Modes of mechanical ventilation

Modes of mechanical ventilation are one of the most important aspects of the usage of mechanical
ventilation. The mode refers to the method of inspiratory support. In general, mode selection is based on
clinician familiarity and institutional preferences, since there is a paucity of evidence indicating that the
mode affects clinical outcome. The most frequently used forms of volume-limited mechanical ventilation
are intermittent mandatory ventilation (IMV) and continuous mandatory ventilation (CMV).[1] There have
been substantial changes in the nomenclature of mechanical ventilation over the years, but more recently it
has become standardized by many respirology and pulmonology groups.[2][3] Writing a mode is most proper
in all capital letters with a dash between the control variable and the strategy (i.e. PC-IMV, or VC-MMV
etc.) .

Contents
Taxonomy for mechanical ventilation
10 maxims
How modes are classified
Example mode classification is given below
Descriptions of common modes
Assist mode, control mode, and assist-control mode
Airway pressure release ventilation
Mandatory minute ventilation
Pressure-regulated volume control
Continuous positive airway pressure
Automatic positive airway pressure
Bilevel positive airway pressure
Medical uses
High-frequency ventilation (Active)
High-frequency ventilation (Passive)
Volume guarantee
Spontaneous breathing and support settings
Positive end-expiratory pressure
Pressure support
Other ventilation modes and strategies
Closed loop systems
Adaptive Support Ventilation
Automatic Tube Compensation
Neurally Adjusted Ventilatory Assist
Proportional Assist Ventilation
Liquid ventilation
Total liquid ventilation
Partial liquid ventilation
See also
References

Taxonomy for mechanical ventilation

The taxonomy is a logical classification system based on 10 maxims of ventilator design[4]

10 maxims
1. A breath is one cycle of positive flow (inspiration) and negative flow (expiration) defined in
terms of the flow-time curve. Inspiratory time is defined as the period from the start of positive
flow to the start of negative flow. Expiratory time is defined as the period from the start of
expiratory flow to the start of inspiratory flow. The flow-time curve is the basis for many
variables related to ventilator settings.
2. A breath is assisted if the ventilator does work on the patient. An assisted breath is one for
which the ventilator does some portion of the work of breathing. For constant flow inflation,
work is defined as inspiratory pressure multiplied by tidal volume. Therefore, an assisted
breath is identified as a breath for which airway pressure (displayed on the ventilator) rises
above baseline during inspiration. An unassisted breath is one for which the ventilator simply
provides the inspiratory flow demanded by the patient and pressure stays constant throughout
the breath.
3. A ventilator assists breathing using either pressure control or volume control based on the
equation of motion for the respiratory system. Providing assistance means doing work on the
patient, which is accomplished by controlling either pressure or volume. A simple mathematical
model describing this fact is known as the equation of motion for the passive respiratory
system:

Pressure = (Elastance × Volume) + (Resistance × Flow)

In this equation, pressure, volume, and flow are all continuous functions of time. Pressure is
actually a pressure difference across the system (e.g., transrespiratory pressure defined as
pressure at the airway opening minus pressure on the body surface). Elastance (defined as
the change in pressure divided by the associated change in volume; the reciprocal of
compliance) and resistance (defined as a change in pressure divided by the associated
change in flow) are parameters assumed to remain constant during a breath.

Volume control (VC) means that both volume and flow are preset prior to
inspiration. In other words, the right hand side of the equation of motion remains
constant while pressure changes with changes in elastance and resistance.
Pressure control (PC) means that inspiratory pressure is preset as either a
constant value or it is proportional to the patient’s inspiratory effort. In other words,
the left-hand side of the equation of motion remains constant while volume and
flow change with changes in elastance and resistance.
Time control (TC) means that, in some rare situations, none of the main variables
(pressure, volume, or flow) are preset. In this case only the inspiratory and
expiratory times are preset.
4. Breaths are classified by the criteria that trigger (start) and cycle (stop) inspiration. The start of
inspiration is called the trigger event. The end of inspiration is called the cycle event.
5. Trigger and cycle events can be initiated by the patient or the machine. Inspiration can be
patient triggered or patient cycled by a signal representing inspiratory effort. Inspiration may
also be machine triggered or machine cycled by preset ventilator thresholds.

Patient triggering means starting inspiration based on a patient signal independent

of a machine trigger signal. Machine triggering means starting inspiratory flow
based on a signal from the ventilator, independent of a patient trigger signal.
Patient cycling means ending inspiratory time based on signals representing the
patient determined components of the equation of motion, (ie, elastance or
resistance and including effects due to inspiratory effort). Flow cycling is a form of
patient cycling because the rate of flow decay to the cycle threshold is determined
by patient mechanics. Machine cycling means ending inspiratory time independent
of signals representing the patient determined components of the equation of
motion.

6. Breaths are classified as spontaneous or mandatory based on both the trigger and cycle
events. A spontaneous breath is a breath for which the patient both triggers and cycles the
breath. A spontaneous breath may occur during a mandatory breath (e.g. Airway Pressure
Release Ventilation). A spontaneous breath may be assisted or unassisted. A mandatory
breath is a breath for which the machine triggers and/or cycles the breath. A mandatory breath
can occur during a spontaneous breath (e.g., High Frequency Jet Ventilation). A mandatory
breath is, by definition, assisted.
7. There are 3 breath sequences: Continuous mandatory ventilation (CMV), Intermittent
Mandatory Ventilation (IMV), and Continuous Spontaneous Ventilation (CSV). A breath
sequence is a particular pattern of spontaneous and/or mandatory breaths. The 3 possible
breath sequences are: continuous mandatory ventilation, (CMV, spontaneous breaths are not
allowed between mandatory breaths), intermittent mandatory ventilation (IMV, spontaneous
breaths may occur between mandatory breaths), and continuous spontaneous ventilation
(CSV, all breaths are spontaneous).
8. There are 5 basic ventilatory patterns: VC-CMV, VC-IMV, PC-CMV, PC-IMV, and PC-CSV. The
combination VC-CSV is not possible because volume control implies machine cycling and
machine cycling makes every breath mandatory, not spontaneous. A sixth pattern, TC-IMV is
possible but rare.
9. Within each ventilatory pattern there are several variations that can be distinguished by their
targeting scheme(s). A targeting scheme is a description of how the ventilator achieves preset
targets. A target is a predetermined goal of ventilator output. 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). 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,
e.g., SmartCarePS or IntelliVent-ASV). The targeting scheme (or combination of targeting
schemes) is what distinguishes one ventilatory pattern from another. There are 7 basic
targeting schemes that comprise the wide variety seen in different modes of ventilation:

Set-point: A targeting scheme for which the operator sets all the parameters of the
pressure waveform (pressure control modes) or volume and flow waveforms
(volume control modes).
Dual: A targeting scheme that allows the ventilator to switch between volume
 control and pressure control during a single inspiration.
Bio-variable: A targeting scheme that allows the ventilator to automatically set the
inspiratory pressure or tidal volume randomly to mimic the variability observed
during normal breathing.
Servo: A targeting scheme for which inspiratory pressure is proportional to
inspiratory effort.
Adaptive: A targeting scheme that allows the ventilator to automatically set one
target (eg, pressure within a breath) to achieve another target (eg, average tidal
volume over several breaths).
Optimal: A targeting scheme that automatically adjusts the targets of the ventilatory
pattern to either minimize or maximize some overall performance characteristic
(eg, minimize the work rate done by the ventilatory pattern).
Intelligent: A targeting scheme that uses artificial intelligence programs such as
fuzzy logic, rule based expert systems, and artificial neural networks.

10. A mode of ventilation is classified according to its control variable, breath sequence, and
targeting scheme(s). The preceding 9 maxims create a theoretical foundation for a taxonomy
of mechanical ventilation. The taxonomy is based on these theoretical constructs and has 4
hierarchical levels:

Control Variable (Pressure or Volume, for the primary breath)

Breath Sequence (CMV, IMV, or CSV)
Primary Breath Targeting Scheme (for CMV or CSV)
Secondary Breath Targeting Scheme (for IMV)

The “primary breath” is either the only breath there is (mandatory for CMV and spontaneous
for CSV) or it is the mandatory breath in IMV. The targeting schemes can be represented by
single, lower case letters: set-point = s, dual = d, servo = r, bio-variable = b, adaptive = a,
optimal = o, intelligent = i. A tag is an abbreviation for a mode classification, such as PC-
IMVs,s. Compound tags are possible, eg, PC-IMVoi,oi.

How modes are classified

Step 1: Identify the primary breath control variable. If inspiration starts with a preset inspiratory pressure, or
if pressure is proportional to inspiratory effort, then the control variable is pressure. If inspiration starts with
a preset tidal volume and inspiratory flow, then the control variable is volume. If neither is true, the control
variable is time.

Step 2: Identify the breath sequence. Determine whether trigger and cycle events are patient or machine
determined. Then, use this information to determine the breath sequence.

Step 3: Identify the targeting schemes for the primary breaths and (if applicable) secondary breaths.

Example mode classification is given below

Mode Name: A/C Volume Control (Covidien PB 840):

1. Inspiratory volume and flow are preset, so the control variable is volume.
 2. Every breath is volume cycled, which is a form of machine cycling. Any breath for which
inspiration is machine cycled is classified as a mandatory breath. Hence, the breath sequence
is continuous mandatory ventilation.
3. The operator sets all the parameters of the volume and flow waveforms so the targeting
scheme is set-point. Thus, the mode is classified as volume control continuous mandatory
ventilation with set-point targeting (VC-CMVs).

Mode Name: SIMV Volume Control Plus (Covidien PB 840):

1. The operator sets the tidal volume but not the inspiratory flow. Because setting volume alone
(like setting flow alone) is a necessary but not sufficient criterion for volume control, the control
variable is pressure.
2. Spontaneous breaths are allowed between mandatory breaths so the breath sequence is IMV.
3. The ventilator adjusts inspiratory pressure between breaths to achieve an average preset tidal
volume, so the targeting scheme is adaptive. The mode tag is PC-IMVa,s.

Descriptions of common modes

Mechanical ventillation machines are available with both invasive modes (such as intubation) and non-
invasive modes (such as BPAP. Invasive has to do with the insertion of medical devices or tubes internal to
the patient, while non-invasive is completely external to the patient, as for example in using a tightly-fitting
mask or other device that covers the patient's nose and mouth.

Assist mode, control mode, and assist-control mode

A basic distinction in mechanical ventilation is whether each breath is initiated by the patient (assist mode)
or by the machine (control mode). Dynamic hybrids of the two (assist-control modes) are also possible, and
control mode without assist is now mostly obsolete.

Airway pressure release ventilation

Airway pressure release ventilation is a time-cycled alternant

between two levels of positive airway pressure, with the main time
on the high level and a brief expiratory release to facilitate
ventilation.[5]

Airway pressure release ventilation is usually utilized as a type of Airway pressure release ventilation
inverse ratio ventilation. The exhalation time (Tlow) is shortened to graph
usually less than one second to maintain alveoli inflation. In the
basic sense, this is a continuous pressure with a brief release. APRV
currently the most efficient conventional mode for lung protective ventilation.[6]

Different perceptions of this mode may exist around the globe. While 'APRV' is common to users in North
America, a very similar mode, biphasic positive airway pressure (BIPAP), was introduced in Europe.[7] The
term APRV has also been used in American journals where, from the ventilation characteristics, BIPAP
would have been perfectly good terminology.[8] But BiPAP(tm) is a trademark for a noninvasive ventilation
mode in a specific ventilator (Respironics Inc.).
Other manufacturers have followed with their own brand names (BILEVEL, DUOPAP, BIVENT). Although
similar in modality, these terms describe how a mode is intended to inflate the lung, rather than defining the
characteristics of synchronization or the way spontaneous breathing efforts are supported.

Intermittent mandatory ventilation has not always had the synchronized feature, so the division of modes
were understood to be SIMV (synchronized) vs IMV (not-synchronized). Since the American Association
for Respiratory Care established a nomenclature of mechanical ventilation the "synchronized" part of the
title has been dropped and now there is only IMV.

Mandatory minute ventilation

Mandatory minute ventilation (MMV) allows spontaneous breathing with automatic adjustments of
mandatory ventilation to the meet the patient's preset minimum minute volume requirement. If the patient
maintains the minute volume settings for VT x f, no mandatory breaths are delivered.

If the patient's minute volume is insufficient, mandatory delivery of the preset tidal volume will occur until
the minute volume is achieved. The method for monitoring whether or not the patient is meeting the
required minute ventilation (VE) differs by ventilator brand and model, but, in general, there is a window of
monitored time, and a smaller window checked against the larger window (i.e., in the Dräger Evita® line of
mechanical ventilators there is a moving 20-second window, and every 7 seconds the current tidal volume
and rate are measured) to decide whether a mechanical breath is needed to maintain the minute ventilation.

MMV is an optimal mode for weaning in neonatal and pediatric populations and has been shown to reduce
long-term complications related to mechanical ventilation.[9]

Pressure-regulated volume control

Pressure-regulated volume control is an IMV based mode. Pressure-regulated volume control utilizes
pressure-limited, volume-targeted, time-cycled breaths that can be either ventilator- or patient-initiated.

The peak inspiratory pressure delivered by the ventilator is varied on a breath-to-breath basis to achieve a
target tidal volume that is set by the clinician.

For example, if a target tidal volume of 500 mL is set but the ventilator delivers 600 mL, the next breath will
be delivered with a lower inspiratory pressure to achieve a lower tidal volume. Though PRVC is regarded as
a hybrid mode because of its tidal-volume (VC) settings and pressure-limiting (PC) settings fundamentally
PRVC is a pressure-control mode with adaptive targeting.

Continuous positive airway pressure

Continuous positive airway pressure (CPAP) is a non-invasive positive pressure mode of respiratory
support. CPAP is a pressure applied at the end of exhalation to keep the alveoli open and not fully deflate.
This mechanism for maintaining inflated alveoli helps increase partial pressure of oxygen in arterial blood,
an appropriate increase in CPAP increases the PaO2. CPAP is not technically a mode of "ventilation" as it
does not directly affect the minute volume.

Automatic positive airway pressure

Automatic positive airway pressure (APAP) is a form of CPAP that automatically tunes the amount of
pressure delivered to the patient to the minimum required to maintain an unobstructed airway on a breath-
by-breath basis by measuring the resistance in the patient's breathing.

Bilevel positive airway pressure

Bilevel positive airway pressure (BPAP) is a mode used during non-invasive ventilation (NIV). First used in
1988 by Professor Benzer in Austria,[10] it delivers a preset inspiratory positive airway pressure (IPAP) and
expiratory positive airway pressure (EPAP). BPAP can be described as a Continuous Positive Airway
Pressure system with a time-cycle change of the applied CPAP level.[11]

CPAP/APAP, BPAP, and other non-invasive ventilation modes have been shown to be effective management
tools for chronic obstructive pulmonary disease, acute respiratory failure, sleep apnea, etc.[12]

Often BPAP is incorrectly referred to as "BiPAP". BiPAP is the name of a portable ventilator manufactured
by Respironics Corporation; it is just one of many ventilators that can deliver BPAP.

Medical uses

BPAP has been shown to be useful in reducing mortality and reducing the need for endotracheal intubation
when used in people with chronic obstructive pulmonary disease (COPD).[13][14]

High-frequency ventilation (Active)

The term active refers to the ventilator's forced expiratory system. In a HFV-A scenario, the ventilator uses
pressure to apply an inspiratory breath and then applies an opposite pressure to force an expiratory breath. In
high-frequency oscillatory ventilation (sometimes abbreviated HFOV) the oscillation bellows and piston
force positive pressure in and apply negative pressure to force an expiration.[15]

High-frequency ventilation (Passive)

The term passive refers to the ventilator's non-forced expiratory system. In a HFV-P scenario, the ventilator
uses pressure to apply an inspiratory breath and then returns to atmospheric pressure to allow for a passive
expiration. This is seen in High-Frequency Jet Ventilation, sometimes abbreviated HFJV. Also categorized
under High Frequency Ventilation is High Frequency Percussive Ventilation, sometimes abbreviated HFPV.
With HFPV it utilizes an open circuit to deliver its subtidal volumes by way of the patient interface known
as the Phasitron.

Volume guarantee

Volume guarantee an additional parameter available in many types of ventilators that allows the ventilator to
change its inspiratory pressure setting to achieve a minimum tidal volume. This is utilized most often in
neonatal patients who need a pressure controlled mode with a consideration for volume control to minimize
volutrauma.

Spontaneous breathing and support settings

Positive end-expiratory pressure

Positive end expiratory pressure (PEEP) is pressure applied upon expiration. PEEP is applied using either a
valve that is connected to the expiratory port and set manually or a valve managed internally by a
mechanical ventilator.

PEEP is a pressure that an exhalation has to bypass, in effect causing alveoli to remain open and not fully
deflate. This mechanism for maintaining inflated alveoli helps increase partial pressure of oxygen in arterial
blood, and an increase in PEEP increases the PaO2.[16]

Pressure support

Pressure support is a spontaneous mode of ventilation also named Pressure Support Ventilation (PSV). The
patient initiates every breath and the ventilator delivers support with the preset pressure value. With support
from the ventilator, the patient also regulates their own respiratory rate and their tidal volume.

In Pressure Support, the set inspiratory pressure support level is kept constant and there is a decelerating
flow. The patient triggers all breaths. If there is a change in the mechanical properties of the lung/thorax and
patient effort, the delivered tidal volume will be affected. The user must then regulate the pressure support
level to obtain desired ventilation.[17][18]

Pressure support improves oxygenation,[19] ventilation and decreases work of breathing.

Also see adaptive support ventilation.

Other ventilation modes and strategies

Closed loop systems

Adaptive Support Ventilation

Adaptive Support Ventilation is the only commercially available closed-loop mode of mechanical ventilation
to date that uses "optimal targeting". This targeting scheme was first described by Tehrani in 1991,[20][21]
and was designed to minimize the work rate of breathing, mimic natural breathing, stimulate spontaneous
breathing, and reduce weaning time.[22]

Automatic Tube Compensation

Automatic Tube Compensation (ATC) is the simplest example of a computer-controlled targeting system on
a ventilator. It is a form of servo targeting.

The goal of ATC is to support the resistive work of breathing through the artificial airway

Neurally Adjusted Ventilatory Assist

Neurally Adjusted Ventilatory Assist (NAVA) is adjusted by a computer (servo) and is similar to ATC but
with more complex requirements for implementation.
In terms of patient-ventilator synchrony, NAVA supports both resistive and elastic work of breathing in
proportion to the patient's inspiratory effort

Proportional Assist Ventilation

Proportional assist ventilation (PAV) is another servo targeting based mode in which the ventilator
guarantees the percentage of work regardless of changes in pulmonary compliance and resistance.[23]

The ventilator varies the tidal volume and pressure based on the patient's work of breathing. The amount it
delivers is proportional to the percentage of assistance it is set to give.

PAV, like NAVA, supports both restrictive and elastic work of breathing in proportion to the patient's
inspiratory effort.

Liquid ventilation

Liquid ventilation is a technique of mechanical ventilation in which the lungs are insufflated with an
oxygenated perfluorochemical liquid rather than an oxygen-containing gas mixture. The use of
perfluorochemicals, rather than nitrogen, as the inert carrier of oxygen and carbon dioxide offers a number
of theoretical advantages for the treatment of acute lung injury, including:

Reducing surface tension by maintaining a fluid interface with alveoli

Opening of collapsed alveoli by hydraulic pressure with a lower risk of barotrauma
Providing a reservoir in which oxygen and carbon dioxide can be exchanged with pulmonary
capillary blood
Functioning as a high-efficiency heat exchanger

Despite its theoretical advantages, efficacy studies have been disappointing and the optimal clinical use of
LV has yet to be defined.[24]

Total liquid ventilation

In total liquid ventilation (TLV), the entire lung is filled with an oxygenated PFC liquid, and a liquid tidal
volume of PFC is actively pumped into and out of the lungs. A specialized apparatus is required to deliver
and remove the relatively dense, viscous PFC tidal volumes, and to extracorporeally oxygenate and remove
carbon dioxide from the liquid.[25][26][27]

Partial liquid ventilation

In partial liquid ventilation (PLV), the lungs are slowly filled with a volume of PFC equivalent or close to
the FRC during gas ventilation. The PFC within the lungs is oxygenated and carbon dioxide is removed by
means of gas breaths cycling in the lungs by a conventional gas ventilator.[28]

See also
Table of modes of mechanical ventilation
Mechanical ventilation – Method to mechanically assist or replace spontaneous breathing
Respiratory therapist
Bubble CPAP
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