Basic Mechanism of PPV

Pressure Difference

Gas Flow

Time

Volume Change
Terminology - pressure and time

Pressure Peak Inspiratory Positive End

PIP Pressure Expiratory Pr.

PEEP

T insp. T exp. I:E=1:2

Mean time
Airway Plateau Pressure I:E=4:1
Pressure
 Terminology: PIP & MAP

Peak Inspiratory Pressure

Pressure

 A=A1+A2+…+An
A

Mean Airway Pressure

 A=A1+A2+…+An

A

time
Inspiration + Exhalation
Mean Airway Pressure and I:E ratio
Insp. Pressure (PIP)
MAP

PEEP

I:E = 1:1

MAP

I:E = 1:2
MAP

I:E = 2:1
Flow - Volume relationship

Time
F
Flow Rate
t

F
t
Volume
 Terminology - flow and volume

Minute Ventilation = Tidal Volume x Breath Rate

Flow Tidal Volume

Pressure
time
 Classification

Control variables
Phase Variables
• Pressure
• Flow
• Time • The beginnning of inspiration
• Volume • Inspiration
• The end of inspiration
• Expiration
Breath Types

• Mandatory
• Spontaneous
 Control variables

• Volume / Flow • Pressure

Pressure Pressure

time time
Flow Flow
 Volume Ventilation

• Constant flow pattern

• Linear increase in airway
pressure until the preset
tidal volume is reached
• Inspiratory pause period
of zero flow prior
exhalation
• Plateau pressure during
inspiratory pause
• Preset tidal volume is
quaranteed, but PIP is
determined by lung
impedance anf flow rate
 Pressure Ventilation

• Constant insp. Pressure

• Decelerating, variable Time Cycled
Pressure
inspiratory flow rate
• Better tolerance, less
sedation is necessary
• Time cycled: (A) Flow
Flow Cycled
– Pressure Control
• Flow cycled: (B)
– Pressure Support

A B
 Pressure Ventilation

Pressure Volume

Flow

Pressure
A B
Volume vs. Pressure Ventilation

VOLUME VENTILATION PRESSURE VENTILATION

• Stable and guaranteed • Allows to set maximum

tidal volume delivery inspiratory pressure

• If the mechanical • Descending flow is better

charactersitics of the tolerated, mach patient’s
lung worsen, peak and demand and improves gas
alveolar pressure can distribution
rise

• Volume delivery varies as

• Set flow rate may not lung characteristics change
mach patient’s demand
 Phase variables

A/ Trigger mechanism
– What causes the breath to
begin?
B C
B/ Limit variable
– Which parameter is sustained
at a preset level during the
breath?
C/ Cycle mechanism
– What causes the breath to A
end?
 Trigger variable

• Time: Machine-initiated (controlled)

breath
• „CONTROL MODE”

• Patient’s inspiratory effort:

– Pressure drop
– Inspiratory flow
– Other
Patient-initiated (assisted) breath
• „ASSIST MODE”
 Cycle Variables

• Time
Pressure
– Neonatal ventilators
Pressure Pressure
• Volume Limited Cycled
– Adult / Pediatric
ventilators
• Pressure
– Bird Mark series
• Flow
– Pressure Support time
– Flow Synchronized
Ventilation Limit vs. Cycle
 Breath Types

Mandatory breath: Spontaneous

Inspiration is: breath:
• machine initiated Inspiration is:
• and/or machine • patient initiated
cycled • and patient
– Assisted terminated
– Controlled – Supported
– Not supported
 Spontaneous Modes

• Continuous Positive Airway Pressure

Paw CPAP
0

• Pressure Support Ventilation

Paw PS
0
 Basic Mandatory Modes

Continuous Mandatory Intermittent Mandatory

Ventilation Ventilation
• Every breath is • Intermittent
mandatory mandatory breaths
– Machine-initiated – Machine-initiated
– Patient-triggered – Patient-triggered
• No spontaneous • Spontaneous
breaths are allowed breaths allowed in
between
 Volume Ventilation

• The mandatory breaths are

– Flow controlled
– Volume cycled *
*(or time cycled and volume limited, if insp. pause time is added)

• Guarantees desired volume delivery

• Airway pressure is variable
– Depending on the pulmonary impedance
• „Gold standard” of mechanical ventilation
• Mostly adult and pediatric patients
Pressure Limited system
IMV
Intermittent Mandatory Ventilation

Patient Patient

Expiration Inspiration
TCPL-IMV
 Trigger variable

• Time: Machine-initiated (controlled)

breath
• „CONTROL MODE”

• Patient’s inspiratory effort:

– Pressure drop
– Inspiratory flow
– Other
Patient-initiated (assisted) breath
• „ASSIST MODE”
CMV
IMV
Inspiratory Trigger Mechanism

• Time
– Controlled Mechanical
Ventilation Pressure
• Pressure
sensitivity
• Flow
• Chest impedance
• Abdominal movement
– Assisted Ventilation
– Patient Trigger
Flow
Ventilation response time
Trigger Mechanisms

Airway Pressure
SLE
Inspiratory Flow Bird
Bear
Drager
Tracheal Pressure Newport
Chest Impedance Sechrist
Esophageal Pressure SLE 250
Abdominal Movement Infant Star
Differential Pressure Sensors


V

R
P1 P2

D P =Vx R

V = (P1 - P2) / R

DV= V xDt
Differential Pressure Sensors

• Fixed Geometry
– Fixed orifice
– Fleisch-type (capillary tubes)
– High accuracy in low range
• Variable Orifice
– Bending flap decreasing resistance at higher flow
– High range of measurement, lower accuracy
– Non-linear characteristics
– Movable elements, manufacturing tolarance
– “Smart sensor” technology improves accuracy
– Additional resistance and dead space
 Thermal Anemometers

• Heated element (wire or film)

– Measures the current necessary to maintain the
temperature constant (cooling effect of gas flow)
• Lack of moving parts
+ -
• Fast and sensitive response
• Virtually no resistance
• Non-linear relationship
• Contamination
Factors Affecting Measurement

• Moisture
• Secretion
• Ambient temperature
• Humidity
Accuracy:
• Altitude ± 10-15 % !
• Placement of the sensor
• Compressible volume
loss
• Dead space
• Added resistance
• Manufacturing tolerance
 „Clean” and / or „sterile”

Gas Flow

Hot Wire

SURFACE COVERAGE BICROMAL CONTAMINATION

 Sensor Maintenance

STERILIZATION SURFACE CLEANING

STERILE, BUT NOT CLEAN CLEAN, BUT NOT STERILE

POOR PERFORMANCE INFECTION

Am J Respir Crit Care Med 162:2109-2112,
2000
 Intermittent Mandatory Ventilation

Ventilator
pressure

Patient’s
spontaneous
breathing
activity
(flow)

Inspiration Expiration
 Synchronized Intermittent
Mandatory Ventilation
Ventilator
pressure

Patient’s
spontaneous
breathing
activity
(flow)

Inspiration Expiration
SIMV
 Time Cycled
Assist/Control Ventilation

Ventilator
pressure

Patient’s
spontaneous
breathing
activity
(flow)

Inspiration Expiration
 SIMV vs. Assist / Control

Assist Window
SIMV 5 bpm

12 sec
A/C 5 bpm
PTV
Inspiration phase

Inspiratory Spontaneous
Pressure respiratory effort
Inspiration phase

Inspiratory Spontaneous
Pressure respiratory effort
Expiration phase

Inspiratory Spontaneous
Pressure respiratory effort
Expiration phase

Inspiratory Spontaneous
Pressure respiratory effort
 Types of
Pressure Limited Ventilation
• Time Cycled Ventilation • Flow Cycled Ventilation
Pressure

Pressure
Time Time
Flow

Flow

Time Time
 Flow Cycled
Assist/Control Ventilation

Ventilator
pressure

Patient’s
spontaneous
breathing
activity
(flow)

Inspiration Expiration
Spontaneous breathing pattern
PSV
Benefits of Flow Synchronization

• Total breath synchronization

• Decreased work of breathing
• Less sedation
• More efficient tidal volume delivery
• Improved gas exchange
• Shorter time spent on ventilator
• Less complications
• Gentle but effective mode of ventilation
 Time vs. Flow Cycling

FLOW CYCLED

TIME CYCLED
P-V loops during FSV and IMV

IMV FSV
V V

P P
 Level of Synchronization

IMV, CMV SIMV A/C, PTV FCV, PSV

Trigger Ventilator Patient Patient Patient

Rate Ventilator Ventilator Patient Patient

Tinsp. Ventilator Ventilator Ventilator Patient

 Insufficient Expiratory Time

Alveolar Pressure
Pressure

Pressure
Tinsp. Texp. Tinsp. Texp.
Flow

Flow

Normal T exp. Too Short T exp.

 Excessive Inspiratory Time

• Presence of inspiratory plateau

• Created when Inspiratory time exceeds the time
constants of the lung or when active exhalation occurs
• May increase WOB and “Fighting” of the ventilator
• May increase intra-thoracic pressure compromising
cardiovascular status
• May result insufficient expiratory time and gas trapping
• Specially dangerous in Assist / Control mode
 Insufficient Expiratory Time

• Expiratory flow is unable to return to baseline

prior to the initiation of the next mechanical
breath
• Incomplete exhalation causes gas trapping,
dynamic hyper-expansion and the
development of intrinsic PEEP

Flow
Prolonged Inspiratory Time
 Increased Airway Resistance
Alveolar Pressure
Pressure

Pressure
dP dP

Tinsp. Texp. Tinsp. Texp.

Flow

Flow

Normal Resistance High Resistance

 Detection of Air Trapping

• High respiratory rates or excessive insp.time

• Relatively normal compliance and/or high
resistance
• Lung over-expansion on X ray
• Decreased chest movement
• Decreased cardiac output, high CVP, low BP
• Increased intra-thoracic pressure (esophageal
cath.)
• Inadvertent PEEP
 Termination Sensitivity

Flow
100% Flow Termination of 10-15 %
might be accurate for many
25% neonatal patients
20%
15%
10%
5%

time
Set insp. time
Inspiratory time
 Flow termination in RDS

100% In RDS, due to the low compliance,

the inspiratory flow rapidly decelerates.
Flow The usual 10-15% might lead to
25% extremely short inspiratory time.
20%
15%
10%
5%

time
 ET Tube Leak
100%
In a case where considerable airway leak
around the ET tube exists,
Flow the constant leak flow may prevent
25% the inspiratory flow to drop to
20% the termination point.
15%
10%
5%

Leak
time
Change of the ET tube leak size
 Insp. Time Setting in MAS
High airway resistance
may prevent the insp. flow
to drop fast enough
100% to reach termination point
Flow
in tolerable insp. time.
Pre-set Insp.
25%
Time

time
Inspiratory Time