MODES OF MECHANICAL VENTILATION. Mazen Kherallah, MD, FCCP
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1 MODES OF MECHANICAL VENTILATION Mazen Kherallah, MD, FCCP
2 POINTS OF DISCUSSIONS Advanced Basics: Flow and Time Limit and cycling Rise Time Volume vs Pressure Control Mandatory Modes of Ventilation Controlled Mandatory Ventilation (CMV or IPPV) Triggered Modes of Ventilation Continuous Positive Airway Pressure (CPAP) Pressure Support Ventilation (PSV) Hybrid Modes of Ventilation Assist Control Mode (A/C) Synchronized Intermittent Mandatory Ventilation (SIMV)
3 ADVANCED BASICS
4 RESPIRATORY CYCLE Inspiration Expiration
5 RELATIONSHIP BETWEEN TIDAL VOLUME, INSPIRATORY TIME AND FLOW Volume V T 3 Flow= 37.5 L/min V T 1 Flow= 30 L/min V T 2 Insp Exp Flow= 15 L/min T i a Time
6 RELATIONSHIP BETWEEN TIDAL VOLUME, INSPIRATORY TIME AND FLOW Volume V T 1 Flow= 60 L/min Flow= 30 L/min Flow= 20 L/min InspInspInsp ExpExp T i b T i a T i c Time
7 PRESSURE LIMITED BREATH Volume Pressure Limit Time
8 EXPIRATORY FLOW CYCLING Flow 100% Flow Cycling 50% Time
9 RISE TIME Pressure Flow Volume T I T E Time
10 MANDATORY, SPONTANEOUS AND TRIGGERED INSPIRATORY CYCLING M M M M M M S S S M M T supp T supp T supp T synch M T supp T supp T supp
11 VOLUME CONTROLLED INFLATION Pressure Flow Tidal Volume Volume T I T E Time
12 VOLUME CONTROL BREATHS 50 Decreased Compliance Paw cmh SEC INSP Flow L/min SEC 120 EXH If compliance decreases the pressure increases to maintain the same Vt
13 VOLUME CONTROL WITH END-INSPIRATORY PAUSE End Inspiratory Pause Pressure Flow Tidal Volume Volume T I T E Time
14 PRESSURE CONTROLLED INFLATION Pressure Rise Time Peak Inspiratory Flow Flow Tidal Volume Volume T I T E Time
15 Volume/Flow Control Pressure Control Inspiration Expiration Inspiration Expiration Pressure Paw Paw Volume Flow 0 Time (s) 0 Time (s) -3-3
16 TRIGGERED MODES OF VENTILATION CPAP and PSVV
17 SPONTANEOUS BREATHING Pressure (cm H 2 O) Flow (L/m) Volume (ml) Time (sec)
18 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) Pressure (cm H 2 O) CPAP Level Flow (L/m) Volume (ml) Time (sec)
19 PRESSURE SUPPORT VENTILATION (PSV) Longer Inspiration Pressure (cm H 2 O) Flow (L/m) Set PS Level Flow Cycling Better Efforts Volume (ml) Time (sec) Patient Triggered, Flow Cycled, Pressure limited Mode
20 CPAP+PSV Pressure (cm H 2 O) Set PS Level CPAP Level Flow Cycling Flow (L/m) Volume (ml) Time (sec) Patient Triggered, Flow Cycled, Pressure limited Mode
21 TRIGGERED MODES OF VENTILATION PRESSURE SUPPORT VENTILATION Control Trigger Limit Target Cycle Pressure Patient Pressure Flow Patient Triggered Flow Cycled Ventilation
22 PRESSURE OR VOLUME-TARGETED VENTILATION Advantages Disadvantages Full to partial ventilatory support Augments the patients spontaneous VT Decreases the patient s spontaneous respiratory rate Decreases patient WOB by overcoming the resistance of the artificial airway, vent circuit and demand valves Allows patient control of TI, Vm I, f and VT Set peak pressure Prevents respiratory muscle atrophy Facilitates weaning Requires consistent spontaneous ventilation Patients in stand-alone mode should have back-up ventilation VT variable and dependant on lung characteristics and synchrony Low exhaled V E Fatigue and tachypnea if PS level is set too low Improves patient comfort and reduces need for sedation May be applied in any mode that allows spontaneous breathing, e.g., VC-SIMV, PC-SIMV
23 MANDATORY MODES OF VENTILATION CMV or IPPV
24 MANDATORY MODES OF VENTILATION CMV Control Trigger Limit Target Cycle Pressure Or Volume Time Time Time Triggered Time Cycled Ventilation
25 CONTROL MODE (PRESSURE-TARGETED VENTILATION) Set PC Level Time Cycling Pressure (cm H 2 O) Flow (L/m) Volume (ml) Time (sec) Time Triggered, Pressure Limited, Time Cycled Ventilation
26 CONTROL MODE (VOLUME-TARGETED VENTILATION) Time Cycling Pressure (cm H 2 O) Dependent on C L & R aw Flow (L/m) Preset V T Volume Cycling Volume (ml) Time Triggered, Flow Limited, Volume Cycled Ventilation Time (sec)
27 PRESSURE OR VOLUME-TARGETED VENTILATION Advantages Disadvantages Decreases the work of breathing (WOB) Helps maintain a normal PaCO2 Not able to assist the ventilator
28
29 HYBRID MODES OF VENTILATION SIMV and A/C
30 HYBRID MODES OF VENTILATION A/C Control Trigger Limit Target Cycle Pressure Or Volume Time Or Patient Time Time or PatientTriggered Time Cycled Ventilation
31 Pressure (cm H 2 O) ASSISTED MODE (VOLUME-TARGETED VENTILATION) Time Cycling Preset peak Flow Flow (L/m) Volume (ml) Time (sec) Patient Triggered, Flow limited, Volume Cycled Ventilation
32 ASSISTED MODE (PRESSURE-TARGETED VENTILATION) Set PC Level Time Cycling Pressure (cm H 2 O) Flow (L/m) Volume (ml) Time (sec) Patient Triggered, Pressure Limited, Time Cycled Ventilation
33 PRESSURE OR VOLUME-TARGETED VENTILATION Advantages Disadvantages Decreases the work of breathing (WOB) Allows patients to regulate respiratory rate Helps maintain a normal PaCO2 Alveolar hyperventilation
34 HYBRID MODES OF VENTILATION SIMV/PS Breath Type Mandatory Control Trigger Limit Cycle Pressure Or Volume Time Or Patient Time Spontaneous Pressure Patient Pressure Flow
35 SIMV (VOLUME TARGETED VENTILATION) Pressure (cm H 2 O) M M M Spontaneous Breaths Flow (L/m) Volume (ml) Time (sec)
36 SIMV+PS (VOLUME TARGETED VENTILATION) Set PS Level Pressure (cm H 2 O) T synch T supp M Flow-cycled Flow (L/m) Volume (ml) Time (sec)
37 SIMV + PS (PRESSURE-TARGETED VENTILATION) Pressure (cm H 2 O) T synch Set PC Level T supp Set PS Level T synch Time Cycled Flow-cycled Flow (L/m) Volume (ml) Time (sec)
38 HYBRID MODE VENTILATION: SUPPRESSION Pressure (cm H 2 O) M M T supp M T supp T supp T supp Flow (L/m) Cycles M M Time (sec)
39 HYBRID MODE VENTILATION: SYNCHRONIZATION (SIMV+PSV) Pressure (cm H 2 O) M T supp T synch M T synch T supp Flow (L/m) Cycles Mandatory Cycle Time Triggered window for supported breaths Triggered window for synchronized breaths Time (sec)
40 SIMV Advantages Disadvantages Maintains respiratory muscle strength by avoiding muscle atrophy When used for weaning, may be done too quickly and cause muscle fatigue Decreases mean airway pressure Facilitates ventilator discontinuation weaning! Mechanical rate and spontaneous rate may asynchronous causing stacking May cause barotrauma or volutrauma
41 ALL MODES TABLES
42 Mandatory Modes of Ventilations Mandatory breaths Inspiratory cycling Time Time Time Time Control Volume Volume Volume (Pressure) Target/Limit - Pressure-limited Volume-targeted Feeadback - - Intra-breath Inter-breath Expiratory cycling Time Time Time Time Triggered Breaths Types None None None None Supported Breaths Control Target Feedback Expiratory Cycling Spontaneous Breaths During mandatory inspiration Otherwise Synonyms Not accommodated Not accommodated IPPV (Draeger) Controlled Mandatory Ventilation Not accommodated Accommodated Intermittent Mandatory Ventilation Not accommodated Not accommodated IPPV (Draeger): trigger off, autoflow off Accommodated Accommodated IPPV (Draeger): trigger off, autoflow on
43 Triggered Modes of Ventilations Mandatory breaths Inspiratory cycling Control Target/Limit Feeadback Expiratory cycling Triggered Breaths Types Supported breaths Supported breaths Supported breaths Supported Breaths Control Pressure (Pressure) (Pressure) Target -- Volume-targeted Flow and Volume Feedback -- Inter-breath Intra-breath Expiratory Cycling Flow Flow Flow Spontaneous Breaths During mandatory inspiration Otherwise Synonyms Assisted Spontaneus Breathing (Draeger) Spontaneous Mode (Hamilton, Puritan Bennet) Pressure Support (Maquet Pressure Support Ventilation (Viasys) CPAP (Respironics) Volume Support (Maquet, Puritan- Bennett) Propotional Assist Ventilation, Proportional Pressure Suport (Draeger) Propotional Assist Ventilation Plus (Puritan-Bennet)
44 Hybrid Mode: Assist Control Mandatory breaths Inspiratory cycling Time or trigger Time or trigger Time or trigger Control Volume Pressure (Pressure) Target/Limit - - Volume-targeted Feeadback - - Inter-breath Expiratory cycling Time Time Time Triggered Breaths Types Mandatory pattern Mandatory pattern Mandatory pattern Supported Breaths Control Target Feedback Expiratory Cycling Spontaneous Breaths During mandatory inspiration Not accommodated Accommodated Accommodated Otherwise Synonyms IPPV ASSIST (Draeger) Synchronized ccntrolled Mandatory Ventilation (Hamilton) Volume Control (Maquet) VCV-A/C (Puritan-Bennett, Respironics) Volume A/C (Viasys) BIPAP ASSIST (Draeger) P-CMV (Hamilton) Pressure Control (Maquet) PCV-A/C (Puritan- Bennett, Respironics) Pressure A/C (Viasys) Adaptive Pressure Ventilation CMV PRVC (Maquet) VC+A/C (Puritan- Bennet) PRVC A/C (Viasys) IPPV Assist Autoflow (Draeger)
45 Mandatory breaths Hybrid Mode: Synchronized Intermittent Mandatory Ventilation Inspiratory cycling Time or trigger Time or trigger Time or trigger Control Volume Pressure (Pressure) Target/Limit - - Volume-targeted Feeadback - - Inter-breath Expiratory cycling Time Time Time Triggered Breaths Types Supported Breaths Mandatory and supported pattern Mandatory and supported pattern Control Pressure Pressure Pressure Target Feedback Expiratory Cycling Flow Flow Flow Spontaneous Breaths Mandatory and supported pattern During mandatory inspiration Not accommodated Accommodated Accommodated Otherwise Only if support is off Only if support is off Only if support is off Synonyms SIMV (Draeger, Hamilton) SIMV (VC)+PS (Maquet) VCV-SIMV (Puritan- Bennett, Respironics) Volume SIMV (Viasys) P-SIMV (Hamilton) SIMV(PC)+PS (Maquet) PCV-SIMV (Puritan- Bennett, Respironics) Pressure SIMV (Viasys) SIMV+Autoflow Adaptive Pressure Ventilation SIMV (Hamilton) SIMV (PRVC)+PS (Puritan-Bennett) PRVC SIMV (Viasys)
46 Hybrid Mode: Bi-Level Ventilatio Mandatory breaths Inspiratory cycling Time or trigger Time or trigger Time or trigger Time or trigger Control Pressure Pressure Pressure Pressure Target/Limit Feeadback Expiratory cycling Time or trigger Time or trigger Time or trigger Time or trigger Triggered Breaths Interaction Supported Breaths Mandatory and supported Mandatory pattern and supported Mandatory and supported Mandatory and supported Control Pressure Pressure Pressure Pressure Target Feedback Expiratory Cycling Flow Flow Flow Flow Spontaneous Breaths During mandatory inspiration Accommodated Trigers suuport to PEEP+P support If this>p high (Hamilton DuoPAP) P low +P support If this>p high (Hamilton APRV) PEEP L +P supp If this>peep H (Puritan-Bennett) Triggers support to PRES HIGH + PSV if T high PSV is activated Tigger support to PSV above P High Otherwise Triggers support Triggers support to PEEP+P support (Hamilton) DuoPAP) P low +P support (Hamilton APRV) PEEPL+P supp (Puritan-Bennett) Triggers support to PREDSLOW=PSV Triggers support to PSV above PEEP Synonyms BIPAP (Draeger) DuoPAP/APRV (Hamilton) BiLevel (Puritan-Bennet) APRV/Bi-phasic (Viasys) Bi-vent (Maquet)
47 THANK YOU
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