Principles of Mechanical Ventilation

RET 2284 Module 2.0 Classification of Ventilators; How a Breath is Delivered

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Factors Controlled and Measured by the Ventilator During Inspiration

To deliver inspiratory volume, the operator most commonly sets either a volume or a pressure The primary variable the ventilator adjusts to achieve inspiration is called the control variable

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CONTROL VARIABLES

The primary variable the ventilator adjusts to achieve inspiration

Mechanical ventilators can control four variables, but

only one at a time

Pressure Volume Flow Time

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CONTROL VARIABLES

Because only one of these variables can be directly controlled at a time, a ventilator must function as either one of the following:
Pressure controller Volume controller Flow controller Time controller

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Pressure Controller

When the ventilator maintains the pressure waveform in a specific pattern, the breathing is described as pressure controlled (also pressure limited or pressure targeted)
The pressure waveform is unaffected by changes in lung

characteristics

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Pressure Controller

The pressure waveform will remain constant but volume and flow will vary with changes in respiratory system mechanics (airway resistance, compliance)

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Volume Controller

The ventilator maintains the volume waveform in a specific pattern, the delivered breath is volume

controlled (volume limited, volume targeted)

The volume and flow waveforms remain unchanged,

but the pressure waveform varies with changes in lung characteristics (resistance and compliance)

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Volume controller

Volume and flow waveforms will remain constant, but pressure will vary with changes in respiratory mechanics (airway resistance and compliance)

Pressure

Volume

Flow

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Flow Controller

Directly measures flow and uses the flow signal as a feedback signal to control its output
Most newer ventilators measure flow and are flow

controllers; volume becomes a function of flow as follows:

Volume (L) = Flow (L/sec) x Inspiratory Time (sec)

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Flow Controller

Flow and volume waveforms will remain constant, but pressure will vary with changes in respiratory mechanics (airway resistance and compliance)

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Time Controller

Measures and controls inspiratory and expiratory time

Pressure and volume waveforms vary with changes in

resistance and compliance (neither pressure or volume are used as a control)

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Inspiration is commonly described as pressure controlled or volume controlled (although flow and time ventilation have been defined, they are not typically used).

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PHASE VARIABLES

Ventilator-supported breath may be divided into four distinct phases

1. The initiation of inspiration
2. Inspiration itself 3. The end of inspiration 4. Expiration

To understand a breath cycle, you must know how the ventilator starts, sustains, and stops inspiration and you must know what occurs between breaths

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PHASE VARIABLES

The phase variable is a variable that is measured and used by the ventilator to initiate some phase of the breath cycle
Trigger variable causes a breath to begin Limit variable limits the magnitude of any parameter (pressure, flow, volume) during inspiration Cycle variable causes the end of inspiration Baseline variable determines what happens during expiration

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Trigger Variable

Determines the start of inspiration

Any one of the following may be sensed/measured by the ventilator and used to initiate inspiration

Pressure Volume Flow Time

Either the ventilator or the patient initiates a breath. If the machine initiates the breath, the trigger variable is time

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Time Triggered

Ventilatory initiates a breath according to a predetermined time interval

Rate control on ventilator is a time-triggering device

Example: Rate 10 (breaths/min) = One breath every 6 seconds

An alternative approach is to provide separate timers for inspiration and expiration. Changing either or both of these timers will alter the breathing rate

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Time Triggered

Ventilatory initiates a breath according to a predetermined time interval

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Pressure Triggered

Occurs when the patients inspiratory effort causes a drop in pressure within the breathing circuit

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Pressure Triggered

Typically, trigger levels (sensitivity) range between 0.5 to 1.5 cm H2O below the patients baseline, or end-expiratory pressure

Setting the sensitivity to a higher number, e.g., 3 cm H2O makes the ventilator less sensitive and requires the patient to work harder to initiate inspiration. Conversely, setting the trigger level lower make the ventilator more sensitive

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Pressure Triggered

The operator must set the sensitivity to meet the patients needs. If it is not set correctly, the ventilator may not be sensitive enough to the patients effort, and the patient will have to work too hard to trigger the breath. If the ventilator is too sensitive, it can autotrigger (i.e., the machine triggers a breath without the patient making an effort)

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Quiz

A patient has a baseline pressure of 10 cm H2O during mechanical ventilation. The trigger sensitivity is set at 1 cm H2O. At what pressure will the ventilator sense a patient effort and start inspiration?

Answer: 9 cm H2O

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Flow Triggered

Ventilator-supported breath is initiated when the ventilator detects a drop in flow through the patient circuit during exhalation
Continuous flow through circuit:

Base Flow

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Flow Triggered

Between breaths, the flow coming out of the main flow control valve and the flow going through the exhalation valve are equal During the patients inspiratory effort, the flow through the exhalation valve falls below the flow from the output valve The difference between these two flows is the flow trigger variable

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Flow Triggered

Ventilator graphic representing flow triggering

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Quiz

The operator decides to use flow triggering for a patient and sets the base flow at 6 L/min and the trigger flow at 2 L/min. The base flow measurement must drop to what value before the ventilator will begin the inspiratory phase?

Answer: 4 L/min.

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Volume Triggered

Occurs when the ventilator detects a small drop in volume in the patient circuit during exhalation. The machine interprets this drop as a patient effort and begins inspiration
Drger Babylog Cardiopulmonary Venturi

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Manual Triggered

A button or touch pad on the control panel labeled Manual breath or Start breath When this control is activated, the ventilator delivers a breath according to the set variables

PB 840

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Inductive Plethysmography Triggered

Infants ventilator-supported breath is initiated when a when chest expands

Sechrist IV-200

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NAVA (Neurally Adjusted Ventilator Assist)

A esophageal probe senses the electrical activity of the diaphragm, which triggers the ventilator Maquets Servo-I

NAVA

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Limit Variable

A limit variable is the maximum value a variable (pressure, flow, volume) can attain. This limits the variable during inspiration but does not end

the inspiratory phase.

Do not confuse this with cycle variable, which always ends inspiration

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Pressure Limiting

Allows pressure to rise to a certain value but not exceed it

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Pressure Limiting

Remember; in pressure ventilation, the pressure the ventilator delivers to the patient is limited; however,

reaching the pressure limit does not end the breath

Example of pressurelimiting modes Pressure support Pressure control

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Volume Limiting

The volume is set by the operator; however, reaching that volume does not necessarily end inspiration

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Flow Limiting

Ventilator flow to the patient reaches but does not exceed a maximum value before the end of inspiration

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Maximum Safety Pressure: Pressure Limiting vs. Pressure Cycling

All ventilators have a maximum pressure limit control, which is used to prevent excessive pressure from reaching a patients lungs reaching the maximum

high pressure limit ends the inspiratory phase

AKA

High pressure limit Upper pressure limit Pressure limit

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Cycle Variable

The variable a ventilator measures to determine the end of inspiration is called the cycling mechanism once cycling occurs, expiratory gas flow begins

Cycle variables

Pressure Volume Flow time

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Pressure Cycled

Ventilator will deliver flow until a present pressure is reached, at which point inspiration ends and expiratory flow begins

The most common application of pressure-cycling is for alarm setting (e.g., high pressure alarm) and IPPB

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Volume Cycled

Ventilator will deliver flow until a present volume is reached, at which point inspiration ends and expiratory flow begins

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Flow Cycled

Ventilator will deliver flow until a present level is met, at which point flow stops and expiration begins

The most frequent application of flow cycling is pressure control mode ventilation (to be discussed in a future module)

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Time Cycled

Expiratory flow starts because a present time interval has elapsed

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Limit Variable
This figure illustrates the importance of distinguishing between the terms limit and cycle. A, Inspiration is pressure limited and time cycled. B, Inspiration is flow limited and volume cycled. C, Inspiration is both flow limited and volume limited (because flow and volume reach preset values before inspiratory time ends) and time cycled (after the preset inspiratory hold time).
A B C

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Inflation Hold (Inspiratory Pause)

Designed to maintain air in the lungs at the end of inspiration

Used to obtain PPlateau for calculating CS Occasionally used to help increase peripheral distribution of gas and improve oxygenation

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Inflation Hold (Inspiratory Pause)

Calculation of CS requires accurate measurement of the plateau pressure the PPlateau value is inaccurate

if the patient is actively breathing when the measurement is taken

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TYPES of Breaths

Spontaneous

Started by the patient (patient triggered) and VT delivery is determined by the patient (i.e., patient cycled) Volume and pressure delivered are based on patient demand rather than a value set by the ventilator operator

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TYPES of Breaths

Mandatory

Ventilator determines the start time (time triggered) or VT (or both) The machine triggers and/or cycles the breath

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BASELINE VARIABLE

The variable that is controlled during the expiratory phase

Note: Most commonly, pressure is controlled during the expiratory phase

CPAP PEEP

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BASELINE VARIABLE

Continuous Positive Airway Pressure (CPAP)

The application of pressures above ambient to improve oxygenation is a spontaneously breathing patient Can be applied through a freestanding CPAP system or a ventilator

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BASELINE VARIABLE

Continuous Positive Airway Pressure (CPAP)

Simplified pressure-time waveform showing continuous positive airway pressure (CPAP). Breathing is spontaneous. Inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) are present. Pressures remain positive and do not return to a zero baseline.

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BASELINE VARIABLE

Positive End Expiratory Pressure (PEEP)

The application of pressures above ambient at the end of exhalation to improve oxygenation during

mechanical ventilation

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BASELINE VARIABLE

Positive End Expiratory Pressure (PEEP)

Positive end-expiratory pressure (PEEP) with intermittent mandatory breaths (also called intermittent mandatory ventilation [IMV] with PEEP). Spontaneous breaths are taken between mandatory breaths, and the baseline is maintained above zero.

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BASELINE VARIABLE

Positive End Expiratory Pressure (PEEP)

Helps prevent early airway closure and alveolar collapse at the end of expiration Recruits collapsed alveoli Augments FRC Facilitates better oxygenation

DOES NOT PROVIDE VENTILATION!