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Mode of Mechanical Ventilator

柳營奇美醫院呼吸治療科
呼吸治療組長
龔淑貞
模式 (Mode)
• 模式的定義─
– 病人與呼吸器交互作用,以完成一個呼吸器
循環 (ventilator cycle) 的方法
– 並沒有任何一種呼吸器模式是最好的
– 醫護人員的經驗與技巧才是決定一個呼吸器
模式成功與否最重要的關鍵
Mode of MV
• Conventional methods of ventilator
support
--CMV, A/C, PCV, VCV, IMV, SIMV, PSV

• Alternative methods of ventilator


support
--IRV, MMV, APRV, Bi-phasic, Servo-
controlled pressure(Paug, VAPS, PRVC,
Auto-flow, APV) , PAV, ATC, ASV
• Control mechanical ventilation(CMV)
-- time trigger, volume or pressure,
no effort at Pt.
• Assist-control Ventilation( A/C)
-- Time or Pt trigger
-- Set: f, Sensitivity., type of breath(V or P)
(1) flow controlled, volume cycled
(VV):
flow, volume preset, Vt reach →flow ends
(2) pressure controlled, time cycled
(PV):
Assisted vs. Controlled

Pressure Assisted Controlled


(cmH20)

Time (sec)
Volume Ventilation(VV)
• Set the volume delivered during the mandatory
breath
• VV guarantees volume (C,R ↑↓→V 不變 )
• Lung worsens,↑peak and alveolar P.
→overdistention →change flow pattern
改善
• High volume give high peak and plateau P.
• Set parameter(7200 ; 900)
• Flow controlled, Time or Pt trigger,
volume limit, Volume cycle
Controlled Mode
(Volume-Targeted Ventilation)
Time triggered, Flow limited, Volume cycled Ventilation
Preset Peak Flow

Flow
(L/m)

Dependent on
Pressure CL & Raw
(cm H2O)
Preset VT
Volume Volume Cycling
(mL)

Time (sec)
Pressure Ventilation (PV)
• Preset a pressure, P. limit ventilation(PCV, PSV)
• 影響 Vt : △P, Ti, TC (R, C), continuous
flow rate (initial flow →P. waveform
shape)
• 優點 : ↓A. overdistention, ↑distribution,
constant P., ↑MAP.
• 缺點 :variability by volume
Controlled Mode (Pressure-
Targeted Ventilation)
Time Triggered, Pressure Limited, Time Cycled Ventilation

Time-Cycled
Time-

Flow
(L/min)

Set PC level

Press
(cm H O)
ure2

Volume
(ml)
Time (sec)
比較 PCV vs VCV
• ↑ Oxygenation(↑ MAP)
- PCV : PIP-PEEP*Ti / TCT+PEEP...…. 正方

- VC : ½(PIP-PEEP*Ti / TCT+PEEP)... 三角

• ↑ gas exchange
• ↓ PIP
• 容易 lung healing
Assisted ventilation
-- Pt trigger ( PSV, VS, PAV)
-- Preset volume or pressure, no
mandatory
breath
-- time interval 不一定相等
Assisted Ventilation
• F5-20
Assisted Mode
(Volume-Targeted Ventilation)
Patient triggered, Flow limited, Volume cycled Ventilation

Flow
(L/m)

Pressure
(cm H2O)

Preset VT
Volume
Volume Cycling
(mL)
Time (sec)
Assisted Mode
(Pressure-Targeted Ventilation)
Patient Triggered, Pressure Limited, Time Cycled Ventilation

Time-Cycled

Flow
(L/min)

Set PC
Press level
(cm H O)
ure2

Volume
(ml)

Time (sec)
Pressure Supported Ventilation
(PSV)
• Pressure – targeted (or limit),
Pt – trigger
• Patient-initiated, patient-
terminated
• 自動調整 maintains flow to reach preset
PSV level keep this pressure until
expiration
The end of inspiration(PSV)
• Decrease of peak flow to specific
threshold
• Above the fixed PSV level (1 to 3
cmH2O), sudden exp. effort from patient
• A time end of the insp.
Flow criterion: % of inspiratory
peak flow

Pressure Support
Pressure PEEP

Peak Flow

Flow ETS
Wider ETS range

Too late switchover Proper switchover Too early switchover

ETS can improve synchrony and change Ti of


spontaneous breaths
PSV
Patient Triggered, Flow Cycled, Pressure limited Mode

Flow Flow Cycling


(L/m)

Set PS
level
Pressure
(cm H2O)

Volume
(mL)
Time (sec)
IMV / SIMV
• IMV
-- Time trigger, continuous (neonatal)or
demand flow
-- open IMV( 通大氣 ), close IMV( 儲存袋 )
-- demand flow 外接 peep, 無法代償 ,trigger
困難→ WOB↑
• SIMV
-- Pt or time trigger
-- Wait for the next insp. Effort ( time
window)
SIMV+PS
(Volume-Targeted Ventilation)
Flow-
cycled
Flow
(L/min)

Set PS level
Pressure
(cm H2O)

Volume
(ml)

PS Breath
SIMV + PS
(Pressure-Targeted
Ventilation)
Time-Cycled Flow-
Cycled

Flow
(L/min)

Set PC level
Press Set PS level
(cm H O)
ure2

Volume
(ml)

Time (sec)
PS Breath
CPAP
Flow
(L/m)

Pressure
(cm H2O) CPAP level

Volume
(mL)
Time (sec)
Inverse Ratio Ventilation (IRV)
• Techniques to increase I / E ratio
(1) VCIRV
-- slowing the flow rate → flow cycle 結束
-- use a inspiratory pause → time cycle 結

(2) PCIRV
-- increase Ti → time cycle 結束
Improving PaO2 with IRV
• Higher mean Paw
• By the short Te →end exp. P.↑(intrinsic
P.)
• Improved distribution due to low mean
insp. flow
• Physiologic effect
-- ↓intrapulmonary shunt, improved V/Q
matching, ↓dead space ventilation
PCIRV
• Selection I / E ratio in a PEEP- like
effect
• Trap gas and ↑FRC and MAP
• Monitor compliance, auto-PEEP, SvO2 and
C.O.
• Will drop Vt as the auto-PEEP developed
(△P = PIP – EEP)
• Auto-PEEP : measurement by flow
waveform
Mandatory Minute Ventilation(MMV)

• Allows spontaneously breath but ensure


MV
• Ventilator support automatically adjusts, can
be achieved by ↑PSV level or mandatory
breaths ( veolar or CPUI )
• But Pt with low Vt and high RR will not
initiate the ventilator support
• Disadvantages – Alveolar ventilation not
monitor, ↓clinician evaluation, MMV level not well
defined
MMV
• T10-1
Methods of delivery ( MMV )
• Change in mechanical breaths
-- Bear 5, Erica, CPUI, Sechrist 2200B
• Change in tidal volume
-- Veolar (change the PS level), Servo 300(VS)
• Target VE, maintain adequate ventilation
• During weaning – 80% on A/C, 90% on
IMV
• Set lower VE→ if Pt is alkalosis or hypocarbic
(PaCO2↓)
Servo–controlled Pressure Ventilation

A) Pressure augmentation → real breath by


breath
*Paug – Bear 1000
*VAPS – Bird 8400sti
B) Closed-loop pressure ventilation
→next breath
*PRVC and VS – Servo 300
*Auto - flow – Drager (Evita )
*APV – Galileo
C) PAV(proportional assisted ventilation), ASV(adaptic
support ventilation), ATC(automatic tube compensation)
Initial setting for Pressure Augmentation
• Paug only work with VV, target volume,
an upper pressure limit (Bear 1000, 8400sti )
• Set P.= Pplateau – PEEP
• Set appropriate flow rate:
-- >30% for peak flow for a PS breath
-- high enough Ti does not longer than Te
-- lower than the actual peak flow→ Paw↑
-- Select rectangular flow wave form ( )
• Weaning:
-- CL ↑ → Vt ↑ => reduce the P. and adjust flow rate
No p’t effort
Dement peak flow 80Lpm Insufficient pressure
PS breath withlevel
high flow demand(strong active insp.)
the breath is time
set flow 40Lpm sustained flow setting may
volume too low
delivry before the flow decreases
set flow 40Lpm(rectangular waveform)
until volume set 0.8 L TI is increased acheved
(flow drop 30% of Vtpeak flow tointo expiratory)
deliverde Vt 0.8L
Peak flow100Lpm
pressure 25cmH2O
volume set 0.8 L
pressure spike

P’t trigger P’t trigger No P’t trigger


P’t trigger
Closed – loop Pressure Ventilation

• Insp. Pressure is regulated,


calculation of previous breath, in next
breath 校正
• Decelerating flow of PCV with
volume guarantee ( )
• PRVC - VS (Servo 300 ), Auto flow (Drager ),
APV(Galileo)
PRVC vs. VS
• Volume target ventilation, pressure
regulator
• PRVC – Pt or time trigger, time cycle
VS – Pt trigger, flow cycle (5% of peak flow in
Servo
300)
• 4 test breath
-- First one 5 (300c) or 10 (300a) cmH2O
-- The next 3 breaths will deliver 75% of the set Vt
-- Calculates compliance for the previous breath
and adjust
Auto - flow
• Volume ventilation 之下 , 使 MV 自動調
節 Insp. flow( depended on lung
C, R )to change pressure, flow wave
form→
• 與 PRVC 不同點 :
– allow Pt in any phases for spontaneous
breath
– 包括 Bi-level V., IPPV, SIMV, MMV
AutoFlow - In Action
 Set desired - Paw
Paw
Freq, Tinsp ,VT
and PEEP Pinsp. = f (VT,C)

 Set Upper Paw


PEEP
alarm(- t

5cmH2O) TI TE
1
 Set Upper f
Flow
Insp. VT alarm VT

 Insp. Pressure t

will
automatically
adjust without spontaneous breathing with spontaneous breathing

(+3cmH2O)to
equal set VT
Adaptive Pressure Ventilation
(APV)
 The inspiratory pressure is adjusted
within this range:(PEEP + 5cmH2O)
to (high pressure alarm limit
-10cmH2O)
 If monitored TV is higher or lower than
the TV(target).the insp pressure is
gradually adjusted by up to 2cmH2O
at per breath
Adaptive Pressure Ventilation
(APV)

VT

Flow

+2cmH2O/breath High Pressure limit -10cmH2O


Pressure

PEEP+5cmH2O
Proportional assisted ventilation
( PAV )
• Pressure, flow and volume delivery are
proportional to Pt spontaneous effort
(Evita-PPS)
• Pressure produces by the ventilator depends on
-- insp. flow and volume demanded by Pt effort ( 不需
setting)
-- only set amplification ( work load 的 ? % ) of
ventilator
response to Pt effort
• Disadvantages :
– only provide for assisted ventilation

Proportional Pressure Support PPS
The Equation of Motion

Airway pressure Paw

R
Resistance

C Paw

Compliance Pmus

1 .

Breathing muscles Pmus P aw + Pmus = ×V + R ×V


C
Proportional Pressure Support PPS
• If R and C of the patient are known, deviations from
normal
values can be targeted and appropriately compensated
• During PPS, the patient should feel as if his lung mechanics
are healthy
Automatic tube compensation
( ATC )
• The flow in a difference in pressure between
the two ends of the tube(E-T)
• Compensates for the flow depend P. drop
across the tracheal tube ( a function, not a
mode )
• The narrower the tube’s diameter→ WOB ↑
• The length of the tube → no significant on Rtube
• Setting – the size of tube
– amount of compensation
( 100% or partially )
What is Tube Compensation?
• Not a mode, but a spontaneous breath
type
• Accurately overcomes the imposed
inspiratory WOB through an artificial
airway
• Hybrid of PS (but more efficient at
overcoming tube resistance)

• Controls the patients carinal pressure to a


Tube Compensation -
What the Carina Sees
Higher Circuit Pressure
• TC adds appropriate pressure to
keep carina pressure at preset
PEEP
No Decreased
Carina Pressure

Paw
PS Limitations For ET-Tube Compensation
• PS may under-support the WOB early in the
inspiratory phase when flows are high

• As patients wake, sleep, become agitated etc, PS is


unable to compensate for variable demands
Insufficient
PCIRC
10
7.5
Support
cmH2O
5
2.5
0
-5
-10
0 2 4 6 8 10 12s
INSP 80
60 Higher Flow
40
. 20
V
0
L 20
min
40
60
EXP -80
On Evita, in Action

Green curve shows the calculated


tracheal pressure in combination
with increased airway pressure
Then What Is APRV?
• APRV is similar but utilizes a very short expiratory time for
Pressure Release
– this short time at low pressure allows for ventilation

• APRV always implies an inverse I:E ratio


• All spontaneous breathing is done at upper pressure level

Spontaneous Breaths

P “Release

T
Airway pressure relieve ventilation
APRV
• Two level of CPAP, applied for set periods
time, allows spontaneous breathing to occur at both
level
• Set P high and P low and time spent at each level
( Thigh, Tlow )
• If P’t isn’t spontaneous, PCIRV and APRV 是不
能辨別
• Is a CPAP system, allow augmentation of alveolar
ventilation 經由短暫 interrupting CPAP(relieve
P. )
• Gas movement → by decreasing Paw below
APRV
• 傳統 pressure – limited IRV vs. APRV 之間關係 :
-- CPPV vs. IMV
• Advantages :
1) Low peak Paw 2) Low intrathoracic P. 3)↑ V/Q
matching
• Disadvantages :
1) ↓ transpulmonary P. ( 排除 CO2 會有問題 )
2) 沒有 spontaneous breath 時為 PCIRV
3) Effect of airway and circuit resistance on
ventilation
4) Interference with spontaneous ventilation
Pressure Oriented Ventilation
APRV (optional)

• Spontaneous breathing IPPVAssist


Paw
E ** ***
add. settings

on elevated 80
Other Modees

CPAP
ASB

pressure level with


Ventilation
60
MMV
Other

short pressure
40 Mode
Phoch 48 mbar Thoch 4.4 s
APRV
Ptief 5 mbar Ttief 0.9 s
---
20 ILV

releases for improved 0 ---

CO2 eliminationsimple
-10
14:39

to adjust Thigh, Tlow, Paw

Phigh, Plow
Phigh

• FiO2 and Ramp t

setting are still present


Plow
Thigh
Tlow

• Apnea ventilation with Flow

adjustable alarm time t

Tapnea
Purpose of APRV
• ALI : ↓ FRC→ elastic WOB↑→ arterial
hypoxemia
not ventilatory failure
• Restoration of FRC to reverse hypoxemia
before ventilatory failure occur
• Indication :
* ↓ Clung with oxygenation failure ex : ARDS
* Ventilation failure may be 不適用 ( auto-PEEP,
PaCO2↑ )
Clinical use of APRV
• Adjustment of CPAP (P high) result in pul.
Gas exchange and lung mechanics, by monitor of
-- PaO2, SpO2, PvO2, SvO2 or BP and HR
• After P-high, relieve Paw to P-low (△P ),
measure Vt, 如必要↑ P-high level or ↓ P-low
• If frequency release ↑, 則 release time (Tlow) 應逐
漸↓ , 避免因 air trapping ↓→ Vt ↓
• Volume change depends on TC (C*R)
-- C ↓ → release time ↓(<1.5sec)
-- Airway obstruction → release time ↑
Guidelines for Adjusting APRV -
Timing Variables
• Set frequency that results in acceptable alveolar
ventilation
– adjusted to maintain desired levels of PaCO2 /
pH
– usual starting rate 6 - 10 b/min

• Release time 1- 2 seconds for adults (1 - 1.5


more common)
– often set to achieve a slight amount of auto-
PEEP
Guidelines for Adjusting APRV -
Pressure Variables
• Upper PEEP level 10-30cmH2O determined by
compliance, adjusted to achieve desired MAP
and oxygenation
• Lower PEEP level 3-5 cmH2O adjusted to affect
FRC, MAP, and thus oxygenation
• Oxygenation can be affected by increasing MAP
through:
– increasing PEEPL
– increasing PEEPH if less than 30 - 35 cmH20
– lengthening TH if changes to either set frequency or TL is
acceptable
Which patients may be poor
candidates for APRV
• Patients with increased airway
resistance
• Who are unable to empty their lungs in
2 seconds
• Asthma and COPD patients
• Examining expiratory flow pattern to
determine increased resistance can be a
reliable indicator
Bi–phasic Positive Airway Pressure

• Use the same principle as APRV


• Pressure target with freedom of
spontaneous breath on two level
• Synchronization of spontaneous and
mechanical ventilation (trigger window)
with BiPAP
What is BiLevel Ventilation?
• Cycling between the two pressure levels can be
synchronized to patient breathing
– BiLevel timing settings or triggered by patient
effort
• The two pressure levels are called PEEPH and PEEPL
• The two timing levels are TH and TL

PEEPHIGH Synchronized Transitions

P PEEPLOW THIGH

TLOW Synchronized Transitions

T
What is BiLevel Ventilation?
• At either pressure level the patient can breathe
spontaneously
– spontaneous breaths may be supported by PS
– if PS is set higher than PEEPH, PS supports
spontaneous breath at upper pressure
PEEPH PEEPHigh + PS

Pressure Support
P
PEEPL

T
Depiction of DuoPAP Ventilation
Spontaneous Breaths
Synchronized Transitions
PHIGH
Spontaneous Breaths
P
PLOW/PEEP/CPAP

Clock Transition

PHIGH PHIGH + PS

PLOW PLOW + Psupport

T
BIPAP* allows Spontaneous Breathing
during the Mandatory Stroke
• Reduction of the
Spontaneous
invasivness of
Breathing Ventilation
• Reduction of
Sedation
BIPA • One Ventilation
P Mode from
Intubation to
Weaning
• More
PC comfortable for
V the Patient
• Fewer Alarms
(easier handling)
BIPAP and the Synchronisation of
Spontaneous Breathing

Exp.
Trigger
P

Insp. Trig. Trig. t


Trigger Window Window
• The set BIPAP phase synchronises with
Spontaneous Breath
• Smooth synchronisation of the mandatory
strokes with appropriate time window
• Flow-trigger in Inspiration and Expiration
3 New BiLevel Settings
• Timing button
• Upper pressure level button - PEEPH
• Lower pressure level button - PEEPL

.
BiLEVEL PC PS V-TRIG
f TH PEEPH PSUPP VSENS O2
1 cm cm L
16 min 1.75 S 20 H2O 15 H2O 5 min 50 %

P PEEPL
5.0 cm
50 % H2O
ESENS
10 %
1.75 2.0 _
PCIRC
0 cm
3.75 5 25 H2O
1:1.14
THIGH Setting
• TH can then be directly adjusted

• Range 0.2 to 30 seconds


.
BiLEVEL PC PS V-TRIG
f TH PEEPH PSUPP VSENS O2
1 cm cm L
16 min 1.75 S 20 H2O 15 H2O 5 min 50 %

P
PEEPL
50 5.0 cm
% H2O
ESENS
10 %
1.75 2.0 _
PCIRC
0 cm
3.75 5 25 H2O
1.75 1:1.14
THIGH : TLOW Setting
• When I:E ratio is locked, TH : TL is is the displayed button
and can be adjusted directly
• Range 1:299 to 149:1

.
BiLEVEL PC PS V-TRIG
f TH : TL PEEPH PSUPP VSENS O2
1 cm cm L
16 min 1: 1.14 20 H2O 15 H2O 5 min 50 %

P
PEEPL
50 5.0 cm
% H2O
ESENS
10 %
1.75 2.0 _
PCIRC
0 cm
3.75 5 25 H2O
1:1.14
TLow Setting
• When TL is locked on the breath timing bar, TL is present
on the timing button and can be set directly
• Range .2 seconds or higher

.
BiLEVEL PC PS V-TRIG
f TL PEEPH PSUPP VSENS O2
1 cm cm L
16 min 2.0 S 20 H2O 15 H2O 5 min 50 %

P
PEEPL
50 5.0 cm
% H2O
ESENS
10 %
1.75 2.0 _
PCIRC
0 cm
3.75 5 25 H2O
1:1.14
APRV versus BIPAP different
philosophies

BIPAP APRV
Ventilation
Pinsp
Phigh
CPAP Plow
Adaptic Support Ventilation
(ASV )

Machine- and/or patient-triggered.


Gas delivery is pressure-controlled for both
mandatory and spontaneous breaths.
Pressure levels are identical.
Mandatory breaths are time-cycled if they
were NOT triggered by the patient; spontaneous
breaths are flow-cycled.
ASV
Flow I + +
Flow E
* *
Pinsp

PEEP

No patient activity: Patient is active:
* Machine­triggered * Patient­triggered
+ Time­cycled + Flow­cycled
Optimal breath pattern
2000

1500 1+2a*RCexp*(MV­V‘D)/VD    ­1
f­target = 
a*RCexp   
Vt ml

1000

500

0
0 20 40 60
f bpm
Lung-protective rules
(boundary conditions)
2000
5 test breaths
10*Vd
A
1500


D b/min C
20/RCexp
Vt (ml)

1000

500 B
2*Vd

0
0 20 40 60
f (b/min)
Optimal breath pattern: Lung
protective strategy
2'000

Avoid:
1'500
a:apnea
Vt in ml

1'000
b b:volume/barotrau
a c
ma
500
d
c: AutoPEEP
0 d: excessive
0 10 20 30 40
VD
Frequency in breaths per minute
ventilationon
/tachypnea
結語
• 呼吸器是用來活命 (supportive) 而不是
用來治病 (curative or therapeutic) 的─
– 支持衰竭的呼吸系統 (failing respiratory
system) ,直到病人的呼吸功能因治療或自然回復
功能
– 避免呼吸器引起之「醫源性肺損傷」 (iatrogenic
lung injury) 與其他併發症
• 不要用呼吸器來延長死亡過程─
– 癌症末期病人
– 末期之慢性呼吸衰竭
– 無復原希望之疾病
Thanks for your
attention