory
flow or pressure and rise time (set-point targeting), tidal volume (dual targeting)
and constant of proportionality between inspiratory pressure and patient effort
(servo targeting). Note that preset values within a breath that end inspiration, such
as tidal volume, inspiratory time, or percent of peak flow, are also cycle variables.
Between-breath targets serve to modify the within-breath targets and/or the
overall ventilatory pattern. Between-breath targets are used with more advanced
targeting schemes, where targets act over multiple breaths.
Examples of between-breath targets and targeting schemes include average tidal
volume (for adaptive targeting), percent minute ventilation (for optimal targeting)
and combined PCO2, volume, and frequency values describing a “zone of comfort”
(for intelligent targeting).

Targeting scheme
A model of the relationship between operator inputs and ventilator outputs to
achieve a specific ventilatory pattern, usually in the form of a feedback control
system. The targeting scheme is a key component of a mode description.
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Taxonomy
A hierarchical classification system. A taxonomy for modes of ventilation has four
levels: 1) the control variable, 2) the breath sequence; 3) the targeting scheme for
primary breaths and ; 4) the targeting scheme for secondary breaths. These levels
correspond to the levels of Family, Class, Genus, and Species of the Linnaean
taxonomy used in biology.

TC-IMV
Time controlled intermittent mandatory ventilation (eg, High Frequency Oscillatory
Ventilation or Intrapulmonary Percussive Ventilation).

Tidal volume
The volume of gas, either inhaled or exhaled, during a breath. The maximum value
of the volume vs time waveform.

Time cycling
Inspiratory time ends after a preset time interval has elapsed. The most common
examples are a preset inspiratory time or a preset inspiratory pause time.

Time constant
The time at which an exponential function attains 63% of its steady state value in
response to a step input; the time necessary for inflated lungs to passively empty
by 63%; the time necessary for the lungs to passively fill 63% during pressure
controlled ventilation with a rectangular pressure waveform. The time constant
for a passive mechanical system is calculated as the product of resistance and
compliance and has units of time (usually expressed in seconds). Passive inhalation
or exhalation is virtually complete after 5 time constants.
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Time control
A general category of ventilator modes for which inspiratory flow, inspiratory
volume, and inspiratory pressure are all dependent on respiratory system
mechanics. As no parameters of the pressure or flow waveform are preset, the only
control of the breath is the timing, ie, inspiratory and expiratory times. Examples
of this are high frequency oscillatory ventilation (CareFusion 3100 ventilator) and
Volumetric Diffusive Respiration (Percussionaire).

Tidal pressure
The change in trans-alveolar pressure (i.e., pressure in the alveolar region minus
pressure in the pleural space, equivalent to elastance times volume in the equation
of motion) associated with the inhalation or exhalation of a tidal volume.

Total cycle time

Same as ventilatory period, the sum of inspiratory time and expiratory time.

Total PEEP
The sum of autoPEEP and intentionally applied PEEP or CPAP. Synonymous with
intrinsic PEEP.

Time triggering
The starting of inspiratory flow due to a preset time interval. The most common
example is a preset ventilatory frequency.

Total ventilatory support

The ventilator provides all the work of breathing; muscle pressure in the equation
of motion is zero. This is normally only possible if the patient is paralyzed or heavily
sedated.
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Transairway pressure
Pressure at the airway opening minus pressure in the lungs (i.e., alveolar pressure).

Transalveolar pressure
Pressure in the lungs minus pressure in the pleural space. Equal to transpulmonary
pressure only under static conditions.

Transchestwall pressure
Pressure in the pleural space minus pressure on the body surface.

Transpulmonary pressure
Pressure at the airway opening minus pressure in the pleural space.

Transrespiratory pressure
Pressure at the airway opening minus pressure on the body surface; equal to
the sum of transairway pressure plus transalveolar pressure plus transchestwall
pressure.

Transthoracic pressure
Pressure in the lungs minus pressure on the body surface; equal to the sum of
transalveolar pressure plus transchestwall pressure.

Trigger (triggering)
To start the inspiratory time. See machine triggering, patient triggering.
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Trigger variable
The variable (usually pressure, volume, flow, or time) that is used to start the
inspiratory time.

Trigger window
The period comprised of the entire expiratory time minus a short “refractory”
period required to reduce the risk of triggering a breath before exhalation is
complete. If a signal from the patient (indicating an inspiratory effort) occurs within
this trigger window, inspiration starts and is defined as a patient triggered event.
See intermittent mandatory ventilation, machine triggering, patient
triggering, synchronization window.

Ventilatory pattern
A sequence of breaths (CMV, IMV, or CSV) with a designated control variable
(volume or pressure) for the mandatory breaths (or the spontaneous breaths for
CSV).

Ventilatory period
The time from the start of inspiratory flow of one breath to the start of inspiratory
flow of the next breath; inspiratory time plus expiratory time; the reciprocal of
ventilatory frequency. Also called total cycle time or total breath cycle.

Volume control
A general category of ventilator modes for which both inspiratory flow and tidal
volume are predetermined by a targeting scheme to have particular waveforms
independent of respiratory system mechanics. Usually, flow and tidal volume may
be set directly by the operator. Alternatively, the ventilator may determine tidal
volume based on operator preset values for frequency and minute ventilation or
the ventilator may determine inspiratory flow based on operator set tidal volume
and inspiratory time.
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When inspiratory volume and flow are preset, we further specify that inspiration
must start out with the preset flow to avoid confusion with dual targeting that may
switch from a preset pressure to a preset flow and volume (eg. Volume Assured
Pressure Support). See dual targeting scheme. Note that setting tidal volume is
a necessary but not sufficient criterion for volume control. The reason is that some
ventilators use pressure control with adaptive targeting and allow the operator to
set a tidal volume but not an inspiratory flow. In this case, the tidal volume setting
refers to the between-breath tidal volume target, not a within-breath target. See
adaptive targeting scheme. Likewise, setting inspiratory flow is also a necessary
but not sufficient criterion for volume control. For example, the Bird Mark 7
ventilator requires an inspiratory flow setting but has no tidal volume setting.
Instead the operator sets the inspiratory pressure, which is also the cycle variable.
Hence, breaths are pressure controlled, and changing lung mechanics change the
rate of pressure rise, the inspiratory time, and hence the delivered tidal volume
as in other examples of pressure control. According to the equation of motion,
volume control means that both volume and flow are predetermined as the
independent variables and pressure is thus the dependent variable. See pressure
control and equation of motion.

Volume cycling
Inspiratory time ends when inspiratory volume reaches a preset threshold (ie, tidal
volume).

VC-CMV
Volume controlled continuous mandatory ventilation.

VC-IMV
Volume controlled intermittent mandatory ventilation.

Volume target
A preset value for tidal volume that the ventilator is set to attain either within a
breath or as an average over multiple breaths.
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Volume triggering
The starting of inspiratory flow due to a patient inspiratory effort that generates an
inspiratory volume signal larger than a preset threshold (ie, the trigger sensitivity
setting).

Work of breathing
The general definition of work is the integral of pressure with respect to volume
during an assisted inspiration. There are two general components of work related
to mechanical ventilation. One kind is the work performed by the ventilator on the
patient, which is reflected by a positive change in airway pressure above baseline
during inspiration. The second component is the work the patient does on the
ventilator to (eg, to trigger inspiration), which is reflected by a negative change in
airway pressure below baseline during inspiration.