.,.

.!

CHAPTER

1
Introduction

. .

"'
A ventilator is a device used to move gas into the lungs. The
design of the ventilator may be such that lung inflation is
accomplished by applying po~itive pressure to the airway or
by applying subatmospheric pressure around the chest.
In acute care institutions, lung expansion involving subatmospheric pressure is not as common as positive-pressure
ventilation. However, a brief review of the principles of
negative-pressure ventilation is essential to a comparison of
both methods of lung inflation .

Pressure Manometer
IM()IItM~ptJIIINo

Negative
Pressure
Control

' .

NEGATIVE-PRESSURE VENfiLATION
The use of negative pressure to expand the lungs dates
back to the start of the nineteenth century, 1 when it involved
enclosing all of the body but the head in a cylindrical tank
called the iron lung2 5 (Fig 1- 1). In subsequently developed
models the anterior portion of the chest and abdomen is
enclosed in an airtight shell (thoracoabdominal shell) (Fig
I-2,A and B) or the patient is fitted with a zippered gar-

INSPIRATION

EXHALATION

Bellows

Rotating
Wheel

FIG 1-1.
Iron lung. All but the head is enclost"~ in a sealed chamber. Slowly revolving wheel imparts reciprocal motion to bellows assembly connected
to chamber. When bellows expand, subatmospheric pressure generated within chamber causes chest to rise and inspiration to begin. During
upward motion of be llows a one-way valve opens and returns pressure within chamber to atmospheric. Chest recoils to normal position and
exhalation begins. Amount of positive and negative pressure can be controlled independently.

CHAPTER

1
Introduction

..
.

A ventilator is a device used to move gas into the lungs. The

design of the ventilator may be such that lung inflation is
accomplished by applying positive pressure to the airway or
by applying subatmospheric pressure around the chest.
In acute care institutions, lung expansion involving subatmospheric pressure is not as common as positive-pressure
ventilation. However, a brief review of the principles of
negative-pressure ventilation is essential to a comparison of
both methods of lung inflation.

"

.,

' .

NEGATIVE-PRESSURE VENfiLATION
The use of negative pressure to expand the lungs dates
back to the start of the nineteenth century, 1 when it involved
enclosing all of the body but the head in a cylindrical tank
called the iron lung 2 5 (Fig 1-1). In subsequently developed
models the anterior portion of the chest and abdomen is
enclosed in an airtight shell (thoracoabdominal shell) (Fig
l-2,A and B) or the patient is fitted with a zippered gar-

A
INSPIRATION

' Negative
Pressure
Control

Bellows

Rotating
Wheel

FIG 1- 1.
Iron lung . All but the head is enclosf'~ in a sealed chamber. Slowly revolving wheel imparts reciprocal motion to bellows assembly connected
to chamber. When bellows expand, subatmospheric pressure generated within chamber causes chest to rise and inspiration to begin. During
upward motion of bellows a one-way valve opens and returns pressure within chamber to atmospheric. Chest recoils to normal position and
exhalation begins. Amount of positive and negative pressure can be controlled independently.

Suprasternal
Notch
CHEST SHELL

Flexible Hose
To Pump Unit
Straps
Pubic Crest

--

FIG 1-2.
A, position of chest shell used for negative-pressure ventilation. Inspiration is initiated when pump unit
generates subatmospheric pressure in airtight shell. When subatmospheric pressure is released, exhalation begins.

8 , cuirass shell used for negatve pressure ventilation. Patient i~ placed in supine position and cuirass is stabilized with
the use of straps and posts. Method of ventilation is identical to chest shell unit.

Basic Concepts

"'

'"""' s.:: d<~d at the neck , arms, and thighs or lower

1 3,A and B). 6 Another rendition encloses

abdomen
the body
I ro1 11 1he neck downward in an airtight bag (Fig 1-3, C). In
:.II 111odds the garment is held off the chest by a plastic shell
1 hr

t l ,,, I

: !) I

n.:gative-pressure ventilation units a pump (Fig 1-4)

,tlmT~ the: pressure within the chamber to below atmo' l'hnl,. level. This reduction causes the pressure surround"'!-'. the chest to drop below the pressure within the lungs ,
;uul the chest rises. As the chest rises, the lungs expand and
the pressure within them becomes less than atmospheric.
Atmospheric gases are thus drawn into the lungs until equilibrium between lung pressure and surrounding pressure is
reached. At that moment inspiration ends.
To allow exhalation the subatmospheric pressure surrounding the chest is released. The natural elastic recoil of
th e lungs and thoracic cage causes lung pressure to exceed
atmospheric pressure, and gas leaves the lungs until lung
pressure and atmospheric pressure are again equal. The opin

.r-

tion of adding a slight positive pressure during exhalation is

also provided in some models and is occasionally useful for
restoring the pressure within the shell to atmospheric levels.
Applying subatmospheric pressure around the chest to
accomplish lung inflation is called intermittent negative pressure ventilation or INPV. However, in today's vocabulary the abbreviation NPV (negative-pressure ventilation) is
often used .
Chest shell or cuirass ventilators still have a place in
alleviating a variety of conditions that compromise spontaneous ventilation, particularly chest wall disease, bilateral
diaphragmatic paralysis, degenerative neuromuscular diseases, sleep-induced hypoventilation, and chronic respira. tory failure.?- 13 With the increase in the popularity of home
care, domiciliary chest shell-assisted ventilation appears to
be ideal for selected patients with non obstructive respiratory
failure . 14 Recent studies suggest that NPV may be useful in
alleviating ventilatory muscle fatigue and hypercapnia in
patients with chronic obstructive pulmonary disease. 15 16

(
I

Arm
straps

Airtight
zipper--~

r
r
Garment shell
connection
(~

Pump unit
connection

Gannent shell

FIG 1-3.
Airtight garments used for negative pressure ventilation. A, garment is sealed at neck, arms, and legs. B, garment is sealed
at '!eck, arms, and waist. C, patient is placed in bag sealed at the neck and arms. To keep garment off patient' s chest and
enhance ventilation, a shell (D) fitted with a pump connection that extends through garment opening is used . Method of
ventilation is identical to shell units .

Introduction
PUMP UNIT

ToChe&Un'' ~ ,

'

~~ O

Expiratory
Pressure
Control
Inspiratory

- - - - Pressure
l l__~an--~
Control

Electric
Motor-

EXHALATION

INSPIRATION

FIG 1-4.
Schematic representation of pump unit used to provide negative pressure ventilation to shell units or garments.
Pump unit consists of piston connected off center to a slowly revolving wheel. The downward stroke of the
piston provides subatmospheric pressure to chest unit or garment to initiate inspiration. The upward stroke of the
piston rel~ases the subatmospheric pressure and allows chest to recoil to normal resting position and allow
eilialation. Amount of negative or positive pressure generated can be controlled independently.

A primary shortcoming that limits the widespread use of

the shell ventilator is its inability to provide adequate ventilation in a!! patients. Other concerns include fit and comfort
for long-term use and the need for the fabrication of specialized shells for patients with severe thoracic asymmetry. 17

POSITIVE-PRESSURE VENTILATION
The process of lung inflation by use of positive pressure
is similar in principle to mouth-to-mouth artificial ventilation. In this approach the rescuer exhales into the victim's
airway and directs positive pressure into the victim's lungs.
When the victim's chest has expanded to a suitable level the
rescuer stops exhaling and releases the pressure, and the
victim's lungs are allowed to empty. The procedure is then
repeated at a frequency appropriate to the victim's size.
When a device is used to inflate the lungs, the device is
called a ventilator. When positive pressure provides the
means for lung inflation, the process is called intermittent

positJve-pressure ventilation or IPPV. For clarity another

acronym common to the field is IPPB, which stands for
intermittent positive-pressure breathing. IPPB differs from
IPPV in that the former describes the use of a ventilator to
deliver aerosolized water or medication under positive pressure.18
It is interesting to note that apart from the bells and
whistles of mecha_nical ventilators, mouth-to-mouth artificial ventilation and IPPV perform identical tasks. However,
the advantages of the modern-day ventilator are clear. For
instance, a ventilator provides better control over the pressure, volume, and flow entering the patient's lungs, and
most are equipped with an elaborate ventilation monitoring
system.
Intermittent positive-pressure ventilation, also called
controlled ventilation, must provide four basic functions:
1.

2.
3.
4.

Inflate the lungs

Stop lung inflation
Allow the lungs to empty
Start lung inflation

Basic Concepts

way in which the ventilator performs these four

l11nctions can be classified into four separate phases 19

f'ltc
1> .. "
! I I }'

5 ):

.\
4.

The inspiratory phase

The changeover from the inspiratory phase to the
expiratory phase
The expiratory phase
The changeover from the expiratory phase to the
inspiratory phase

Although the functional characteristics among ventilators are many, all ventilators must provide these four basic
l11nctions. Understanding the rationale behind this system of
classification enhances the clinician's ability to predict the
behavior of any ventilator in the clinical setting. In the
:'cclions that follow, the method used to determine the classification of each phase is closely examined.

BASIC CONCEPTS
Although current literature clearly indicates that the
availability of diverse ventilatory support is essential for the
intact survival of the critically ill,20 - 46 ventilator therapy is
not a perfect substitute for natural breathing. A ventilator
that can exactly mimic the normal physiological responses
of spontaneous ventilation has not been invented. We must
therefore concentrate on improving our knowledge of ventilators and the techniques involved with their use to mini-

Changeover from
insp'ir~ory phase

Changeover from.
to

expiratory phase

inspiratory phase

Inspiratory Phase - i --

mize any adverse effects they may have on the pulmonary

and cardiovascul_ar system.
A number of physiological differences exist between
spontaneous ventilation and controlled ventilation. These
differences must be understood before ventilator therapy
can be attempted. The following brief review begins with
the concept of pulmonary mechanics .
Compliance47 - 50
In Figure 1-6 we have two balloons that contain the
same volume, but balloon B has a greater internal pressure
than balloon A. We could say that the reason for the difference in pressures within the balloons is that balloon B
does not stretch as easily as balloon A. Tb be precise, however, balloon B is under more pressure because it has a
greater amount of elastic substance than balloon A. Elastic
substance, or elastance, is defined as an index of the ability
of a substance to resist deformation by stress. This concept
can be seen in the example of stretching a rubber band: the
more elastic the material, the more effo:-t required to extend
it. In terms of pressure and volume, elastance is defined as
the ratio of the change in pressure to the change in volume.
Compliance, on the other hand, is simply the opposite
of elastance; compliance is the ratio of the change in volume
to the change in pressure. In Figure J-6, both balloons
contain the same volume, but since B has a greater internal
pressure than A, the compliance of B' is. less than the compliance of A. In fact, since balloon B has twice the pressure
of balloon A, the compliance of B is one half that of A, or
A has twice the compliance of B.
.
' 'In pulmonary physiology compliance is used to de-
scribe the elastic properties of the lungs and chest wall. In
the form of an equation it is defined by

expiratory phase

to

j
:-

- Expiratory Phase -

_....._
I

J
l

a:

:;)

"'"'a:w

a L---------~~-----------=~==-----J-------TIME - -- - -

FIG 1-5.
Four phases of respiratory cycle on controlled ventilation.

FIG 1-6.
Using balloons to describe the concept of compliance. (See text for de-
scription.)

Introduction

C = !J..V
!J..P
where
/, V
LP
C

Change in volume in li te rs
Ch ange in prcssu n.: in ern H2 0
Compli ance in L!c m H 2 0

Chest wall compliance (Ccw) and lung compliance (CL)

make up total compliance (Cr) . They are related in such a
way that they are added reciprocally:

In the lungs total -compliance determines the volume

change to each unit of pressure change.
C0111pliance varies with body position, age, and various pathological entities;.52 - 6 1 In the chapters that follow,
an arbit.rary value of 0 .05 Ucm H2 0 is used to represent
standard conditions for a patient on controlled ventilation.
The actual nom1al value for compliance is reported to be
approximately 0. 1 Ucm H2 0 for a spontaneously breathing
individu al. It is calculated as follows :
Ccw = 0.2 Ucm H2 0
CL = 0.2 Llcm H2 0
and since they are added reciprocally,

Sol ving for

Cr:
0.2
_
02

X 0.2
L
+
_ = 0 .1 /em H 20
02

of this book, a review of a few basic principles is necessary

to appreciate fully the concept of airway resistance.
In Figure 1-7 two pressure manometers , A and B, are
attached at oppos ite ends of a tube. Manometer A is positioned to measure the pressure at the inlet of the tube while
manometer B measures the pressure at the outlet. When a
continuous flow of gas passes through the tube , both manometers indicate a pressure. However, manometer B registers a lower pressure than manometer A . This finding
indicates that energy is lost along the tube.
The energy lost is the result of frictional forces and in
a flowing fluid is seen as a loss in pressure. This pressure
loss or pressure drop is actually a measurement of the resistance that must be overcome when a gas is forced or
drawn through a tube. The source of friction is greatly influenced by the type of flow present. Generally, there are
two types of flow : lanlinar flow and turbulent flow.

Laminar Flow
Laminar flow is defined as a smooth, orderly flow in
which the particles constituting the fluid move in a path
parallel to the wall of the tube, as in Figure l-8 ,A. The
flow moves as concentric layers along the tube . The layer of
fluid next to the wall of the tube has zero velocity. Layers of
fluid at progressively greater distances from the wall have
higher velocities, with the maximum velocity occurring at
the very center of the tube.
Since the layer of fluid next to the wall of the tube is
essentially at rest, the frictional forces between the fluid and
the wall of the tube cannot be responsible for the drop in
pressure. In fact, the pressure drop along the tube during
laminar flow is caused by the viscosity of the gas. 65 - 66
. Viscosity can be thought of as the fluid's internal resistance
to flow and is caused by friction between the molecules of
the fluid. Different gases have different viscosities, as
shown in Table 1-1. It is interesting to note that if the fluid
is a liquid, the viscosity decreases with increases in tern- .

Note that total compliance resulting from the reciprocal

sum of the chest wall compliance and lung compliance must
always be less than the compliance of the smallest of the
two individual compliances .
More on the topic of compliance is presented at the end
of this chapter under the headi~g Estimating Lung MechanICS .

Resistance to Flow in Tubes

In the study of hydrodynamics there are certain laws

that govern the flow of fluids in tubes. 62 - 64 Since a gas is
considered a fluid, the Jaws generally apply. Although a
complete discussion of fluid dynamics is beyond the scope

FIG 1-7.
When a steady flow of gas (\!) passes through tube , energy lost along tube
is demonstrated as drop in pressure(~) between ends of tube (P 1 - P2 ) .

Basic Concepts

Velocity head
Laminar flow

is increased, the pressure drop increases correspondingly.

However, because the pressure drop varies inversely to the. ''
fourth power of the radius, the effects of the radius on the
pressure drop are striking .
For example, if the viscosity, fiowrate, and the length
of the tube are kept constant (K) , and the value of unity is
assigned to the radius (r = 1), then:

Velocity head
Turbulent flow

=Kx.!

=KX1

FIG 1-8.
Velocity profile of gas particles moving along tube during A, laminar flow,
and B, iurbulent flow.

When the radius is reduced by one half:

TABLE 1-1.
Viscosities of Common Gases

'""

.....,

Oxygen
Viscosity
@ 20C
I0- 4 Poise*

Helium

Air

Nitrogen

Carbon
Dioxide

=K

l
0.0625

=K

16
.\

2.00

1.96

1.81

1.74

1.46

*Unit of viscosity equivalent to I dyn-sec/cm 2

perature; but if the fluid is a gas, the viscosity increases with

increases in temperature.
Keeping viscosity and flowrate constant, other factors
that influence the pressure drop along tubes during laminar
flow include the length and the radius of the tube. This
pressure drop varies directly with the length of the tube and
inversely to the fourth power of its radius . This statement
can be expressed by a simple formula:
I
PI - P2 = K x L X r4

where
PI - P 2 = Pressure drop along the tube
K = Constant of proportionality, which
includes flowrate and viscosity of
the gas
L = Length of the tube
r = Radius of the tube
The relationship between the length of the tube and the
pressure drop along the tube is linear; that is, if the length

This demonstrates that if the radius is reduced by one

half, the drop in pressure along the tube would be 16 times
greater than in the originaL To put it another way, it would
now take 16 times more pressure to pass the same flow
through the narrower tube.
The behavior of fluids duri~g laminar flow in pipes was
documented between 1839 and..I841 by the Gel:man civil
engineer Heinrich Gotthilf Hagen and by the French physiologist Jean Leonard Marie Poiseuille. 67 Their investigation led to the development of an equation known today as
the Hagen-Poiseuille Law: 68

where
PI - P2 = Pressure drop along the tube
fJ- = Viscosity of the gas
L = Length of the tube
'lT = Pi (a mathematical constant)
r = Radius of the tube
V = Flowrate of the gas
In the human airway, conditions thai predispose to excesses in bronchial secretions and constriction oLthe smooth
muscles of the bronchi all contribute to the narrowing of the
airway and increase the effort required to move gas into and

Introduction

10

out of the lungs. (Chapter 16 provides a description of the

factors that influence the work of breathing .)
Laminar flow is the most efficient type of gas flow in
tubes . As demonstrated in Figure 1-9, during this type of
flow (with the geometry of the tube and viscosity of the gas
kept constant) the pressure drop along the tube is directly
proportional to the flowrate of the gas:

Furthermore, because the velocity of gas is uniform

across the diameter of the tube , frictional resistance between the gas and the wall of the tube also contributes to
this pressure drop. In laminar flow the pressure drop is
proportional to the flowrate , but when flow is turbulent the
pressure drop along a tube is directly proportional to the
square of the flowrate (see Fig 1-9):
P = K2 <P

where

where

P = Pressure drop along the tube

K2 = Length and radius of the tube, along
with viscosity and density of the gas
V = Flowrate of the gas

P = Pressure drop along the tube

K 1 = Constant of proportionality, which

includes the length and the radius of

the tube and viscosity of the gas
V = Flowrate of the gas

Turbulent Flow
A transition from laminar flow to turbulent flow takes
place above a certain flowrate.69 The point at which this
happens is known as the critical flowrate of the gas . In
turbulent flow the fluid particles no longer travel in straight
lines parallel to the wall of the tube but move in a haphazard
fashion across and opposite the general direction of flow, as
demonstrated in Figure 1-8 ,B. With a large number of
random particle fluctuations , gas in turbulent flow travels
along the tube in a uniform velocity, and the velocity of gas
closest to the wall of the tube is the same as the velocity at
its center. With turbulent flow the factor's responsible for the
pressure drop along the; tube include those described for
laminar flow but also involve gas density. In fact, the density of the gas becomes more important than its viscosity.

Turbulent flow is the least efficient type of flow, but in

the human airway both laminar and turbulent flow exist.
The relationships that describe the pressure loss for laminar
and turbulent flow can be combined to summarize the pressure drop across a given airway:

Airway Resistance
From the preceding discussion we conclude that the
pressure drop across a given tube is determined by the product of resistance and flowrate:

P1

P2

= resistance X flowrate
= em H 20 /Lisee x Lisee
=em H 20

Resistance can therefore be deteimined by simple substitution:

--!-- -

'

.
Resistance

'
'

; ---t-

1'

P 1 - P2
fl
owrate

Airway resistance is defined as the pressure drop between the mouth and the alveoli divided by the flow-.
rate. 5 1 69 If P 1 and P2 are substituted for mouth pressure and
alveolar pressure respectively, the relationship that describes airway resistance is given:

where

.l

Flow laminar Tur bulent

FIG 1-9.
Graph relating pressure drop along tube to type of flow present in tube.

PM
PA

= Mouth pressure in em H20

V=
RAw

= Alveolar pressure in em H20

Flowrate in Lisee
Airway resistance in em H2 0 /Lisee

-~

'

Basic Concepts

r.~

..~

(~

r
r-

,r-

Resistance to flow through the conducting airways in

the spontaneously breathing adult constitutes about 80% of
total airway resistance; the remaining 20% is viscous-tissue
resistance of the lung . The value for airway resistance (total
resistance) in the spontaneously breathing adult has been
estimated to be between 2 and 3 em H2 0 /Lisee.
In this text it is assumed that laminar flow is present at
all times and that lung inflation is accomplished by applying
positive pressure to a tube positioned in the patient's airway
(endotracheal tube). Since the diameter of this tube must be
smaller than the diameter of the airway, it is reasonable to
conclude that the placement of this tube increases the resistance across the airway. 7 For this reason, in this text the
standard value for airway resistance has been assigned an
arbitrary value of 6 em H20/Lisee.
More on the subject of airway resistance is presented at
the end of this chapter under the heading Estimating Lung

Mechanics.

,.--

Mechanism of Spontaneous Ventilation 71 72

r--

r
.r-

r(

During a spontaneous inspiration the diaphragm contracts and moves downward. At the same time the rib cage
swings outward and elevates the sternum. This maneuver
enlarges the volume in the thoracic cavity and expands the
lungs. As the lungs expand, the pressure within them becomes less than atmospheric and gas is drawn down the
airway and into the lungs. Inspiration contil!ues until lung
pressure rises to equal atmospheric pressure.
Because the lungs and thoracic wall contain elastic tissue, exhalation is passive. When the diaphragm and the
muscles of the rib cage relax, the lungs and thoracic cage
recoil to their original size. As this happens the volume of
the thoracic compartment is reduced, the pressure within
the lungs becomes slightly greater than atmospheric pres~
sure, and gas moves out of the lungs until alveolar pressure-
and atmospheric pressure are again equal.
The lungs never completely empty;. the volume .,that
remains in the lungs at the end of a quiet spontan~ous exhalation is called the functional residual capacity (FRC).
Cardiovascular Responses to Spontaneous Ventilation
Cardiac output is defined as the product of stroke volume and heart rate. Stroke volume is the amount of blood
pumped from the heart with each beat. The more blood
returning to the heart by way of the veins (venous return),
the greater the stroke volume and cardiac output.
Blood pressure is the force of blood exerted against the
inner walls of an arterial vessel. Since blood pressure decreases markedly as blood travels through the arterial system
into venules, blood returning to the heart cannot entirely be
the result of heart action. 71 Spontaneous ventilation plays an

11

important role in venous return to th~beart (Fig 1-1 0) . The

mechanism involved is often referred to as the thoracic
pump, 19 which can be described as follows .
During a spontaneous inspiration the expanding rib
cage pulls upward on the parietal pleura lining the right and
left thoracic compartments, which in tum pulls up on the
visceral pleura that covers the lungs. The pleural membranes are separated by a thin serous fluid, and the pulling
action is similar to the effort required to detach two flat
surfaces separated by a viscous fluid: they slide along each
other very easily but are difficult to pull apart.
Although tpere is no space between the pleural membranes, the potential space called the pleural cavity increases in subatmospheric pressure as the rib cage expands.
This negative pressure-is transrilltted to the contents of the
thoracic compartments.
.
. At end inspiration, the.'~<Point at which the transition
from inspiration to e~ttlation occurs, blood flow returning
to the heart is .JIIitest because the pressure gradient between the thoraCic vessels and those Gutside is greatest.
Venousretum during inspiration ' is also enhanced by
the downward motion of the diaphragm, which tends to
squeeze blood out of the abdominal veins into the thoracic
veins . Back flow is prevented by one-way valves in .the
veins.
The pressure in the pleural cavity, ,also calledintrapleural pressure, is reported to be about , --,. 5 em H20 during the
quiescent part of exhalation and --; 10 em H20 at end in" spidttion. Intrapleural pressure reflects venous return; the
. more negative the intrapleural pressure, the greater the
venous return to the heart and the greater the right ventricular preload.
Cardiovascular Responses to Controlled
Ventilation73 - 75
During the inspiratory phase of controlled ventilation
the lungs are expanded by positive pressure applied from
within. As the lungs expand, the rib cage is forced upward,
and all intrathoracic structures are compressed. This action
causes the following (see Fig 1-10):
1. Intrapleural pressure rises to a positive value and will
return to its normal subatmospheric pressure level only during the quiescent part (expiratory pause) of the exhalation
phase if lung pressure is allowed to reach atmospheric level.
2. The rise in intrathoracic pressure to above-atmospheric levels nullifies the action of the thoracic pump mechanism, and venous return falls.
3. All structures within the mediastinum, especially the
heart, are squeezed between the expanding lungs, and cardiac output falls. The effects are similar to a cardiac
tamponade. 76 - 79

12

Introduction
SPONTANEOUS
VENTILATION

CONTROLLED
VENTILATION

Expiratory
pause

Volume

Expiratory
pause
Q

FRC+-------------~--

Alveolar
pressure

Intrapleural
pressure

O+-----------

Venous
return

1+----- I~--- E --:-+1

FIG 1-10.
Physiologic differences between spontaneous and controlled ventilation.
(See text.)

4. The positive pressure also compresses the small pulmonary vessels, especially those in direct contact with alveolar pressure. This impedes pulmonary blood flow and
increases the work of the right side of the heart.
5. During positive-pressure ventilation, as the central
venous pressure (right atrial pressure) rises, venous return
to the heart falls.
Although the effects of these responses are not uniform , the reduction in the right heart output can lead to a
reduction in systemic blood pressure in- the hypovolemic

patient. In others the blood pressure is normally maintained

by a compensatory mechanism with effects that include the
development of tachycardia, vasoconstriction, increases in
systemic vascular resistance, and peripheral shunting of .
blood away from the kidneys and the lower extremities .
Spontaneous Ventilation and Ventilation/Perfusion
Ratio

During spontaneous ventilation the inspired volume is

never distributed evenly throughout the lungs. Likewise

Basic Concepts

there is an uneven distribution of blood supplying the lung

segments. An evaluation of this mismatch is called the ventilation/perfusion ratio or V/Q ratio. 69
Perfusion
The two most significant factors in uneven pulmonary
perfusion are pressure in the pulmonary vascular system and
gravitational forces. In the upright lung the least amount of
blood flows to the apices of the lungs and the flow increases
progressively as it reaches the base, thus producing a vertical hydrostatic pressure gradient (hydrostatic effect) in the
pulmonary vessels. This phenomenon has led to the development of a pulmonary perfusion zone model such as represented in Figure 1-11.

ZONE 1

....

Upright
Standing

ZONE2

ZONE3

Left Lateral
recumbent

Supine

FIG 1-11.
The concept of zones to illustrate lung perfusion to body position. In the
upright body, perfusion is least at the apices (zone 1) and greatest at the
bases (zone 3). Perfusion changes with body posjtion because of gravitational forces.

13

West describes three zones 80 that are defined on the

basis ofthe relative pressures in the pulmonary arterial system, pulmonary venous system, and pulmonary alveoli.
As illustrated in Figure 1-12, there is very little or no
perfusion in the first zone because the pulmonary artery
pressure at this elevation from the heart is not quite high
enough to offset the hydrostatic effect. Mean pulmonary
artery pressure is approximately 12 mm Hg but nearly zero
at the apices. Consequently, the capillaries are collapsed
and perfusion is completely absent during ventilation cycles
in which alveolar pressure (PA) exceeds pulmonary artery
pressure (P a).
It should be noted that although some perfusion normally exists in zone 1, that condition could easily be compromised in the presence of hypovolemia or a deterioration
of right-side heart function that leads to pulmonary hypotension.
Perfusion in the upper area of zone 2 is sporadic because of its proximity to zone 1. The middle-to-lower portion of zone 2 is normally supplied with blood because of its
position relative to the heart and because the vertical hydrostatic pressure provides little or no opposition to the
pulmonary arterial pressure. The capillaries remain open
and perfusion increases down this zone as pulmonary artery
pressure exceeds alveolar pressure .
Zone 3 receives most of the blood flow because of the
hydrostatic effect, which in this instance can be visualized
as assisting the pulmonary artery pressure in perfusing the
lower segments of the lungs. Perfusion is constant because
the pulmonary artery pressure is greater than the pulmonary
venous pressure, which in tum exceeds alveolar pressure.
Dependent lung regions are those areas of the lungs that
depend on gravity for their supply of blood. Therefore, in
the upright individual, the least dependent lung region is
zone 1, the dependent region is zone 2, and the most dependent lung region is zone 3.
Other factors that affect the pattern of perfusion are
changes in body position, as shown in Figure 1-11, and the
caliber of the pulmonary vasculature. Pulmonary vascular
flow increases steadily from the least dependent to the most
dependent lung regions because of hydrostatic pressure that
dilates the small capillaries. With an increase in diameter
there is less resistance to blood flow through these capillaries according to the Hagen-Poiseuille law.

Ventilation
The functional residual capacity (FRC) is defined as the
gas volume that remains in the lungs at the end of a normal
exhalation. An inspired volume from the point of FRC is
called the tidal volume; it is the volume that enters the lungs
with each breath.
There are several reasons for the nonuniform distribution of ventilation throughout the lungs. The first is the

14

Introduction

APEX

ZONE f

CJ

ZON2

Pulmonary
Artery (Pa)
Alveolar
Pressure (PA = 0)

Pa > PA> Pv

c;

Pulmonary
Vein (Py)

ZON3

...
BASE

FIG 17 12.
Simplified zone inodel of the upright lung showing the factors responsible for the distribution of perfusion and alveolar diameter
at resting lung vol.ume. The vertical hydrostatic pressure results from gravitational forces. (See text for description.)

regional differences in lung compliance that result from

r~gional differences in intrapleural pressure . In the upright
lung intrapleural pressure is more negative at the apices
( = - 10 em H2 0) than at the bases (= -2 cm -H2 0)
hecause of the weight of lung tissue. As a result of this
pr~ssure difference the diameter of the alveoli is greatest
at the apices and decreases steadily toward the bases, as is
depicted in Figure 1-12. Consequently, most of the FRC
is ui strihuted in the least dependent lung regions.
During a' breath at normal tidal volume, very little volume ~n tcrs the uppermost lung regions. Most of the ventilation' ahout 150 percent of that in the apex, 81 is distributed
to th~ lower regions because of the following.

I . At FRC the uppermost alveoli are far more expanu~u than those of the lower regions. Therefore they are
Jess compliant than those of the lower regions because they
already contain a proportionately larger volume and will
resist further ex pansion.
2. The chest symmetry and movement of the ribs . The
lower ribs are more mobile and displace more volume than
the upper ribs.
3. The movement of the hemidiaphragms, which expands the lower regions more than the upper regions .

Consequently, distribution of ventilation is greatest in

the most dependent lung regions and decreases almost linearly as it reaches least dependent regions.
In summary it can be said that in the upright lung, ventilation and perfusion increase progressively from the apex to
the base. The overall ventilation/perfusion ratio (V/Q) represents the volume that ventilates the alveoli (see discussion that
follows) and the blood flow supplying the pulmonary capillaries. In the normal individual the average .alveolar ventilation is
approximately 4 L per minute and the average capillary blood
flow is about 5 L per minute, which results in a mean V/Q of
0. 8. Disturbances in ventilation or perfusion can be assessed
quite readily by a lung scan (Fig 1-13).
Controlled Ventilation and Ventilation/Perfusion
Ratio82;83
Disturbance in the V/Q ratio is reported to be the most
common clinical cause of arterial hypoxemia. Controlled
ventilation has been shown to disrupt the V/Q ratio by distributing ventilation to nondependent lung regions and by
redistributing pulmonary blood flow,
Gas will always flow to an area of least resistance, and,
compared with spontaneous ventilation, during controlled
ventilation that area is the nondependenf lung regions. In-

Basic Concepts

15

quence of withholding ventilatory support from those in

need is clear. Fortunately, there are ventilation techniques
and several ventilatory adjuncts that can be implemented to
minimize the adverse effects.
Alveolar Ventilation 84

A.

...

As mentioned earlier, the volume of air moving into

and out of the lungs with each breath is called the tidal
volume. During inspiration not all of this volume reaches
the alveoli; some of it must fill the space within the conducting airways. Since the volume that occupies this space
never reaches the alveoli, it does not play a part in gaseous
exchange. The space into which this volume goes is called
anatomic dead space.
The gas that ventilates the alveoli but is not perfused by
capillary blood also produces a dead space called alveolar
dead space. Anatomic dead space (V 0 anat) and alveolar
dead space (V 0 alv) make up the physiologic dead space
(V0 phys):
V 0 phys

B.

V 0 anat

V 0 alv

(Note: If a unit of time is implied, then a dot is phtced above

the V; thus V0 phys = V0 anat + V~alv.)
In the normal individual the mean alveolar dead space
is usually so small that for all intents and purposes the
physiologic dead space is equal to the anatomic dead space.
Alveolar ventilation (VA), also called effective ventilation, can be thought of as the fresh gas that reaches the
alveoli. It is expressed as the difference between the tidal
volume (VT) and the dead space volume (V 0 ):

FIG 1-13.
Normal anterior view of lung scan (supine position) showing A, ventilation, and B, perfusion. (Courtesy Nuclear Medicine Department, Victoria
Hospital, London, Ontario, Canada.)

ftation of the dependent lung regions requires relatively

more pressure to move the passive diaphragm and chest
wall. Furthermore, during the positive-pressure breath, gas
is compressed in the conducting airways, which increase in
size, thus wasting ventilation to regions of the lungs that do
not participate in gaseous exchange.
As stated earlier (see Cardiovascular Responses to Controlled Ventilation), positive-pressure ventilation interferes
with pulmonary blood flow. Controlled ventilation has been
shown to compress the capillaries, especially those in direct
contact with alveolar pressure, and to direct blood from the
nondependent regions to the dependent or other regions of
the lung where ventilation is lower.
It would seem that the initiation of controlled ventilation can impose a tremendous strain on the cardiovascular
and pulmonary systems. However, the negative conse-

The value for anatomic dead space in milliliters can be

approximated to the subject's ideal weight in pounds: 85
V0 (anat) = lml/lb

For example, in a 150-lb person anatomic dead space would

equal:
150 lb

1ml/lb

150 ml

If this person has a tidal volume of 500 ml, then alveolar ventilation per breath is approximately

VA= VT- Yo
= 500 ml - 150 ml
= 350 ml

Physiological Response to Alveokir Ventilation .

Alveolar ventila.tion provides the essential mechanism
whereby a sufficient amount of oxygen is added to the cir-

16

Introduction

culating blood and excess , ;u-hon dio xide is renrovcd.

Changes in alveolar vcnlibl 1on arc priu1arily rcllcclcd in the
amount or C< lrhnn dio xide di ssol ved in the blood.
Carbon d1o x1dc d1ssolvcd in arterial plasma exerts a
pn:,, tlr . 1I J(' p:u 1i:tl pn -;stm: or C0 2 . which is denoted by
lk sy 111hol l';wo, _ The rel ationship between alveolar venti1:11 ion and l'a " 2 is inverse. A decrease in alveolar ventilation rncrcascs Paco2 and vice versa (Fig 1-14).
Because of this relationship, the most important assessmcnl of the adequacy of alveolar ventilation is a blood gas
. to determme
. the paco . 72 83
analys1s
2
During mechanical ventilation minor adjustments to
ventilator settings can have a profound effect on alveolar
ventilation. Close monitoring of the Paco2 during controlled
ventilation is therefore essential to adequate volume exchange and Glearance of carbon dioxide.
Normal alveolar ventilation results in a Paco 2 of about
40 mm Hg. Reduction in alveolar ventilation, which leads
to an elevation in Paco2 , is called hypoventilation. An increase in alveolar ventilation, which leads to a reduction in
Paco2 , is called hyperventilation . The diagnosis of hypoventilation or hyperventilation can be made only by arterial
blood gas analysis.
Hypoventilation invariably leads to respiratory acidosis . An increase in C02 has been shown to cause increases
in systolic and diastolic blood pre.ssure, heart rate, and the
force of myocardial contraction, as well as peripheral vasodilation.
Hyperventilation leads to respiratory alkalosis and generally produces the opposite:! effects of hypoventilation. In

sustained periods of hyperventilation the patient may experience dizziness , numbness, and tingling of the extremities.
If the Paco 2 is lowered even further, tetany may result. 69
This condition is characterized by increases in neuromuscular excitability, involuntary muscle contracti ons, and
spontaneous twitching .

Cerebral Blood Flow, Carbon Dioxide, and

Oxygen86-ss
The work of Kety and Schmidt has shown that a direct
relationship exists between cerebral blood flow and C0 2 .
Although the exact mechanism is not clear, it is consistently
demonstrated that a decrease in Paco 2 is associated with a
reduction in the cerebral blood flow, while an increase in
Paco2 produces the opposite effect.
Ventilation techniques designed to increase the Paco2
may be of some value in overcoming cerebral vascular
spasm or in improving cerebral blood flow in stroke victims
but may be devastating where cerebral vascular hemorrhage
is present.
The response of cerebral blood flow to changes in the
arterial tension of oxygen (Pao2 ) is opposite to and less
pronounced than that produced by the Paco2 Normal Pao2 is
in the range of98 to 100 mm Hg. Cerebral vasodilatation in
respo~se to a low Pao 2 (50 to 60 mmHg) is greater than the
vasoconstriction produced by high levels of Pao 2 (> 100
mm Hg).

Factors Affecting Alveolar Ventilation During

Controlled Ventilation

100

During mechanical ventilation several factors must be

considered to ensure adequate volume exchange. Following
are common sources responsible for inadequate alveolar
ventilation.

90
80
70

Underestimation of Tidal Volume

There are nomograms available that offer guidelines to
determine the appropriate tidal volume. 89 90 These nomograms should be studied and consulted before ventilatory
support is begun. However, because -the nomograms indicate that a direct relationship exists between tidal volume
and a subject's weight, some have adopted the use of 10 to
15 ml/kg as the initial setting for tidal volume until the
Paco2 is evaluated. 85

60

PaC02

50 40

10

Alveolar Ventilation (L/min)

FIG 1-14.
Relationship between alveolar ventilation and Paco2 . Intersection of curve
and shaded area indicates normal range.

Improper Setting of the Ventilator Controls

Since each new ventilator is more sophisticated than its
predecessor, only those persons completely familiar with
the operation and functional characteristics of the ventilator
should be given the responsibility of providing ventilatory
support.

Basic Concepts

Leaks in the Ventilator and Circuit

Leaks around the humidifier and tubing connectors are
common concerns. A poorly assembled external or internal
exhalation manifold may result in the improper se~ling of
the exhalation port during the inspiratory phase and may
contribute to a leak.

....

Tubing and Ventilator Complianc?1

The ventilator and the patient circuit have a compliance
of their own. This mechanical compliance, often referred to
as the compliance factor f, is the result of the elastance of
the material used in the construction of the tubing and the
internal compressible volume in the circuit. The larger the
internal volume, the greater the compliance factor. While
little can be done about the compressibility characteristics
of a gas, the use of unnecessarily long circuits should be
avoided. Another source of compressible volume is the
space above the water line of the humidifier. The humidifier
should be kept at its maximum water level.
During the inspiratory phase of controlled ventilation,
the volume delivered from the ventilator is shared between
the ventilator circuit and the patient in proportion to their
compliances. The greater the ventilator compliance, the
lower the volume delivered to the patient. An equation
showing the relationship between the tidal volume delivered
and the compliance of the patient and the ventilator is as
follows 92 :
VT

= --=-Cv
Cp

Vs

+where
VT
Vs
Cp
Cv

Tidal volume delivered in milliliters

Volume setting at the ventilator in milliliters
= Patient compliance in ml/cm H 20
= Ventilator compliance in ml/cm H 2 0
=
=

For example, if the compliance of the ventilator is the

same as that of the Pttient, 50 ml/cm H 2 0, and the ventilator is set to delive~ a tidal volume of 500 rnl, then the
actual volume (VT) reaching the patient would be ~educed
by one half:
1

VT = - - X 500
1 + 50
50

=1~

=.!_X

500

= 250 ml

X 500

17

Fortunately, compliance factors of this magnitude (50

ml/cm H 2 0) are not common, since they are far beyond
acceptable clinical range. Compliance factors for adult ventilators are usually in the range of 3 to 5 ml!cm H 2 0.
The ventilator compliance can be readily determined by
occluding the circuit outlet and having the ventilator compress a known volume into the circuit. At the moment this
volume is delivered, the pressure displayed on the ventilator's manometer is recorded. The compliance factor is then
determined by dividing the volume compress.ed by the pressure developed in the circuit.
Another method is to seal the exhalation port or exhaust
port of the circuit and inject a known volume of gas into the
circuit outlet. Dividing this volume by the pressure displayed determines ventilator compliance. To perfomi this
test on some microprocessor-controlled ventilators may require switching the ventilator on and selecting a spontaneous breathing mode. Otherwise, a built-in safety valve will
prevent the buildup of pressure in the circuit when the ventilator is turned off.
In Figure 1-15 a volume of 100 'ml is injected into the
patient circuit and the pressure developed in the circuit is 33
em H 20. The compliance factor f is then calculated:

Volume = 100 rnl

Pressure
33cm H 20
= 3 ml!cm H 20
=

This compliance factor means that for every em H 20

pressure increase in the patient circuit, 3 rnl of volume will
be lost in the ventilator and tubing. If during the course of
lung inflation the pressure reaches 30 em H 20, then 90 rnl
(3 X 30) of the volume set at the ventilator will not reach
the patient.
When the compliance factor is known, the volume that
reaches the patient can be estimated in one simple operation:

where
VT = Patient's tidal volume
Vs = Volume setting at the ventilator
PPK = Peak pressure
f = Compliance factor
It is important to note that the above equation provides
but a reasonable approximation of the actual volume that
reaches the patient. There are several factors that influence
the results. One is the location of the pressure sampling
port. Some ventilators sample the pressure at the airway
while others sample the pressure before the humidifier. One
mode of ventilator therapy provides two different sets of
pressure readings during the same inspiratory phase. These

18

Introduction

V~. N

III/11 /J II

II

rtl.ATOR

!! __:_~~

rJ_I~.

COCO DODD
fo-100ml-j

+--

SYRINGE
EXHAUST PORT
OCCLUDED

I'

.. ~

~---- 1

HUMIDIFIER

FIG 1-15.
Method used to determine tubing and ventilator compliance. (See text for description.)

...
will be evaluated under the heading Estimating Lung Mechanics.
There is yet another ventilatory technique that holds the
lungs inflated at a predetermined pressure during the expiratory phase (detailed in Section Four). This procedure,
called positive end-expiratory pressure or PEEP, must be
included in the calculations. When PEEP is used the equation should be modified to read
VT

Vs - [(PPK -PEEP) X f)]

where
VT =
Vs =
PPK =
PEEP =

f =

Patient's tiqal volume

Volume setting at the ventilator
Peak pressure
Positive end - expiratory pressure
Compliance factor

However, by not actually measuring the patient's exhaled

volume, this equation provides a reasonable approximation
at best.

placed between the ventilator outlet and the patient as

shown in Figure 1-16,B. At this location only the patient's
tidal volume will register on the VMD, while the volume
from the circuit will be vented directly through the exhalation port.
Once the correct position for measuring exhaled volume is established, the procedure for determining the tidal
volume begins with obtaining the minute volume. The
minute volume is the sum of all tidal volumes recorded on
the VMD in one minute. Dividing the minute volume by the
respiratory rate .(number of breaths in one minute) yields the
most accurate assessment of the tidal volume.
.d
T1 a1 vo1ume

Minute volume
= Resprratory
.
rate

The more sophisticated microprocessor-controlled ventilator usually has a built-in VMD. This device takes the
ventilator and circuit compliances into account and displays
a plausible assessment of the patient's actual tidal volume.
Nevertheless , it is good practice to periodically measure the

patient's tidal volume with a hand-held VMD.

Measuring Tidal Volume

To measure the patient's tidal volume accurately it is
necessary to note the correct placement of the volume measuring device (VMD). As demonstrated in Figure 1-16,A,
when the device fs connected to the exhalation port or exhaust port of the circuit, a false reading will result because
the volume measured at this point reflects the patient's exhaled volume plus the volume that was previously compressed in the ventilator and circuit. For an accurate assessment of the patient's exhaled volume, the VMD should be

PRESSURE SAMPLING
All ventilators must provide a means for sampling and
displaying the pressure developed during the process of
lung inflation. If the pressure displayed was the result of
only the patient's lung characteristics it would provide the
clinician with valuable information about the condition of
the conducting airways and lungs. Unfortunately, this is not
the case, because the pressure reading is also a reflection of

Basic Concepts

19

A
VENTID\TOR

FIG 1-16.
Placement of volume measuring device (VMD) to indicate patient's exhaled volume. (See text for description.)

the ventilator's compliance and, depending on where the

pressure is sampled, often includes the resistance of the
ventilator's circuit and humidifier. Although little can be
done to extract the influence of ventilator compliance from
the pressure reading, some progress has been made in the
placement of the ventilator's pressure-sampling port to
eliminate the effects of circuit and humidifier resistance.
Figure 1-17 ,A shows a popular circuit design that consists of an inspiratory limb and a short expiratory limb that
terminates in an exhalation manifold. In earlier ventilators
employing this circuit, the pressure-sensing line was connected before the humidifier and would therefore indicate
the resistance and compliance of the circuit as well as that
of the patient's. A manometer connected to such a sensing
line is said to display distal airway pressure or, more commonly, machine pressure.
Figure 1-17 ,B demonstrates how the display of circuit
resistance is eliminated by placing the pressure-sensing line
at the patient connection. With such an arrangement the
manometer is said to display proximal airway pressure.
Although the concept is practical, it has some disadvantages
in that it adds to the ventilator's compliance, and the placement of the sensing line distal to the humidifier and in line
with exhaled gases promotes blockage from condensation.
The sensing line at the patient connection also makes the
circuit cumbersome and heavy.

Figure 1-17 ,C shows how weight is significantly reduced by extending the expiratory limb and exhalation manifold back to the ventilator. However, the circuit still requires a sensing line at the patient connection.
Figure 1-17 ,D displays how most of the problems are
solved by keeping the sensing line i~side the veptilator and
sampling the pressure in the expiratory limb pro_x.imal to the
exhalation valve. It is interesting to note that although the
pressure builds up in both the inspiratory and expiratory
limb during the positive-pressure breath, the position of the
sensing line does not sample the circuit resistance, because
gas does not flow in the expiratory limb during the inspiratory phase. The problem of moisture accumulation in the
sensing line still exists but has been minimized in most
ventilators by purging of the line with a small continuous
flow of dry gas. The sensing line can also be heated to
promote evaporation.

. PEAK INSPIRATORY PRESSURE, PLATEAU

PRESSURE, END-EXPIRATORY PRESSURE,
AND MEAN AIRWAY PRESSURE
The ventilator is capable of displaying all pressures
developed during the inspiratory phase, the expiratory
phase, and the mean airway pressure (the mean pressure of

Introduction

20

A
' Exhalation

_; ManKold ,,

Expiratoty

Umb

Patient
Connection

FIG 1-17.
Common pressure-sampling sites found in ventilators. (See text.)

tke respiratory cycle). These pressure displays are also

found in modem ventilators that have spontaneous modes
whereby the patient is allowed to breathe through the ventilator with or without assistance. Understanding the significance of each pressure reading is necessary in the evaluation of the patient's lung mechanics and to minimize
cardiovascular and pulmonary side effects of ventilatory
support.
Peak Inspiratory Pressure

Figure 1- 18 is a simplified waveform of the pressure

that can be observed on the ventilator's manometer during
the respiratory cycle.
Peak inspiratory pressure is defined as the highest pressure developed during the inspiratory phase. If this pressure
is measured before the humidifier -then the level will vary
with changes in
1.

The resistance of the ventilator circuit, which

includes the humidifier

2.

3:
4.

The compliance of the ventilator, which includes

the circuit and humidifier
The patient's airway resistance, which includes
the endotracheal tube
The patient's compliance (total compliance)

If the pressure sampled is the proximal airway pressure,

then the level will vary with all of the listed factors except
the resistance of the ventilator circuit. The proximal airway
pressure is an integral tool in establishing the patient's airway resistance.

Plateau Pres.sure

Once the peak pressure is reached, the pressure in the

patient circuit is normally released (exhalation valve opens)
and the lungs are allowed to empty to atmospheric pressure.
A plateau pressure is established when a volume has been
delivered from the ventilator but the exhalation valve remains closed for a predetermined time. At the onset of this
mode a drop in pressure from the peak is observed; it results

Basic Concepts

loon1 lhc distribution of gas from the upper airways to the

I wcr airways. When the plateau pressure is perfectly fiat ,
:1s shown in Figure 1-18,.,.the pressure displayed is the
:11 1ual pressure in the lungs and ventilator circuit.
Th e: plateau pressure , measured proximally or distally,
,., un<~llcc ted by the resistance of the ventilator or the palwnt" s airway resistance. However, the level of the plateau
JHL'ssu re will vary with changes in
i.

2.

The ventilator and circuit compliance

The patient's compliance

At the bedside, the proximal peak inspiratory pressure

and plateau pressure are used to estimate the patient's total
airway resistance; the plateau pressure alone is useful in
approximating the patient's static lung compliance (described in the following discussion).

End-Expiratory Pressure
The end-expiratory pressure is defined as the pressure
maintained in the lungs during the expiratory pause. The
lungs are normally allowed to empty to atmospheric pressure, as in Figure 1-18. However, the pressure can be
clinician-selected to b~low-atmospheric pressure (negative
end-expiratory pressure, NEEP) or to above-atmospheric

End Expiratory
Pressure

pressure (positive end-expiratory pressure, PEEP). The use

of NEEP during positive-pressure ventilation has been
abandoned but the use of PEEP is widespread in contemporary respiratory care. The applications of NEEP and
PEEP are detailed in Section 4.

Mean Airway Pressure93 - 99

The instantaneous values for positive pressure measured at the mouth and those measured intrathoracically are
nqt the same quantitatively. They are related, however, in
that a change in the mean mouth pressure, or more precisely, mean airway pressure (MAP), indicates a change in
the mean intrathoracic pressure. Since intrathoracic pressure mediates venous return to the heart, understanding the
concept of mean airway pressure is essential. 100 101
, Mean airway pressure is defined as the area under the
pressure curve for the duration of one respiratory cycle (Fig
1-19). Any ventil.atory parameter that alters the area under
this curve translates as a change in mean airway pressure.
Since the contour of the airway pressure curve varies
during the respiratory cycle and also with the type of ventilator used or waveform selected, the manual calculation of
mean airway pressure is tedious and not always practical at the
bedside 102 (see Appendix). Fortunately, microprocessorcontrolled ventilators make this information readily accessible.

Plateau
Pressure

Peak
Pressure

I.,_ inspiratory

1
i - -- -- - lnspiration time

Pause

End Expiratory
Pressure

r--

Expiratory Pause

- - - - - - . j..<---- - - - -

Exhalation nme-- - ---1>1

Respiratory Cyde Time - --

- - - - - - -- -- -1>1

1---- - - - -- -- - -- -

21

FIG 1-18.
Common pressure levels that may be observed during the respiratory cycle on controlled ventilation.

22

Introduction

Mean Airway Pressure

a:

::>

12
w
a:
Q_

~--INSPIRATION TIME - ---..~~ ...~1----- EXHALATION TIME ---------1:~1

~---------

RESPIRATORY CYCLE

------------1-~

FIG 1-19.
Mean airway pressure is defined as area under pressure curve for duration of respiratory cycle . Area can be approximated
by drawing equally spaced vertical lines extending from the pressure curve to line of zero pressure on time axis. When
pressure curve reaches zero pressure , equally spaced dots are substituted for vertical lines. When heights of each line
(including dots) are measured against corresponding pressure scale, dividing sum of pressure readings by number of
readings results in mean airway pressure (shaded area) .

Factors Affecting Mean Airway Pressure103 -

105

In addition to ventilation techniques that directly result

in high airway pressures (for example, the deliberate use of
high pressure or excessive volume), several factors influence the mean airway pressure. With the duration of the
respiratory cycle and tidal volume kept constant, these include
1.

2.
3.
4.
5.

I : E ratio
Inspiratory hold
Expiratory resistance
Positive end-expiratory pressure
Negative end-expiratory pressure

I: E Ratio
Within each respiratory cycle a period of time is devoted to inspiration and a period of time is devoted to exhalation. A quantitative comparison of one with the other is
called the I:E ratio. For instance, an inspiration time of 2
seconds and an exhalation time of 4 seconds yields an I:E
ratio of I :2 .
Since the area under the pressure curve varies directly
with the length of inspiration and inversely with the length
of exhalation, the greater the I:E ratio, the greater the mean
airway pressure (Fig 1- 20). Simply stated, an I:E ratio of
I: I results in a greater increase in the mean airway pressure
than an I: E ratio of 1:3.
Some ventilators have inverse I:E ratio capabilities; for
example, 2:1 and 3:1. When ventilation techniques with

such ratios are used, close monitoring of the mean airway

pressure and cardiopulmonary status is imperative.

Inspiratory Plateau .
Inspiratory plateau-also cailed inspiratory hold, inflation hold, or inspiratory pause-is that portion of the inspiratory phase in which the lungs are held inflated at a fixed
level of volume (Fig 1- 21 ,B) or a fixed level of pressure
(Fig 1-21,C) until a predetermined time has elapsed (see
also Section Three). The longer the lungs are held inflated,
the greater the area under the pressure curve and the greater
the mean airway pressure.
Expiratory Resistance
Expiratory resistance, or expiratory retard , has been
used frequently during mechanical ventilation to mimic
pursed-lip breathing, which is commonly seen in patients
with chronic obstructive pulmonary disease. The procedure
supposedly splints the airways and facilitates uniform emptying of the lungs. The method employed during mechanical ventilation involves the placement of a variable resistance to the exhalation port of the circuit (see also Section
Four). The maneuver slows the exhaled flow from the lungs
and in the process contributes to an increase in mean airway
pressure (Fig 1-22,B).
Positive End-Expiratory Pressure
Positive end-expiratory pressure (PEEP) is a maneuver
that prevents the lung pressure from reaching atmospheric
pressure during the exhalation phase (details are found in

Basic Concepts

Standard conditions
I:E 1:2

23

Standard conalitions
Q)

::;

::J
(/)

(/)
(/)

(/)

~
0..

(j)

0::

'

~I

..

, ~

..

f---- 1

........
~

:J
(/)
(/)

, ~

-~ ,

~-.

::; .

"

Inspiration time
I:E 1:1

Inspiratory plateau
type 1

Q)

::;
(/)

Q)

f/l

0::

0..

~,

I~

..

, ~

.. ,
I~

.. ...
,

Exhalation time
I:E 1:1

..,

Inspiratory plateau
type 2

Q)

::J

::;

/ ct

(/)

f/l
f/l

f/l

a..

~I

E ~

Figure 1-2

FIG 1-20.
Effects of altering I:E ratio on mean airway pressure.- Stippled region
denotes normal area of p(!:ssure curve. Vertical hatched region represents
increase in area of curve and thus increase in mean airway pressure. A
shows normal area. In B, inspiration time was increased by decreasing
flowrate . In C, exhalation time was decrea8ed thus removing much of
expiratory pause at zero pressure.

Section 4). Because of its unquestionable value as a ventilatory adjunct, the use of positive end-expiratory pressure is
common. However, the elevated baseline pressure that results from its use also contributes to an increase in the mean
airway pressure (Fig l-22,C).

Negative End-Expiratory Pressure

To minimize the adverse effects of positive-pressure
ventilation, a procedure called negative end-expiratory
pressure (NEEP) evolved. In this procedure, the negative
pressure is applied to the airway from the moment the ventilator cycles from inspiration to exhalation. Although it has
some merit in reducing mean airway pressure (Fig 1-23),
its use has been associated with airway collapse, especially

. - - - - 1-

r.
-j
. .

- .,...j.._-

- E - - --...~J

FIG 1-21.
Effects of inspiratory plateau on mean airway pressure. Stippled region
denotes normal area of pressure curve. Vertical hatched region represents
incre;se in area of curve and thus increase in mean airway pressure. A
shows normal area. In B, inspiratory plateau was established by holding a
fixed volume in the lungs for a predetennined time. In C, the plateau was
developed by holding a fixed pressure at the airway for a predetermined
time.

in patients with chronic obstructive pulmonary disease. For

this reason, NEEP is no longer considered a valuable therapeutic tool.

DAMAGE TO THE LUNGS

There is no safe level of positive pressure in the lungs.
Damage to the lungs as a direct result of positive-pressure
ventilation (barotrauma) is not infrequent. 106 107 One of the
most serious consequences of controlled ventilation is rupture of the lung, which causes a one-directional passage of

24

Introduction

A
Standard

conditions ~

I ~~ ~----E ----11.,...,1

Standard conditions

~ ~ ---..+j..
.--------E------~~1

B
Expiratory resistance

r~ - - 1

Negative end-expiratory
pressure (NEEP)

I~
-----~-----E -------~1
~I

c
Positive end-expiratory .
pressure (PEEP)

::J

"'"'

Q)

a::

--..~~....1 - - - - --

-------11~~

FIG 1-23.
Effects of negative end-expiratory pressure on mean airway pressure. Stippled region denotes normal area of pressure curve. Vertical hatched region
represents decrease in area of curve and decrease in mean airway pressure.
A shows normal area.

'""'

..

.... ,
~I -~~------E------11~1
FIG 1-22.
Effects of expiratory resistance (B) and positive end-expiratory pressure
(C) on mean airway pressure. Stippled region denotes normal area of
pressure curve. Vertical hatched region represents increase in area of curve
and thus increase in mean airway pressure. A shows normal area.

gas to the pleural space-a condition called tension pneumothorax. The probability of this disorder occurring increases in patients already suffering from lung damage. 108
The primary cause of lung rupture is overdistension of
the alveoli; it is the result of excessive volume rather than
pressure. To clarify this statement, say we have two balloons. The first balloon is inflated with air and allowed to
expand until it bursts. The second balloon is placed in a
container designed to limit its expansion. This balloon may
now be inflated using as much pressl}re as possible, but if it
cannot expand, it will never burst. This simple example
suggests that if the alveoli cannot be overinflated, lung rupture is unlikely to occur.

A common cause of alveolar overdistension is improper use of the ventilator and high levels of positive endexpiratory pressure.

ESTIMATING LUNG MECHANICS 109

The patient's lung characteristics may improve or deteriorate during the course of ventilator therapy. When a
change in lung mechanics occurs, the clinician is alerted by ---._
a change in the ventilating pressure (Table 1- 2). Periodic
assessment of the pressure is essentiai and allows for tlw ~
establishment of a trend in the patient's airway resistance
and lung compliance. Changes in the trend and, most im ---._
portant, identification of the cause of the change allow the
respiratory care practitioner to adjust the ventilation paran '
eters to the current lung conditions and to determin~
whether further medical intervention is required.
'
Estimating Static Compliance
To determine static compliance the exact volume in fhc
lungs and the corresponding pressure must be known . T.:-..,,
measurement must be done under static conditions with no
further gas flow into or out of the lungs.
'
To provide these conditions the ventilator must be adjusted to deliver a specific volume and also set to deliv ~n
inspiratory plateau such as the type shown in Fi~~c
l-2l,B. This type of plateau provides the only reli ...,lc
means of assessing alveolar pressure during mecha ~ al

CHAPTER2
\

Ventilator Drive Mechanisms

~

As stated in Chapter 1i}ffig inflation takes place because of

6. Blowers
a pressure gradient created between the mouth and alveoli.
7. Injectors
During positive-pressure ventilation, gas moves into the
lungs because of positive pressure applied to the mouth:)
This chapter investigates the various drive mechanisms
WEIGHTED BELLOWS
responsible for generating the pressure necessary to accomplish lung inflation. This subject is important because the
The simplest method of generating pressure is with the
pattern of pressure generated by the drive mechanism deuse of a weighted bellows (Fig 2-1 ,A). Since pressure is
termines the waveforms of pressure and flow entering the
defined as force per unit. area,
lungs and the classification of the ventilator in the inspiraForce
Pressure= - A
tory phase.
rea
The period following the last polio epidemic witnessed
the pressure generated within the bellows is a function of weight
the development of many types of drive mechanisms. Al(force) acting on the cross-sectional area of the bellows. The
though any one type is sufficient to provide lurig inflation,
greater the weight, the greater the pressure generated.
the various types were used on the basis that each mechaWhen the stopcock is opened (Fig 2-1 ,B), the downward
nism or linkage had a unique method of generating a certain
pattern of pressure and flow during the positive-pressure . force of the weight causes the bellows to empty. As the bellows empties, the pressure within it remains unchanged bebreath. The ideal pattern would mimic the normal physiocause the factors that determine the original pressure in the
logical breath in that barotrauma and adverse cardiovascular
bellows-force and area--have not changed. Consequently,
effects would not occur. Unfortunately, the search for the
the pressure _generated Qx this drive mechanism is constant.
ide~l pattern continues to this day.
--TheB~ompton-Manl;y -BM--._2 ~e~tiiatofS incorporated
However, with the advent of microprocessor technology, the cumbersome and complicated plumbing that once
this drive mechanism and was used quite effectively in crit was associated with the generation of a specific waveform is
ical care units.
no longer necessary. The microprocessor-controlled venti. lator can produce any waveform with only one simple drive
mechanism.
SPRING-LOADED BELLOWS
For historical purposes this chapter provides an overview of all common types of drive mechanisms.
Lung inflation can also be acc()mplished with the use of
Generally, there are seven types of drive mechanisms 1- 4 :
a spring-loaded bellows . In Figure 2-2 the tension of a
. spring applies a continuous downward force at -the top of an
I. Weighted bellows
expanded bellows . The amount of pressure generated is a
2. Spring-loaded bellows
function of the force of the spring and the cross-sect ion a I
area o{ the bellows, similar to the weighted bellows rnech
3. Linear-drive pistons
4. Nonlinear-drive pistons
anism just described. The greater the force of the spring, the
5. Pressure-reducing valves
greater the pressure generated.
30

Basic Concepts

31

Bellows

FIG 2-1.
Weighted bellows drive mechanism.

When the stopcock of the spring-loaded bellows is

opened, the force of the spring causes the bellows to empty.
However, unlike the weighted bellows drive mechanism, as
the 'bellows empties the spring relaxes and the pressure
within the bellows does not remain constant but decreases.
Although the pressure progressively decreases as the spring
expands, the tension of the spring is such that enough pressure is generated to inflate the lungs before the spring is
fully relaxed.
A similar drive mechanism, is used in the Siemens
Servo 900 series ventilators .6 In this type of ventilator the
action of the microprocessor-controlled valve compensates
for the reduction of pressure a.1d flow. The pressure and
flow developed by a spring-loaded drive mechanism is detailed in Section Two. The Servo 900C ventilator is described in Section VII.

LINEAR-DRIVEN PISTON
Check valve

Check vaJve

FIG 2- 2.
Spring-loaded bellows drive mechanism.

Figure 2-3 demonstrates one method of generating

pressure with the use of an electric motor and a piston. In
this figure the center of a circular gear is connected to the

32

Ventilator Drive Mechanisms

shaft of a motor (not shown) . Connected to the center of the

piston is a rod, and along the bottom of the rod is a series
of projections called cogs. When the cogs of the rod are
engaged with the gears of the wheel (also called rack and
pinion , respectively J. linear motion is transferred to the piston , and posi ti ve pressure ..is generated during the piston's
forward stroke.
This drive mechanism was formerly popular for use in an
electronic pediatric ventilator. 7 Although the ventilator is no
longer manufactured, there are still quite a few in operation.

pressure is generated during the forward stroke of the piston. However, because the connecting rod is attached offcenter to the large wheel, the piston does not move in the
cylinder at a constant speed. Consequently, the pressure and
flow developed by this drive mechanism vary with the motion of the piston.
This drive .mechanism has been in the field for quite
some time and is still found in at least one critical care
ventilator8 and in some ventilators specifically designed for
home care. The effects of a nonlinear-drive mechanism on
the pattern of flow and pressure entering the lungs are detailed in Section Two.

NONLINEAR-DRIVEN PISTONS
fn Figure 2-4 a constant-speed electric motor (not
shown) rotates a large wheel to which a connecting rod and
piston are attached. The arrangement causes the piston to
travel in a reciprocating motion in the cylinder, and positive

PRESSURE-REDUCING VALVES
Pressure-reducing valves (PRVs) are probably the most
popular type of drive mechanism and are used extensively

Check valve

FIG 2-3.
Linear-driven piston.

Rotating wheel

FIG 2-4.
Nonlinear-driven pistons.

Check valve

Basic Concepts

in microprocessor-controlled ventilators. As the name implies, a PRY reduces a high input pressure to a lower constant output pressure. 9 The high input pressure may originate from high-pressure cylinders, in which pressure in
excess of 2000 psig (13,790 kPa) is common, or from hospital station outlets, whei'e the pressure is usually maintained at 50 psig (344.75 kPa).
Regardless of the input pressure, the output pressure
from the PRY becomes the generated pressure. Some
PRYs have their output pressure preset as high as 50 psig,
while in others the pressure can be adjusted to only a few
em H20.
Figure 2-5 is a schematic representation of an adjustable PR V. The relationship that describes the functioning
principle of an adjustable PRY may be given by
p

_ (Fs I - Fs 2 ) - (PH X a)
L-

High pressure

(PH)

-------.. . .

FIG 2-5.
Adjustable pressure-reducing valve.

33

where
PL = Low or reduced pressure (generated pressure)
Fs, = Force of the large spring (adjusting spring)
Fs 2 = Force of the small spring (sealing spring)
PH = High input pressure (source pressure)
a = Area of the small seat
A = Area of large diaphragm
As mentioned earlier, pressure-reducing valves may be
adjustable or preset. The main difference between the two is
that in the former, the tension of the large spring (Fs) can
be regulated externally to adjust the output pressure. A sealing spring CFs) is used to prevent source pressure from
entering the PRY when the adjusting spring (Fs) is fully
relaxed. In the preset PRY, Fs, cannot be adjusted externally
and the output pressure is preset by the manufacturer.
Some ventilators do not have PRYs built within them and
are connected directly to the hospital station outlet. In such

'

34

Ventilator Drive Mechanisms

instances, and if the ventilator does not have a built-in device

~ ;apable of further modifying the pressure, the station outlet
,~{>ressure becomes the generated pressure of the ventilator.

Solenoid
Open

Solenoid
Closed

~3LOWERS

In Figure 2- 6 an electric motor connected to a series of

(fan) rotates at a high constant speed. This arrangement propels gas forward and generates a constant level of
.~ 1ressure. As long as no other device capable of modifying
the pressure from the drive mechanism is present, the pres(~ ure developed by the blower is the generated pressure of
the ventilator.
r
With this drive mechanism the motor runs continuously
J mt the patient is connected to the blower only during in( piration. During exhalation, pressure from the blower is
..-->'ented to atmosphere by a series of electrically operated
t "witches.
This type of drive mechanism was common in early
electronic ventilators. It has regained popularity in the mod....- rn ventilator as a backup air compressor (air source) for the
pressure-reducing valve drive mechanism.
.~lades

Fan

Inlet

FIG 2-6 .
Blower drive mechanism.

,_.--.. Injectors, often called Venturis, are drive mechanisms

normally powered by pressure-reducing valves or blowers.
aeir main function is to increase the overall flowrate car>'lbility of the ventilator.
In Figure 2-7 a high constant pressure is applied to the
,~t of the injector, and gas leaves the jet nozzle at a high
velocity. This causes the pressure nearest the high velocity
r-- gas to drop below atmospheric pressure and atmospheric
Aases to be drawn in around the jet of gas. A well-designed
j<.;ctor entrains more flow than the flow driving it. The
result is an increase in the total flowrate at the outlet of the
r-...

'

J CCtOC.

The behavior of injectors is similar to that of pressure-ducing valves in that the pressure of gas leaving the outlet

of the injector is always lower than the pressure applied to

the inlet of the jet. The pressure generated at the outlet is
constant and determined by the flowrate of gas applied to
the jet. Another characteristic of the injector is a reduction
in the flow entrained when resistance is met at its distal end.
Technically speaking, an injector and a Venturi are different; a brief explanation is necessary.
In 1797 the Italian physicist Giovanni Battista Venturi
described a cylindrical tube with a convergent entrance, a
throat, and a divergent outlet, such as the type depicted in
Figure 2-8,A. With this tube Venturi demonstrated that
when water flowed along the tube (Fig 2-8,B) subatmospheric pressure was created in the region of the constriction. With a measurement of this pressure drop the volumetric flowrate of water could be determined. To this day
Venturi tubes are used to measure ftowrates of fluid s. 11

r
Air entrainment

Input

FIG 2-7.
Injector drive mechanism.

Output

Basic Concepts

Inial

35

Outlet

______ J______
U-tube manometer

Pressure Gradient

FIG 2-8.
Venturi tube, which was actually designed to meter flow. U-tube manometer indicates that when a gas flows through the tube, a pressure gradient is created
between the convergent inlet and the constriction of the tube. Pressure gradient can be translated to indicate flowrate.

Injectors, on the other hand, entrain gas and make use

of the Venturi tube for the following reasons .
The divergent outlet of the Venturi tube placed downstream to the jet is used to minimize turbulence as the velocity of gas decreases after the gas leaves the jet nozzle.
The second function is to recover as much pressure downstream to the constriction from the value it had at the upstream side of the constriction. 12

When the secondary circuit contains bellows, the primary drive mechanism may be a pressure-reducing valve, a
blower, or an injector, such as shown in Figure 2-10.
The primary reason for the development of the double.circuit ventilator is that it provided a reliable method for the
delivery of predictable tidal volumes (see Volume Cycling
in Section Three). Present-day ventilators have returned to a
single-circuit mechanism but now incorporate electronic
measuring devices that can detect and respond to minute
changes in pressure, flow, and volume.

CIRCUITS
Direct Acting (Single Circuit)
A ventilator may be classified as having a direct acting
or an indireCt acting drive mechanism. If gas from the drive
mechanism is used directly as the source of pressure for
lung inflation, as assumed in the examples used thus far, the
ventilator is considered to be direct acting. Ventilators having a direct acting circuit have also been called single-circuit

ventilators_

Indirect Acting (Double Circuit) An indirect acting circuit is one that uses the direct
acting drive mechanism to operate another circuit. Ventilators having an indirect acting circuit are also called doublecircuit ventilators.
Secondary circuits may consist of a bag or a bellows
and may be powered by any drive mechanism. However,
when the secondary circuit comprises a bag, it is customary
to have the secondary circuit powered by a nonlinear-driven
piston, as in Figure 2-9.

PRESSURE-LIMITING MECHANISMS
the maximum pressure developed by the drive mechanism of the ventilator is called the generated pressure.
Since some drive mechanism can generate pressures as high
as 50 psig (= 3500 em H2 0), a level far beyond clinical
range, a pressure-limiting mechanism is built into every
ventilator to prevent excessive pressures from reaching the
lungs. The device can be preset or adjustable and is positioned between the drive mechanism of the ventilator and
the patient. Present-day ventilators have both, an adjustable
pressure-limiting mechanism, which is found on the control
panel of tbe ventilator, and a preset failsafe mechanism,
which forms an integral part of the ventilator circuit.
In Figure 2-11 ,A the mechanism consists of a springloaded valve assembly. Noimally the valve never opens, but
when the pressure within the patient circuit exceeds the
closing force of the spring, the disk lifts and the excess
pressure is vented to atmosphere (Fig 2-11 ,B). During this
time the lungs are held inflated at the set pressure level until
a cycling mechanism terminates the inspiratory phase.

\
36

Ventilator Drive Mechanisms

Check valve

Check valve

Primary circuit
Connecting rod
Piston
::::: ::.::: .:: :: :.: :: ...: ::.: :

r~

I
Rotating wheel

FIG 2-9.
Indirect acting ventilator (double circuit). Primary circuit is nonlinear-driven piston, and secondary circuit consists of large bag enclosed
within rigid chamber.

Check valve

'

-.

Secondary circuit

Primary circuit

Pressure-reducing valve
or
Blower
or
Injector
Primary drive mechanism

FIG 2-10.
Indirect acting ventilator (double circuit) . Primary drive mechanism may
be pressure-reducing valve, blower, or injector. Secondary circuit c,onsists
of bellows enclosed in rigid chamber.

Figure 2-12 demonstrates another type of pressurelimiting mechanism, which consists of two series resistarices and a parallel vent. Gas in the, exhalation' .valve line
travels to the exhalation manifold where it is used to power
the exhalation balloon valve during inspiration. The amou.nt
of pressure transmitted to the balloon valve is determined by
the back pressure created by the flow ~f gas through the
fixed resistance of the parallel vent. The tfow of gas through
the resistance of the parallel vent is in turn determined by
the position of the needle valve of the pressure-limit control. The greater the flow, the greater the pressure in the
balloon valve, and vice versa. When the pressure in the
patient circuit exceeds the sealing force of the balloon, the
excess circuit pressure squeezes past the balloon and spills
over to atmosphere. Once again the lungs are held inflated
until a cycling mechanism terminates the inspiratory phase.
The maximum pressur.e-lirnit control is preset but is otherwise identical to the pressure-limit control. It is designed as
a safety system and prevents the pressure from exceeding a
certain value.
In Figure 2::-13 ,A the pressure-limiting device comprises a disk, a rigid accumulator compressed by an adjustable force of a spring, and two electrical contacts . During

/
Basic Concepts

8
~ Control knob

Spring

Disk

From drive
mechanism

To patient

Patient circuit

FIG 2-11.
A, Pressure-limiting device consisting of spring-loaded valve. B, When pressure within patient circuit exceeds value set by tension of
spring, disk lifts and excess pressure is vented to atmosphere.

Pressure limit
control knob

EXHALATION
MANIFOLD

Exhalation
valve line

From drive

To exhalation
valve line

mechanism

PRESSURE LIMIT
MECHANISM

From drive
mechanism

FIG 2-12.
Pressure-limiting mechanism. See text for description.

Patient circuit

To
patient

37

- /
38

Ventilator Drive Mechanisms

lung inflation the rigid accumulator fills , opposes the force

of the spring, and moves the disk closer to the lower contact. When the contacts meet (Fig 2-13,B), an electrical
signal is tra nsmitted to the dri ve mechanism , and pressure
to the ratient circuit is cut off. Unlike the previous two
examr les. once thi s pressure-limiting device is activated the
inspiratory phase is immediately terminated. The mechanism can also be thought of as a pressure-cycling device.
More on the subject of pressure limiting and pressure cycling is found in Section Three.

CONTROLLING FLOWRATE
When the generated pressure is high, it is not advisable
to connect the patient directly to the ventilator without some
means of controlling flowrate. In its simplest form the flowrate control is a high series resistance, which is interposed
between the drive mechanism of the ventilator and the patient (Fig 2-14). The relationship between the amount of
resistance offered by the control and the flowrate through
the patient circuit is inverse. Increasing resistance decreases
flowrate and vice versa.
In the chapters that follow, other methods of controlling
flowrate, including contributions made by microprocessor
technology, will be examined.

Pressure limit
control knob

SUMMARY
The drive mechanism of the ventilator provides the
source of pressure necessary to inflate the lungs. The maximum pressure the drive mechanism develops is called the
generated pressure of the ventilator.
The drive mechanism can be direct or indirect acting. A
ventilator is considered to be direct acting if the pressure
generated by the drive mechanism is used directly as the
source of lung inflation. These ventilators are called singlecircuit ventilators. A ventilator is said to be indirect acting
when the pressure generated from the primary drive mechanism is used to power a secondary circuit, which in tum
inflates the lungs. These are called double-circuit ventilators; they evolved to permit the deliv-ery of predictable volumes and the use of other ventilator adjuncts such as an
inflation hold.
Whether a ventilator has a direct or indirect acting
mechanism has no influence on the magnitude of the generated pressure and has little effect on the pattern of pressure and flow developed in the process of lung inflation.
State-of-the-art ventilators under microprocessor control are single-circuit and can be programmed to deliver any
waveform or ventilatory adjunct conceivable.
Since the pressure generated by some drive mechanisms can reach levels exceeding 3500 em H2 0, certain

-.
Electrical
contacts

Rigid
accumulator

From
patient circuit

FIG 2-13.
A, Pressure-limiting mechanism consisting of spring-loaded accumulator and electric contacts. B, When pressure in patient circuit exceeds
predetermined value, contacts meet and electric signal is transmitted to drive mechanism, which interrupts gas flow through patient circuit.

Basic Concept.,-

39

Flowrate
control

From drive
mechanism

To patient

Patient circuit

FIG 2-14.
Series resistance type of flowrate control. (See text.)

safety devices must be incorporated within all ventilators .

Among the most important of these is the pressure-limiting
mechanism. Although the mechanism has virtually no influence on the magnitude of the generated pressure, it prevents inadvertent use of high pressure in the patient circuit
by either venting the excess pressure to atmosphere or by
terminating the inspiratory phase.
Finally, to control the flow of gas from the drive mechanism to the patient, some ventilators make use of a high
series resistance placed between the drive mechanism and
the patient. The flowrate is then adjusted by increasing or
decreasing the resistance through the control.

REFERENCES
1. Mushin WW, Rendall-Balcer L , Thompson PW, et a1: Automatic Ventilation of the Lungs, ed 3. Oxford , England,
Blackwell Scientific Publications Ltd , 1980.
2. Schreiber PJ: Ventilators. In Anesthesia equipment, Performance, Classification and Safety. Telford, Pa, North American Drager, 1972.

3. McPherson SP: Respiratory Therapy Equipment, ed 4. St

Louis , Mosby-Year Book, 1990.
4. Scanlan CL, Spearman CB, Sheldon RL: Egan's Fundamentals of Respiratory Care, ed 5. StLouis, Mosby-Year
Book, 1990.
5. Brompton-Manley BM-2 Ventilator. Deansway, Chesham,
Bucks, UK, Blease Medical Equipment Ltd.
6. Siemens Servo Ventilator 900C. Solna, Sweden, SiemensEiema AB .
7. Bourns LS 104-150 Ventilator. Riverside, Calif, Bourns
Inc. Life Systems Division.
8. Emerson 3MV Ventilator. Cambridge, Mass , JH Emerson
Company.
9. Dorsch JA , Dorsch SE: Understanding Anesthesia Equipment, ed 2. Baltimore, Williams & Wilkins, 1984.
10. The understanding and logic behind the Bird Venturi systems, Consumer information data, Form L852 . Palm
Springs , Calif, Bird Corp.
11. Murdock, WE: Fluid Mechanics and Its Applications. Boston, Houghton Mifflin Co , 1976.
12. Macintosh R, Mushin, WW, Epstein, HG: Physics for the
Anaesthetist, ed 3. Oxford, England, Blackwell Scientific
Publications Ltd, 1963.

CHAPTER3

The Constant Pressure Generator

- INTRODUCTION
~ The only function of the ventilator in the inspiratory

phas~"'ls to move gas into the lungs. In order for a gas to

move from one area to another, a pressure gradient must

exist between two points of a conducting system. In mechanical ventilation this pressure gradient is found between
the generated pressure of the ventilator and alveolar pressure. The conducting system involves t:wQcomponents: the
ventilator circuit and the patient's airway.
Based on the magnitude of the generated pressure, a
ventilator can !;>~ classified as either a pressure generator or
a flow gen~rator~ each type of generator a further subclassification is/ provided, which depends entirely on the
~pattern of pressure and flow developed during the process of
lung inflation.)rable 3-1 outlines the two general classifications of ventilators along with their subclassifications.
In the first edition of this text it was stated that the
classification of the ventilator in the inspiratory phase is
" based entirely on which of the two waveforms, pressure or
flow, resembles the waveforms generated by the drive
mechanism. This statement no longer holds true if the ventilator is microprocessor controlled. The reason is that a

TABLE 3-1.
,../"'

microprocessor-operated valve can produce waveforms that

are quite different from those generated by its drive mechanism. For microprocessor-controlled ventilators the classification depends on the waveform selected and not on the
pattern or the level of generated pressure. This will be examined later in this section.
This chapter inv:estigates the waveforms produced by
the non-microprocessor-controlled ventilator when the
level of pressure generated by the drive mechanism is low.
There are still quite a few of these ventilators in circulation,
and some are still being manufactured.

THE PRESSURE GENERATOR

When the generated pressure is low and alveolai pres~
sure is allowed to approach the level of the generated pressure, the flowrate will not remain constant but will always
decay to approach zero. On the other hand, because there is
very little resistance between the generated pressure and the
mouth, the pattern of pressure developed at the mouth will
approximate the pattern of pressure generated by the drive
mechanism. This is the fundamental characteristic of a pressure _generator.
! A pressure generator is defined as a ventilator that generates--a fixed pattern of pressure at the mouth, regardless ()f
lung conditions, while the flow waveform is free to VarY_))

Classifications and Subclassifications of Ventilators

Pressure
Generators
(Low generated
pressure)

Flow
Generators
(High generated
pressure)

Microprocessor
Generated
(usually high generated
pressure)

Constant
Nonconstant
Increasing
Decreasing

Constant
Non constant
Decreasing

Constant flow
Nonconstant flow
Increasing flow
Decreasing flow

THE CONSTANT PRESSURE GENERATOR 1 ' 2

/'\

(..__In order for a ventilator to be suitably classified as a

consliint pressure generator, the drive mechanism must
meet two specific conditions. The first is that it must generate a constant pattern of pressure; that is, it must generate
a level of pressure that does not vary from the beginning to
49

........

I-_

50

,..

The Constant Pressure Generator

the end of the inspiratory phase. Examples of such drive

mechanisms include the weighted bellows, the pressurereduciJ?,g valve, the blower, the injector, and the linear-drive
piston.
The second cond ition that must be met is that the pressure generated by the drive mechanism must be low enough
to allow equilibrium between the pressure generated and
alveolar pressure. Although any of the drive mechanisms
just mentioned can be made to satisfy these requirements,
for convenience an example involving the use of an adjustable pressure-reducing valve will be presented.
In Figure 3-1 an adjustable pressure-reducing valve is
attached to a lung model by means of the ventilator circuit.
Pressure from the reducing vaiv~ is prevented from entering
the lungs by the position of an independently operated electrical switch (solenoid). When the pressure-reducing valve
is adjusted to generate a low pressure and the solenoid is
opened, the following waveforms are generated.

!
The Initial Flow Waveform
( Figure 3-2 demonstrates that the initial flow into the
'-....lungs represents the flow of gas through the ventilator circuit and the patient's airway. Therefore the initial flow varies directly with

1.

the difference between the generated pressure

and alveolar pressure,

and varies inversely with

2.

the resistanceof the ventilator and the resistance

of the airways.

Because of this relationship, changes in lung compliance

have no influence over the initial flow.

The Dynamic Flow Waveform

_..-.

( At first the flow is high because the gradient between

the generated pressure and alveolar pressure is greatest. If
this ftowrate were maintained, alveolar pressure would rise
to equal the generated pressure and the flow would decay to
zero in a period known as the time constant of the system.
The time constant (TC) results from the product of compliance (Cp) and the sum of ventilator resistance (RJ and
airway resistance (RAw):
TC

= (Cp) L!cm

H 20

<Rv +

RAw) em H:iO/L!sec

= sec
'

Thus the time constant represents an interval of time. :.

/

Pressure
control
Pressure reducing

High inlet
pressure (50

MG'.Jih

~-

'j
Humidifier

~"

FIG 3-1.
Schematic represe:1tation, showing the essential components of a ventilator designed as a constant pressure generator.

The Inspiratory Phase

1.0

51

-r---------------,

--

From
ventilator

Initial
flow (l./s)

.!-

10 . --

- - - - - - - --

--,

Initial
Mouth pressure
(em H 2 0)
AiJWays fill

lime

FIG 3-2.
Initial flow and initial mouth pressure levels. Note that only the airways are charged.
Generated pressure
Ventilator resistance
Airway resistance

10 em H2 0
4 em H2 0/Usec
6 em H2 0/Usec

.../ - ~

In Figure 3-3 the value for airway resistance was given

a value of 6 em H 2 0/Lisee, ventilator resistance an arbitrary
value of 4 em H 2 0/Lisee, and lung compliance 0.05 L/cm
H2 0. Consequently, if the initial flowrate was maintained at
'1 Lisee, equilibrium between the generated pressure and
alveolar pressure would be complete, and the flow would
decrease (decay) to zero in
TC = Cp X (Rv + RAw)
= 0.05 X (4 + 6)
= 0.5 sec

5% of its initial value, and so on. These values are universal

and can be found in exponential tables. If you have a scientific
calculator with an ex key, enter - 1 and then press the ex key.
You should get a value of0.3679. Repeat the procedure, using
- 2 and - 3, to get the values stated above.
The second characteristic of any exponential curve is
that .the quantity remaining will never .decline to zero regardless of the number of time constants used. However, it
has been suggested that for the purpose of ventilator analysis, the exponential process should be considered complete
(although it only approaches zero) in three times the amount
of one time constant. 4 ,
R~turning to our original situation, the time at which
the decay in flowrate is considered complete (flow stops) is
~...._

However, this initial flowrate is not maintained because

the gradient between the generated pressure and alveolar .
pressure does not remain constartt but decreases.
Experimental data have shown that the Q.~crease in
flowrate follows that of an exponential functi~ In other
words , the flowrate does not decrease as a straight downward slope as the pressure gradient decreases but decreases
as a smooth orderly curve such as shown in Figure 3-4,A.
l,tJi exponential decay curves have two important characteristiCs:' The first dictates that at the end of a period of time
equal to one time constant (TC = compliance x resistance),
the initial quantity will have declined to 37% of its initial
value. At the end of a period of time equal to two time constants , the decline is to 13.5% of its initial value; at the end of
a period of time equal to three time constants, the decline is to

TC

=
=

3 X 0.5 1.5 sec

The trow waveform produced when a constant low level

of pressure is applied to the airway is shown in Figure
3-5,A.

lj:ffects of Lung Compliance

When lung compliance is reduced by one half, the initial flowrate is unaffected because no changes have been
made to the generated pressure or the resistance of the system. The shape of the dynamic flow curve, however, must

52

The Constant Pressure Generator

1.0 - . - - - - - - - - - --

-,

From
ventilator

Flow
(LJsec)

Mouth
pressure
(em H 2 0)
Lungs fill

1 TC
0.5

2 TC

3 TC

1.0

1.5

Time (sec)

FIG 3-3.
Initial and dynamic waveforms produced when a constant level of low pressure is applied to the airway. Broken diagonal lines

indicate the time constant of the system.

Generated pressure
Ventilator resistance
Lung compliance
Airway resistance

10 em H 2 0

4 em H20/Usec
0.05 L!cm H2 0
6 em H20/Lisee

change because the reduction in lung compliance causes a

reduction in the time constant of the system. When lung
compliance is reduced by one half, the time constant decreases to
TC

+ RAw)
+ 6)

(Cp/2) X (Rv

= 0.02:5 X
= 0.25 sec

(4

Since the exponential process is considered complete after a

period three times the amount of one time constant, this new
time constant indicates that the flow waveform will now
decay exponentially to approach zero in
~ X

TC = 3

0.25 = 0. 75 sec

Figure 3-5,B demonstrates that with the new time constant the flow waveform de~ays exponentially to approach
zen:~- from the same initial level in only half the previous
time. )
. -~ ..:

,..

tern. Therefore, changes in airway resistance affect both the

initial flow and the dynamic flow waveform. When airway
resistance increases the initial flowrate drops because less
flow is available to charge the airways. The increase in
airway resistance also decreases the dynamic flow, and the
time constant increases to
TC

= Cp
=
=

[Rv + (2RAw)]
0.05 X [4 + 2(6)]
0.8 sec
X

which suggests that the flow waveform will now decay to

approach zero in
3

TC

0.8

2.4 sec

Figure 3-5,C demonstrates the general shape, of the flow

waveform when airway resistance is doubled. )
The Mouth Pressure Waveform

..

\ffects of Airway Resistance

The flow through a conducting system will always
change in response to changes in the resistance of the sys-

When the solenoid opens (see Fig 3-2), mouth pressuritn~es sharply but never quite high enough to reach the
level of the generated pressure for two reasons:

)
)

The Inspiratory Phase

1. The resistance of the ventilator circuit, which causes

a pressure drop along the circuit. The greater the ventilator
resistance, the lower the initial mouth pressure.
2. The airway resistance . This is a direct relationship in
that the greater the airw~y resistance, the greater the initial
rise in mouth pressure. )
/

1~

Figure 3-3 shows that from this initial level mouth

pressure will increase continuously to approach the level of
- ; the generated pressure in an exponential fashion.
The increasing exponential curve is demonstrated in
-- Figure 3-4,B and is identical K:J the exponential decay
~ curve of Figure 3-4,A except that the curve is upside
down . A simple evaluation of this curve reveals that after a
~ period of time equal to one time constant, the increase in the
' exponential curve is 63% (100% - 37%) . At the end of 2
- TC, the increase is 86.5% (100% - 13.5%), at the end of
3 TC the increase is 95% (100% - 5%), and so on.
Since the value for initial mouth pressure represents the
pressure already present at the mouth, from this level mouth
:pressure will rise exponentially to reach the generated pres~ sure in a period of time equal to 3 TC. Under standard lung

1\

\
\

1\

\
1\.

"

.........,i'-.

'/

1/

TC

0.5

1.5 sec

The general shape of the mouth pressure waveform is

shown in Figure 3-5 ,A.
)~ffects of Lung Compliance (Fig 3-S,B)
( Lung compliance has virtually no effect on the initial
value-for mouth pressure because no alterations have been
made to the resistance of the system. However, when the
compliance is reduced by one half, the time constant decreases to 0.25 seconds (determined earlier with the flow
waveform) . Since equilibrium is considered complete atter
a period equal to three times the amount of one time constant, mouth pressure will now rise to approach the generated pressure in only half the previous time, that is,

TC

0 .25

= 0 .75

sec)

Pffects of Airway Resistance (Fig 3-S,C)

( Increases in airway resistance cause less flow to charge
the arrways and in the process increase the back pressure at
the mouth. Therefore, the value for initial mouth pressure
must increase in response to increases in airway resistance.
From this higher initial level mouth pressure will rise to
approach the generated pressure in a period equal to three
times the amount of one time constant. When airway resistance is doubled, the time constant increases to 0.8 seconds
(determined earlier with the flow waveform) . Consequently,
mouth .pressure will approach the generated pressure in
X

TC = 3

0 .8 = 2.4 sec

/ A NOTE ON MICROPROCESSORCONTROLLED VENTILATORS

7
3

-~ -

conditions the time constant equals 0.5 seconds. Therefore,

equilibrium will take place in

--.

53

Time constants

_ ..G 3-4.
lll)iversal exponential curves. A, decay; B, rise. (See text for description .)

Microprocessor-controlled ventilators can generate any

flow pattern imaginable . To accomplish this , the flow waveform must be controlled by the ventilator and must not
change with changes in the patient's lung characteristics. If
the flow pattern must not be influenced by lung characteristics, the generated pressure must be at a very high level,
as we shall see in the following chapters. For this reason,
microprocessor-operated valves cannot replicate the waveforms produced by a pressure generator where the generated
pressure is very low. Waveforms generated by microprocessorcontrolled ventilators may appear identical to those produced
by a pressure generator, but the way in which the computer-
generated waveform responds to changes in lung characteristics is quite different. This is detailed in the next chapter.

l
l

l
i

The Constant Pressure Generator

54

'

STANDARD CONDITlONS

COMPUANCE HALVED

RESISTANCE DOUBLED

l
1

,..-\

11

( -----.

Rowrate
(Usee)

-----.

10

Mouth pressure
(em

~ 0)

1 TC

2 TC

3 TC

1 TC

2TC

3TC

1 TC

2 TC

3 TC

0.5

1.0

1.5

0.25

0.5

0.75

0.8

1.6

2.4

Time (sec)

Time (sec)

..-...._.

Time (sec)

FIG 3-S.
Theoretical waveforms produced by a constant pressure generator. Diagonal lines of each set represent time constant of system.
Generated pressure
Ventilator resistance
Standard conditions:
Lung compliance
Airway resistance

10 em H2 0
4 em H2 0/Lisee
0 .05 L!cm H2 0
6 em H20/Lisee

SUMMARY
In the inspiratory phase a ventilator can be classified as
either a pressure generator or a flow generator. The classification is based entirely on the pattern of flow and pressure
developed during the process of lung inflation. The flow and
pressure pattern is determined by three factors:

Microprocessor-controlled ventilators may generate

flow waveforms that resemble those produced by the constant pressure generator. However, with changes in lung
conditions, the behavior of these artificially generated
waveforms will not be the same as those produced by a true
pressure generator.

. .

f~

1.
2.
3.

The magnitude of pressure generated by the

drive me.chanism
The pattern of pressure and flow developed by
the drive mechanism
Lung characteristics of the patient

When a ventilator is classified as a pressure generator,

the term pressure generator implies that the pressure generated by the drive mechanism is low. The term constant
suggests that the pressure deveioped at the mouth will remain relatively constant, regardless of lung conditions,
while the flow waveform is free to vary.

t____

REFERENCES
1. Mushin WW, Rendall-Baker L, Thompson PW, et a!: Automatic Ventilation of the Lungs, ed 3. Oxford, England,
Blackwell Scientific Publications Ltd , 1980.
2. Dupuis YG: A mathematical approach to the classification of
the inspiratory phase. Respir Tech 1978;. 14(4):9 .
3. Waters DJ, Mapleson WV.': Exponentials and the anaesthetist. Anaesthesia 1964; 19(2):274.
4. Spalding JMK: Pressure and duration of inspiration during
artificial_respiration .by intermittent positive pressure. Lancet
1955; 268:1099.

I '

L"

~
f

'

'

r=

.- CHAPTER4

The Constant Flow Generator

'

In some ventilators it is possible for the drive mechanism tp___ be allowed to equalize with alveolar pressure. In Fig 4-1 a
generate pressures as high as 50 psig (= 3500 em H 20). ) high series resistance (flowrate control) is interposed be~
tween the generated pressure and the mouth and a solenc:~id
This situation is shown in Figure 4-1, where the generated
is used for initiating and terminating the mspiratory phase.)
pressure has been increased from 10 em H2 0 to 3500 em
In keeping as closely as possible with the conditioos'
H 2 0 ,-,
specified in Chapter 3, say that(the inspiratory phase is
.!Yith a generated pressure of this magnitude, it is
ended after a period of 1.5 secoillts-and that during this
clearly not advisable to connect the patient to the ventilator
time, a volume of 0 .5 L leaves the outJet of the ventilator.
~ without some means of controlling the flow. It should be
equally clear that pressures of this magnitude should never
If a volume of 0. 5 L is to leave the v~ntilator in 1. 5 seconds,

Pressure

control
Pressure reducing

'' .

I ,

r--,.

Humidifier

FIG 4-1.
Schematic representation of ventilator designed as constant flow generator. Note high generated pressure and position of flowrate control.

55

56

The Consiant Flow Generator

the flowrate control must be adjusted to allow an average

flowrate of
Volume
0 5 L
Flowrate = _T___ _ = - = 0 .33 Lisee
1me
1.5 sec
Since the generated pressure is 3500 em H2 0, the resistance offered by this flowrate control must be extremely high.
In fact , to accommodate this volume the vaJue for the resistance is approximately 10,600 em H 20/L/sedl(see Appendix) .
With these values, the waveforms o/flow and mouth
pressure developed when the pressure generated by the drive
mechanism is constant at 3500 em H 2 0 can be determined.

THE FLOW WAVEFORM

Figure 4-2 demonstrates that at the onset of the inspiratory phase the step rise in the initial flowrate reaches a
value of 0.33 Lisee. From this initial level, and if inspiration wer~ allowed to continue, alveolar pressure would rise
expone~tially to appro'ach th~ level of the generated pressure, and the fiowrate would decay exponentially to approach zero in three times the amount of one time constant
(see Chapter 3). The value for the time constant results from
the product of lung compliance and total resistance. In this
situation, lung compliance is 0.05 L!cm H 2 0, the value for
airway resistance is 6 em H 20/Lisee, and ventilator resis-

tance is 10,600 em H 20 /Lisee . Therefore, the time constant

equals
./""'
TC = Cp X (Rv + RAw)
= 0.05 X (10 ,600 + 6)
= 530 sec
Consequently, the flow would decay to approach zero in
3 x 530 sec = 1590 sec(= 26.5 min)
However, inspiration must not be allowed to continue because at the end of 26.5 minutes , alveolar pressure would
rise to nearly equal 3500 em H2 0. To maintain the prescribed parameters, the inspiratory phase must be ended in
1.5 seconds.
Since the time constant is 530 seconds, an inspiration time
of 1.5 seconds represents a very small portion of the exponential curve. In fact, this represents 1.5/530 = 0.00283 time
constant. A simple scientific calculator will show that the decay of an exponential curve in 0.00283 time constant is to
99 .7% of its initial value. Therefore, at the end of 1.5 seconds
the value for fiowrate is
0.33 x 0 .997 = 0.33 Lisee
There is little purpose in determining the intermediate
values for the flow waveform because, for all intents and
purposes, the fiowrate has remained constant for the dura-

0.4 . - - - - - - - - - - - - - - - - - ,

From
ver1!ilator

Initial

flow (LJs)

)'

14,----------------,

'- t

------.

'-

Initial
Mouth pressure

'

(em H 20)

Airways

till

'

'-l
.......,

-!
0

lime

FIG 4-2.
Step rise in initial flow and mouth pressure generated by constant flow generator. Note that initial values represent airway filling .

The Inspiratory Phase

51

From
venti lator

Flow

(Usee)

14 , . - - - - - - - - - - - - - - - ,

r
Mouth
pressure
(em H 2 0)
Lungs fill

~TC
530

1ime (sec)

1.5

FIG 4-3.
Dynamic waveforms generated by constant flow generator. Lungs fill after initial step rise in flow and mouth pressure.

tion of the inspiratory phase:-lrhis is evident by flow waveform of Figure 4-3.

/
.
Effects
,.., of Lung Compliance
( Lung compliance has no effect on the initial flowrate,

r; but <Cc1iimge in lung compliance causes a change in the tiine

,

constant of the system. When lung compliance is reduced

by one half, the time constant equals
TC

= (Cp/2)
= 0.05/2

X
X

(Rv + RAw)
(10,600 + 6)

= 265 sec.

"

Since inspiration is still maintained at 1.5 seconds, the

decay in flowrate must now be assessed at 1.5/265 = 0.00566
time constant. The decay of an exponential curve in 0.00566
time constant is to 99.4% of its initial value (the decay is still
very small), so that at the end of 1.5 seconds, the flowrate
equals
0.33 X 0.994 = 0.33 Lisee

Figure 4-4,B clearly demonstrates that when the compliance is reduced b( one half, the flow waveform does not
,...--.., change appreciabl~)

Effects of Airway Resistance

/

l~ompared with the very high resistance of the ventilator (flowrate control), changes in airway resistance have
little influence over the total resistance of the system. Consequently, when airway resistance is doubled, the step rise
in 'the initial flowrate remains unchanged . However, the
time constant increases to

TC

Cp X [Rv + 2(RAw)J
0 .05 X [10,600 + 2(6))
= 531 sec
=
=

so that at the end of 1.5/531 (0.00282) time constant the

decay in the ftowrate is to 99 .7% 'o f its initial value. Figure
4-4,C demonstrates that the ftowrate remains constant for
the duration of the inspiratory phase. From this analysis it is
clear that w_hfn the pressure generated by the drive mechanism is very high, changes in lung characteristics have no
appreciable effect on the flow waveform_:)

THE MOUTH PRESSURE WAVEFORM

It was stated in the previous chapter that, keeping the
level of the generated pressure constant, the value for initial

58

The Constant Flow Generator

A

STANDARD CONDITIONS

COMPUANCE HALVED

RESISTANCE DOUBLED

04 1

r---------------------

Rowrate

(Usee)

25

rv\outh pressure
(em H20)

1.5

1.5

1ime (sec)

lime (sec)

1.5

1ime (sec)

FIG 4-4.
Theoretical wavefonns produced by constant flow generator showing effects of lung characteristics.
Generated pressure
Ventilator resistance
Inspiration time
Standard conditions
Lung compliance
Airway resistance

3500 em H20
10,600 em H20
1.5 sec
-

0.05 Ucm H2 0
6 em H2 0/Usec

mouth pressure varies directly with aj:way resistance and

with the resistance of the ventilator~~s instance the
resistance of the ventilator is very high, so that the st~rise
in mouth pressure is low, about 2 em H 2 0 pressur/ as
shown in Figure 4-2.

From this initial level, and if inspiration were allowed

to continue, mouth pressure would increase exponentially to
reach the level of the generated pressure in a period of time
equal to three times the amount of one time constant.
(in the evaluation of the flow waveform it was found that
under--standard lung conditions the time constant equals 530
seconds. Since inspiration is ended after 1.5 seconds, the
exponential process must be evaluated in a period equal to
1.5/530 = 0.00283 time constant. It was shown earlier that
the decay of the exponential curve for this period was to
99.7% of its initial value. The increase in the curve must
therefore be 100% - 99 .7% = 0.3%. Figure 4-3 shows
that when inspiration is ended, mouth pressure (Pm) increases steadily from 2 em H2 0 to:
PM

= (% rise x generated pressure)

=
=

+ initial mouth pressure

(0.003 X 3500) + 2
12.5 em H20

i'

Effects of Lung Compliance

---....,

The initial mouth pressure is not affected by changes in

lung compliance and remains at 2 em H2 0. Reducing lung
compliance by one half results in a time constant of 265 seconds. Since the decay of the exponential curve in 1.5/265
(0.00566) time constant is 99.4%, the Increase of the curve is
100% - 99.4% = 0.6%. Figure 4-4,B shows that when inspiration is ended mouth pressure increases steadily from 2 em
H 20 to:
PM

= (% rise

X generated pressure)
initial mouth pressure
= (0.006 X 3500) + 2
= 23 em H20

Effects .of Airway Resistance

When airway resistance is doubled the step rise fu the
initial mouth pressure increases to approximately 4 em H 20 .
The time constant increases to 531 seconds, and the exponential process is evaluated in 1.5/531 (0.00282) time constant.
Since the decay of an exponential curve in 0.00282 time constant is 99.7%, the rise is 100% - 99 .7% ,;, 0.3%. Therefore, at the end of 1.5 seconds mouth pressure increases to

'_I,,
l

---....,

~
__J

-,
i

'i

~I

The Inspiratory Phase

PM

= (%rise x

generated pressure)
initial mouth pressure
= (0.003 X 350Q) + 4
= 14.5 em H2 0 )

59

In this instance, because the flow waveform remains

constant (begins and ends at the same level) throughout the
inspiratory phase, the ventilator is classified as a constant
flow generator. 1 ' 2

//

The effects of airway resistance on the general shape of

~ tht mouth pressure waveform are shown in Figure 4-4,C.
From the waveforms of Figure 4-4 it is evident that when
'""' the generated pressure is high, the mouth pressure waveform
does not remain constant but varies dl!P.ng the inspiratory
. ~ phase and also with changes in lung characteristics.

WAVEFORM ANALYSIS

In considering the waveforms produced when the generated pressure is high, it is evident that the waveforms
- differ significantly from those produced when the generated
pressure was low (see Chapter 3). When the generated pres~ ;ure was increased to 3500 em H 2 0, the flow waveform, for
all intents and purposes, remained constant regardless of
~. ung characteristics. This was due to the very large gradient
~that still existed between the generated pressure and alveoar pressure when inspiration ended. With no significant
_change in,the pressure gradient, there can be no changes in
.iow.
Mouth pressure could not rise to approach the level of
lhe generated pressure because of the resistance imposed by
'le flowrate control. Essentially, the mouth pressure waverorm was the result of this constant flow applied to the
- irway. Consequently, mouth pressure was influenced by
~ changes in lung characteristics.
. . . ._ The concept perhaps may be clarified with the use of a
_,...s.imple relationship:

From this relationship we can see that when the flowrate (V ) is held constant, any changes in alveolar pressure
- ,A) or in airway resistance (RAw) will have a corresponding effect on the mouth pressure (PM) - An increase in al:>~ .olar pressure as a result of a decrease in lung compliance
J.Xill cause an increase in mouth pressure. Furthermore, be....use the flow is not influenced by changes in lung condi, .tions, increases in airway .resistance must also cause an
uJCrease in the mouth pressure. Therefore when the gener___.<:d pressure is high, the mouth pressure waveform will
a.iter during the inflation process and also with changes in
. ~ 1g conditions.
From this discussion we conclude that aflow generator
.-..a ventilator that generates a pattern of flow that does not
Y1!fY during the inflation process, regardless of lung condi, ...ns, while the mouth pressure waveform is free to vary.

FLOW VERSUS PRESSURE GENERATOR

Conventional Ventilators

Not all ventilators have their generated pressure set at

extreme ends of the scale as described thus far; most ventilators generate pressures in between these values . Depending on the level of pressure generated and the existing lung
conditions, a ventilator may behave as a flow generator at
one point and a pressure generator at another. Perhaps the
most controversial topic in the classification of ventilators is
where this transition takes place.
For conventional ventilators (ventilators that are not
microprocessor controlled), a proposed rule of thumb declares that if the generated pressure is at least five times the
maximum pressure developed at the mouth, then the. ventilator should be classified as a flow generator. 2 If the generated pressure falls short of this value, the ventilator
should be classified as a pressure generator.
For example, say that during controlled ventilation
mouth pressure reaches 30 em H 2 0. If the ventilator' s drive
mechanism is capable of generating a pressure of at least
5 x 30 = 150 em H 20
then the flow waveform would vary less than that of the
mouth pressure waveform and the ventilator-would be classified as a flow generator.
. However, say that after a period of time, the patient's
lung condition deteriorates and mouth pressure now reaches
50 em H2 0. Since the ventilator can only generate a maximum pressure of 150 em H2 0, the ventilator would now be
classified as a pressure generator because the generated
pressure is no longer five times the maximum pressure developed at the mouth. The generated pressure would now
have to be at least
5 x 50 = 250 em H20

to suitably classify the ventilator as a flow generator.

Although it is enough to understand . the differences
between a pressure generator and a flow generator, other.
terms such as high pressure generator and low flow generator have been introduced, and these tend to confuse the
main issue. The problem need not be insurmountable if the
following key points are remembered.
1. A true pressure generator maintains a fixed pattern of
pressure at the mouth, regardless of lung conditions , while

60

The Constant Flow Generator

the flow waveform is free to vary. The pressure generated by

the drive mechanism must be very low for this to take place.
2. A true flow generator maintains a fixed pattern offlow
at the mouth while the mouth pressure is free to vary. The
pressure generated by the drive mechanism must be very
high to accomplish this .
3. The transition from a flow generator to a pressure
generator occurs when the generated pressure is no longer
five times the pressure developed at the mouth.
Now, if the pressure generated by the drive mechanism
is slightly lower (by a few em H2 0) than five times the
pressure developed at the mouth, the ventilator is still a
pressure generator but may be classified as a high pressure
generator. If the pressure is slightly greater (by a few em
H2 0) than five times the pressure developed at the mouth,
the ventilator is still a flow generator but may be classified
as a low flow generator.
,. Microprocessor Mechanism

./

Most modern-day ventilators have high generated pressures and make use of a microprocessor-operated valve or

valves to replicate any waveform generated by a flow generator. It is interesting to note that because these ventilators
have high generated pressures they cannot reproduce the
waveforms of a pressure generator.
Although microprocessor technology is a complex
field , the way in which these ventilators shape the flow
waveforms is riot necessarily complicated.
Figure 4-5 shows the essential components of such a
mechanism. Once the clinician selects the desired waveform
from the control panel, the microprocessor circuit identifies
the option and then sets up a program for the proportional
solenoid. The proportional solenoid is not a simple solenoid
having only two positions, oN or oFF, but is capable of a
great number of intermediate steps, thus capable of shaping
any flow pattern. The action of the solenoid is analogous to
the clinician manually adjusting the flowrate control
throughout the inspiratory phase to achieve the desired
waveform. Of course, the microprocessor-operated solenoi<f .
is much quicker and far more accurate than the human hand.
Inspiration is declared when the solenoid opens. However, the solenoid does not open all the way as in CQnventional ventilators but just enough to accommodate the pre-

'>--;

Flow wavefonn
selector

Control panel
circuit board
Differential
transducer

pressur~

Microprocessor
circuit

!
I

'"""""'

From drive
mechanism

To patient
circuit

FIG 4-5.
Schematic representation showing essential components of microprocessor operated proportional solenoid. Flow pattern selected is compared
with actual flow to patient circuit by pneumotachometer connected to differential pressure transducer. When discrepancy occurs, microprocessor relays appropriate signals to proportional solenoid and condition is corrected. See Chapter 9 for description of pressure transducer.

The Inspiratory Phase

"'"l ~ r; uurned

parameters. The flowrate and flow pattern

through the patient circuit are monitored continoously. If a deviation occurs, the monitoring mechanism,
wh1c h in Figure 4-5 consists of a pneumotachometer and
~ 'd krcntial pressure transducer, relays this information to
th e microprocessor circuit. The microprocessor then trans__.- 1it s appropriate signals to the proportional solenoid, which
~adju sts its aperture to correct the situation. The continuous
.ampling and adjusting is known as a/eedback loop.
This feedback loop plays havoc with the traditional
..;lassification of the inspiratory phase. The reason is that the
nicroprocessor-controlled ventilator may have a low generated pressure but may still be able to deliver the wave~0rms of a flow generator.
For example, say that such a ventilator has a generated
- ressure of 100 em H20 and the flow pattern selected is that
..s>f a constant flow. Furthermore, say that during the process
f lung inflation mouth pressure reaches a value of 50 em
H2 0 . By the current classification system this ventilator
~nould not be able to deliver aconstant flow pattern because
"he generated pressure is not five times the highest pressure
ueveloped at the mouth. However, the feedback loop mechnism knows what the flow should be at any point in time
lei vcrcd

A microprocessor-controlled ventilator with an adjustable generated pressure has its limitations. Ifthe generated
pressure is inadvertently set too low and mouth pressure
approaches the level of the generated pressure, the feedback
loop mechanism would be unable to compensate for the
reduction in flow and the ventilator would beliave as a pressure generator.

SUMMARY
When the level of pressure generated by the drive
mechanism is far beyond what is needed in the alveoli to

::

);~; JH

.:!, __ , ,

J!T i r:' '!

Hr:
?:.i , .

~~

ffi'ri-8 -- f

'' ::~ :;
- ~~r ~~t ~"~i'':

:: : ;

. .,, ,

T;l:;c'l~iI-'-' I '~_,-11111111111111111111:1!1;11111111111111111111~-~H~~~~~-

0 Ji; I :;; :: ;J~

Flowrate

A Final Note

i: ii!T : ' H+ S::p ;

;;::;

r r: .

(LPM)

and continuously adjusts the flow to maintain a constant

pattern such as that in Figure 4-6 .
It now appears that some caution is required for the
classification of the ventilator in the inspiratory phase. If the
ventilator is conventional, then the rules described thus far
apply. If the ventilator is microprocessor controlled it will
m,ost certainly behave as a flow generator and the subclassification will depend entirely on the waveform selected.

-":::; ,, ,

40

..

:;:;

''

. .

;r:]:;

41

50

Pressure
(ern H o)
2

Time

61

..__ _ _ _ _ _ 3 sec. - - - - - - -

FIG 4-6.
Actual tracings showing action of microprocessor operated valve. Generated pressure reduced to 100 em H2 0 and lung
analogue adjusted until peak mouth pressure reached approximately 50 em H2 0. Note that flow pattern is maintained although
generated pressure is much Itiss than 5 times peak mouth pressure.

62

The Constant Flow Generator

accomplish the desired volume exchange, the ventilator

must provide a means to control the flow into the lungs. In
conventional ventilators this is usually accomplished by the
placement of a high series resistance , generally referred to
as the ftowrate control , between the generated pressure and
the patient. All ventilators must provide a cycling mechanism to terminate the inspiratory phase. Without this cycling mechanism , alveolar pressure would eventually rise to
equal the generated pressure; the flowrate control would
merely determine how long the process would take.
A flow generator is defined as a ventilator that generates a fixed pattern of flow, regardless of lung conditions,
while the molith pressure waveform is free to vary.
A constant flow generator is a ventilator that generates
a flowrate that remains constant from the beginning to the
end of the inspiratory phase.
In conventional ventilators the general classification of
the ventilator in the inspiratory-Phase depends on the magnitude of the generated pressure. A ventilator is classified as
a flow generator when the pressure generated by the drive
mechanism is at least five times the maximum pressure

developed at the mouth. If the ventilator falls short of this

value, the ventilator is classified as a pressure generator.
All microprocessor-controlled ventilators were designed as flow generators , and most have high generated
pressures. However, the magnitude of the generated pressure should not be used solely as the basis for the classification of these ventilators in the inspiratory phase. The
reason is that some have adjustable generated pressures that
can be set at levels below five times the pressure developed
at the mouth and still maintain a constant pattern of flow.
This is accomplished by the action of a microprocessoroperated solenoid valve, which continuously adjusts the
flow to the preprogrammed level.

REFERENCES
1. Dupuis YG: A mathematical approach to the classification of
the inspiratory phase. Respir Tech 1978; 14(4):9.
2. Mushin WW, Rendall-Eaker L, Thompson PW, et al: Automatic Ventilation of the Lungs, ed 3. Oxford, England,
Blackwell Scientific Publications Ltd, 1980.

-.:....._

..

.1

!\

'

' 1

i
_.,_

..

,\

C--: 1APTER

5
The Nonconstant Flow Generator
,

f'l, ._,_, far it has been established that ventilators are classified
IS vlther flow generators or pressure generators. When the
~<- ~' rated pressure is high, the pattern of flow remains con;tant while the mouth pressure waveform is free to vary.
r\ '"' n {he generated pressure is low, the pattern of the
nouth pressure waveform remains constant while the flow
1../ ~ :form is free to vary.
_ Chapters 3 and 4 investigated the waveforms produced
>) . drive mechanism that generated a constant level of
>ressure. Consequently, when the generated pressure was
<h. , the ventilator was classified ' as a constant pressure
~e~rator, and when the generated pressure was high, the
leiutlator was classified as a constant flow generator.
' This chapter considers the waveforms produced by a
ype of flow generator whose drive mechanism consists of a
1c ~~ear-drive piston.
i__}~Figure 5-l a constant speed electric motor (not
:t~ .n) rotates a large wheel to which a connecting rod and
>istQn are attached. This arrangement causes the piston to
n._ . .! in a reciprocating motion in the cylinder. During the
'o~ard stroke of the piston, pressure developed in the cylnu-..r is directed to the patient circuit and inflates the lungs.
-A.lthough the wheel rotates at a constant speed, such a
nechanical linkage does not permit the piston to travel in
h<' -...ylinder at a constant speed.
This is demonstrated in Figure 5-2, where the upper
1c: -...of a large wheel is divided into equally spaced dots .
)i~ the wheel rotates at a constant speed, points a through
~ : Jng the circumference of the wheel pass a reference
)0 ~ (indicated by the ghosted arrow at the top of the
;vl,vd), in equal increments of time. However, when these
)C ts are synchronized to the position of the piston in the
;yhnder, it becomes evident that the motion of the piston is
lC ~ niform . In fact, the speed of the piston is lowest beween points a and band progressively increases to a maxIT ----. 1 speed between points d and e when the piston has

delivered exactly half of its .st~oke volume. This coincides

with point e on the wheel, which is 90 degrees from its .
center. From this point on, the p\lttern of piston speed is
repeated, but exactly in reverse order.
Because the piston does not travel in the cylinder at a
constant speed, the pattern of the flow and pressure developed by the drive mechanism cannot resemble that produced by a drive mechanism that generates a constant level
of pressur;(rrhe pattern of flow and pressure resulting from
a piston.7rutected off-center to a rotating wheel is shown in
Figure 5-3. From this figure we conclude that the pattern of
flow is that of the positive aspect of a sine wave and the
pattern of pressure is sigmoid in shape. 1- 6
1

THE FLOW WAVEFORM

( In Fi.gure 5-l the speed of the motor is adjusted so that
the'wheel makes a complete revolution in 3 seconds. Since
we are interested only in the forward stroke of the piston,
and the wheel rotates at a uniform speed, the inspiratory
phase must last
3
. . time
.
Insptratwn
= 2 = 1.5 sec
If a volume of 0.5 L is to be displaced by the piston
within this period of time , the average flowrate (Vav) must
be

V
av

=Volume= 0.5
Time
1.5
= 0.33 Llset )

However, in a situation where the flow waveform takes

the shape of a half sine wave, the ftowrate required to deliver a volume within the time specified by the duration of
63

.--..

64

The Nonconstant Flow Generator

Mouth pressure

Humidifier

"FIG
5-l.
Schematic representation of a ventilator designed as a nonconstant flow generator.

- -

--

_.,..

..&
Wheel rotation
constant

H
ab

11
g

hi

Piston speed
not constant

FIG
5-2. associated wit.'l motion of piston connected away from center of rotating wheel. (See text for description.)
Phenomenon

The Inspiratory Phase

ROTATING WHEEL

PRESSURE WAVEFORM

FLOW WAVEFORM

PISTON

65

.
_;___-'
L
-

LL
LL_
LL
~-'
LL
--'
__, LL
___.

_;__-1

L
__I
L

--+

------t

--+

L
___.

L
__I

FIG 5-3.
Aow and pressure waveforms produced by motion of piston connected off-center to wheel rotating at
uniform speed .

~r_

--

- - ---

:~~#:. ~-- ~;

. ._:;:,. .,._ ~~ .;, ,:,. ,. :~~~i-~i1hi~ -.f.'~~--'.>>:: :-i~;.~-~::;;-~i;-.:.::

u.

~~~ - -

------~----

---~-

--

----

. ,,

--

1-

'-~:-.'!~ti'::_.~

.L

The Nonconstant Flow Generator

66

the half sine wave must by necessity be greater than the

average flowrate. The reason is that the fiowrate is not held
constant but increases from zero to a maximum level in
exactly half the time devoted to the inspiratory phase and
then progressively decreases to zero again when the inspiratory yhase is ended .
For example , Figure 5- 4 outlines the positive aspect of
a sine wave with a number of vertical lines drawn within it.
If the height of each line is measured and then averaged,
repeating the process using more and more lines would
eventually show an average of 63 .7% of the highest line. In
terms of flowra.te , the highest vertical line represents the
peak fiowrate (Vpk), and since the average flowrate CV.) is
63.7% (0.637) of the peak flowrate, that is,

vpk

o.637 x vpk

Effe~ts

the peak flowrate can be determined by simple substitution:

.
vpk

X 1.57
0 .52 Lisee

of Lung Characteristics

such magnitude that changes in lung compliance or in airway

no eff~t on the motion of the piston
m th~ cylmder. ;@ecause of this, the flow pattern also must
remam constanf:f s shown in Figure 5-5,B and C.

= 0 .637

Vav

(~-~entilators of this type the mechanical advantage is of

v.y

~esistance .hav\vj,rtually

Because 110.637 = 1.57, the relationship can be simplified

to read

Vpk

v.v x 1.57

= 0.33

Under these conditions, Figure 5- 5,A was constructed to

demonstrate the flow waveform resulting from a noclineardriven mechanism."\
The equation~~~hat describe the functional and pneumatic characteristics of this drive mechanism are detailed in
the Appendix. But since the difference between a pressure
generator and a flow generator has already been established,
it is not necessary to be proficient at trigonometry or instantaneous equations to understand the basic characteristics of
this drive mechanism. All that must be remembered is that
during the inspiratory phase, the flow waveform assumes
the shape of a half sine wave.

v.v

1.57

THE MOUTH PRESSURE WAVEFORM

In the preceding equation the average fiowrate was determined to be 0.33 Lisee, and if 0.5 Lis to be displaced by
the piston in 1.5 sec, the peak fiowrate must be

('

(!he mouth pressure (PM) waveform result:; from the

alveolar pressure (PA) pattern and the pattern of pressure

Flow

Vpk = Vav

1.57

"

0
1\

I
I

I
I

\
\

''

/
/
./

FIG 5-4.
Method of dete~pjng peak value of sine wave. During mechanical ventilation, peak value of wave represents
peak ftowrate, Vpk- (See text for de~cription.)

~-~

~j
~~
jj
~

t.~

The Nonconstant Flow Generator

O;c

PM

PA

= i;

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

RA

Pressure
(em H 2 0)

10

~7

oL

'

0 ;..--------. 6

0
~

('

Time (sec)

1.5

1.5

1.5

FIG S-6.
Wavefonns depicting effects of lung characteristics on mouth pressure wavefonn. In all instances lung inflation was accomplished by half
sine wave flow pattern .

At the end of the inspiratory phase alveolar pressure

r-- and mouth pressure reach a level of

Figure 5-6,B demonstrates that the increase in mouth

pressure results from the reduction in lung compliance alone
because the flowrate pattern and the airway resistance were
C" kept unchanged. The effects of lung compliance on the
,---.. mouth pressure waveform are also demonstrated in Figure
5-S,B .

sembly if the ventilator is microprocessor controlled. In

such a system (Fig 5-7), the microprocessor-operated
proportional solenoid is programmed to m.lmic the motion
of the piston and delivers a flawless half sine wave for the
flow waveform regardless of lung conditions.

SUMMARY

.,---.. Effects of Airway Resistance

When airway resistance is doubled, the highest value
on the mouth pressure curve-is greater than .the value attained for standard lung conditionS)Fi~ 5-6,C). This increase is due to airway resistance alone because no alterations were made to the compliance of the lungs. At the end
of the inspiratory phase, when the flowrate is again zero , the
value for mouth pressure returns to the level previously
obtained for standard lung conditions.
The effects of airway resistance on the general shape of
the flow and mouth pressure waveforms are demonstrated in
Figure 5-s':c,-

MICROPROCESSOR MECHANISM
The waveforms of the nonconstant flow generator can
be duplicated without the need of a wheel and piston as-

When the drive mechanism consists of a piston connected off-center to a wheel rotating at constant speed, the .
speed of the piston within the cylinder cannot be constant.
Because of this, the flowrate that develops during the forward stroke of the piston cannot be maintained at a constant
level. In fact , the motion of the piston generates a flow
waveform that assumes the shape of a half sine wave; because of the flow pattern, the pat_tern of pressure that develops_during lung inflation is sigmoid in shape .
Since the wheel rotates at a constant speed and is totally
uninfluenced by changes in lung conditions, the pattern of the
piston's speed must also be constant. Consequently, the pattern of flow generated during the forward stroke of the piston
remains equally unaffected by c~anges in lung conditions.
Furthermore, because the motion of the piston is maintained regardless of lung characteristics, the volume displaced
from the cylinder must also be constant. If the volume delivered
into the lungs is constant, then any changes to the lung compliance will have an effect on the mouth pressure waveform.
Moreover, any c~ange to the airway resistance while the pattern
of flow is maintained must also affect the mouth pressure.
( A flow gl!nerator has been defined as a ventilator that
generates a fixed pattern of flow into the lungs, regardless of
lung conditions, while the mouth pressure is free to vary)

.!

A
Flow waveform

STAND~&IOONDITIONS

0 50

t l{)wrate
(1/Ytr:)

m<>O~:Jll.....eJ.~J:roJm~

20

advent of microprocessors,
ventilators have as an option the
a half sine-wave flow waveform
wheel and
AI-

1.5

1.5

REFERENCES
1. Kacmarek RM, Mack CW, Dimas S: The Essentials of Respiratory Care, ed 3. StLouis, Mosby-Year Book Inc, 1990.
2. Scanlan, CL, Spearman CB, Sheldon RL: Egan's FuncU1mentals of Respiratory Care, ed 5. StLouis, Mosby-Year Book,
1990.
3. McPherson SP: Respiratory TherapyEquipment, ed 4 . St.
Louis, Mosby-Year Book, 1990.
4 . Deshpande VM, Pilbearn SP, Dixon RJ: A Comprehensive
Review in Respiratory Care, Norwalk, Conn, Appleton &

olar ~e1ID\~- mouth pressure are equal, alveolar pres-

su~ (}ipy'HfuWffa&ill1~Y~~8f L, Thompson PW, et al: Auton/dtic Ventilation of the 'i~ngs, ed 3. Oxford, England,
is -~pressure because
Black\Yctl Scienti~ Publicati
td, 1980.
.
.
mechanism
6. K~by \~,JneSR~ ;El;
,
: Mech~1cal v~ntlFIG fi'NI7r= PA + (V X RAw)
latwn, in~B.urton 00,
e
,1
JE (eds). RespiraSchemaiic BlPt'ffirtft~ ri?~o9es~%. 'ffr6cnt !:~~~ to generate a
tory Care : A Guide tifdlfhm Ph.fJtice, Philadelphia,
half sine wa.Ye ~wfi!l(jrii>, Once waveform IS sHedM Eohi control panel,
.TR T.inoincott Co 1977 .
microproc~or sets fip piograrn for proportional solenmd to nmruc the
. Tnrs Va1ue musf also represent the final value for mouth
mcffis ~~ijtyfu-c\WB{Jtffid 'f~ from cen~e;: of r~tating_ wheel. Exa.~t
pressure because when the piston has completed its forward
sif n of ~olenoidlsmonil6r~3"clbh<fin'!Ydb'~W<W\hlt!M\kd&~!Wei"cm
To patient
circuit

5ffid'tk\?

atclf wl'ien tne pattern of alveolar pressure is added to the

pattern of pressure generated from the product of ftowrate
and airway resistance is shown in Figure 5-6,A. Also from
this figure we note that at the end of 1.5 seconds, when the
piston has completed its forward stroke, the ftowrate is
~ero, and the final value for mouth pressure is the same as
llveolar pressure. This was expected because if airway re;istance was not present, the alveolar pressure waveform
:vould follow the mouth pressure waveform identically. But
ince airway resistance is always present, mouth pressure
- nust alwa_y-.tlead alveolar pressure until the ftowrate is zero.
For standard conditions, lung compliance (Cp) is0.05
km H2 0, and if the volume (V) displaced by the piston is
.5 L, then at the end of the inspiratory phase, when alve-

stroke, the flowrate is zero, and the effects of ftowrate and

airway resistance are no longer present.)rbe general shape
. of the mouth pressure waveform undef standard lung conditions is demonstrated in Figure 5-5,A.
Effects of Lung Compliance
(sinc,e the motion of the piston is not influenced by
changes in lung conditions, the pattern of flow and the
volume displaced from the cylinder must also remain constant.~en the volume delivered to the lungs is held fOnstan!but the compliance is reduced by one half, the effect of
alveolar pressure on the mouth pressure waveform is considerable (Figure 5-6,B) .

1"2HAPTER

6
The Nonconstant
Pressure Generator

The most significant difference between a pressure generafor and a flow generator is tj:J.e generated pressure. Therefore
it is possible to transform a nonconstant flow generator into
a nonconstant pressure generator~ providing a means of
reducing the generated pressure.;

Figure 6-1 demonstrates one method of accomplishing

that. The only modifications made to the nonconstant flow
generator of Chapter 5 are the placement of a low parallel
resistance in the patient circuit and setting of the piston to
displace its maximum stroke volume. The vent is designed

Mouth pressure

Humidifier

FIG 6-1.
Schematic representation of a ventilator designed as a nonconstant pressure generator.

70

The Inspiratory Phase

so that during the forward stroke of the piston, most of the

flow is vented to atmosphere.
As the piston begins its positive stroke (as shown in Fig
6-1), the flow of gas is directed to the resistance of the vent
and the resistance of the airway. Flowrate varies inversely
with resistance, and since most of the flow must be vented
to atmosphere, the resistance of the vent is set lower than
the resistance of the airway. Consequentlyimost of the flow
is vented through the parallel resistance, .;;no-the pressure
generated for lung inflation results from the pressure drop
across the resistance of the vent. In other words, the pressure generated within the circuit is actually the back pressure created by the resistance of the vent~';
- ~/

71

Time

...

Generated pressure waveform of nonconstant pressure generator.

r'

Recall from Chapter 5-..that pressure results from the

product of flowrate and resistance, that is,
Pressure = FloWt-ate X Resistance
= Lisee x em H20/Lisee
=em H20
In this situation, because of the wheel and piston assembly, the flowrate is that of a half sine wave, just as in the
nonconstant flow generator. Consequently, the pattern of
pressure drop across the resistance of the vent must also
approximate that of a half sine wave) such as shown in
.-/
Figure 6-2.
The magnitude of pressure generated is a function of
flowrate and the resistance of the vent. Since the resistance
of the vent is very low, the pattern of pressure generated
must also be low.
Not all of the flow is vented to atmosphere; some of it
travels down the airway. However, since the generated
pressure is low, the flowrate into the lungs progressively
decreases as the lungs fill . As the flowrate into the lungs
decreases, the flowrate through the vent increases. Since
the lungs fill exponentially to the product of compliance
and airway resistance, the effects of lung characteristics
must also determine the rate of flow through the vent and
thus the pattern of pressure generated. However, the increase in the vented flow as the lungs fill is so small
compared ,with the overall flow vented to atmosphere that,
for all intents and purposes, the pattern of pressure generated by the drive mechanism is unaffected by changes in
lung conditions. This is demonstrated in Figure 6-3.

pressure rises to meet it (Fig 6-4). As the generated pressure decreases from its peak value, mouth pressure also
decreases but only to the point where it meets alveolar pressure. From this level any further reduction in mouth pressure is prevented by the position of a check valve, which
closes the moment the generated pressure drops slightly
below alveolar pressure. This results in an inflation hold
that is maintained until the piston has completed its forward
stroke) Under s~dard lung. conditions, the .mouth pressure
waveform resultmg from thts arrangement ts demonstrated
in Fig 6-3,A.
Effects of Lung Characteristics _
It was shown in Figure 6-2 that the rate of flow
through the resistance of the vent determines,~e pattern of
pressure generated by the drive mechanism (~ms.sunost of
the flow is vented to atmosphere, changes in lung conditions
cause an unappreciable increase over the total vented flow.
Hence the pattern of pressure drop across the resistance of
the vent, and the mouth pressure pattern remains unaffected
by changes in lung conditions1Fig 6-3,B and C).

___/
THE FLOW WAVEFORM
In considering the complexity of the drive mechanism,
the simplest method of assessing the flowrate into the lungs
is with the use .of the formula
PA
v. = PM__::_:_ _.:.::

THE MOUTH PRESSURE WAVEFORM

/"7

u or a great portion of the inspiratory .phase, mouth

pressure follows that of the generated pressure and alveolar

l
,_..,.
_,--..,

F1G 6-2.

THE GENERATED PRESSURE WAVEFORM

RAw
_ The flowrate (V) into the lungs is determined by the difference between mouth pressure (PM) and alveolar pressure
(PA), divided by the resistance of the airway CRAw) .

72

The Nonconstant Pressure Generator

COMPLIANCE HALVED

STANDARD CONDITIONS

A
10

RESI S TANCE DOUBLED

Gen era ted pressure

(e m H20 i

10
r-

,-

I
I
I

Mouth pressure
(e m H 2 0)

_,--....._

I
~

0.34

1...

Flowrate
(Lisee)

~,

Time (sec)
~.

1.5

1.5

FIG 6-3.
Theoretical waveforms

1.5
i

produce~

Stroke volume
Inspiration time
Average ftowrate
Peak ftowrate
Resistance of vent
Standard conditions
Lung compliance
Airway resistance

by nonconstant pressure generator.

5L
1.5 sec
3.33 Usee
5.23 Usee
2 em H20 /Usec

..{'

0.05 Ucm H20

6 em H2 0/Usec

0
~

<!'()r most of the inspiratory phase, mouth pressure follows the generated pressure and alveolar pressure rises exponentially to meet it. When alveolar pressure and mouth
pressure are equal, the check valve in the circuit closes and
flow into the lungs stops) Under standard lung conditions
the flow waveform that results is demonstrated in Figure
6-3,A.

Effects of Lung Characteristics

~
I

I .

\
~

'

"

I~

\....since most of the flow is .vented to atmosphere, the

pressure generated by the drive mechanism is low, and as
with any drive mechanism that generates a low pattern of
pressure, the flow pattern cannot remain--pnstant but must
vary with changes in lung characteristic..s} The effects of
lung characteristics on the flow _waveform are demonstrated
in Figure 6~3,B and C.

WAVEFORM ANALYSIS

If a pressure generator is defined as ventilator that

maintains a fixed pattern of pressure at the mouth while the
flowrate is free to vary, then the fundamental action of this
ventilator must be regarded as a pressure generator. As with
all_pres~ure generators, the specific classification depends
on the pattern of pressure developed at the mouth.
In this situation mouth pressure was not held constant,
but the pattern of the mouth pressure waveform was repeated within every stroke, regardless of lung conditions.
Because of this pressure pattern, the ventilator is classified
specifically as a nonconstant pressure generator.
Although the use of the drive mechanism as a direct
source for lung inflation is no longer common, it was shown
at least theoretically to be quite adequate for the task. To
demonstrate this in a more practical way, a ventilator clas-

The Inspiratory Phase

73

Mouth pressure

~~~~7
'

','

'

Generated
pressure

'
'\
\
\
\

\
\
\

lime - - - - - 1 1
...
~

FIG 6-4.
General shape of mouth pressure waveform. (See text for description.)

sified as a nonconstant flow generator was fitted with a

parallel resistance and check valve assembly positioned exactly as described in Figure 6-1. The ventilator was adjusted to displace its maximum stroke volume, and the parallel resistance was adjusted to provide a suitable inflating
pressure. The ventilator was tl].en connected to a lung analogue and simultax}eous pressureand flow recordings were
performed (Fig 6-5). A comparison of the actual waveforms to the theoretical ones supports the conclusion present~d here.
( J)le common use of a drive mechanism generating a
no~constant pressure pattern is in a double-circuit ventilator. 1The functional specification and characteristics of the
proposed arrangement, although closely related to the nonconstant pressure generator, differ significantly from the
system presented. For clarity, this drive mechanism is discussed under a separate heading.

THE INCREASING PRESSURE GENERATOR

As stated earlier, a drive mechanism that generates a
nonconstant pattern of pressure is seldom us-ed as the primary source for lung inflation. Howeveq~vhen two further
modifications are made to the drive mechanism, it is quite
adequate as the primary circuit in a double-circuit ventilator.In such a ventilator the pattem of pressure generated by
the primary circuit is appliedto the seondary circuit, and
the secondary circuit inflates the lung_~)

Figure 6-6 shows the simplified schematic of the actual ventilator where the secondary circuit consists of a
respiratory bag enclosed within a rigid chamber. 2 From this
schematic we note that one of the modifications made to the
drive mechanism is the placement of a shaft connected to
the center of the piston. The shaft is of uneven diameter, the
design of which permits the ratio of inspiration to exhalation
time to be maintained at 1 : 2.
In Figure 6-7 the piston is connected to the wheel not
by a simple connecting rod, but by an arm that extends to
the right side of the shaft, as indicated by the broken line.
To simplify the concept of this modification, the parallel
resistance (emptying pressure control) has been omitted
from Figure 6-7.
In 1 the rotation of the wheel pulls the shaft and piston
forward, causing a pressure buildup in the cylinder. Pressure from the cylinder is directed to a pressure chamber
where it is used to compress the respiratory bag. The volume of gas expelled from the bag inflates the expiration
valve, opens a one-way valve, and is then directed to the
patient outlet.
In 2 the bag has expelled all of its volume, but the
piston continues its positive stroke. The mouth pressure
waveform that develops is shown at the top right corner of
each illustration.
In 3 the piston is still in its forward stroke so the bag is
held compressed and prevented from reexpanding. An inflation hold results, and pressure travels down the airway
until equilibrium is reached between mouth pressure and

74

The Nonconstant Pressure Generator

STANDARD CONDITIONS

COMPLIANCE HALV ED

RESISTANCE DOUBLED

Generated pressure
(e rn H,.O:

II

12
Mouth pressure
(ern H20 )

0.5
Flowrate
(Lisee)

lu

,.

Time (sec)

1.5

1.5

1.5

FIG 6-5.
Actual tracings produeed by nonconstant flow generator fitted with parallel vent as described for Figure 6-1. Ventilator displaced
stroke volume of 2 L and was connected to a lung analogue under following conditions:
Standard condition
Lung compliance
Airway resistance
Compliance halved
Lung compliance
Resistance doubled
Airway resistance

0.052 Ucm H 2 0
6.6 em H2 0 /Usec

alveolar pressure. The speed at which equilibrium takes

place depends on the lung characteristics of the patient.
In 4 the wheel has completed one third of its total
revolution. This coincides with the piston having traveled
two thirds of the distance of the cylinder. At this onset,
pressure in the cylinder is vented to atmosphere via the
smaller diameter of the shaft. This marks the end of the
inspiratory phase and the beginning of the exhalation phase.
Although the piston continues to move forward, the smaller
diameter of the shaft prevents any positive pressure from
building up in the circuit. As a result, the pressure surrounding the bag is released, the exhalation valve deflates,-and
the patient's lungs are free to empty.
In 5 the ventilator is still in the exhalation phase, aild
the leftward motion of the piston pulls the shaft into the
cylinder. At the moment the smaller diameter of the shaft
returns into the cylinder, subatmospheric pressure is created
in the chamber surrounding the bag, but not at the patient
outlet because of the one-way valve. The negative pressure
within the chamber expands the bag and gas is entrained
into the bag by way of a cine-way valve and the dosage
valve (a variable resistance designed to entrain air at a metered rate).

In 6 the completion uf the leftward motion of the piston

marks the end of the exhalation phase and the beginning of
the inspiratory phase. The procedure is then repeated, starting with number 1.
Since the wheel makes a complete revolution at a uniform speed and only one third ofthe wheel's rotation makes
up the inspiratory phase, the remaining two thirds of the
wheel's rotation must be devoted to the exhalation phase.
Accordingly, the mechanical design of the mechanism provides a fixed inspiration to exhalation ratio (I : E ratio) of
1 : 2, which is maintained regardless of the respiratory frequency.
It was mentioned earlier that two modifications were
made to the original drive mechanism. The other modification was the addition of a spring-loaded valve positioned
against the vent of the parallel resistance , such as in Figure
6-8. The valve and spring assembly are linked to the shaft
of the piston in a way to distribute the increase in pressure
surrounding the bag evenly throughout the inspiratory
phase. The operation of the mechanisms follows:
In Figure 6-8 rod (1) , slider (2) , and lever (3) are
connected to the shaft of the piston. During the forward
stroke of the piston, rod (1) pushes slider (2) upward, which

- - - -- - - -- - -

~1/\liA~ Pressure
vvrv.,----01imit
control

Water
lock

Respiratory
bag

Humidifier

Air inlet+

Air outlet+

Compressor

- -0- -

C)
Spirometer

On/ Off Frequency

control control

Emptying pressure
control

FIG 6-6.
Simplified schematic of ventilator classified as increasing pressure generator. (Courtesy Gambro Engstrom AB, Sweden.)

-- -- -- -

- -,

76

The Nonconstant p ressure Generator

r--

....... --

..-

__
,.

,....

I
I

---

@
4

r---

-----

---

increasing pressure generator. (S ee text for description .)

The Inspiratory Phase

77

Emptying
pressure
control

To
pressure
chamber

,... I

----1>~---- - l>

Inspiration ends

FIG 6-8.
Modified drive mechanism of increasing pressure generator. 1, rod; 2, slider; 3, lever; 4, control; 5, plunger; 6, spring; 7, disk.

in tum pulls upward on lever (3) . Since lever (3) is pivoted

against control (4), the upward motion of the slider, as the
piston moves forward, applies pressure progressively
against the vent, via disk (7) , spring (6), and plunger (5).
With this arrangement the maximum pressure generated in the pressure chamber is a function of control (4), the
emptying pressure control. The nearer control (4) is to
plunger (5), the greater the pressure generated.
The pattern of pressure generated is one that increases
steadily until the wheel has completed one third of its total
revolution , and the smaller diameter of the shaft is outside
the cylinder.
The waveforms of Figure 6-9 were made with the use of
the actual ventilator connected to a lung analogue. A complete
discussion of the ventilator is presented in Chapter 33.

SUMMARY
The main difference between a flow generator and a
pressure generator is the generated pressure. Therefore it is
possible to transform any flow generator into its equivalent
pressure generator by providing a means of reducing the

generated pressure. This was demonstrated with the nonconstant flow generator. The method involved the placement
of a low parallel resistance in the circuit of the ventilator. The
paral4!1 resistance allowed most of the flow to be vented to
atmosphere, and the pressure drop across the resistance generated the pressure necessary for lung inflation.
The pressure generated by this drive mechanism was
low, and because of this, the flowrate into the lungs did not
remain constant but decreased as the lungs filled. However,
the pattern of pressure generated at the mouth remained
constant regardless of lung conditions. Therefore the fundamental action of this ventilator must be regarded as a
pressure generator. Since the mouth pressure was not held
constant but the pattern of the mouth pressure waveform
was repeated within every stroke, the ventilator is classified
as a nonconstant pressure generator.
When the drive mechanism of a nonconstant pressure
generator is used to power a secondary circuit, the generated pressure waveform differs significantly from the one
produced by the original drive mechanism. Although both
ventilators are considered to be pressure generators, there
are no similarities between the pressure waveforms generated (Fig 6-10). Therefore the ventilator can no longer be
classified as a nonconstant pressure generator.

--_ The Nonconstant Pressure Generator

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

1.5

1.5

so I

~n er ated

press u re
(em HJO)

22

,.

Mouth pressure
(em H 2 0 )

Flowrate
(Lisee)

Time (sec)

1.5

--..FIG 6-9.
Actual pressure and flow tracings produced by ventilator classified as increasing pressure generator. Volume in respiratory bag was set at 0 .5 L (air)
--._ and frequency was adjusted to 12 breaths per minute. Emptying pressure control (spring-loaded parallel vent) was adjusted to generate pressure of
50 em H2 0. Ventilator was connected to lung analogue under following conditions:

0.052 Llcm H2 0
6 .6 em H20 /Lisee

14 em H20 /Lisee

GENERATED PRESSURE WAVEFORMS

INCREASING
PRESSURE GENERATOR

NONCONSTANT
PRESSURE GENERATOR

.,..... ..

I
!!'!

:l"

lime

;1

--.._ Standard conditions

Lung compliance
. ""
Airway resistance
Compliance halved
Lung compliance
Resistance doubled
Airway resistance

j
,

..

~
~
a:

Time

..

FIG 6-10.
Differences between waveforms generated by nonconstant pressure generator and increasing pressure generator.

r-

CHAPTER

9
Pressure Cycling

PRESSURE-CYCLING MECHANISMS
G _yentilator is said to be pressure cycled if the inspira-

r- tory phase is ended when a pressure-sensing mechanism,

built within the ventilator, reaches a predetermined vahie-:',
,..--... At the moment of cycling, the volume delivered, the ti1:l:le'
taken to deliver the volume, and the flowrate may all vary
r'
from one respiratory cycle to the other. The only nonvari,--... able _is the preset cycling pressure. 2 - 4
( Pressure-cycling mechanism_~..may be pneumatic, elecr- tro~ic;-or a combination of both. ,
.~""~

Pneumatic-Cycling
Mechanism
......
~-....

/
l.~Q!lse

of the simplest methods in which pressure cycling

can be accomplished pneumatically is shown in Figure 9-1. 5
Here a flexible diaphragm (4) separates two compartments,
the pressure compartment (16) and the ambient compartment
(17). Connected to the center of the diaphragm is a sliding
valve (5). Attached to both ends of the sliding valve are soft
iron disks {6, 7), and directly in line with these iron disks and
r opposite each other are magnets (8, 9). The position of each
magnet relative to the disks can be adjusted independently of
,. each other by controls (10) and (11).
The system is designed so that when the diaphragm
,. bows to the left (as shown in Fig 9-1 ,C), the sliding valve
is held stable in the oFF position by the attractive forces
/'"""
between the ambient magnet (8) and disk (6). When the
,--... diaphragm moves to the right (as shown in Fig 9-1 ,A), the
sliding valve is held in the ON position by the attractive
forces between pressure magnet (9) and disk (7).
During the inspiratory phase (Fig 9--: I ,A) the sliding
valve is in the oN position and source gas from inlet (I)
flows past the flowrate control (2) and through a channel

opening in the sliding valve. From the sliding valve, gas is

directed to the exhalation valve (12) and test lung (14) via
circuit (15). Pressure cycling is accomplished as follows.
From the beginning of the inspiratory phase, pressure
progressively builds up in the test lung (14) and in the
pressure compartment (16). This pressure is applied to the
large diaphragm by way of communication holes (3) . This
tends to bow the diaphragm leftward and thus opposes the
attraction between pressure magnet {9) and disk (7) (Fig
9-1 ,B). The process continues until the pressure against the
diaphragm is great enough to overcome the attraction of the
pressure magnet. When this occurs, the sliding valve is
moved completely to the left, and gas supply to the ,pressure
compartment is interrupted (Fig 9-1 ,C) .
This marks the end of the inspiratory phase, and at this
moment the exhalation valve deflates and pressure in 'the
test lung is returned to atmospheric pressure. The switch is
now held stationary 11.! the oFF position by ambient magnet
(8) and iron disk (~
With this design, the amount of pressure developed in
the system is governed by the distance between metal disk
(7) and pressure magnet (9). The closer the magnet is
moved toward the disk, the greater the attractive forces
between them and the greater the pressure required for separation . StJch a pressure-cycling mechanism is found in the
Bird ventilators6 described in Chapters 26 and 27.
Fluidic-Cycling Mechanism

/ The latest pneumatic mechanism employed for pressure

cycling evolved with the advent of a relatively new technology, fluid logic, commonly referred to as fiuidic'i) The
National Fluid Power Association defines fluidics as ''The
technology associated with sensing, control, information
97

98

Pressure Cycling

17
/

/ '

10
A

13

6
..

t r

12 ~+

15~
14

...

FIG 9-1.
Schematic representation of pneumatically operated, pressure-cycled ventilator. (See
text for description.) 1, Pressure inlet; 2, flow rate control; 3, communication holes;
4, diaphragm; 5, sliding valve; 6, iron disk; 7, iron disk; 8 , ambient magnet; 9,
pressure magnet; 10, control knob; 11, control knob; 12, exhalation valve; 13, pressure manometer; 14, test lung; 15, patient circuit; 16, pressure compartment; / 7,
ambient compartment.

process, and/or actuating functions performed solely

through the utilization of fluid dynamic phenomena." 7
Fluidic devices employed in ventilators u:;e either air or
oxygen under pressure as an operating medium and can
perform all cycling functions of any present-day electronic
ventilator. To explain how pressure cycling is accomplished
through the use of fluidics, it is necessary first to consider

the two basic principles of a fluidic element: wall attachment and beam deflection. 8
When a jet of gas is forced through an opening, as in
Figure 9-2,A, the turbulent jet flow causes a localized drop
in lateral pressure and draws in ambient gas . If the entrainment of gas on one side of the jet is limited by the addition
of an adjacent surface such as in Figure 9-2,B, a low

The Changeover from the Inspiratory Phase to the Expiratory Phase

,.

99

~-

Ps

Ps

FIG 9-2.
Wall attachment phenomenon, or Coanda effect. (See text for description.)

FIG 9-3.
Schematic representation of flip-flop valve showing what is known as beam deflection.

J2!:essure vortex bubble, or separation bubble, is created

~tween the jet and the wall. The separation bubble tends to
.~nd the jet toward the wall. Stable conditions exist when
..e gas entrained into the bubble from the jet stream closest
-"'\ the wall equals the amount returned to the stream by the
vortex flow inside the bubble.
......., This "wall attachment" phenomenon was reported in
1932 by the Romanian aeronautical engineer Dr. Henri
~ ,anda. 9 For this reason, the wall attachment phenomenon
is often referred to as the Coanda effect.
___.,

The Flip-Flop Valve

The Coanda effect is used in the heart of fluidic ventilators in the form of a fluidic element called a flip-flop
valve, 10 shown schematically in Figure 9-3 .
When a continuous pressure source enters the valve at
Ps, wall attachment occurs and gas leaves from one leg of
the valve. Although the selection is arbitrary, in Figure
9-3,A that output is at 0 2 . Once at 0 2 the output will
remain in that state until a control signal originating from C 1
is made. The control signal is actually a single pulse of gas

~
~.l

f./
.j~

100

Pressure Cycling

The Schmitt Trigger

applied at a right angle to the main stream of gas. At the

onset of this control signal the main stream of gas is deflected from outlet 0 2 to outlet 0 1 (Fig 9-3,B). This is what
is known as beam deflection. Once beam deflection is accomplished, the stream of gas will remain stable at its new
outlet even though the control signal is discontinued.
Because the flip-flop valve is capable of assuming either of the two stable output states, it is said to have memory
and is thus classified as a bistable device. 11

Pressure sensing, positive or negative, is accomplished

with the addition of another fluidic device called a Schmitt
trigger. 12 The Schmitt trigger actually is not a single element but an integrated circuit made up of three proportional
amplifiers and two flip-flop valves connected in series as in
Figure 9-4. 1
The proportional amplifier (Fig 9-5) is similar in design to the flip-flop valve except that because of a slight

\7

\7

."
.

or
c ontrol signal
--t> (negative)

__..

Control sign al
(positive)

C,

c2

0,
\7

\]

c2

02
\7

'

~7

c,

o,
\7

\7

1\

1\

c2

02
~7

1\

\7

c,

/1\
o,+

FIG 9-4.
A, Schmitt trigger is an integrated fluidic circuit made up of 3 proportional amplifiers and 2
flip-flop valves. B shows how beam deflection is accomplished by applying positive pressure
at C 1 or negative pressure at C2 .

'

The Changeover from the Inspiratory Phase to the Expiratory Phase

101

- ~ifference

0 1. Although beam deflection is accomplished by a control

signal originating from C2, once that signal is removed the
output will automatically return to 0 9,Therefore, unlike the
flip-flop valve (~efer to Fig 9-6,A), the Schmitt trigger is
said to have no memory and is therefore classified as a
monostable device. 11
The most useful characteristic of the Schmitt trigger is its
ability to sense differential control signals. For this reason it is
used extensively in pressure-cycled fluidic ventilators .

in splitter configuration, wall attachment is prevented and the input pressure source (P 5 ) leaves from both
--..utlets simultaneously. The output from the amplifier is
taken as the difference between output 0 1 and 0 2.
"' When the control signal at C 1 is equal to the control
~ignal at C2> the differential output is zero (Fig 9-S,A) .
_iowever, a control signal applied to C 1 and of greater mag_..~ itude than c2 causes the beam to deflect to 01' increasing
ne output flow from that port and decreasing the flow from
- utput 0 2 (Fig 9-S,B). A similar control signal applied at
c 2 has the opposite effect (Fig 9-S,C).
For the sake of simplicity this text has adopted the
symbol given to the Schmitt trigger by the National Fluid
~ :>wer Association (illustrated in Fig 9-6,B). 1
~ (The Schmitt trigger module (refer to Fig 9-6,B) has art
Jetl''Ort, P5 , two output ports, 0 1 and 02> and two control
-"~Orts, c) and C2. But because of its design, in the absence
vi control signals at either ports, the output must always be

c,

The OR/NOR Gate

For completeness another fluidic element called the
11 13
O~R gate 1 will be considered (Fig 9-6,C) .
~OR/NOR gate is also a monostable device with t~o
output ports but only one control port. In the absence of a
control signal P 5 normally outputs to 0 1 . Whep. a control
signalis applied at C2, the beam is deflected to 0 2." However, when this control signal is removed the output returns

Ps

Ps

Ps

Control
signal
1----+-,~,...----i c2
+t------,lr-----i

Control
signal

c2

c,

iero

Output
decreased

output differential

Output
increased

c, t-------J.:.--.......j+
c2

Output
increased

Output
decreased

FIG 9-5.
Proportional amplifier. (See text for description.)

L..

SCHMITT TRIGGER

OR/NOR

FLIP-FLOP
Ps

Ps
'7

C, 1--/~. ---tC2

02

o,

02

FIG 9-6.
Fluidic symbols for 3 fluidic devices.

('

o,

o,

02

102

"
'
......,

Pressure Cycling

1. Apply a continuous signal to C2 of the OR/NOR gate.

This causes the gate to change from output 0 1 to 0 2 , and the
output from 0 2 inflates the exhalation valve (not shown) .
2. Actuate the power valve. The function of the power
valve is to allow gas from the inlet to the patient circuit via
the fiowrate control.

to 0 1 .) The OR/NOR gate is well suited to operate various

valve(, especially the exhalation valve.
With this limited introduction to fluidic devices, a simple fluidically operated pressure-cycled ventilator can be
constructed.
Pressure-Cycled Fluidic Ventilator

Connected to the patient circuit is a pressure-sensing

line, which monitors the pressure in the circuit. The opposite end of the sensing line is connected to control port C2
of a Schmitt trigger. At control port C 1 of the Schmitt
trigger is an adjustable reference pressure control. The function of this control is to supply a continuous pressure signal
at C 1 tb ensure the output from the Schmitt trigger at 0 1 .
Pressure cycling is accomplished as follows.
During the inspiratory phase, pressure in the patient
circuit increases and this increase is monitored in the sensing line. When pressure in the sensing line measured at
control port C2 of the Schmitt trigger exceeds the reference.
pressure control signal at c1, beam deflection is accomc

Figure 9-7 is a simplified schematic of the fluidic

pressure-cycling mechanism found in the Monaghan
225/SIMV ventilator described in Chapter 31.
( The ventilator is supplied with gas under pressure from
the i:filet and gas from the inlet is directed to a pressurereducing valve and to a power valve. The output from the
reducing valve supplies the necessary pressure source (P 5)
for all the fluidic elements. The function of the power valve
is described below.
During the inspiratory phase gas leaves the flip-flop
from 0 1 . The continuous output from 0 1 is directed to two
areas simultaneously and is used to

Adjustable
reference pressure

c2

C,

------r-----~~----~~------~-----,

o 2 ..(,.~

o,

c2

C,-1-----""'7~,.------'i..A- ____ .J Gas pathway when

pressure cycling occurs

Sensing
line

02

c2

To fluidic
elements
(Ps)

Inlet

Power valve

Flowrate control

FIG 9-7. Schematic representation of fluidically powered,

pres~ure-cycled

ventilator. (See text for description .)

'
'

'
--"'.
---.._

'
......_

.......,
......_
~

---..,

The Changeover from the Inspiratory Phase to the Expiratory Phase

103

piished and the output from the Schmitt trigger switches

' 1m 0 1 to 0 2 . Since output 0 2 of the Schmitt trigger is
connected to control port C2 of the flip-flop valve, the out. t signal (now at 0 2 , indicated by the broken line) from the
~hmitt trigger applies a control signal at c2 of the flip-flop
_lve. This causes the flip-flop valve to switch from outputs
Q 1 to 0 2 , and the following occurs:
1. The output signal from 0 1 of the flip-flop valve to
control port C2 of the OR/NOR gate is discontinued and the
~ te automatically switches from output 0 2 to output 0 1
and allows deflation of the exhalation valve.
2. Since the power valve no longer receives a signal
fr_om 0 1 of the flip-flop valve, the power valve returns to its
rmal resting position and isolates the inlet pressure from
!b.e patient circuit.
3. Because of steps 1 and 2, the pressure in the patient
~cuit and in the sensing line is returned to atmospheric
levels. This interrupts the control signal at C2 of the Schmitt
. ~ ;ger, and the continuous reference signal applied at C 1
restores the output of the Schmitt trigger to 0 1 .
~. 4. The flip-flop valve remains stable at 0 2 until a control
signal is again applied to its control port,
The way in
,ich the flip-flop valve may initiate the inspiratory phase
is described in Chapter 15.

--It

---th____.,.:L_r:::;..
_ _ _ _ _ _ _ _ _,.lt, To patient
"

_SJ

0t the moment the flip-flop valve switches from output

to output 0 2 , the ventilator is said to have pressure
,.--v;led. The amount of pressure required in the patient circuit before cycling can occur is determined by the amount
reference pressure applied to control port c1 of the
~~hmitt trigger.)

' ctrcutt

To patient circuit

FIG 9-8.
Pressure-cycling mechanism consisting of spring-loaded diaphragm and
microswitch. Silhouetted diagram below indicates position of cycling
mechanism in inspiratory limb of circuit.

\.J 1

~ zumatic/Electronic

Type I

,__..__ Many pressure-cycling mechanisms consist of an adJ"table spring-loaded diaphragm and microswitch, 14 simi!_,.,.,_ to that depicted in Figure 9-8. The mechanism is placed
IH !!J.e inspiratory limb of the ventilator circuit.
~:. During the inspiratory phase, as pressure in the patient
cir2illrificreases, the diaphragm bows upward, opposes the
',.....,Nnward force of the spring, and moves the pivoted lever
upward and closer to the microswitch. When the pressure in
"""" patient circuit is great enough to cause the pivotfd lever
!~ trip the micros witch, an electrical signal is sent to a
..~croprocessor (an electroni.s- logic circ;uit) and relayed to a
~"'-l enoid, which closes to end the inspiratory phase. The
n1aximum pressure allowed in the system is determined by
~ tension of the spring, which is adjusted by the control
knob. The greater the sQ.ti,_ng tension, the greater the cycling
.~' ssure and vice versa..:)
Although this system is used more commonly as a
"';kup safety system for other cycling mechanisms, it can
,

>

perform well as the primary cycling mechanism. When the

cycling mechanism is used as a high pressure safety system,
the microprocessor can not only terminate the inspiratory
phase but also can elicit an audiovisual alarm to alert the
operator of the condition.

Pneumatic/Electronic Type II
Pressure cycling can also be accomplished with the use
of a pressure transducer. Although there are many types of
pressure transducers, basically pressure transducers convert
mechanical energy into electrical energy. 15 - 19
In Figure 9-9 the transducer is placed in the inspiratory
limb of the ventilator circuit and electrical means are used to
measure the motion of the diaphragm. During the inspira, tory phase, the diaphragm is deformed by the action of the
pressure building up in the system. When the pressure
against the diaphragm equals an electronic reference potential set by the operator, an electrical signal is transmitted to
the microprocessor and relayed to the solenoid, which
closes to end the inspiratory phase. The amount of pressure
allowed in the system is therefore governed electronically

104

(Pressure Cycling
i
./

t
Primary winding
1nput

<:::::=::::><

Secondary winding

<===><

o~tp ut

Diaphragm

_.If

---1-----L.::;._
_________+~

To patient
CirCUit

Control knob

Input

To patient circuit

the initial setting of the pressure-cycling mechanism because the patient's lung condition is not known at that moment. Clinical judgment dictates the cycling pressure selected and is customarily in the range of 10 to 20 em H2 0.
The exact setting for flowrate is also impossible to establish
but is initially adjusted to provide an adequate inspiration
time.
Once these preliminary settings are made, the patient is
connected to the ventilator. The volume delivered at that
pressure and flowrate is determined with a volume measuring device. The final adjustments to the cycling pressure
and flowrate are then performed based on the outcome of
the measured data. If the tidal volume is too low, the cycling pressure is increased. If the tidal volume is too high,
the cycling pressure is reduced.
Keeping the patient's lung characteristics constant, the
length of the inspiratory phase is also influenced by the cycling
pressure and the flowrate selected. Adjusting the cycling pressure alone may require further manipulation of the flowrate
control to maintain inspiration time.
When any pressure-cycled ventilator is confronted with
changes in lung conditions, the only parameter that remains
constant is the cycling pressure. Consequently, changes in
lung compliance or in airway resistance will have an adverse effect on the tidal volume and inspiration time, as
demonstrated in Figure 9-10.

FIG 9-9.
Pressure-cycling mechanism cons1stmg of pressure transducer. Type
shown schematically i~ a linear variable differential transformer (LVDT).
Iron core placed symmetrically between electrical windings monitors motion of diaphragm. Silhouetted diagram beloW shows mechanism in in, spiratory limb of patient .circuit.
'

by the setting of the reference control knob . The greater the

reference setting, the greater the cycling pressure and vice
versa.
Although a pressure transducer is quite adequate as a
primary cycling mechanism, it may also be used as a
backup safety system for other cycling mechanisms. Furthermore , with the help of a microprocessor, the same transducer can monitor and respond to the entire range of pressure during the respiratory cycle. This compares favorably
with the rnicroswitch mechanism of Figure 9-8, which can
respond to only one pressure setting at a time.

CLINICAL CONSIDERATIONS
When pressure-cycled ventilators are used in the clinical setting, the volume delivered into the lungs and the time
taken to deliver the volume are related to the cycling pressure, the flowrate, and the -lung characteristics of the patient. 20 Unfortunately, there is no simple way of predicting

Effects of Lung Compliance

In Section Two it was established that reductions in
lung compliance decrease the time constant of the lung and
accelerate equilibrium between the generated pressure and
alveolar pressure. It follows that reductions in lung compliance must also decrease the time required to reach the cycling pressure.
In the clinical setting the only outward indication that a
reduction in lung compliance has taken place will be noticed
as a shortened inspiratory phase. Measuring the exhaled
volume will always reveal a fall from the previous value..
The theoretical waveforms of Figures 9-11 ,B and 9-12,B
demonstrate that when the compliance is halved, the volume delivered and the inspiratory time are also halved,
regardless of the generated pressure.
Because of the predominantly shortened inspiratory
phase, those unfamiliar with pressure-cycled ventilators may
be tempted to correct the situation by first decreasing the
flowrate. While such a maneuver would indeed correct for
inspiration time, it has little or no value in restoring the tidal
volume. In fact, when a pure decrease in lung compliance has
taken place, the tidal volume cannot be fully restored by
adjusting the flowrate alone. The corrective procedure is with
the cycling pressure, which must be increased.

L,

.i......,

--..

CHAPTER10

Flow Cycling

~~ntilator is flow cycled if the inspiratory phase is ended

when the flowrate through a flow-sensitive valve, built
within the ventilator, has fallen to a criticial levefl':l
At the
/
moment of flow cycling, the pressure and volume in the
lungs, along with the time taken to end the inspiratory
phase, may all vary from one respiratory cycle to the other. 3
The only parameter that remains constant is the terminal
flowrate (that is, the flowrate required for cycling to occur.)
A complete discussion of the flow-cycled ventilator is
presented in Chapter 17.

.._, j FLOW-CYCLING MECHANISMS

G _Eigure 10-1 a metal cylindrical drum with an internal channel for gas flow (4, 5) is mounted horizontally on
jeweled bearings within a precision manifold. Source gas to
the cylindrical dmm is supplied at inlet (1) and originates
from an adjustable pressure-reducing valve (not shown).
The pressure-reducing valve is adjusted to generate a pressure just high enough to achieve the desired volume exchange.
In Fig 10-1 ,A when no gas flows through the valve, a
metal rod (3) set off-center within the drum keeps the valve
closed by providing a counterbalance torque, which tends to
rotate the cylinder clockwise. In Figure 10-1,B when the
valve is rotated counterclockwise to initiate the inspiratory
phase, gas flows through the cylinder and acts against a
vane (2). Gas flow against the vane counteracts the effects
of the metal rod and keeps the valve open. The valve remains open for as long as the flow against the vane is great
enough to offset the effects of the metal rod.
Since the generated pressure is not very high, as lung
pressure increases, the gradient between alveolar pressure
and generated pressure decreases, and the flow through the
valve decreases. The reduction in flowrate rotates the dmm
112

clockwise (Fig 10-1 ,C) , which narrows the channel opening and further reduces the f,owrate. Once the flowrate is at
a level that is not high enough to offset the effects of the
metal rod, the valve rotates shut (Fig 10-1 ,D). At that
moment the ventilator is said to have flow cycl~
From this discussion it should be clear that-the flowcycled ventilator most operate as a constant pressure generator since the generated pressure and alveolar pressure
must approach equilibrium to achieve the desired volume
exchange. In the flow-cycled ventilator the reduction in
pressure gradient as the lungs fill provides the necessary
decay in flowrate for cycling to occur. The theoretical waveforms produced by the ventilatm: must approximate those of
the constant pressure generator discussed in Chapter 3.
Flow cycling must not be confused with pressure cycling since in the latter, a predetermined pressure set at the
ventilator must be met to end the inspiratory phase. With
flow-cycled ventilators, the preset pressure (which is in fact
the generated pressure) is never quite reached because at the
moment of flow cycling, a small pressure gradient still exists and provides the terminal flow required for cycling.
The terminal flow in these ventilations ranges between
1 and 4 Llmin. 4 In the examples that follow the inspiratory
phase is considered complete when the flow has decayed to
an arbitrary value of 3 Llmin (0.05 Lisee)/

CLiNICAL CONSIDERATIONS
With flow-cycled ventilators the vohime delivered into
the lungs and the time taken to deliver the yolume vary with
the level of pressure selected and lung characteristics of the
patient. Therefore the initial set up of the flow-cycled ventilator involves adjusting the generated pressure to a level
between 10 to 20 em H2 0. 5 The patient is then connected to
the ventilator and the volume exchange from the pressure

' ii i

'

The Changeover from the Inspiratory Phase to the Expiratory Phase

113

F1G 10-1.
Schematic representation of flow-sensitive valve. A, Expiratory phase. B, Inspiratory phase. C,
Terminal flow reached. D, End inspiration, begin expiration. 1, Gas inlet; 2, vane; 3, counterweight; 4, 5, channel openings.

selected is determined. The final adjustment to the generated pressure is then made based on the volume desired. 6
Increasing the generated pressure increases the tidal volume
and vice versa.
In the simplest form of the flow-cycled ventilator (such
as described thus far) the operator has no control over flowrate. When the generated pressure is held at a fixed level,
the length of the inspiratory phase depends entirely on the
behavior of the flow-cycling mechanism and lung characteristics of the paJient. This is demonstrated in Figure 10-2,
where the effects of lung characteristics on inspiration time
and tidal volume are presented. To co.nstruct the graph, the
generated pressure was adjusted to 10.5 em H20, and flow
cycling was assumed when the flowrate decayed to a level
of 0.05 Usee (3 Umin).

Effects of Lung Compliance

With changes in lung compliance, the flow-cycled ventilator behaves similarly to the pressure-cycled ventilator.
For instance, Figure 10-3,B demonstrates that when lung
compliance is reduced by one half, inspiration time and
tidal volume are also halved. Therefore, with changes in
lung compliance the pressure-cycled ventilator and the
flow-cycled ventilator differ only in the way in which the
inspiratory phase is ended.
In the flow-cycled ventilator the only method provided
to compensate for reduction in lung compliance is to increase the generated pressure until the tidal volume is restored. However, once the volume is restored, inspiration
time will always be less than observed during standard lung

114

Flow Cycling

IN CREAS ING COMPLIANCE

0.7 5

A
Volume
(L)

0.5

Standard conditions

- - - - - - - - - - -

0 .25
1

x0 .25

i
i

f
~

..

INCREASING RESISTANCE

0.75
B
Volume
(L )

Standard conditions

_ _ _ _ _ xo
2:

x1
~

0.5

)(

)(

x5

""*---?<

I
I
f,

0.25

+
0

0.5

1.5
2
Inspiration time (sec)

2.5

FIG 10-2.
r

Effects of lung characteristics on volume and inspiration time with flow-cycled ventilator. Flow cycling occurs at 0.05 Lisee (3 L!min). A shows effects of lung compliance while maintaining airway resistance. B shows effects of airway resistance
while maintaining lung compliance.
Standard conditions
Lung compliance
Airway resistance

I
I
l

0.05 Ucm H2 0
6 em H2 0/Lisee

t
I

conditions. Since there is no flowrate control on the simplest form of the ventilator, nothing can be done to correct
the situation.
In the more sophisticated version -o f flow-cycled ventilator (Bennett PR-2 in Chapter 21) a variable series resistance (peak flow control) is positioned downstream to the
flow-sensitive valve (Fig 10-4). The peak flow control can
be adjusted to provide minimum or maximum resistance to
flow. Intermediate settings are also possible but the flowrate
cannot be completely shut off.

The initial setup of the flow-cycled ventilator is similar

to that described for the pressure-cycled ventilator. In this
instance, the generated pressure is adjusted between 10 and
20 em H2 0 and the peak flow control is rotated to some
intermediate level, that is, halfway between minimum and
maximum resistance. The patient is connected to the ventilator, and the tidal volume is checked with a volume measuring device. The generated pressure is then adjusted until
the prescribed volume is established. Inspiration time is
then adjusted with the peak flow control.

115

The Changeover from the Inspiratory Phase to the Expiratory Phase

A

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

1.05
Flowrate
(Lisee)

10.31
Mouth pressure
(em H,O)

10
Alveolar pressure
(em H,O)

Volume
(L)
I

t
Time (sec)

1.5

1.5

1.5

FIG 10-3.

'
Theoretical waveforms produced by flow-cycled ventilator. Flow cycling
occurs at Of05 Usee (3 Umin).
10.5 em H 20
4. em H20 /Usee

Generated pressure
Ventilator resistance
Standard conditions
Lung compliance
Airway resistance

0.05 Ucm H20

6 em H 20/Usee

tor; the latter shortens the inspiratory phase, the former

lengthens it.
Doubling airway resistance increases the step rise in the
initial mouth pressure, which decreases the initial gradient
between the generated pressure and mouth pressure. With a
step decrease in the pressure gradient, the initial flowrate
drops, and the reduction in the initial flowrate rotates the
valve toward the closed position at!d further narrows the
channel size for the passage of gas. As long as the step rise
in the initial mouth pressure is not great enough to cause the
terminal flow to be reached prematurely, the end result is a
reduction in flowrate and an increase in inspiration time (see
Fig 10-3,C). The reduction in flowrate allows more time
for the pressure to reach the alveoli and thus a major change
in tidal volume is minimized. hi this respect, the flow-

To compensate for decreases in lung compliance, the

generated pressure is increased until the volume is restored.
However, with the flow-cycled ventilator, once the volume
is restored, inspiration time will still be less than observed
during standard lung c<;mditions. To compensate for this, the
peak flow control is turned toward the maximum resistance
setting until inspiration time is corrected. Although the ventilator still flow cycles to end the inspiratory phase, the
corrective procedure is verysimilar to that described for the
pressure-cycled ventilator.
Effects of Airway Resistance
With changes in airway resistance the flow-sensitive
valve behaves oppositely from the pressure-cycled ventila-

--

'

--

--

~::"'"'.a' .,.;.;.,;;;~-.~..;;.,,

~-

---

... ~- .

_ _, _

~ .. .

'

--

. . ;., "

----

--

. ~.

r~
!
116

Flow Cycling

TABLE 10-1.
Characteristics of a Flow-Cycled Ventilator
Flow Cycling
Parameter
Mouth
pressure*
Flow
Alveolar
pressure
Volume
Inspiration time

Compliance

t
t

Res istance

To
Compensate

for Cp
for RAwt

<t >
<t >
t

Mouth pressure = generated pressure

If peak fl ow control is present
j Increase
! Decrease
<-+ No change
< ! > May change and denotes trend

Peak flow control

...
To patient

FIG 10-4.
Position of variables series resistance (peak flow control). (See text for
description.)

cycling mechanism reacts more favorably to increases in

airway resistance than the pressure-cycling mechanism.
Clinically, however, the valve cannot totally compensate for major increases in airway resistance, and a drop in
the tidal volume along with an increase in the inspiratory
phase will always be observed (see Figs 10-2,B and 103,C). Although the reduction in tidal volume can be corrected by increasing the generated pressure, little can be
done to restore inspiration time. Furthermore, with major
changes in airway resistance, the addition of a peak flow
control also has little value in restoring the length of the
inspiratory phase.
As a quick reference guide, Table 10-1 summarizes the
characteristics of the flow-cycled ventilator.

SUMMARY
A ventilator is said to be flow cycled if the inspiratory
phase is ended when the flow of gas through a flowsensitive valve decreases to a critical level. At the moment
of cycling, the pressure and volume in the lungs, along with
inspiration time, may all vary from one respiratory cycle to
the other. The only nonvariable is the terminal flowrate.
The flow-sensitive valve cannot compensate for changes
in lung compliance and in this respect behaves similarly to

the pressure-cycled ventilator. With reductions in lung compliance the volume in the lungs and inspiration time are decreased. To compensate, the generated pressure is increased
until the volume is restored . However, the maneuver does not
restore the length of-the inspiratory phase, which remains
shorter than originally observed . With the simplest form of
the flow-cycled ventilator nothing can be done to correct for
inspiration time.
In the more sophisticated versiop of the ventilator, a
variable series resistance (peak flow control) is positioned
downstream to the flow-sensitive valve and provides more
control over flowrate and the length of the inspiratory phase.
The flow-cycling mechanism reacts favorably to
changes in airway resistance. With increases in airway resistance the valve automatically compensates by decreasing
the flowrate. Although complete compensation is theoretically impossible, the reduction in flowrate allows more of
the generated pressure to reach the alveoli, and large fluctuations in tidal volume are minimized.
With changes in airway resistance the valve will attempt to maintain alveolar pressure at the expense of inspiration time. With minor increases in airway resistance the
increase in inspiration time may not be clinically significant. However, in the simplest form of the ventilator, the
operator has no control over flowrate, and the length of the
inspifatory phase cannot be fully corrected.
Some control is offered with the placement of a peak
flow control, but with pronounced increases in airway resistance, inspiration time can never be completely restored.

REFERENCES
1. Kacmarek RM, Mack CW, Dimas S: The Essentials of Respiratory Care, ed 3. StLouis, Mosby-Year Book Inc, 1990.

.
'

...

<.,/

r:
i

CHAPTER

11

I
j

I
I

Volume Cycling

1
I

II
I

i~

_../, ...

,.,

~__yentilator is volume cycled when the inspiratory phase is

ended at the moment a predetermined volume seJ at the
ventilator has been delivered into the patient circu~ At the
moment of cycling, the time taken to deliver -the volume,
the pressure developed in the patient circuit, and the flowrate may all vary from one respiratory cycle to the next. The
only parameter that remains constant is the preset volume .12
Traditionally, volume cycling is accomplished with the
use of a double-circuit ventilator. In these ventilators the
prirrlary circuit is usually a blower, and the secondary circuit comprises a bellows assembly. The volume-cycling
mechanism can be pneumatically or electronically operated.
Because of rapid advancement in the field of electronics, reliable timing and flow-sensing devices integrated
electronically to measure volume can now be found in
single-circuit, volume-cycled ventilators. For clarity, volume cycling using double-circuit and single-circuit ventilators will be investigated separately.

DOUBLE-CIRCUIT, VOLUME-CYCLING
MECHANISMS
Pneumatic/Fluidic

( Figure 11-1 i~ a ~implified schematic o~ a fluidically

operated, double-Clrcmt, volume-cycled ventllator. Such a
volume-cycling mechanism is found in the Monaghan
225/SIMV ventilato~ described in Section Seven.
During the inspiratory phase, output 0 2 from the flipflop valve applies a continuous control signal to the power
valve and to C2 of the OR/NOR gate. With this signal the
following occurs:
,--..., _

1. The power valve opens and source gas is directed to

the bellows canister.
2. The OR/NOR gate switches to output 0 2 and pressurizes the bellows canister valve and the exhalation valve.
With the canister valve inflated, pressure in the canister
increases and the bellows rises, displacing its content into
the patient circuit.
Located within the bellows and at the top of the canister
is a plunger valve and vent assembly. The vent is supplied
with gas by a line that is also connected to control port C 1
of the flip-flop valve. Normally, the flow of gas through this
line is vented to atmosphere and no gas is directed toward
the flip-flop valve.
When the bottom of the bellows has traveled a distance
sufficient to move the plunger upward, the vent is occluded
and gas is directed to control port C 1 of the flip-flop valve
(pathway indicated by ghosted arrows .) This serves as a
control signal and the flip-flop valve switches from output
0 2 to 0 1, and the following occurs:
1. The power valve is spring-loaded to close, and with
no control signal to keep it open, the valve closes and gas
supply to the bellows canister is discontinued.
2. The OR/NOR gate is monostable, and with the control signal at C2 removed, the gate returns to output 0 1. This
causes the canister valve and the exhalation valve to depressurize. With the canister valve and exhalation valve empty,
the bellows expands and the lungs are free to empty.

At the onset of steps 1 and 2, the ventilator is said to

have volume cycled. To control the volume delivered into
the patient circuit when volume cycling occurs, an adjust-

118

\ -;,.,_~.

"

' ,'

-,-

-~

r-i~:~~~~~'~' ,_~,~ ~~'2ia-':c?~;~t~~~;,~;)~;~ . ~ ., ,:J:e~i~i

The Change over from the Inspiratory Phase to the Expiratory Phase

'

119

-.''
Flip-flop
valve

'

I
c, t----k-----1

c,

Gas flow when vent occluded

::g:::::=::=::=:~:=::::::=:::~:=:=::E.
-

'

I'I

'
\

'

o, &

l[J

'
'

OR / NOR

c,

To patient

'
'
\

-----..

"

'

To exhalation valve

---._

Plate

'
\

:?

From reduced pressure sou~ce

Volume control
crank

FIG 11-1.
Schematic representation of fluidically operated volume-cycled ventilator. (See text for description.)

able plate located within the canister limits the expansion of

the bellows and therefore specifies the volume delivered
during the subsequent inspiratory phas;-'\

__/
Pneumatic/Electronic

Microswitch

i'
II

/ "Figure 11-2 shows how volume cycling can be accomplished-with the use of a bellows and microswitch assembly.
The mechanism is found in the Ohio ventilators 4 described
in Chapters 37 and 38.

To initiate the inspiratory phase, the solenoid opens and

gas from the primary circuit is directed to the canister valve,
the exhalation valve (not shown), and the bellows canister.
As the canister pressure increases, the bellows is forced
upward, displacing its volume into the patient circuit.
The bellows continues to rise until the microswitch
positioned at the top of the canister is triggered by the
bottom of the bellows. Once the microswitch is activated,
an electrical signal is transmitted to an electronic processing
unit and then relayed to the solenoid, which closes to end
the inspiratory phase.

120

Volume Cycling

Electronic circuit

[~ l~- ----H

Volume

ooctml

jc'""'"
50 1
- - - - - l f -_ _ e_n_o_id_ _ _ _ _ _ _ _ _ _ _ _.Jj
From primary
drive mechanism

~stervalve

t1.-.

To exhalation va lve

_._----------------'--------__j

FIG 11-2.

1..

Bellows and microswitch volume-cycling mechanism.

To control the volume delivered, a cord connecting a

pulley to the bottom of the bellows limits the expansion of
the bellows. The cord is wrapped around the pulley, and
rotating the pulley by way of the volume control knob determines the resting position of the bellows and the volume
delivered during the next inspiratory phasV
/

Potentiometer
In Figure 11-3 a potentiometer fitted with springloaded pulley is positioned outside and at the bottom of the
bellows canister. A spring-tensioned cord wrapped around
the pulley connects the bellows potentiometer to the bottom
of the bellows.
During the inspiratory phase, gas from the primary
drive mechanism inflates the exhalation valve, the canister
valve, and the bellows canister. As pressure in the canister
increases, the bellows rises and rotates the pulley of the
bellows potentiometer. This rotation is relayed electronically to the reference potentiometer on the control panel of
the ventilator. Once the bellows potentiometer has rotated to
a point where it matches the setting of the reference potentiometer, an electrical signal is transmitted to the solenoid,
which closes to end the inspiratory phase. At that moment
the ventilator is said to have volume cycled.
With this arrangement the bellows must always rise
from the bottom of the canister. The volume delivered into
the circuit is governed by the position of the reference potentiometer, which is calibrated to read volume. The higher
the reference setting, the greater the distance the bellows
must travel to match the reference settin.g and the greater the

volume delivered. Such a volume-cycling mechanism is

found in the Bennett MA series ventilators 5 described in
Chapter 24.

SINGLE-CIRCUIT, ELECTRONIC VOLUMECYCLING MECHANISMS

Ultrasonic

This type of volume-cycling mechanism consists of an

ultrasonic transmitter and receiver positioned in the inspiratory limb of the circuit, such as shown in Figure 11-4, A.
Normally, the ultrasonic waves generated by the transmitter crystal travel across the flow tube unimpeded and are
picked up by the receiver crystal. The output from the receiver is then processed by an electronic circuit within the
ventilator.
During the inspiratory phase (Fig 11-4, B), gas flows
through the tube and acts against a wedge placed in line
with the oncoming flow of gas. The wedge generates vortices that disrupt the signal transmitted to the receiver. The
design of the system is such that the electronic measuring
circuitry translates each vortex as 1 cc of gas . Volume cycling occurs when the number of vortices measured through
the flow tube is equal to the setting of an electronic reference control. At that moment a signal is transmitted to the
solenoid, which closes to end the inspiratory phase.
A similar volume-cycling mechanism is described for
the BEAR ventilators 6 in Chapter 26.

The Change over from the Inspiratory Phase to the Expiratory Phase

121

To pat1 ent

\'

Canis ter

Volume contro l

Coed

Pulley

Bellows
potentiometer

Reference
potentiometer

ISI(canister valve

tLd~~~;;Hoo "'"

From pnmary
dnve mechanism _
-_
. ._ _ _ _ _ _ _ _ _ _ _ _
__..
_ _ _ _ _ _ _ _ _ _ _ ___J

FIG 11-3.
Use of potentiometers to accomplish volume cycling in double-circuit ventilator.

Volume control

- -

- I

I
I ,

Receiver
crystal

Electronic circ uit

_g_
g

Rece ive r
-

~ Vo_rt_e_x_ _

--
-

..,.

1 From drive mechani sm

Wedge

Tra nsmitter
crystal

Wedge

\..___)

To patient

A Transm itter
L_j

- J

Electronic
oscillator

FIG 11-4.
Ultrasonic flow transducer as volume-cycling mechanism.

The Strain Gauge

A strain gauge operates on the principle that the resis. tance of a conductor changes when the conductor is subjected to strain. 7 For example, the resistance of a wire increases as it is stretched because the wire is now longer and

- - -'
'-

'

an

..

C:-~ .;,.~.f.. \ . ,_, . ...

:;:..:,"'.':::_ . : ...

thinner. Figure 11-5 demonstrates one practical application

of this principle in volume-cycled ventilators . The insert of
, Fi gure 11-5, A shows the transverse section of the strain
gauge.
. _
A thin wire (filament) is bonded on
insulated backing to the material for which the strain is to be determined.

--

' ..... : _.

: . : ......

~---.

.:..

---

- -- -

...

. . .,.. :

, 121

Volume Cycling

Volume coniro l

Electronic circuit

Strain gauge

Ventilator circuit
A

From drive mechanism

To patient
B

FIG 11-5.
Strain gauge used as volume-cycling mechanism.

1be material, usually a silicon rod, encapsulates the leads

the filament. The silicon rod is connected to a small
disk called a flag, which extends in the inspiratory limb of
'~ nd
r--- .

:le CirCUit.

'""
During the inspiratory phase the flow of gas acts against
. .he flag, which by way of a small pin deforms the silicon
~rod (exaggerated in this schematic). This stretches the filament within the rod and thus changes its resistance. The
,.-- r:hange in resistance is monitored by an electronic circuit
built within the ventilator. Although the strain gauge actu~ally responds to flow,8 given an inspiration time, the signal
from the strain gauge is integrated electronically to measure
r"'volume. The solenoid closes when the volume measured
electronically through the circuit corresponds to a reference
"'setting on the control panel of the ventilator.
A similar volume-cycling mechanism is described in
Chapter 39 for the Siemens Servo 900C ventilator.
,....._, The Hot-Wire Anemometer

"

"
r-.

A hot-wire anemometer is a resistive flow-velocity

transducer consisting of heated wire. 9 In Figure 11-6 the
wire is positioned within the inspiratory limb of the circuit.
The wire is heated and supported at its ends so that it loses
heat to the flowrate being measured.

During the inspiratory phase the flow of gas cools the

wire, and the resistance of the wire changes. The more flow
through the circuit, the greater the change in resistance. The
change in resistance is measured electronically and, given
an inspiration time, integrated to measure volume. Volume
cyciing occurs when the volume measurea through the circuit matches the reference setting on the control panel of the
ventilator.
In the Bennett 7200 Microprocessor ventilator described in Chapter 25, a thin film is used instead of a wire. 10
This configuration consists of a quartz rod plated with a thin
platinum wire. However, regardless of the material used,
the theory of operation remains the same.

CLINICAL CONSIDERATIONS
Compared with the pressure- or flow-cycled ventilator,
the initial setup of the volume-cycled ventilator is straightforward. The operator merely has to determine what volume
is to be delivered and then adjust the specific dial on the
control panel of the ventilator.
As a working rule, the initial setting for the tidal volume is between 10 and 15 mllkg of body weight. 11 Once the
desired tidal volume is established, provisions must be

The Change over from the Inspiratory Phase to the Expiratory Phase

123

Volum e contro l

So leooid

o_____

E-Ie-c-tro n_i_c_
c -ir_c:_it_

From drive mec hanism

_l.__---il-/-To pati ent

F1G 11-6.
Hot-wire anemometer used as volume-cycling mechanism.

made to assure that the volume is delivered within a reasonable time . With most volume-cycled ventilators, a flowrate control is present and provides the necessary means of
regulating the length of the inspiratory phase.
The fact that all preliminary control adjustments can be
made before connecting the patient to the ventilator represents one of the many advantages of the volume-cycled
ventilator. .
Regardless of the cycling mechanism, as soon as the
patient is connected to the ventilator, the volume delivered
\O the patient must still be verified with a volume measuring
device (VMD). Not all of the volume selected at the ventilator will reach the patient. Some of the volume will be
lost in the ventilator circuit as a consequence of the system's
compliance . 12 - 14 To determine the volume that actually
reaches the patient, the VMD must be connected between
the ventilator outlet .and the patient. Lost volume can then
be obtained by subtracting the measured volume from the
control setting. The usual method of correcting for lost volume is by slowly increasing the control setting stepwise
until the desired volume. is displayed on the VMD. The
flowrate control may then require further adjustment to
maintain inspiration time.
With volume-cycled ventilators the only parameter remaining constant is the volume delivered by the ventilator.
The time required to deliver the volume and the pressure
developed during the process are greatly influenced by the
magnitude of the generated pressure and lung characteristics
of the patient.
In Figure 11-7 three levels of generated pressure are
used to demonstrate these effects. For each level, the ventilator was adjusted so that, under standard lung conditions,
a volume of 0 .5 L was delivered in 1.5 seconds . Figures
I i- 7 , A and II- 7, B show that when changes in lung
characteristics occur, the length of the inspiratory phase

..

increases as the level of generated pressure decreases.

. When the generated pressure is very high, a constant pattern
' of flow is generated and inspiration time remains constant.
In this case, only the pressure developed in the patient circuit alters with changes in lung conditions.
When the generated pressure is very low and a major
reduction in lung compliance occurs, it is possible that the
pressure generated by the drive mechanism is not high
enough to deliver the volume. In such instances, volume
cycling would be impossible and the ventilator would stall
in the inspiratory phase.

Effects of Lung Characteristics When the Generated

Pressure Is High
Figure 11-8 represents the waveforms produced by a
constant flow, volume-cycled ventilator. The waveforms
demonstrate that when a constant pattern of flow is generated, the volume delivered into the patient circuit and the
time taken to deliver the volume remain constant, regardless
of hmg charaCteristics. The pressure developed in the system, however, is free to vary.

Determination of Flowrate
Constant Flow Generator (Square Wave, Top Hat)
Microprocessor-controlled, volume-cycled ventilators
are capable of generating any flow waveform. When a constant flow is generated and a specific volume and
inspiration-to-exhalation ratio (I:E ratio) is required, a simple formula is used to determine the exact setting of the
flowrate control:

V = (VT x

Rate) x (I

E)

124

Volume Cycling

DECREASING COMPLIANCE

45

40

30
A
Mouth pressure
(em H20)

20

10

:-:-:.:-:-:-::::::::-:-: . ._ - - - - - - - - Standard conditions

0 PG = 3500 em H20

1.5

2.5

1.5

.2

2.5

6. PG = 100 em H 20
0 PG = 25 em H 20

20
B
Mouth pressure
10
(em H 20)

Inspiration time (sec)

FIG 11-7.
Volume cycling: Effects of generated pressure and lung characteristics on length of inspiratory
phase. Cycling occurs when volume delivered equals 0.5 L. For standard lung conditions, lung
compliance is 0.05 Lfcm H2 0 and airway resistance is 6 em H2 0/Usec. A. shows effects of lung
compliance while maintaining standard airway resistance. Range depicted for lung compliance is
from 0.0125 to 0.1 Ucm H2 0 . B demonstrates effects of airway resistance while maintaining
standard lung compliance. Range depicted for airway resistance is from 0 to 30 em H20 /Lisee.

where

IC
fr,,
'

V T = Tidal volume in liters

Rate = Number of breaths per minute
I = Portion of the respiratory cycle devoted to
inspiration (no units)
E = Portion of the respiratory cycle devoted to
ex halati on (no units)
V = Flowrate in liters per minute

For example, given the following parameters:

Inspiration time = 1.5 sec

Respiratory rate = 10 breaths per minute
I:E = 1:3
Tidal volume = 0.5 L
the ftowrate control is adjusted to

V = (VT
=

Rate) X (I + E)
(0.5 X 10) X (1 + 3)
20 L/rnin (= 0.33 Lisee)
X

The Change over from the Inspiratory Phase to the Expiratory Phase

125

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

21 .96
Mouth pressure
(em H,O)

Flow rate
(Li see)

Alveolar pressure
(cmH,O)

Volume
(L)
~------~-------- -,

Time (sec)

1.5

1.5

1.5

FIG 11-8.
Theoretical waveforms produced by constant flow, volume-cycled ventilator. Moment of cycling is indicated by black dot.
3500 em H 2 0
10,479 em H2 0 /Usec

Generated pressure
Ventilator resistance
Standard conditions
Lung compliance
Airway resistance

0 .05 Ucm H2 0
6 em H20 /Usec

Nonconstant Flow Waveform (Sine Wave)

When the flow waveform is that of a half sine wave, the
peak flowrate and the average flowrate are not the same. As
demonstrated in Chapter 5, when the flow waveform is that
of a half sine wave, the peak ftowrate CVpk) is given by the
product of the average flowrate and a factor of 1.57 .
Therefore, when the above parameters are to be maintained the flowrate control must be adjusted to
Vpk

+ E) X 1.57
(1 + 3) X 1.57
(= 0.52 Lisee)

(VT X Rate) X (I

= (0.5 X 10)
= 31.4 Llmin

The theoretical waveforms produced by a volumecycled ventilator that generates a half sine wave flow pattern
are shown in Figure 11-9.

Increasing and Decreasing Flow Waveforms

(Increasing and Decreasing Ramps)
When the flow pattern selected is that of an increasing
or decreasing flow generator, the peak value for the flowrate must also be established. In the case of the increasing
flow generator it is understood that the initial flow will be
50% of the calculated peak value. The flow will then
increase linearly to the peak flow setting, such as in Figure

126

Volume Cycling

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

20.43 .

Mouth pressure
(em H,O)

0.52

Flow rate
(Li see)

20

Alveolar pressure
(em H,O)

Volume

(L)

t
0

Time (sec)

1.5

1.5

......"'---

---, -- -- - --

-,

1.b

FIG 11-9.
Theoretical waveforms produced by nonconstant flow; volume-cycled ventilator. Moment of volume cycling is indicated by black dot.
Tidal volume
Inspiration time
Average ftowrate
Peak ftowrate
Standard conditions
Lung compliance
Airway resistance

0.5 L
1.5 sec
0.33 Usee
0.52 Usee

0.05 UcmHp
6 em H 2 0/Usec

11-10. If a decreasing flow pattern is selected then the

initial flow will be the calculated peak flow. The flow will
then decrease linearly to 50% of the peak flow setting,
such as in .Figure 11-11.
Since the overall flowrate decreases or increases by the
same amount, the peak flow can be determined by the product of the average flowrate and a factor of 1.33. In keeping
with the conditions prescribed earlier, the peak flow can be
determined by:
Rate) X (I+ E) X 1.33
(0.5 X 10) X (1 + 3) X 1.33
26.6 Llmin (= 0.44 Lisee)

Vpk = lYT X

With respect to maintaining tidal volume a.'1d inspiration time, the behavior of the nonconstant flow, decreasing
or increasing flow, and the volume-cycled ventilator is identical to that of the constant flow generator. They differ only
in the shapes of the waveforms generated.

Effects of Lung Characteristics When the Generated

Pressure is Low
With volume-cycled pressure generators, changes in
lung compliance or airway resistance have an adverse effect
on the flowrate, inspiration time, and the pressure developed in the lungs (Figures 11-12 and 11-13). Under vary-

l
The Change over from the Inspiratory Phase to the Expiratory Phase

t
A

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

127

25

Mouth pressure
(em H 2 0)

0.40

Rowrate

(Usee)

.- .
~

~.

20

Alveoar pressure
(em H2 0)

0.5

Volume
(l)

1.5

1.5

Theoretical waveforms generated by microprocessor ventilator in the increasing flow (increasing ramp, accelerating
flow) mode.

";:. __ ,

Tidal volume
Inspiration time
Average flowrate
Peak flowrate
Standard conditions
Lung compliance
Airway resistance

~~,

'

1.5

FIG 11-10.

! , ;t,;.
1
,....--....

Time (sec)

1':"

ct..,

0.5 L
1.5 sec
0.33 Usee
0.44 Lisee

0.05 Ucm H20

6 em H20/Lisee

'

I~~~'..
.

.
,

--

. ,~
- ~

--

I ilK lung conditions, the length of the inspiratory phase depends t:ntirely on the level of pressure generated by the
ddvt: nlt:chanism. Therefore, when the generated pressure
in low, no simple equation can be used to determine the
llowrak rt:quired to maintain a given inspiration time or an
I I . !il tH> . Manipulation of the ftowrate control provides the
w d y method of regulating the length of the inspiratory
phn~c

it is not desirable that a volume-cycled venht: designed to generate a pressure as low as 25 em

If ,(' Such a theoretical ventilator was presented here only
'" IIIIIVIIify the effects of generated pressure and lung chariii h t isl ics on the length of the inspiratory phase. The level
ol gcunatc.:d pressure commonly found in clinical practice
( ' lllll cally,

ti l~ttor

ranges from a high of 3500 em H 2 0 to a low C?f approximately 120 em H2 0.

SUMMARY
A ventilator is said to be volume cycled if the inspiratory phase is ended at the moment a predetermined volume
has been delivered into the patient circuit. At the moment of
cycling, the ftowrate, the time taken to deliver the volume,
and the pressure developed in the patient circuit may all
vary from one respiratory cycle to another. The only parameter remaining constant is the volume preset at the ventilator.

!t
'~

ll
It

128

Volume Cycling

i~

~~

'

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

25

Mouth pressure
(em H 2 0)

0.40

R cwrate
(Lisee)

20

~-=-- I

Alveoar pressure
(em H 2 0)

~
- - --- - - - -- .,

0.5

Volume
(L)

Time (sec)

1.5

1.5

1.5

FIG 11 - 11.
Theoretical waveforms generated by microprocessor ventilator in the decreasing flow (decreasing ramp, decelerating
flow) mode.
Tidal volume
Inspiration time
Average flowrate
Peak flowrate
Standard conditions
Lung compliance
Airway resistance

0.5 L
1.5 sec
0.33 Usee
0.44 Lisee
0.05 L!cm H20
6 em H2 0 /Lisee

The length of the inspiratory phase depends entirely on

the level of pressure generated by the drive mechanism and
on the patient's lung characteristics. When the drive mechanism generates a fixed pattern of flow, inspiration time is
not affected, and the pressure developed during the process
of lung inflation is related to the lung characteristics of the
patient. In conventi onal ventilators, when the generated
pressure is not hi gh enough to maintain a constant pattern of
flow , decrease~ in iung compliance or increases in airway
resistance cause an increase in the length of the inspiratory
phase. In such instances, inspiration time is restored by
increasing the ftowrate.

(/

When the ventilator generates a constant flow waveform and a specific I:E ratio and tidal v~lume are required,
a simple formula is used to determine the exact setting of
the flowrate control:

V = (VT x

Rate) x (I

+ E)

However, the relationship is valid only when the flow

waveform does not vary from the beginning to the end of the
inspiratory phase. Any other flow pattern will give inaccurate results.

CHAPTER

12

J
Time Cycling

......-....

( A ventilator is time cycled when the inspiratory phase is

"-en-ded at the moment a timing mechanism~uilt within the
ventilator, reaches a predetermined value. ~t the moment
of cycling, the pressure developed in thepatient circuit, the
flowrate, and the volume in the lungs may all vary from one
respiratory cycle to another. The only parameter that remains constant is the preset inspiratory time. 2
The timing mechanism can be pneumatic, electromechanical, or electronic and may be found in single- or
double-circuit ventilators. The design of the circuit, however, has no influence on the operation of the time-cycling
mechanism.

TIME-CYCLING MECHANISMS
Pneumatic

,.--Type I
:. A typical pneumatic time-cycling mechanism 3 is shown
in Figure 12-1 . The actual design may vary from one ventilator to another, but the principle of operation is the same.
The system consists of the placement of a balloon valve
between the drive mechanism of the ventilator and the patient circuit. During the inspiratory phase (Fig 12-1 ,A), the
filling of the balloon valve is controlled by the variable
resistance. The variable resistance, labeled "inspiration
time" on the control panel of the ventilator, controls the
time required to inflate the balloon . After a period of time,
the balloon becomes fully pressurized and source gas from
the drive mechanism to the patient circuit is cut off (Fig
12-1 ,B). Hence the changeover from the inspiratory phase
to the expiratory phase is time cycled~~\

132

Type II
Figure 12-2 demonstrates a simplified schematic of a
pneumatically operated time-cycled ventilator. The ventilator
represented schematically is the Bird Mark 24 (Fig 12-3).
The ventilator can be divided into two separate compartments: the exhalation timing compartment and the inspiration timing compartment. Each compartment consists
of a needle valve and a spring-loaded plunger and diaphragm assembly.
Figure 12-2,A shows the ventilator in the expiratory
phase. In this phase source gas is prevented from entering
the patient circuit by the position of the exhalation plunger
and diaphragm. Instead, source gas is directed to the right
of the diaphragm in the exhalation compartment by way of
a needle valve (exhalation time control) .
After a period of time, determined by the position of
the exhalation time control, the exhalation compartment
becomes fully pressurized and the diaphragm and plunger
are moved completely to the left (Fig 12-2,B). When this
happens, source gas is directed to three specific areas:
1. To a line that occludes a vent in the inspiratory timing
compartment
2. To the patient circuit by way of the ftowrate control
3. To another line extending from the ftowrate control to
the left side of the diaphragm in the inspiration timing compartment
During the inspiratory phase, pressure increases in the
inspiration timing compartment. This rate of increase is
governed by the position of the inspiration time needle
valve.

----._

133

The Change over from the Inspiratory Phase to the Expiratory Phase

Source gas

'
'

~Fro m low
pressu re so u rce

,,

Bllooo

==:::-:::J
_tW
_j

==

;
fl

--

,.

~I

INSPIRATION PHASE

-'\

Ball oo n
infl ated

./

'

.' ,
'

IN.SPIR ATION ENDS

'

"-

'
,.

FIG 12-1.
Essential feature of simple pneumatic time-cycling mechanism.

After a period of time the inspiration diaphragm and

plunger are moved completely to the right (Fig 12-2,C).
This action vents the exhalation timing compartment to aF
mosphere by way of a line linking the compartment to the
right side of the diaphragm in the inspiration timing compartment. At that moment the exhalation diaphragm and
plunger return to their original resting position and
1. Source gas to the patient circuit is cut off.
2; Pressure to the vent is discontinued, and the inspiration compartment is returned to atmospheric pressure.
The ventilator is said to be time cycled because the
inspiratory phase is ended by a pneumatic timing mechanism that is totally independent of the patient's lung conditions.
Pneumatic/Fluidic
Figure 12-4 is a simplified schematic of an inspirationtiming mechanism found in a fluidic ally operated ventilatoii
(see Chapter 9 for a review of fluidic devices) .
The time-cycling mechanism consists of a tiny bellows
and plunger/vent assembly positioned outside and at the top
of the canister. A flexible line connects the vent in parallel
to control port C 1 of the flip-flop valve. Pressure in this line

is normally vented to atmosphere so that no gas is directed

to the flip-flop valve. The tension of a spring holds the
entire assembly against a variable cam. Extending from
within the canister and in line with the plunger and bellows
is a free sliding rod.
To initiate the inspiratory phase, a control signal is
applied to C2 of the flip-flop valve (see Fig 12-4). With this
signal the output from the valve switches from 0 1 to 0 2 and
the following occurs:

1
\

1. A continuous control signal is applied to C2 of the \

OR/NOR gate. The OR/NOR gate switches from output 0 1
to output 0 2 and inflates the exhalation valve in the patient --,
circuit (not shown).
\
2. The signal then travels to the inspiration-timing bellows mechanism, where it inflates the canister valve and \
pressurizes the bellows canister at a metered rate.
3. The signal continues onward to the relay valve,
which opens to initiate the inspiratory phase.
Because of the metered resistance in the canister-filling
line, the inspiration-timing bellows rises at a fixed rate dur- ~
ing the inspiratory phase. Once the bottom of the bellows
has risen a distance sufficient to move the sliding rod and
plunger upward , the vent is occluded and pressure in the .--,
flexible line is directed to control port cl of the flip-flop

.'

134

Time Cycling

Inspiratory timing
compartment
Vent

I===?

lvent

_ _ _j

L------------------ -,
To patient circuit

FIG 12-2.
\c hc""t c re prese ntation of Bi rd Mark 2 time cycled ven ti lator.

'
/~

FIG 12-3.
Bird Mark 2 time-cycled ventilator.
p~

Ps

Flip-Flop

vI
Gas pathway
when vent occluded

c2

c,
Cam

,--,

~ +~li====D lnsp~i~~~ 1t1me

'

"

t"'

--Vent

OR/NOR

,_

Plunger

~ Spnng

'--l-1
Sliding
rod

o,.&

To
exhalation
valve

Canister

) ( Resistance

__ ~~------ --- - To tidal volume

Source gas_~
~.- bellows canister

L__j

Relay valve

= Low pressure supply

FIG 12-4.
Schematic diagram of ftuidicall y operated, time-cycling mechanism.

135

136

Time Cycling

valve (pathway indicated by the ghosted arrows). With this

signal the flip-flop valve switches from output 0 2 to output
0 1 , and with this change in output the relay valve closes,
the OR/NOR gate returns to output 0 1 , and inspiration ends.
Inspiration time varies with the distance the bellow~
must travel to make contact with the plunger and occlude
the vent. The position of the plunger assembly is controlled
by rotating the cam via the inspiration time control knob.
Moving the plunger away from the bellows canister increases the length of the inspiratory phase because more
time is required for the bellows to make contact with the
plunger.
Inspiration time could also be controlled by substituting
a variable resistance instead of the fixed resistance in the
canister-filling line. With this arrangement the sliding rod
would not be necessary bc;:cause the plunger could be made
to extend into the caniste; J
__./

Electromechanical

'

, / --.~

' - Fi~e 12-5 is a schematic representation of a doublecircllit,electromechanically operated, time-cycled ventilator. 6

A constant speed electric motor is linked to a mechanical gear box called a variator. Connected to the variator is
an arm, which is attached to the shaft of the piston by a

semirectangular-shaped connecting rod. The speed of the

electric motor is transferred to the variator where the circular speed of the arm is modified by the frequency control
knob. The rotation of the arm imparts reciprocating motion
to the piston in the cylinder.
During the forward stroke of the piston, the pressure
developed in the cylinder is directed to a rigid chamber
where it is used to compress a respiratory bag. The volume
within the bag is forced into the patient circuit. The amount
of pressure squeezing the respiratory bag is governed by the
bag-emptying pressure control knob, which operates a
spring-loaded parallel vent (also described in Chapter 2).
Once the piston has traveled two thirds of the distance
in the cylinder (as shown), the smaller diameter of the
shaft vents the cylinder pressure to atmosphere. The pres-sure surrounding the bag is thus released ami at that
moment the inspiratory phase ends. Although the ventilator
is now in the expiratory phase, the piston com pletes the
final third of the forward stroke before returning.
The ventilator is said to be time cycled because the
inspiratory phas~ always ends at the moment the piston has
traveled two thirds 9f therd15tance in the cvlinder, regardless
of the frequency selected. _)
Volume cycling cannot be considered here because the
exact moment the volume is delivered from the bag is not

'

)' _f'

H
J

~.

Pressure
chamber

Cylinder

Rate control
ln sp1ra:ory phase;

.., 1
I

Expira tory phase '

-r___,-..,

1.....

1/ 3 2/3 3/3

FIG 12-5.
Double-circuit, electromechanical, time-cycled ventilator.

\._,/ '

Bag ernp t; 1ng

pressure co ntrol

The Change over from the Inspiratory Phase to the Expiratory Phase

constant and depends on a number of v "abies. For one

reason, the emptying pressure control is normally set so that
the bag is completely empty before the inspiratory phase
ends. Furthermore, the emptying time of the bag is closely
related to the lung characteristics of the patient. In fact,
decreases in lung compliance or increases in airway resistance will slow the bag emptying time. If the lung conditions are severe enough, the bag may not be completely
empJ)! ,at the time inspiration ends.
this electromechanically operated ventilator the frequency-i-s governed by the control knob of the variator.
Once a specific frequency has been set, the spee.q of the
forward and return ~troke of the piston is constant. !
Since the inspiratory phase ends at the mom'ent the
piston has traveled a specific distance in the cylinder, the
inspiration to exhalation ratio (I:E) must also be constant.
For example, when the piston has completed two thirds
of the positive stroke, the arm has rotated through one third
of its complete revolution. The remaining two thirds of the
revolution must therefore be devoted to the exhalation
phase. In other words, the I:E ratio for this ventilator is
fixed at 1:2.
Taking a simple mathematical approach, given a respiratory rate of 12 breaths per minute, each respiratory cycle
lasts

( ar;

60

5 sec

12

Since one third of the respiratory cycle is devoted to the

inspiratory phase, inspiration time lasts
1/ 3

1.67 sec

and exhalation time lasts

"3 x 5 = 3.33 sec
It is customary to report I:E ratios using unity (1) for
that portion of the respiratory cycle devoted to inspiration.
Given an actual inspiration and exhalation time, the I:E
ratio can easily be calculated using this simple formula:

E = 1

X Actual exhalation time

Actual inspiration time

Using unity for the inspiration portion of the ratio, the exhalation portion must be:
E

3.33
1.67

=2
and therefore the I:E ratio is 1:2.

137

With this procedure it could also be shown that the

same I:E ratio would result regardless of the respiratory
frequency selected.

Electromechanical Mixed-Cycling Mechanism

Another type of electromechanical cycling mechanism
is shown schematically in Figure 12-6. Although the ventilator7 is not strictly time cycled, it is appropriate to consider the cycling mechanism at this time.
An electric motor rotates a large wheel and a cam by
way of a belt. A rod connected off-center to the rotating
cam imparts reciprocal motion to the pivoted lever. A slider
positioned on the pivoted lever transfers the motion to a rod
and piston.
The speed of the motor is variable and at any given
moment governed by the setting of one of the two electrical
resistances. The resistance controls are adjustable. One control is labeled "inhale time" and the other "exhale time."
A three-way switch at the top of the cam determines which
of the two controls will receive, modify, and transmit the
electrical signal to the motor. The function of the rotating
''
cam is to "inform" the switch of the direction the piston is
moving.
l
During the positive stroke of the piston, the switch is in
)
the lower cam (as shown) . In this position the inhale time
control sets the speed of the motor and therefore determines
the length of the inspiratory phase. At the moment the piston completes its positive stroke, the switch is moved to the
outer cam. In this position the inhale time control is deactivated, and the speed of the motor is now governed by the )
setting of the exhale time control.
With this mechanism inspiration time and exhalation .-.....,
time are controlled independently of each other. Therefore
the I:E ratio, the -respiratory cycle, and the respiratory fre- )
quency are all governed by the settings of these controls.
In this ventilator the changeover from the inspiratory )
phase to tl1e expiratory phase is accomplished through both
volume and time. The reason fer this is that the piston must 1
complete its positive stroke in a time determined by the
setting of the inhaie time control. In other words, because
the piston and cam are !inked together physically, it is im- )
possible for the piston to complete its forward stroke and
return while the switch is still in the lower cam. Both must )
occur simultaneously. Furthermore, adjusting the inhale
time control affects the speed of the piston but not the stroh
volume. On the other hand , adjusting the stroke volume
affects the volume delivered bnt not the length of the in
spiratory phase. What does change in both instances, how
ever, is the ftowrate .
The stroke volume is controlled by the volume adju
crank. Rotating this crank moves the slider away from or
closer to the fulcrum of the pivoted lever. Since the pist
rod connects the slider to the piston, the closer the slider is

138

Time Cycling

w
--~,.,,, CI
Check

Inhale time
control

ExhaletimQ
control

Piston

~__Belt

----

Cylinder

Wheel

~~@

___ _.......-...-

--

Electric motor

lever
Slider

FIG 12-6.
Single-circuit, electromechanical, mixed-cycled ventilator. (See text for description.)

moved toward the fulcrum of the pivoted lever, the smaller

the volume delivered, and vice versa.

Electronic Timers
'-

Under this lleading only the time-cycling mechanism is

considered. The factors that determine the volume delivered
at the moment of cycling are investigated below under clinical considerations.

Inspiration Timer 8
The simplest method in which time cycling can be accomplished electronically is shown schematically in Figure
12-7 . The mechanism consists of an electronic timer, circuit board, and solenoid. During the inspiratory phase the
solenoid is open and gas from the drive mechanism is directed to the patient circuit. After a period of time determined by the setting of the inspiration time control, an
electrical signal is sent to the solenoid, which closes to end
the inspiratory phase. To control the respiratory cycle, rate ,
and I:E ratio, an exhalation timer is also present.

Rate and Inspiration Timer 9 .

The timing mechanism in Figure 12-8 is similar to the
inspiration titne'r .in Figure 12-7, where the length of the inspiratory phase' is controlled directly by the setting of the inspiration time control. The only difference between the two is
that in Figure 12-8 exhalation time is not directly controllable
but given as a result of the rate and inspiration time settings.
Given a rate and inspiration time, the electronic circuit uses the
following formula to determine how long the exhalation phase
is to last:
.
.
Ehl
x a at10n time

60
= -R
ate

...
nsprrahon time

Given a rate of 10 breaths per minute and an inspiration

time of 1.5 seconds, exhalation time is automatically set for

Exhalation time

= ~~ -

= 4 .5 sec

1.5

The Clumge over from the Inspiratory Phase to the Expiratory Phase
Inspiration time
control

139

Exhalation time
control
I

,.-

- ...,--I
-,
~

,- - <J-1

r<l-,

L-- _

_.

~.&
Electronic
circuit

' ,.

Solenoid

Source gas __..

__,..To patient circuit

FIG 12-7.
Time-cycling mechanism consisting of simple electronic inspiration timer.

Inspiration time
control

L.------+1:1

____Q

_____.I El~~~.;'

L--

Soleooid
~

Source gas_,..

To patient circuit

FIG 12-8. Time-cycling mechanism consisting of electronic inspiration time and rate controls.

The l :E ratio in this time-cycling mechanism is a function of rate and inspiration time. Once exhalation time is
determined, the I:E ratio can be calculated quite easily with
lhc formula presented earlier:
E

= 1 X 4.5
1.5
3

'

Since the "I" portion of the ratio in this relationshiQ is

1
unity (I = 1), the I:E ratio is I :3.
1

Rate and Percent Inspiration Time Controls 10

In some ventilators inspiration time is not controued
directly but instead governed by the setting of rate '"""'lld
percent inspiration time controls (Fig 12-9). Given a spe-

140

Time Cycling
Rate
control

Percent of inspiration
time control

II

LL
+---

.....

-+

Electronic
circuit

1
Solenoid

Source gas . _ . .

......,.. To patient c ircuit

FIG 12-9.
Electronic time-cycling mechanism consisting of rate and percent inspiration time controls.

cific I:E ratio, a simple formula determines the exact setting

of the percent inspiration time control:
Percent inspiration time

= I+
- 1- E x

100

When an I:E ratio of 1:3 is desired, the percent inspiration

time control is set for
Percent inspiration time

=-

1
-

x 100

75% of the respiratory cycle must be exhalation time.

1
Therefore the I: E ratio is 1: 3.
The length of the inspiratory phase is also governed bv,
the setting of the rate control. However, the rate control ha...
no effect on the I:E ratio. If we return to our original ex --...
ample and increase the rate to 20 breaths per minute, the
inspiratory phase would now last
"""'60
. . time
.
=
x 0 .25
Insp1rat10n
20

= 0.75

= 25%
For a specific example, say that the rate control is set to
deliver 10 breaths per minute and the percent inspiration
time control is adjusted to 25% . The electronic circuit
"looks" at the control settings and sets up this relationship
to determine inspiration time:
.
. t"
I nsp1ra
1on time

= -60Rate

. . . time
.
Percent msp1rat10n

Exhalation time would automatically be adjusted to

Exhalation time =
=

10

1.5 sec

The I:E ratio in this time-cycling mechanism is a function of the percent inspiration time setting. In the example,
the percent inspiration time setting is 25%. The remaining

~~ -

0. 75

2.25 sec

but the I:E ratio would remain constant at

Substituting:
60
. .
I nsp1ration time = - X 0.25

sec

X 2.25
0.75

= 3

= 1:3
Rate and I:E Ratio Controls 11
In other time-cycled ventilators inspiration time is governed by the setting of the rate and I:E ratio controls (Fit_'
12-10). With this mechanism the length of the inspirato~,
~

The Change over from the Inspiratory Phase to the Expiratory Phase
Maxi mum inspiration
time con tro l

Rate
contro l

I:E ratio
co ntrol

II

f+--

141

I+~

,....

T1

s afety system

'
Electronic
circuit

1~
Source gas _ _ .

_ _ . To patient circuit

FIG 12-10.
Electronic time-cycling mechanism consisting of rate and I: E ratio controls. Presence of maximum inspiration time control prevents
inadvertent selection of prolonged inspiration time.

phase is calculated electronically with the following formula:

..
.
60XI
InsprratJ.On time = Rate X (I + E)
When a respiratory rate of 10 breaths per minute is
required along with an I:E ratio of 1:3, time cycling occurs
in
Inspiration time

10

60 X 1
X ( + 3)
1

1.5 sec

From this relationship we can also see that any changes

to the rate or to the I:E ratio will also affect inspiration time .
Keeping the I:E ratio constant, inspiration time doubles
when the rate is halved:
Inspiration time

60 X 1
X (1 + 3)

3 sec

Keeping the rate constant, increasing the I:E ratio from 1:3
to 1:1 would also double inspiration time.

CLINICAL CONSIDERATIONS
During controlled ventilation the single most important
parameter to consider is the volume exchange in the lungs.
With some time-cycled ventilators the tidal volume is not
controlled directly but determined by the product of flowrate and inspiration time. In others the tidal volume or
minute volume, rate, and I:E ratio are selected and the
ventilator automatically assigns the fiowrate.
However, on most time-cycled ventilators a direct
access to a fiowrate control is provided, and the setting
of this control and the setting of the time-cycling mechanism determine the volume delivered at the moment of
cycling.
With these time-cycled ventilators all parameters except for the fiowrate are selected at the discretion of the
operator. The fiowrate setting is not arbitrary and must be
calculated. The procedure is similar for all time-cycled ventilators.
In the case of the simple inspiration timer, assuming the
ftowrate control is calibrated in liters per minute (L!min),
the setting is determined by the following formula:
x
.
_
Volume (1)
Flowrate - In . .
.
( )
60(sec/mm)
sprratwn tlme sec

142 )Time Cycling

To deliver a volume of 0.5 Lin an inspiration time of

1.5 seconds, the flowrate (V) must be adjusted to

= 20L!min (= 0.33 Lisee)

The respiratory rate and I:E ratio are then determined

by the setting of the exhalation timer. When inspiration time
is 1.5 seconds and an I:E ratio of 1:3 is desired, the exhalation timer is set at 3 X 1.5 = 4.5 sec, or in other words,
three times the setting of the inspiration time control. This
gives a respiratory cycle of 1.5 + 4.5 = 6 sec and a respiratory rate of 60/6 = 10 breaths per minute.
This procedure is accurate but somewhat cumbersome
and time consuming. The alternative is to perform the operation in one step using the following formula:

V = Volume

Rate

X (I

When the volume is expressed in liters and the rate in --..,.

breaths per minute, the unit for flowrate (V) is liters per
minute (Limin).
It is important to emphasize that this relationship is
valid only when the flow pattern generated by the drive '
mechanism is constant and does not vary with changes in . . . ,
lung conditions.
Since the volume delivered from a time-cycled venti- ,
lator is determined by
Volume

Flow x Time

when inspiration time is constant, the volume delivered is

determined by the flowrate. However, during the inspiratory
phase, the flowrate does not necessarily remain constant but
at times varies as the lungs fill. The extent of the change in

DECREAS ING COMPLIANCE

Standard condi tions

Volume
(L)

0.4

0.3

...

0.2 +----.,.c---,r----,-----.40
10
20
30

0 PG = 3500 em H2 0
6 PG = 100 em H 2 0

0 Pr: = 25 em H 20

INCREASING RESISTANCE

Volume
(L)

+ E)

0.4

0.3 -+---- -...,--- ---,

10
20
Mouth pressu re
rem H ..Q )

FIG 12-11.
Time cycling: Effects of generated pressure and lung characteristics on volume delivered at moment
of cycling. Cycling occurs when inspiration time equals 1.5 seconds. For standard lung conditions.
lung compliance is 0.05 Llcm H 20 and airway resistance is 6 em H 2 0/Lisee. A shows effects of lung
compliance while maintaining standard airway resistance. Range depicted for lung compliance is
from 0.0125 to 0.1 Llcm H20. B shows effects of airway resistance while maintaining standard lung
compliance. Range depicted for airway resistance is from 0 to 30 em H2 0 /Lisee.

CHAPTER14

Classification and Ventilatory

Adjuncts

Once the changeover from the inspiratory phase to the expiratory phase is complete, the ventilator must allow the
lungs to empty. This represents the only function of the
ventilator in the expiratory phase. 1
There are a few ways in which the ventilator can allow .
the lungs to empty, and therefore it is also possible to classify the ventilator during this phase. The three most common classifications are listed below:
1.
2.
3.

Constant atmospheric-pressure generator

Constant negative-pressure generator
Constant positive-pressure generator)

' THE CONSTANT ATMOSPHERIC-PRESSURE

GENERATOR
During the expiratory phase the ventilator is classified
as a constant atmospheric-pressure generator when the lungs
are allowed to empty passively to atmospheric pressure. Be"
cause no positive pressure remains in the lungs during the
quiescent portion of the expiratory phase, the ventilator is
said to provide zero end-expiratory pressure, or simply,
ZEEP. All mechanical ventilators must provide this option.
During the ZEEP option the time required for the lungs
,
to completely empty is proportional to the product of lung
compliance and total resistance, that is, the time constant of
~, the system (see Chapter 3 for a review of time constants).
Assuming no resistance exists or is placed at the exhalation
\
port of the patient circuit, the emptying of the lungs varies
with the lung characteristics of the patient. This is demon' ' strated in Figure 14-1, A where the exhalation phase is
followed for 3 seconds.
Figure 14-1, B demonstrates that with decreases in
lung compliance, the time constant decreases and the emptying of the lungs is accelerated. Figure 14-1, C shows that
~

with increases in airway resistance, the time constant of the

lungs increases and the lungs empty more slowly. The time
constant is indicated by the broken diagonal line.
Expiratory Resistance

/
( To mimic "pursed-llp" breathing as seen with patients
suffering from chronic obstructive pulmonary disease
(COPD), some ventilators have the option of adding resistance to retard expiratory flow from the lungs. The procedure
is thought to facilitate emptying of the lungS-b-r ''splinting''
the airways and reducing airway collapse. 2___..,)
Methods
The method of providing expiratory resistance is simple and involves the application of mechanical resistance to
the exhalation port of the breathing circuit. In Figure 14-2
the variable resistance consists of a cap (also called "retard
cap" on Bird ventilators, described in Chapter 28), which
fits tightly on the exhalation port of the breathing manifold.
The cap has apertures of varying diameters , which are
aligned on the exhalation port so that the expired gas must
pass through one of the openings. Rotating the cap to the
smallest opening provides maximum expiratory resistance.
Figure 14-3 demonstrates another method of providing
expiratory resistance. Such a system is found in the Bennett
MA-J-,ventilator, presented in Chapter 24.
, During the exhalation phase the position of the pilot
val've-allews the exhalation balloon valve to empty to atmospheric pressure via the fixed and variable resistance
(labeled as expiratory resistance control). Normally, the expiratory resistance control is wide open and the rate at
which the exhalation valve empties is not impeded. In this
state no resistance is imposed on the exhaled flow and the
lungs empty passively to atmospheric pressure. Expiratory
resistance results when the control knob is adjusted to nar163

164

Classification and Ventilatory Adjuncts

A

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

Mouth pre ssure

(em H 20 )

Flow rate
(Lisee)

Alveolar pressure
(em H 2 0)

0.5
I

Volume

(L)

I
I
I
I

2
Time (sec)

FIG 14- 1.
Theoretical wavef?rrns of expiratory phase produced by constant atmospheric pressure generator. Lungs were previously inflated with
volume of 0.5 L. Mouth pressure and alveolar pressure were at equilibrium at moment of cycling from inspiratory phase. Broken
diagonal line represents time constant of system:
Generated pressure
Ventilator resistance
Standard conditions
Lung compliance
Airway resistance

0 em H 2 0
2 em H 2 0 /Lisee

0.05 L!cm H2 0
6 em H2 0/Lisee

row the channel opening for the passage of gas from the
exhalation balloon valve. In such instances the exhalation
valve deflates slowly and delays the emptying of the lungs.
Maximum resistance is accomplished by rotating the control
knob and fully occluding one opening. When this is done,
all of the gas from the exhalation valve must pass through
the fixed resistance.
The capacitance (also called a booster) acts as a gas
reservoir and provides a means of regulating a smooth and
orderly . flow of gas from the exhalation balloon valve.
When fully charged, the exhalation balloon valve holds less
than a few cubic centimeters of gas : We can appreciate that
without the booster it would be impossible to control the

emptying of a few cubic centimeters of gas over a period of

several secon~

. Clinical Considerations
The use.of expiratory resistanc~ has met with varying
degrees of success. Expiratory resistance increases the mean
airway pressure, impedes cardiovascular function, and also'
promotes the dangers of air trapping. Air trapping occurs
when the lungs are reinflated before they have a chance to
completely empty (Fig 14-4). The likelihood of air trapping
increases with the amount of mechanical expiratory resistance applied . and on the lung characteristics of the
patient. 3 - 7

f lassification and Ventilatory Adjuncts

A

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

2G.,

Mouth pressure
(em H 2 0)

Fl owrate
(Lisee)

20
_ A lveo lar pressure
;
(em H 2 0)

0.5

Vo lume
\

(L)

\
\

I
\

2
Time (sec)

FIG 14-1.
Theoretical waveforms of expiratory phase produced by constant atmospheric pressure generator. Lungs were previously inflated with
volume of 0.5 L. Mouth pressure and alveolar pressure were at equilibrium at moment of cycling from inspiratory phase. Broken
diagonal line represents time constant of system:
Generated pressure
Ventilator resistance
Standard conditions
Lung compliance
Airway resistance

0 em H 20
2 em H20/Lisee

0.05 L!cm H2 0
6 em H2 0/Lisee

; ) . the channel opening for the passage of gas from the

exhalation balloon valve. In such instances the exhalation
J ve deflates slowly and delays the emptying of the lungs.
~ximum resistance is accomplished by rotating the control
h..,,ob and fully occluding one opening. When this is done,
1
of the gas from the exhalation valve must pass through
the fixed resistance.
!
The capacitance (also called a booster) acts as a gas
reservoir and provides a means of regulating a smooth and
' derly flow of gas from the exhalation balloon valve.
When fully charged, the exhalation balloon valve holds less
~an a few cubic centimeters of gas. We can appreciate that
_ ~ithout the booster it would be impossible to control the

')

emptying of a few cubic centimeters of gas over a period of

several seconds)
/.

Clinical Considerations
The use of expiratory resistance has met with varying
degrees of success. Expiratory resistance increases the mean
airway pressure, impedes cardiovascular function , and also
promotes the dangers of air trapping. Air trapping occurs
when the lungs are reinflated before they have a chance to
completely empty (Fig 14-4). The likelihood of air trapping
increases with the amount of mechanical expiratory resistance applied and on the lung characteristics of the
patient. 3 - 7

Airway
pressure

Time--+-

Air trapping

FIG 14-4.
Air trapping occurs when inspiratory phase begins before lungs have completely emptied.

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

20
Mouth pressure
(em H 20)

\
\

Flowrate
(Lisee)

0.77

20
Alveolar pressure
(em H 20)

0.5

'

Volum e
(L)

' '\\

-...

Time (sec)

FIG 14-5.
Theoretical waveforms of expiratory phase produced by constant atmospheric pressure generator having a high resistance. Lungs were
previously inflated with volume of 0.5 L. Mouth pressure and alveolar pressure were at equilibrium at moment of cycling from inspiratory
phase. Broken diagonal line represents time constant of system:
Generated pressure
Ventilator resistance
Standard conditions
Lung compliance
Airway resistance
~.

0 em H20
20 em H 20/Usec

0.05 Ucm H2 0
6 em H20/Usec

The Expiratory Phase

161

lung pressure is held abo"~<,e atmospheric pressure throughout the respiratory eye~ The use of positive expiratory
pressure was reported as early as 1959 1 and continues to
play a major role in modern ventilatory techniques . 11 - 16
Positive expiratory pressure increases the mean airway
pressure and to some degree alters cardiovascular function.
The effects on the cardiovascular system are not uniform
and result when the intrapulmonary pressure is reflected
intrathoracically. Normally, increases in the mean airway
pressure cause a decrease in cardiovascular function, but
this is not always the case. Therefore the mean airway pressure should not be taken as an absolute indicator of intrathoClinical Considerations
racic pressure. In disease states associated with severe reThe use of NEEP is aimed at reducing the mean airway
ductions in lung compliance the transmission of
pressure and minimizing the cardiovascular effects of interintrapulmonary pressure to the intrathoracic space is not the
mittent positive-pressure ventilation. The mean airway pressame quantitatively.
Consider the simple lung thorax model in Figure 14sure decreases when negative pressure is applied to the airway
8,A, where a respiratory bag (lung) is suspended within a
during the exhalation phase. As demonstrated by the waverigid chamber (thoracic space). The bottom of the chamber
forms of Figure 14-7, the maneuver accelerates the emptying
of the lungs, regardless of the existing lung conditions.
is sealed with a flexible diaphragm (chest wall). The downAlthough NEEP has been shown to reduce cardiovascular . . ward force of a small weight connected to the center of the
effects of controlled ventilation, its use has also been associdiaphragm generates a subatmospheric pressure of - 5 em
ated with air trapping, 9 10 especially in patients with COPD.
H2 0 around the bag and represents intrathoracic pressure.
Although the content of the bag is at atmospheric pressure,
Consequently, the use ofNEEP has been abandoned.
it is partially expanded by the negative pressure surrounding
it. The volume present in the bag is considered to be the
functional residual capacity (FRC).
THE CONSTANT POSITIVE-PRESSURE
The compliance of the lung and the compliance of the
GENERATOR
chest wall are each given an arbitrary value of 0.2 Ucm
( _Jn contrast to the constant negative-pressure generator,
H 2 0. Lung compliance (CL) and chest wall compliance
a constant positive-pressure generator is one in which the
(Ccw) make up total compliance (Cr) and are related in

Method
One common method of generating NEEP is shown in
Figure 14-6. In" this schematic a Venturi is connected to the
exhalation port in such a way that negative pressure is created in the circuit and thus reflected in the lungs. The
amount of negative pressure generated is governed by the
position of the needle valve, which controls the flow of gas
to the jet of the Venturi. The greater the gas flow, the greater
the negative pressure. The mechanism operates during the
exhalation phase only. During the inspiratory phase gas to
the Venturi is interrup~

Pressure manometer

Negative pressure
control

Source gas
'

--~- ---

-...;;.;;......;;;'--,::--.....-~
U ---=-=-

connection

''

Exhaled gas

FIG 14-6.
Use of a Venturi to generate negative pressure during expiratory phase.

168

Classification and Ventilatory Adjuncts

18
r-

Mouth pressure
(em H 20)

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

-2 h~=

/.

Flowrate
(Lisee)

1.25
18

~=

Alveolar pressure
(em H 2 0)

-2
0.5

Volume
(L)

\
\
\

\
\

Time (sec)

FIG 14-7.
Theoretical waveforms of expiratory phase produced by constant negative-pressure generator. Lungs were previously inflated with
volume of 0.5 L. Mouth pressure and alveolar pressure were at equilibrium at moment of cycling from inspiratory phase. Broken
diagonal line represents time constant of system:
Generated pressure
Ventilator resistance
Standard conditions
Lung compliance
Airway resistance

- 2 em H2 0
10 em H2 0 /Usec

0.05 Ucm H20

6 ern H2 0/Usec

such a way that they are added reciprocally. Total compliance of this system is calculated as follows:

0.2
0.2

0.2

+ 0.2

Since the lungs expand by 0.5 L, the thoracic cage

must also expand by the same amount. Hence the intrathoracic pressure (PTX) must increase to a level that corresponds to the increase in volume (V) divided by the compliance of the chest wall (Ccw); that is,

PTx=c-

In Figure 14-S,B, 5 em H2 0 positive end-expiratory

pressure (PEEP) Is applied to the airway. The FRC increases
by a volume (V) of

V =

PEEP
= 0.1 L!cm H2 0 x 5 em H2 0
= 0.5 L
CT X

cw

Substituting:

0.5 L
0.2 L!cm H20

= 2.5

em H2 0

The Expiratory Phase_

STANDARD CONDITIONS
Airway pressure

169

STANDARD CONDITIONS + 5 PEEP

Respiratory bag ----1

(lung)

Rigid chamber-

-5 em H2 0
Intrathoracic
pressure

LUNG COMPLIANCE HALVED+ 5 PEEP

LUNG COMPLIANCE HALVED+ 7.5 PEEP

FIG 14-8.
Lung/thc>rax model showing relationship between airway pressure and intrathoracic pressure. (See text for description.)

The original intrathoracic pressure was -5 em H2 0,

and it now increases by 2.5 em H2 0. Therefore the new
intrathoracic pressure must be:
-5

+ 2.5 = -2.5 em H20

In Figure 14-S,C lung compliance (not total compliance) is reduced by one half, and the numerical values for
the FRC and pressure were obtained using the procedure
just described.
With this simple experiment we can see that although
the same amount of PEEP was applied to the airway, less
pressure was transmitted intrathoracically because the FRC
could not be maintained at its original level. In Figure 14S,D lung compliance is still halved, but the FRC was restored to 0.5 L by increasing PEEP to 7.5 em H2 0 . If we
compare Figure 14-S,C with Figure 14-S,D, we can fur-

ther appreciate that the level of pressure applied to the airway is not necessarily the pressure reflected intrathoracically. In fact, if the respiratory bag in Figure 14-8 were
substituted for a bag that could not expand, the pressure in
the rigid container would not change regardless of the
amount of pressure applied within the bag.
Clinically speaking, it is with patients suffering from reductions in lung compliance that positive expiratory pressure
has been shown to increase lung compliance, reduce intrapulmonary shunting, and improve arterial oxygenation without
significant compromises to the cardiovascular system.
The traditional range of positive expiratory pressure is
between 5 and 15 em H20. However, there are no hardand-fast rules for determining the exact level. The level
must be tailored to meet the needs of the individual
patient. 17 - 26 In this respect, positive expiratory pressures

_,

170

Classification and Ventilatory Adjuncts

.xceeding 15 em H 20 and in the range of 30 to 40 em H2 0

have been used effectively. 27 28

provide all the benefits of CPAP therapy while at the same,

time reducing the mean airway pressure. During EPAP ther- \!
apy the work of breathing is significantly greater than during conventional CPAP therapy.
of Positive Expiratory Pressure
4 . IMV and PEEP: intermittent mandatory ventilation
~ There are at least four different forms of positive expiraand PEEP is a combination of PEEP and CPAP. As the term
implies , during this mode the patient receives controlled
.ory pressure, and each is designated by a unique acronym 29 :
/ breaths intermittently between spontaneous breaths. During
the controlled and the spontaneous breatbs, airway pressure
l . PEEP: positive end-expiratory pressure refers to
,-'-)olding positive pressure in the lungs during the exhalation
never drops below atmospheric pressure ) Figure 14-9,D).
phase on controlled or assisted ventilation. During this
(IMV is detailed in Section Six .)
/
- node airway pressure never drops below atmospheric presMost current mechanical ventilators have built-in
;ure (Fig 14-9,A) . Assisted ventilation implies that the
mechanisms to provide PEEP, CPAP, and IMV. Less sophis.- 'entilator responds to an attempt at inspiration by the paticated ventilators can be easily modified to provide any or
all of the options. CPAP and EPAP can also be provided
ient and delivers a controlled breath. The procedure is dis~
without a ventilator attached.
ussed in Section Five under patient cycling.
2. CPAP: continuous positive airway pressure is a
~chnique that maintains positive pressure in the lungs dur. ~ 1g spontaneous ventilation. During this mode airway presBeneficial Effects of Positive Expiratory Pressure
Ire never drops below atmospheric pressure (Fig 14-9,B).
3. EPAP: expiratory positive airway pressure is similar
There is no question about the value of positive expiratory pressure in improving arterial oxygenation. Exactly
CPAP in that the patient breathes spontaneously without
how this beneficial effect is achieved, however, is still not
mtrolled breaths. However, during EPAP therapy positive
clear, and many theories have been proposed. The mecha~ rway pressure is maintained during exhala~ion only. Dur\ g a spontaneous inspiration the patient must lower the
nisms that are currently thought responsible for the im_. -way pressure to or below atmospheric pressure to inspire
provement of arterial oxygenation with this form of therapy
' Ia! air (Fig 14-9,C). This form of therapy is thought to
are examined in the following paragraphs.

(~orms

7-

-.~

PEEP

CPAP

Airway
pressure

EPAP

c
"""'

IMVand PEEP

Airway
pressure

Time---

1- I -1-

-1- I -1-

FIG 14-9.
Four forms of positive expiratory pressure.

-1

1- I -1-

-1- I -1-

-1

The Expiratory Phase

l.:tfccts on Pulmonary Function

Functional Residual Capacity.-Positive expiratory
pr rN~ rrrc increases FRC, 30 - 35 and the FRC increases lint'nrl y with the amount of pressure applied . The FRC has
l l('r l\ \'S t 11nated to increase at a rate of 400 ml for each 5 em
11 1 ( >applied . 36 In the presence of restrictive lung conditions
where a reduction in the FRC is observed, the application of
po ~ iti vc expiratory pressure aimed at returning the FRC
toward normal increases the number of alveoli that remain
opt~ n and available for gas exchange during all phases of the
rcNpiratory cycle.

n
n

d
g
e

171

Effects on Gas Exchange

High concentrations of oxygen for prolonged periods
result in cellular toxicity (oxygen toxicity). Pulmonary effects are seen after 48 hours of continuous exposure to
oxygen levels greater than 50% . 39 Positive expiratory pressure provides an effective means of improving arterial oxygenation without increasing the inspired oxygen concentration. The increase in the FRC during positive expiratory
pressure provides more area for gas diffusion and thus improves gas exchange. 40 .4 1

Effects on Ventilation/Peifusion Ratio

n
r
j

I .ung Compliance. -An increase in lung compliance

iii normally observed during the use of positive expiratory
Jrr ssurc. However, lung compliance decreases when exces; "' vc levels are used. During controlled ventilation, a tech: ""luc described as best PEEP provides a method of deter~ ntining the highest level of positive end-expiratory pressure
~ lllllt produces maximum lung compliance. 37
In this technique the ventilator is adjusted to provide an
i inspiratory plateau (see Time Cycled, Volume Limited in
'huptcr 13). Static compliance is then detehnined by di~ vlding the patient's tidal volume by the difference between
~ the plateau pressure and PEEP:

i(
f

CsT

= P pit

VT
-PEEP

1wlwrc
~

VT = Tidal volume in liters

CsT = Static compliance in L/cm H 2 0
P pit = Plateau pressure in em H 2 0
PEEP = Positive end-expiratory pressure
in em H 20
When the baseline value for static compliance is establbhcd , the level of PEEP is increased and static compliance
)s again calculated. The procedure is repeated until a further
ill\.:rcmcnt of PEEP does not improve lung compliance. The
jlighcst level of PEEP before lung compliance falls is con~ ldncd to be best PEEP.
Dead Space to Tidal Volume Ratio.-The dead space
volume ratio (V 0 /VT) estimates the so-called wasted
ventilation. Wasted ventilation increases with the number of
iurg units that are well ventilated but poorly perfused. Inlreasing levels of positive expiratory pressure decreases the
V11 /VT ratio. 37 38 The greatest reduction is seen when the
li ghcst static lung compliance is reached. Positive expirailry pressure beyond this point decreases cardiac output,
iltd the V0 /VT ratio increases.
~ , 1ida I

A mismatch normally exists between ventilated and

perfused areas of the lungs. Positive expiratory pressure
improves the ventilation/perfusion ratio (\lfQ) by distributing more ventilation to areas of the lungs that have high V/Q
ratios. 42 43
Harmful Effects of Positive Expiratory Pressure
The harmful effects of positive expiratory pressure are
generally the same as those described for intermittent
positive-pressure ventilation (IPPV) in Chapter 1. There is
no safe level of positive pressure in the lungs. Excessive
levels of positive expiratory pressure not only overdistend
the lungs and increase the risk of barotrauma but also raise
intrathoracic pressure and impede cardiovascular function.
Other effects of positive expiratory pressure include disturbances in renal function.
As a working rule, the lowest level of positive expiratory pressure to achieve an arterial oxygen tension (Pao2 ) of
60 to 80 mm Hg at an inspired oxygen concentration (Fio2 )
of less than 0.5 is advocated?

Pulmonary Effects
Barotrauma. 44 - 46- The term suggests that physical
damage to the lungs occurs as a result of pressure. Despite this
definition, damage to the lungs is more likely associated with
alveolar overdistension rather than with pressure. 47 If the alveoli cannot be hyperinflated, lung rupture is unlikely to occur.
The consequences of barotrauma include the following:

1. Subcutaneous emphysema is a condition where leakage of air from the alveoli finds its way into the mediastinum and expands out beneath the tissues of the neck. Air in
the mediastinum (mediastinal emphysema) can lead to cardiac tamponade and decrease cardiac output. Apart from
alveolar rupture, subcutaneous emphysema can also result
from high levels of positive pressure delivered via a tracheostomy tube. Quite often subcutaneous emphysema is a sign
of a pneumothorax .
2. Pneumothorax is defined as the presence of air in the
pleural space. Alveolar rupture leading to air in the pleural

172

Classification and Ventilatory Adjuncts

STANDARD CONDITIONS

COMPLIANCE HALVED

RESISTANCE DOUBLED

25

Mouth pressure
(em H20)
+5

''

'

Flowrate
(Lisee)
~

2.22

------

25

,~

,..----.,,

Alveolar pressure
(em H 2 0)
+5

0.5
,.--.

Volume
(L)

I
I

2
Time (sec}

FIG 14-10 . .
Theoretical waveforms of expiratory phase produced by constant positive-pressure generator. Lungs were previously inflated with volume
of 0.5 L. Mouth pressure and alveolar pressure were at equilibrium at moment of cycling from inspiratory phase. Broken diagonal line
represents time constant of system:
Generated pressure
Ventilator resistance
Standard conditions

+5 em HzO
3 em H2 0/Usec
0.05 UcmHzO

Lung compliance
Airway resistance

6 em H 20/Usec
GOOD PEEP VALVE

POOR PEEP VALVE

''

\,,E'P7 '''''""''

Airway pressure

''

PEEP-

Time-

-+I+

FIG 14-11.
Difference between good and poor

P~EP

valve . PEEP valve should not increase expiratory resistance.

-+I

The Expiratory Phase

crrcssure in the thoracic cavity beyond at' and causes varying degrees of lung colRESISTANCE
.ty of lung collapse depends on the amount
in the thoracic space. Pneumothorax is a
us complication than subcutaneous emphy:s immediate medical attention.
,.-,-,--~oJar Effects48-6I
+--"'------->ive levels of positive expiratory pressure
+--~-=o the intrathoracic space, cardiac output
)f a reduction in the venous return to the

Jre known as optimal PEEP, the highest

:xpiratory pressure that produces the greatntrapulinonary shunting is determined. 62
.que baseline values for cardiac output and
rapulmonary shunting is determined. The
essure is then incremented until the max~
,
n intrapulmonary shunting is achieved.
\
ite often during this procedure , cardiac out\
e desired reduction in shunt is achieved. In
\
+--~---es , pharmacologic intervention and intrainistration are required to maintain cardiac
I

ion63,64

\
I

ratory pr~ssure increases the level of ane (ADH) and changes renal -perfusion.
+-----.~..-~eduction in urine output is commonly as3
:itive expiratory pressure. A fall in urine
1 as 40% has been reported with a positive
37

.
. fl t re of 10 em H 2 0 .
Diuretics are often
1gs were prevwus1y m a < .
.
.
inspiratory phase. Brokeltam satisfactory unnary flow.
I

device should not increase expiratory resistance but should

allow the lungs to reach the prescribed PEEP level in the
shortest time possible . Otherwise , unnecessary increases in
the mean airway pressure will result. Figure 14-11 demonstrates the criteria used to contrast between a good and a
poor PEEP device.
There are many forms of PEEP devices. Some are built
within the ventilator while others are connected externally
to the exhalation port of the ventilator circuit. Although
their overall function is the same, the essential features of
the traditional sort will be examined beginning with those in
the category of external PEEP devices.

External PEEP Devices

Before we begin, it should be mentioned that whenever
an external PEEP device is in place, the level of PEEP is
displayed on the ventilator manometer or by an external
manometer interposed between the PEEP device and the
patient connection. The level of PEEP is not displayed on
the device itself.
Underwater Seai.-Figure 14-12 demonstrates how
PEEP is accomplished with the use of a simple water-filled
container. In this procedure a flexible hose connects the
exhalation port of the circuit to an open-ended tube extending into a container of water. During the initial portion of
the exhalation phase the patient's exhaled gas travels down

Exhaled gas

,,,

III

- R igid tube

vices to Provide PEEP

~EP mode of th~rapy lung pressure is held
c pressure throughout the respiratory cy:hed , the level of PEEP remains constant
fluenced by the lung characteristics of the
R PEEP VALVE
~monstrated in the theoretical waveforms
where 5 em H 20 PEEP is applied to the
I
~forms clearly indicate that the level of
I
Expiratory resist<
.
.
.
\
ed regardless of lung compliance or arr\
ung characteristics merely determine the
'\
lungs empty to reach the level of PEEP.
'' /
' ..... -=----led as exhalation against a threshold reprocedure allows the lungs to empty to a
- - - - - - - -el of pressure. The term threshold resistor
construed to imply that expiratory resis+Jided with the maneuver. In fact, PEEP
E
:ntiated by the amount of mechanical rese on the exhaled flow. 65 The ideal PEEP
tiratory resistance.

173

Vent

; \--

~
______ t _
- c -:: --

FIG 14-12.

Underwater seal PEEP device.

Water line

,-

,--.

174

Classification and Ventilatory Adjuncts

the tube, bubbles through the water, and is vented to atmosphere. The exhalation process continues until lung pressure
empties to a level equal to the pressure exerted by the
weight of the water in the tube. At that moment bubbling is
no longer observed, and positive pressure (PEEP) remains
in the lungs .
The level of PEEP is controlled by the position of the
tube in the water. The deeper the tube is in the water, the
greater the level of PEEP. The PEEP level is displayed on
the ventilator manometer (not shown) or by connecting an
external manometer to sample the pressure in the flexible
hose.
The Emerson PEEP Valve. 66-Another mechanism
that uses water to generate positive expiratory pressure is
shown in Figure 14-13. In this system the PEEP mechanism is an integral part of the exhalation valve. Normally,
when no water is present in the column, the patient's exhaled gas is directed to the underside of the diaphragm,
which lifts and allows the lungs to empty passively to atmospheric pressure. When water is placed in the column,
the lungs do not completely empty and are held inflated to
a level that corresponds with the weight of the' water on the
exhalation diaphragm. The amount of PEEP is displayed on
the ventilator manometer and is controlled by varying the
amount of water in the column.

ring-Loaded Valve.-A spring-loaded valve such

as.shown in Figure 14-14 is connected to the exhalation
port of the circuit. The tension of an adjustable spring applies a continuous force against a disk and the exhalation
port. Initially, lung pressure overcomes the tension of the
spring, lifts the disk, and the lungs begin to empty. PEEP
results when lung pressure is no longer sufficient to offset
the closing force of the spring, and the exhalation port is
occluded. The PEEP is displayed on the ventilator manometer and is controll~d by adjusting the tension of the spring.
Dead-Weight PEEP.-In Figure 14-15 the weight of a
ball is used to provide positive expiratory pressure. During
the initial part of the expiratory phase the ball is lifted and
the exhaled gas flows around the ball and is vented to atmosphere (as shown) . When lung pressure is not high
enough to keep the ball afloat, the ball drops to the bottom
of the column and prevents any further escape of gas from
the lungs. PEEP is controlled by replacipg the assembly
with another containing a ball of a different weight.
It should be noted that this type of PEEP mechanism
functions properly only when it is mounted on the exhalation port in a vertical position. When this is impossible, an
alternative is to fasten the device vertically to a stand (for
example, an IV pole) and then link the device to the exhalation port with a flexible hose.

~agnetic
Pressurized

dociog '"'Ttioo ooly

PEEP.-In Figure 14-16 a magnet is

aligned with a metal rod to which a plastic disk is connected. The disk is held in position by the attractive forces
between the magnet and the rod. At the beginning of the
PEEP control

Water column

Diaphragm

Exhaled gas

Exhaled gas

FIG 14-13.

FIG 14-14.

Emerson PEEP valve.

Spring-loaded PEEP valve.

The Expiratory Phase

175

t
Weighted ball

PEEP control

FIG 14-16.

Exhaled gas

Magnetic PEEP valve.

FIG 14-15.
Dead-weight PEEP valve.

Filling port

Balloon valve

Disk

~------------~~~~-~---ln_le_t

Spring- loaded
ch eck valve

..,.._ Exhaled gas

~,.---____.

! . .

Pilot valve

~. L,.

FIG 14-17.
Balloon valve PEEP device.

expiratory phase, lung pressure opposes the magnetic attraction and lifts the disk. The pathway for exhaled gas
remains open until lung pressure drops to a level where it
can no longer overcome the attractive forces between the
magnet and the rod. At that moment, the disk returns to its
normal resting position and PEEP results. The level of
PEEP is displayed on the ventilator manometer and is controlled by adjusting the position of the magnet relative to the
metal rod. The closer the magnet.is moved toward the rod
.
'
the greater the level of PEEP, and vice v:_9

Balloon valve PEEP.-In Figure 14-17 a balloon valve

is used to apply pressure against a disk. The mechanism is
similar inoperation to the spring-loaded valve in Figure 1414. However, in this system the PEEP level is not controlled
by varying the tension of a spring but rather by regulating the
amount of pressure in the balloon valve. The balloon valve
is pressurized by using a syringe and injecting air into the
filling port. Withdrawal of air from the same port produces
the opposite effects. The pilot bulb is used to monitor pressure in the balloon valve. Fine tuning is accomplished by

176

Classification and Ventilatory Adjuncts

rotating the filling port assembly until the prescribed level of

PEEP is displayed on the ventilator manometer.
Venturi (injector ) PEEP device.-In Figure 14-18 a
Venturi is pl aced in line with the exhalation port of the
circuit and positioned so that the pressure generated by the
jet of the Venturi opposes the emptying of the lungs. When
equilibrium between Venturi pressure and lung pressure is
reached , positive pressure remains in the lungs. The level of
PEEP is controlled by adjusting the needle valve, which
regulates the flow of gas to the jet of the Venturi. It is
important to note that during the entire process the flow
from the Venturi never reaches the airway.
Proximal PEEP. 6768-The device in Figure 14-19
also employs a Venturi to generate PEEP and behaves identically to the Venturi PEEP device described in Figure 1418. They differ only in the position where the Venturi is
connected. In Figure 14-18 the Venturi is placed after (or
distal to) the exhalation valve, but for proximal PEEP the
Venturi is placed before (or proximal to) the exhalation
valve.
Figure 14-19 shows the proximal P,EEP device
mounted on a Bird Mark 8 breathing manifold (see Bird
ventilators, Chapter 28). The Venturi is powered during exhalation only (by the negative interrupter cartridge), and the
amount of PEEP is controlled by adjusting the flowrate to the
jet of the Venturi (with the negative generator valve). With
this system no positive pressure is reflected back to the ventilator. Therefore the assembly requires the addition of another manometer, which is connected between the Venturi
and the circuit outlet.

Internal PEEP Mechanisms

. /Internal PEEP simply means that the ventilator has a
built-in mechanism designed to generate positive expiratory
pressure. The behavior of the internal PEEP mechanism is
identical to that described for the external device.
In most ventilator circuits the exhalation port is aligned
with a balloon valve, which is inflated during the inspiratory

PEEP control

phase and allowed to deflate during the expiratory phase. In

these ventilators PEEP is accomplished by varying the
amount of pressure that remains in the balloon valve during
the expiratory phase . There are three common ways in
which this may be accomplished. The examples below were
taken from the ventilators described in Section Seven .
. Parallel Vent and Needle Valve.-In Figure 14-20
source gas flows past a variable resistance and a fixed resistance and is then vented to atmosphere above the canister
valve (which is deflated during the expiratory phase) . The
flowrate of gas against the fixed resistance creates back
pressure in the exhalation line and pressurizes the exhalation balloon valve. The level of PEEP is governed by the
variable resistance, which controls the flowrate of gas
through the fixed resistance. Increasing the flowrate, for
example, generates more back pressure in the exhalation
balloon valve and thus increases the level of PEEP. A similar system is found in the Ohio ventilators described in
Chapters 37 and 38 .
Parallel Vett and Pressure Regulator.-The mechanism shown schematically in Figure 14-21 is similar to the
one used for the Benne~t MA-l ventilator in Chapter 24.
In this system a pressure regulator receives source gas
during the expiratory phase only~ When the PEEP regulator
is attached to the ventilator but is not in use, source gas is
vented to atmosphere through an opening at the bottom of
the regulator. The exhalation valve normally empties passively via the pilot valve (as in Fig 14-3) and through a
small fixed internal resistance. The function of the PEEP
regulator is to control the amount of source gas that is
directed to the parallel vent downstream to the pilot valve.
When the PEEP regulator is turned on, source gas opens a
one-way check valve , flows past the fixed resistance, and is
then vented to atmosphere. The back pressure created by the
flowrate of gas through the fixed resistance pressurizes the
exhalation balloon valve. The level of PEEP is governed by
the pressure regulator, which controls the back pressure
reflected in the exhalation valve.

Inlet

. . . - - - - Exhaled gas
Source gas

Exhalation port

FIG 14-18.
Venturi PEEP device.

The Expiratory Phase

ed to deflate during the 1

> PEEP is accomplish
lfe that remains in the b
>hase. There are three
e accomplished. The e>
entilators described in

Source gas

177

== =======:;-~
I

Mic ronebul izer

1t and Needle Valve.

past a variable resista

en vented to atmospher
leflated during the exp
against the fixed resis~
malation line and pre!
e. The level of PEEP
. ___/~
~;e, which controls t1
I resistance . Increasin.: --~~
~ __ _
es more back pressm
-
. thus increases the lev
md in the Ohio venti
38.

Venturi "T"
Exhalation
valve

Pressure manometer
Inlet

and Pressure Regul

1atically in Figure 14Exhaled gas
lennett MA-l ventilal'l.
a pressure regulator ~ '. HI' system mounted on Bird breathing manifold. (See text.)
ry phase only. When
rentilator but is not ir
ere through an openi~l'. -ln Figure 14-22 a Venturi is used to
moves the cylinder/coil and plunger upward allowing exexhalation valve nOr:J.alation balloon valve. This method of
haled gas to move freely past the diaphragm to atmosphere.
t valve (as in Fig 14Js quite common in modern ventilators.
PEEP is achieved when electrical current is transmitted to
I -.resistance. The furtbcd in this schematic is a simplified verthe coil in direct proportion to the force required on the
ttrol the amount of nmd in the BEAR 1 and BEAR 2 ventiladiaphragm to establish the desired PEEP level.
tllel vent downstreant'hapter 26.
5ulator is turned on, of an electrically operated three-way soe, flows past the fix~ lilling and the emptying of the exhalation
CPAP AND EPAP
sphere. The back preluring the expiratory phase the solenoid
ugh the fixed resist~ li. port and opens the 12 o'clock port, and
It is also possible to hold positive pressure irt the lungs
ralve. The level of Pq ~ p Venturi is directed to the exhalation
during spontaneous ventilation. Spontaneous ventilation imtor, which controls . The amount of pressure generated in the
plies that the patient is ventilatirlg unassisted and without the
llation valve.
det ermines the level of PEEP, which is
addition of intermittent positive pressure breaths from the venjusting the flow of gas to the jet of the
tilator. As stated earlier in this chapter, when positive pressure
is held in the lungs during spontaneous ventilation, the mauilihrium is reached, gas to the Venturi is
neuver is called continuous positive airway pressure (CPAP),
here through the entrainment ports.
or end positive airway pressure (EPAP). It is also shown that
lo;or Mechanism.-Figure 14-23 shows
CPAP and EPAP differ only ill the shape of airway pressure
~~.: achieved when the exhalation valve is
waveform. The same devices used to produce PEEP are also
used
to provide CPAP or EPAP.
_ _ Exhaled gas :ssor control. The type shown here is a
tmic motor but the mechanism could easily
There are four major concerns involving the design of
a proportional solenoid, a stepper motor
CPAP or EPAP systems . The ideal system should be constructed so that it
'Oprocessor-operated valve.
Exhalation por: of operation of the electrodynamic motor
that of a common radio speaker. When no
1. Meets the peak inspiratory fiowrate of the
tlows to the coil the force of a spring
patient.
/

,'

....
~

Pressure manometer

Bellow

--

_l

Check valve

Canister

-~~

----1

PEEP control

Source gas.

~0,~
Exhalation valve

Variable
resistance

FIG 14-20.
Method of providing PEEP with continuous flow applied to exhalat!on balloon

v~ve

,,

~L

To"""'"''"
Fixed resistance

by way of parallel and fixed resistance.

::

Exhaled
gas

Pressure manometer

Check valve

--~
PEEP control

To ventilator

0
:'

L
Exhaled
gas

-~

- .....-

Pressure
regulator

Source gas
Vent

Relay valve

'1'

I I

Vent

FIG 14-21.
Method of providing PEEP using pressure regulator. (See text for description.)

....
-....!
\C)

')

)l

....
00
Q

Pressure manometer

Check valve
To ventilator

PEEP control

j1

Venturi_

:==~

----:---~

Source gas

Vent

I
3-way solenoid

Qi

FIG 14-22.
Method of providing PEEP using a Venturi to generate pressure in exhalation valve.

Exhalation va lve

.-

Exhaled
gas

The Expiratory Phase

Fully opened

181

Fully closed

Actuating shaft
(plunger)

To
atmosphere

From
patient

FIG 14-23.
Schematic representation of electrodynamic motor used to generate positive end-respiratory pressure.

B.

A.

T
Airway pressure

Resistance

1
0

Time-

1..-

-+j.-

FIG 14-24.
Airway pressure waveforms showing resistance to spontaneous ventilation
during CPAP therapy.

2.
3.
4.

Imposes little resistance to spontaneous

ventilation.
Provides 100% relative humidity at body
temperature.
Provides no fluctuations in the 0 2 concentration.

Resistance to spontaneous ventilation during the CPAP

mode of therapy is demonstrated in Figure 14-24. In Figure
14-24,A the system provides little resistance to spontaneous ventilation, and the prescribed level of CPAP remains
relatively constant. The opposite is shown in Figure 14-

24 ,B, where the resistance of the CPAP system causes significant fluctuations in the airway pressure.
With both CPAP and EPAP resistance to spontaneous
ventilation increases the work of breathing, and resistance
to exhalation increases the mean airway pressure.

CPAP and EPAP Systems

In Figure 14-25 the same Venturi PEEP mechanism
described in Figure 14-22 is now used to provide CPAP
therapy. To provide this mode, the ventilator is adjusted so

_)

_)

_)

.)

_)

...

~)

_)

_)

_)

_)

QC

Pressure manometer

~I
So"'"'" -

A
\J!

r-===:::::::::...=L......-,::::JII

T
I

bll "'"

Diaphragm

.
__.D .....

CPAP control

---...--- - ~

Source
gas

;:::::::J

Sensing \me

Demand valve

II
I I

L--~~J
Vent

l
~--

Humidifier
Spring-loaded

Venturi

FIG 14-25.
Method of providing CPAP with use of demand valve.

Patient
conn ection

_)

_)

_)

The Expiratory Phase

that no controlled breaths are delivered during the entire

session. Source gas for spontaneous ventilation originates
from a device called a demand valve.
During a spontaneous inspiration the subatmospheric
pressure generated by the expanding lungs is reflected in the
sensing line, which connects the patient wye to the superior
surface of the diaphragm in the demand valve. This moves
the diaphragm upward and lifts a spring-loaded ball valve.
Source gas then flows around the ball valve and into the
lungs by way of the ventilator circuit. At the beginning of a
spontaneous exhalation the slight increase in lung pressure
returns the diaphragm to its normal resting position and
source gas to the lungs is discontinued. Lung pressure then
empties by way of the partially inflated exhalation balloon
valve to the prescribed CPAP level.
It should be noted that an equal amount of pressure
generated by the Venturi is also applied to the underside of
the diaphragm in the demand valve. Without this connection EPAP would result because the patient would have to
inspire below the CPAP level in order to lift the diaphragm
and receive fresh gas.
,
Figure 14-26 shows how EPAP can be achieved without the need of specialized equipment. In this system the
humidified gas mixture originates from an oxygen powered
nebulizer equipped with a diluter. Aerosol tubing links the
nebulizer to an aerosol T piece, and a one-way valve, a
pressure manometer, and a PEEP device are placed between
the T piece and the patient connection. The position of the
PEEP device is indicated by the broken rectangle and can be
any one of the external devices described earlier.
Normally, the mainstream of gas from the nebulizer
flows through the T piece and is vented to atmosphere.
During a spontaneous inspiration the patient opens the oneway valve and draws in gas from the mainstream. During

exhalation the check valve closes and the patient must exhale through the PEEP devices .
With a simple modification made to the system in Figure 14-26, CPAP can also be provided. In Figure 14-27
the aerosol T is replaced with a Bird Venturi T. 67 The
Venturi is supplied with gas from an oxygen flowmeter connected to a blender. The blender is adjusted to the corresponding 0 2 setting of the nebulizer to prevent fluctuations
in the inspired oxygen concentration. The Venturi is positioned to generate an equal amount of positive pressure
above the check valve to nullify the net pressure difference
across the valve and thus minimize fluctuations in airway
pressure. This is accomplished by observing the pressure
manometer during spontaneous ventilation and adjusting the
flowrate to the Venturi until the least amount of fluctuations
are seen. This method provides CPAP because the patient
no longer has to inspire below the CPAP pressure to open
the check valve and receive fresh gas. During exhalation the
check valve closes and the lungs empty through the PEEP
device to the prescribed level of CPAP.
With a further modification made to Figure 14-27,
CPAP can be provided without the need of check valves or
additional PEEP devices (Figure 14-28). The system consists of the same Venturi T piece described for Figure 1427; because of its position upstream from the exhalation
port, the procedure has been termed proximal CPAP. 67
During inspiration the patient draws in humidified gas
from the mainstream and some from the Venturi. During
exhalation the Venturi flow opposes the exhaled flow and
prevents lung pressure from emptying to atmospheric levels. At first, most of the exhaled gas is carried away by the
m~stream and vented to atmosphere. At equilibrium, only
the excess flow from the Venturi spills over into the mainstream. The level of CPAP is controlled by adjusting the

Flowmeter

__
0/

Aerosol tubing .
Ambient air

l I
Nebulizer

FIG 14-26.
Typical setup to deliver EPAP therapy.

183

::~~~:~r

heck

~~
L........;-

Mainstream
1

:-__l' r--L- ~Exhaled

valve

I
Patient
connection

PEEP valve

gas

lUncts

Blender

02
flowmeter

11eter

Mainstream

Pressure
manometer
jebulizer
Patient
connection

AP system into CPAP system with use of a Venturi T piece.

Blender

02
flowmeter

CPAP control
Flowmeter

I I
I I

Vootoci T

Aom,~t~i ~
Nebulizer

r= =0
Mainstream
and

l j . l - - - - - 1_

1r
Patient
connection

. With this system no check valves or additio!la! PEEP devices are required.

==

.:::...:;:,.

The Expiratory Phase

flowrate to the Venturi while observing the pressure manometer. In this system the manometer must be connected
between the Venturi T and the patient connection. Otherwise , CPAP levels will not register on the manometer.
A popular method of providing CPAP is shown in Figure 14-29. Here a 3-L respiratory bag is filled continuously
by an oxygen flowmeter connected to a blender. Gas from
the bag opens the check valve, passes through the heated
humidifier, and is vented to atmosphere through any external PEEP valve (position indicated by the broken rectangle) . During inspiration the patient draws in gas from the
mainstream. The respiratory bag assures that inspiratory
flowrate demands of the patient are always met. During
exhalation the check valve at the humidifier closes and the
patient exhales through the PEEP valve. The spring-loaded
pressure relief valve is set slightly higher than the CPAP
level and is designed to prevent excessive pressure from

185

building up in the system. The fail-safe valve provides a

pathway for inspired gas should source gas fail or inadvertently be set too low to meet the inspiratory flowrate demands of the patient.

PEDIATRIC CPAP SYSTEMS

One technique commonly used to provide CPAP in the
newborn is shown in Figure 14-30. In this system, designed
by Gregory and colleagues, 69 a continuous flow of humidified
gas (no greater than 5 Uminute) enters the system at the modified elbow in the patient connection. Gas flow is then directed
along the tube to fill a respiratory bag, and the excess flow is
vented to atmosphere. The amount of pressure remaining in
the system (CPAP) is controlled by varying the resistance at
the distal end of the bag. During inspiration the infant receives

Blender

02
flowmete r
PEEP valve

,---,

I
---~...._ _ _j

Spring
loaded
valve

Failsafe
valve

Heated humidifer

Respiratory bag

. FIG 14-29.
Method of providing CPAP in continuous flow system.

Mainstream and
exhaled gas

186

Classification and Ventilatory Adjuncts

Continuous
humidified air/ 0 2 mixture

CPAP control

Mainstream and
exhaled gas

Respiratory bag

Patient
connection

Pressure
manometer

II

Pressure
relief system

Water column

FIG 14-30.
Method of providing CPAP for neonates in continuous flow system.

.\

~\

fresh humidified gas from the inlet and from the larger tubing.
During exhalation the expired gas is washed out of the system
by the continuous flow of gas. The water column is a safety
relief system that prevents excessive pressure from building up
in the system.
The CPAP system in Figure 14-31 operates identically
to the one just described. The only difference is that a
coaxial tube70 is used instead of the modified elbow. A
water column can also be used instead of the spring-loaded
pressure relief valve.
Figure 14-32 is a simplified schematic of another
CPAP system proposed by Gregory and others. 69 In this
system the infant's head is positioned in a rigid transparent
chamber through an iris sleeve, which forms a partial seal
around the baby's neck. Warm humidified gas flows into the
chamber and is vented to atmosphere through a variable
resistance. The variable resistance controls the CPAP level
in the chamber and is displayed on the pressure manometer.
A spring-loaded valve acts as a safety system to prevent
excessive pressures from developing in the system. A water
column can be used instead of the spring-loaded valve.
Another port is used for emergency manual ventilation.
An oxygen sampling port and a trapdoor to provide
quick access to the infant's head are not shown in this
schematic.

SUMMARY
The only function of the ventilator in the expiratory
phase is to allow the lungs to empty. There are three com1
mon methods in which the ventilator can control the emptying of the lungs, and depending on the method selected, a
v~ntilator can be classified as a
Constant atmospheric-pressure generator
Constant negative-pressure generator
Constant positive-pressure generator
The Constant Atmospheric-Pressure Generator

This classification is used when the lungs are allowed to

empty passively to atmospheric pressure. Since lung pressure empties to atmospheric levels ~ the ventilator is also
said to provide zero end-expiratory pressure, or ZEEP. All
ventilators must provide this option.
Some ventilators have the option of adding mechanical
resistance to retard exhaled volume in an attempt to reduce
airway collapse and facilitate the emptying of the lungs.
However, because the procedure has been knqwn to cause
air trapping, expiratory resistance is no longer considered a
useful form of therapy.

The Expiratory Phase

187

Pressure
manometer
Coaxial tube

'11
Continuous humidified
air/ 0 2 mixture

Respiratory bag

Patient connection

. CPAP control

Mainstream and exhaled gas

FIG 14-31.
Method of providing CPAP for neonates in c,ontinuous flow ~ystem using coaxial tube.

Blender

02

Pressure manometer

Mainstream and
exhaled gas

CPAP control

~~

\
''"

Iris sleeve

'\\ /
'\ f

flowmeter

Spring-loaded

.__Ve_n_
t - - - - ' .__ ____.:

LlL.....-____

.,_
.

.......-

cI

I I
I I

Ji
I
\
'

Jl

~:n~~=~ion

~/
-...:i

port

Heated humidifier

Transparent chamber

FIG 14-32.
Method of providing CPAP for neonates by placing infant's head in pressurized chamber. (See text for description.)

_ ______ , ,.

188

Classification and Ventilatory Adjuncts

The Constant Negative-Pressure Generator

During this mode negative pressure is applied to the airway at the onset of the expiratory phase, and lung pressure is
held below atmospheric pressure during the quiescent portion
of exhalation . The ventilator is said to provide negative endexpiratory pressure, or NEEP. The objective of NEEP is to
decrease the mean airway pressure and minimize cardiovascular effects of intermittent positive-pressure ventilation.
However, this form of therapy also has been associated with
air trapping and alveolar overdistention. Consequently, the use
of NEEP has been abandoned in modem clinical practice.
The Constant Positive-Pressure Generator
During this mode of therapy the lungs are not permitted
to completely empty to atmospheric pressure but are maintained at a predetermined level of positive pressure. There
are four fonns of positive expiratory pressure:
1. Positive end-expiratory pressure (PEEP). PEEP maintains positive pressure in the lungs throughout the respiratory
cycle during controlled ventilation.
2. Continuous positive airway pressure (CPAP). CPAP
maintains positive pressure in the lungs during spontaneous
ventilation, and lung pressure never reaches atmospheric
pressure. This mode may be provided with or without the
ventilator attached. However, no controlled breaths are delivered du!ing the entire session.
3. Expiratory positive airway pressure (EPAP). EPAP is
similar to CPAP in that the patient breathes spontaneously
while positive pressure is applied to the airway. However,
during EPAP therapy positive pressure is maintained in the
lungs during exhalation only. During inspiration the patient
must inspire to atmospheric pressure.
4. Intermittet:~-t mandatory ventilation (IMV) and PEEP.
IMV and PEEP are a combination of CPAP and PEEP in
that positive pressure is maintained in the lungs and the
patient receives controlled breaths intermittently between
spontaneous breaths. IMV is detailed in Section Six.

Positive expiratory pressure increases the FRC. In disease states associated with reductions in the FRC, the application of positive expiratory pressure aimed at returning
the FRC toward normal improves lung compliance, decreases intrapulmonary shunting, and increases arterial oxygenation without the need of high levels of inspired oxygen concentrations.
Positive expiratory pressure increases the mean airway
pressure, but the effects on the cardiovascular system are
not uniform. A reduction in cardiovascular function is observed when positive intrapulmonary pressure is transmitted
intrathoracically. The amount of pressure transmitted in-

trathoracically depends on the increase in the FRC. During

severe reductions in lung compliance, the level of positive
expiratory pressure may not increase the FRC significantly
and the cardiovascular system will not be compromised.
Accordingly, the level of positive expiratory pressure
should be directed toward restoring the FRC toward normal.
At higher FRCs cardiac output falls and the risk of
barotrauma increases.
Reductions in renal function have also been observed
during positive expiratory pressure therapy.
The usual range of positive expiratory pressure is between 5 and 15 em H2 0. However, pressure levels as high
as 30 to 40 em H 2 0 have been used effectively. In a procedure known as best PEEP, positive expiratory pressure is
increased until the maximum compliance is achieved. In
another procedure called optimum PEEP the highest expiratory pressure that produces the greatest reduction in intrapulmonary shunting without interfering with cardiac output is determined.
In a less aggressive technique the level of positive expiratory pressure is determined as the lowest pressure to
achieve an arterial oxygen tension of 60 to 80 mm Hg at an
inspired oxygen concentration of 0.5% or less.
PEEP is defined as e.xhalation against a threshold resistor in that the lungs are allowed to empty to a predetermined level of positive pressure. Once that level is established, the PEEP level does not vary, regardless of lung
characteristics.
The device that is used to hold positive pressure in the
lung during the exhalation phase is called a PEEP valve
even though the same valve may be used during the CPAP
or EPAP mode of therapy. The PEEP mode may be accomplished by a valve built within the ventilator or by a valve
connected e;ternally; the results are the same. External
PEEP devices are connected to the exhalation port of the
patient circuit. However, in a procedure called proximal
PEEP the device (a Venturi) is positioned before the exhalation valve.
Four conditions must be met in the construction of a
CPAP or EPAP system. The system must
1.
2.

3.
4.

Meet the peak inspiratory ftowrate of the patient

Impose little resistance to spontaneous
ventilation
Provide 100% relative humidity at body
temperature
Cause no fluctuations in the 0 2 concentration

The methods of providing CPAP in the adult patient are

generally the same. The patient inspires a humidified gas
mixture from source and exhales through a PEEP valve.
Source gas may or may not be conJinuous.

CHAPTER15

Initiation of the Inspiratory Phase

There are four phases in the respiratory cycle and four

"""0asic functions of a ventilator. Thus far we have considered
1.
2.
3.

The inspiratory phase

The changeover from the inspiratory phase to the
expiratory phase
The expiratory phase

.---.._;
The fourth and final function of the ventilator is to end
the expiratory phase and begin the process of lung inflation.
The final phase is called .
4 . The changeover from the expiratory phase to the
inspiratory phase
'\
The ventilator can be cycled into the inspiratory phase
m three ways:

Although only one cycling mechanism is necessary,

modem ventilators may have all three.

PATIENT CYCLING
Patient cycling implies that the ventilator resp<'lnds to
an attempt at inspiration by the patient and delivers a controlled breath. This mode also has been called assisted ventilation. To accomplish patient cycling, the ventilator must
have an assist mechanism (discussed later). If such a mechanism is not present, the patient cannot initiate the inspiratory phase and the ventilator is thus classified as a strict
controller.
Two parameters are evaluated to establish the efficacy
of the assist mechanism: sensitivity and response time.

-----.,
~

1.
2.
3.

By an inspiratory effort of the patient

After a predetermined time has elapsed
Manually

Therefore the changeover from the expiratory phase to

~he inspiratory phase can be accomplished through

""

1. Patient cycling
2. Time cycling
3. . Manual cycling

Sensitiv.ity
This parameter determines the inspiratory effort required to trigger the ventilator. Normally, the patient inhales
a small volume of gas from the ventilator circuit, and the
corresponding drop in pressure activates the assist 'mechanism and a controlled breath is delivered. Some mechanisms may respond to volume or flow instead of pressure.
The sensitivity is usually adjustable and governed by the
setting of a knob at the ventilator. In its most sensitive
position only a small inspiratory effort is required to trigger
195

196

Initiation of the Inspirator; Phase

the ventilator. At the other extreme, the mechanism is usually disabled-and will no longer respond to any effort.
A ratio is used to determine the efficiency of the sensitivity mechanism, 1 and although the ratio was primarily
designed for neonatal application, it is useful in evaluating
the performance of ventilators in general:
Percent sensitivity ratio

Inspired volume to trigger

Patient tidal volume

----------'-'-- X

100

The ideal assist mechanism should be sensitive enough

to respond to an inspired volume of less than 1% of the
patient's tidal volume. For example, if the mechanism responds to a volume of 1.5 ml and the patient's tidal volume
is 500 ml, the percent sensitivity ratio would be

1.5 ml
500 ml

x 100

= 0.3%
Since this is well below 1% of the tidal volume , it
would be considered adequate for this patient. However, if .
the same mechanism were used with a pediatric patient
having a tidal volume of 50 rnl, the percent sensitivity ratio
would be

the assist mechanism. The ventilator then cycles to the inspiratory phase, and the pressure wave travels back to the
patient in the same way.
Pressure waves travel at the speed of sound, which
under normal conditions is approximately 1083 ft/sec (330
m/sec) or 1 msec (millisecond) per foot of ventilator tubing . While this may appear to be a very high velocity, it is not
necessarily so when we compare it with the patient' s inspiration time.
The comparison of the ventilator's response time with
the patient's inspiration time is called the percent response
time ratio:
Percent response time ratio

Ventilator
response
time
_
___
_:___ _
_ X

100

Inspiration time
Ideally, the ventilator's response time should not occupy more than 10% of the patient's inspiration time. 1 For
example, given a ventilator response time of 0.08 second
(80 msec) and an inspiration time of 1.5 seconds, the percent response time ratio would be
=

0:08 sec x 100

1.5 sec

= 5%

= !.:2 !IlJ

100

50 ml

3%

Since this is now above 1% of the tidal volume, the

mechanism would no longer be considered adequate for
assisted ventilation with this patient.
It should be obvious that the patient should not have to
inhale a large portion of his tidal volume to trigger the
ventilator. Fortunately, most adult ventilators can be adjusted to respond to an inspired volume of 0.5 mi. 2 The
figure is much lower in pediatric ventilators.

Response Time
Once tlie inspiratory effort is made, the ventilator
should respond and deliver a breath within a reasonable
time.
Response time is defined as the time lag between the
initial inspiratory effort and the moment the controlled
breath reaches the patient's airway. The factors responsible
for this time lag include the length of the ventilator circuit
and the characteristics of the assist mechanism.
An inspiratory effort generates a pressure wave that
travels along the circuit, enters the ventilator, and activates

and therefore would be considered adequate for this patient.

The situation changes, however, when the same ventilator is
used to assist an infant having an inspiration time of 0.5
seconds:
=

0.08 sec
0.5 sec

100

= 16%

Since 16% of the infant's inspiration time is wasted in

triggering the ventilator, the response time is no longer considered adequate.
A response time of 0.08 second is common among
electronically operated adult ventilators and is adequate for
assisted ventilation as long as the patient's inspiration time
is no less than 0.8 second. In some pneumatically powered
ventilators, an average response time of 0. 2 second is conventionai, and these ventilators do not meet the response
time criteria for assisted ventilation when the patient's inspiration time is less than 2 seconds.
A slow response time causes asynchrony between the
patient and the ventilator, and when maximal asynchrony
exists, the rise in arterial carbon dioxide tension (PaC0 2 ) is
greater than with no ventilator assistance at all. 3

-~--------

- --

---

The Changeover from the Expiratory Phase to the Inspiratory Phase

Assist Mechanisms
The assist mechanism is the device built within the
ventilator that is responsible for sensing an inspiratory effort and cycling the ventilator into the inspiratory phase .
The assist mechanism may operate pneumatically, electronically, or as a combination of both.

Pneumatic
Type I.-Figure 15-1 is a schematic representation of
the Bird pressure-cycled mechanism detailed in Chapter 9
and shown in Figure 9-1. For clarity, only the assist mechanism will be considered in this discussion. The reader
should consult Section Seven for the complete analysis of
the ventilators .
In Figure 15-1 a flexible diaphragm separates the pressure compartment from the ambient compartment, and a
sliding valve is connected to the center of the diaphragm.

197

Attached to both ends of the sliding valve are soft iron

disks , and directly in line with the iron disks are magnets .
During the exhalation phase, source gas is prevented from
entering the patient circuit by the position of the sliding
valve , which at this moment is under the influence of the
ambient magnet (Fig 15-1 ,A) .
To cycle the ventilator into the inspiratory phase, the
patient makes an inspiratory effort and generates a pressure
drop in the pressure compartment. The drop in pressure is
reflected on the right-hand side of the diaphragm by means
of two communication holes . If the drop in pressure is sufficient to overcome the attractive forces between the ambient magnet and the iron disk, the diaphragm and the sliding
valve are moved completely to the right, thus initiating the
inspiratory phase (Fig 15- 1, B).
.
Sensitivity is controlled by adjusting the position of the
ambient magnet relative to the iron disk . The closer the
magnet is moved toward the iron disk , the greater the inspiratory effort required to trigger the ventilator.

INSPIRATORY EFFORT

Source gas
!

i. .
l

INSPIRATORY PHASE

FIG 15-1.
Pneumatic assist mechanism such as found in first generation Bird ventilators .

198

Initiation of the Inspiratory Phase

INSPIRATORY EFFORT

INSPIRATORY PHASE

Source gas

Patient connection

FIG 15-2.
Pneumatic assist mechanism such as found in Bennett PR series ventilators.

Type 11.-Another pneumatic assist mechanism is

shown in Figure 15-2. The same mechanism was presented
earlier in Chapter 10 and.is also discussed in Section Seven
under Bennett ventilators.
A metal cylindrical drum with an internal channel for
the passage of gas is mounted horizontally within a manifold . During the expiratory phase a metal rod set off-center
within the drum provides a counterbalance torque and keeps
the valve closed. To trigger the ventilator, the patient's inspiratory effort is applied to the vane connected to the cylindrical drum (Fig 15-2,A). When the inspiratory effort is
sufficient to offset the effects of the metal rod, the drum
rotates counterclockwise and source gas is directed into the
patient circuit (Fig 15-2,B) .
To increase sensitivity, another vane is required and
positioned on the cylindrical drum, as shown in Figure
15-3. Sensitivity is controlled by applying a small flow of
gas to the upper vane so as to rotate the drum counterclockwise but not all the way. Sensitivity increases because less
inspiratory effort is now required to rotate the drum the rest
of the way. With this mechanism sensitivity can be increased but not decreased.

Pneumatic-Fluidic
In Figure 15-4 the assist mechanism consists of a
Schmitt trigger and a flip-f!op valve (see Chapter 9 for a
review of fluidic devices) . During the expiratory phase the
Schmitt trigger and the flip-flop valve are both at output 0 1 ,
An attempt at inspiration by the patient generates negative

Sensitivity control

Source gas

Ill
II

Patient connection

FIG 15-3.
Pneumatic sensitivity mechanism.

The Changeover from the Expiratory Phase to the Inspiratory Phase

199

Flip-flop
valve

'.
~

Sensitivity
control

'I
)

To patient
circuit
Relay valve

FIG 15-4.

'I

~:

Typical sensitivity mechanism in fluidic ventilator.

)
)

pressure in the sensing line, which connects the patient

j ircuit to C 1 of the Schmitt trigger. When the inspiratory .
effort is great enough, the Schmitt trigger switches from
) utput 0 1 to 0 2 The output signal _0 2 from t~e Schmitt
trigger applies a control signal at C2 Of the flip-flop valve,
l nd with this signal, the flip-flop valve switches to output
0 and activates a power valve (pathway indicated by the .
1 2
uroken arrows), and the inspiratory phase begins.
To control sensitivity; a variable reference signal is ap1
plied at C2 of the Schmitt trigger. The greater this control
'\ignal, the less inspiratory effort (negative pressure) is required at C 1 to switch the Schmitt trigger to output 0 2 The
' arallel vent permits fine tuning of the sensitivity mechanism.

Electro-Pneumatic
In figure 15-5,A a spring-loaded diaphragm separates
}..,o electrical contacts. The superior surface of the dia--;rragm samples the pressure in the patient circuit by way of
a sensing line. During an inspiratory effort the diaphragm
~ws upward, moving the electrical contacts closer together.
When the inspiratory effort is sufficient to bring the contacts
\ gether, an electrical signal is transmitted to a valve that
opens to begin the inspiratory phase (Fig 15-5,B).
-----. Sensitivity is controlled by rotating a knob that adjusts
~e tension of the spring on the diaphragm. When the ten~on of the spring is increased, the contacts move further

apart, making it more difficult for the patient to trigger the

ventilator.

Pressure Transducer
The second type of electro-pneumatic assist mechanism
is a pressure transducer (Fig 15-6). This pressure transducer is identical to the one introduced in Chapter 9, which
was then used as a pressure-cycling mechanism.
As stated in Chapter 9, the function of a pressure transducer is to convert mechanical energy into electrical energy.
In Figure 15-6 the transducer is positioned in the inspiratory circuit of the ventilator and electrical means are used to
measure the motion of the diaphragm. The mechanism consists of an iron core suspended on a diaphragm and 'placed
between two electrical windings. Moving the core within
the windings causes a net difference in output voltage. During an inspiratory effort the diaphragm moves the core
downward, and the net output voltage from the transducer
changes. This is recognized by the ventilator as an attempt
at inspiration by the patient. When the core is moved to a
position that generates a signal equal to an electronic reference potential set by sensitivity control, a controlled
breath is delivered.
Sensitivity is controlled by adjusting the reference control knob, which determines the distance the core must
travel downward to trigger the ventilator.

200

Initiation of the Inspiratory Phase

A

Sensitivity
control

. l_~,;ogUoe

S p n ng

:::-----=:

--

Diaphragm

'------1

Electrical

I contacts

__
:,____ _ _ _ _ _ _- - J .

FIG 15-5.
Electro-pneumatic assist mechanism.

Winding

lop~

Output

Iron core

.lnspirato.ry effort

Sen sitivity
control

Input

To patient circuit

FIG 15-6.
Use of pressure transducer as assist mechanism.

Photoelectric
Photoelectric cells are used to convert light energy into
electrical energy. Figure 15-7 demonstrates one practical
application of this principle in an assist mechanism. In this
system the photoelectric cell is separated from ~he light
source by a shutter connected to the bottom of a diaphragm.
The opposite side of the diaphragm monitors the pressure in
the patient circuit.
A sensitivity mechanism on the control piJ.nel of the
ventilator (not shown) supplies all but the necessary elec-

trical current to trigger the ventilator. The small current that

remains to be added must be generated by the photoelectric
cell. During an inspiratory effort the pressure drop in the
ventilator circuit lifts the diaphragm and the shutter upward
and exposes the photoelectric cell to the light source. This
generates a small electrical current, and the current generated by the cell together with the current supplied by the
sensitivity mechanism are sufficient to trigger the ventilator

into the inspiratory phase.

The amount of inspiratory effort required to trigger the
ventilator is controlled by adjusting the electrical current
from the sensitivity control. In the least sensitive setting no
reference current is provided , and the current generated by
the photoelectric cell is not enough the trigger the ventilator
regardless of the inspiratory effort made. In its most sensitive position less current is required from the photoelectric
cell, and triggering the ventilator becomes easier.
A similar photoelectric mechanism is found in the Ohio
560 and Ohio CCV ventilators.

Heated Thermistor Bead

A temperature sensitive resistor, called a thermistor,
can also be used as an assist mechanism. In Figure 15-8 the
thermistor is placed in the inspiratory limb of the ventilator
circuit and heated by the application of a constant electrical
current. The air in immediate contact with the thermistor is
also heated to the sam~ temperature. During an inspiratory
effori the displacement of air from the circuit cools the
thermistor and causes a change in voltage. The voltage drop
across the thermistor is recognized by the ventilator as an
attempt at inspiration, and the ventilator cycl~s into the
inspiratory phase.
The amount of effort required to trigger the ventilator is
governed by the sensitivity mechanism, which essentially
sets up the reference potential determining the degree of

J
J
1

The Changeover from the Expiratory Phase to the Inspiratory Phase

c:

if~ng line

t _

Diaphragm

Photoeleotcic cell

!=[] I~ cx=J=! Light <oocce

k T~oto~

201

eHoct

!=[] ~cx=J=!

Shutter

FIG 15-7.
Use of photoelectric cell as assist mechanism.

Sensitivity control

Electronic circuit

Source gas _ .....

~
Solenoid

To patient circuit
Thermistor

FIG 15-8.
Use of heated thermistor bead as assist mechanism.

>'Oltage change (cooling) required to trigger the ventilator.

similar system is built in the BEAR 1, BEAR 2 and
BEAR 3 ventilators.
~

.~()ow

By

---._ The past few years have seen the development of a new
Jncept in patient cycling. The cycling mechanism, which
;Qe manufacturer calls flow by, 4 responds to the patient's
. _,spiratory flowrate rather than inspiratory pressure. 5 Al~pugh the flow triggering mechanism is straightforward,
me approach merits special consideration and is therefore
tailed in Chapter 19.

TIME
CYCLING
.......
~

A ventilator is said to be time cycled when the change~ . er from the expiratory phase -to the inspiratory phase is
"--"complished through a timing mechanism that is totally
lHdependent of the patient. If such a ventilator has no assist
.chanism, it is classified as a strict controller.
The time-cycling option is often used as a backup
ety system during assisted ventilation. During this mode
~e exhalation timer is usually set to cycle the ventilator

when the patient's exhalation time exceeds a certain limit.

In other words, the electronic timer is set just behind the
patient's exhalation time, and each breath resets the electronic timer. If for some reason the patient fails to trigger
the ventilator within the specified time period, the exhalation timer automatically cycles the ventilator into the inspiratory phase. This timing mechanism is present in most
ventilators.

Time-cycling Mechanisms
The construction of the exhalation timer is essentially
the same as the inspiration timer discussed in Chapter 12.
Therefore they may be pneumatic, fluidic, electromechanical, or electronic.
Pneumatic
There are many types of pneumatically operated exhalation timers and far too many to consider in full detail.
However, all pneumatic timers behave the same way, and
for completeness a brief overview of the essential f~atures
of the most common types will be presented.
One of the simplest methods of timing the exhalation
phase is shown schematically in Figure 15-9. This mechanism is used in the first generation Bird ventilators detailed

202

Initiation of the Inspiratory Phase

Disk

Arm

Timer cartridge

Expiratory time
control

vane of the circular drum . The entire assembly has free

motion and is enclosed within a rigid chamber.
During the inspiratory phase the balloon valve is deflated and held stable at the top of the chamber by the action
of a spring . In this position the channel in the shaft and the
line connecting source gas to the upper vane of the drum are
not aligned. During the exhalation phase (as shown) the
balloon valve is slowly inflated with source gas by way of
a needle valve and a line connected to the bottom of the
rigid chamber. As the balloon valve is pressurized, the shaft
is moved downward. When the channel opening of the shaft
is in a position to provide a pathway for source gas to the
upper vane, the drum is rotated counterclockwise and inspiration begins. The length of the expiratory phase is thus
controlled by the needle valve, which regulates the speed at
which the balloon valve is inflated.
Fluidic
The fluidically operated exhalation timer is identical to
the one presented in Chapter 12 (refer to Fig 12-4). The
only difference is that another tiny bellows is used and filled
during the exhalation phase. Once the bellows is filled and
occludes a vent, a signal is transmitted to C2 of the flip-flop
valve and inspiration begins.

FIG 15-9.
Pnewnatic exhalation timer such as found in first generation Bird ventilators.

in Section Seven. The system, called the expiratory timer

cartridge in these ventilators, uses a diaphragm and a
spring-loaded plunger and arm assembly. During the inspiratory phase source gas enters the cartridge via the oneway valve and pressurizes the small diaphragm. This moves
the diaphragm, plunger, and arm completely to the 1!-!ft.
During the expiratory phase (as shown) pressure in the cartridge is slowly vented to atmosphere by way of a variable
resistance. As the chamber pressure falls, the spring relaxes
and forces the diaphragm, plunger, and arm to the right.
When the arm makes contact with the disk, the same motion
is transferred to the sliding valve. The inspiratory phase
begins when the channel opening in the sliding valve is
aligned with the source gas. This also resets the expiratory
timer cartridge.
Expiration time is controlled by adjusting the needle
valve, which controls the rate at which the cartridge empties. The faster the cartridge is allowed to empty, the shorter
the exhalation time, and vice versa.
Another common pneumatic-timing mechanism is
found in the Bennett PR series ventilators (also see Section
Seven). Figure 15-10 shows the essential components of
the system. In this simplified schematic a balloon valve is
connected to a plunger, the shaft of which is hollow to
permit inflation of the balloon valve. The shaft also has a
channel to provide a pathway for source gas to the uppe1;

Electromechanical
Electromechanical mechanisms were described in
Chapter 12 and comprise a piston connected off-center to a
slower revolving wheel. Exhalation time in one such system
is determined by the speed of the piston's return stroke. In
the electromechanical system described for Figure 12-5 the
I:E ratio is fixed, and the rate control determines the length
Qf the expiratory phase.
In another electromechanical system described for Figure 12-6 the speed of the piston is controllable in both
directions, and therefore exhalation time is determined by
adjusting the speed of the motor during the piston's return
stroke.
Electronic
In these mechanisms the exhalation phase is timed by
an electronic circuit, just as in the inspiratory phase. Once
the expiration time has elapsed, an electrical signal is transmitted to a solenoid, which now opens to initiate the inspiratory phase. The reader should consult Chapter 12 for
complete details.

MANUAL CYCLING
The changeover from the inspiratory phase is said to be
manually cycled when the expiratory phase is ended by the
action of the operator.

The Changeover from the Expiratory Phase to the Inspiratory Phase

203

Balloon valve
Rigid chamber
Spring

"'==:.=;'I r=--___J
~========~==-

-shaft

Expiratory
time control

Source gas

I
I

II
II
I

To patient circuit

FIG 15-10.
Pneumatic exhalation timer such as found in Bennett PR series ventilators.

,......,

In some ventilators an external means of cycling the

is possible. Activating this mechanism overrides
...}d resets all other cycling options , and a control breath is
.-J~ ivered. Manual-cycling mechanisms are quite simple and
are considered along with the specific ventilators in Section
........,ven.
~ntilator

~ The last function of the ventilator is to end the expiraLv'ry phase and begin the process of lung inflation. There are
t~ee ways in which the ventilator can be triggered into the
mspiratory phase:

1.
2.
3.

By the patient
After a predetermined time has elapsed
Manually

Therefore the changeover from the expiratory phase to the

inspiratory phase may be
1.
2.
3.

Patient cycled
Time cycled
Manually cycled

In order for the patient to trigger the ventilator into the

inspiratory phase, the ventilator must have an assist mechanism. The assist mechanism may operate pneumatically,
electronically, or as a combination of both. The sensitivity
mechanism determines the amount of inspiratory effort the
patient must make to trigger the ventilator; it is usually
adjustable.
The patient should not have to inspire a large volume
from the circuit to trigger the ventilator. The ideal sensitivity mechanism must cycle the ventilator when less than 1%
of the patient's tidal volume is inspired.

204

Initiation of the Inspiratory Phase

The ventilator response time is defined as the time lag

between the initial inspiratory effort to the moment the controlled breath reaches the patient's airway. The ventilator's
response time should not occupy more than 10% of the
patient' s inspiration time .
The ventilator is classified as being time cycled when
the changeover from the expiratory phase to the inspiratory
phase is accomplished through a timing mechanism that is
totally independent of the patient. The timing circuit may be
pneumatic, electronic, or a combination of both. A strict
controller is defined as a time-cycled ventilator that has no
assist mechanism.
Some ventilators may also be manually cycled into the
inspiratory phase.

REFERENCES
1. Rodgers EJ: Physics vs physiology in infant ventilation .
Respir Ther 1972; 2(5):45 .
2. Epstein RA: The sensitivities and response times of ventilatory assistors . Anesthesiology 1971; 34(4):321.
3. Kirby RR: RDS and Infant Ventilation . Consumer Information Data. Palm Springs , Calif, Bird Corp, 1975 .
4. Puritan-Bennett Corp, Santa Monica, Calif.
5. Dupuis YG: Response time: Flow by vs pressure. RRT 1988;
42(3):5.

~\ CHAPTER 26
~,

The Bird Ventilators

THE BIRD MARK 7

)
~~

'
~)
~

,-,
\
'
.,
~
~

The Bird Mark 7 (Fig 26-1) is a single-circuit, pneumatically powered and controlled ventilator that is designed
to operate with air or oxygen at a pressure of 50 psi. 1 2
In Figure 26-2 the ventilator consists of.an ambient
compartment (2) and a pressure compartment (6), separated
by a large diaphragm (5). Connected to the center of the
diaphragm is a sliding valve, called a ceramic switch (9).
The opposite ends of the ceramic switch are connected to
metal disks called clutch plates (3,8). Directly in line with
the clutch plate in the ambient compartment is the sensitivity magnet (15), and in line with the clutch plate in the
pressure compartment is the pressure magnet (7).
The ceramic switch has a channel opl!ning for the passage of source gas to the various pneumatic components
within the ventilator. During the expiratory phase (Fig 262,A) the ceramic switch is held stable in the oFF position (to
the left) by the magnetic attraction between the sensitivity
magnet (15) and the ambient clutch plate (3). In this position the channel opening in the ceramic switch is not aligned
with the source inlet, and no gas flows through the ventilator.
The ventilator operates in three modes:
1.
2.
3.

Assist
Assist/control
Manual

Assist Mode
During an inspiratory effort, subatmospheric pressure
is generated in the pressure compartment and is communicated to the right side of the large diaphragm by way of two
openings in the center body of the ventilator. When the
inspiratory effort is sufficient to overcome the attraction

330

FIG 26-1.
Bird Mark 7 ventilator.

between the ambient clutch, plate and the sensitivity magnet,

the ceramic switch is moved to the oN position (to the right).
Once moved completely to the right (Fig 26-2,B), the
switch is held in position by the attractive forces between
the pressure magnet (7) and clutch plate (8) and remains
there even though subatmospheric pressure may no longer
be present in the pressure compartment.
In this state, source gas passes through the flow rate
control (1), through the channel opening in the ceramic
switch, and travels to the air mix plunger (19) (Fig 26-3,
A). From the air mix plunger, source gas takes two pathways and supplies

Ventilators
A

EXPIRATORY PHASE

331

INSPIRATORY EFFORT

FIG 26-2.
Pneumatic diagram of Bird Mark 7 ventilator. 1, Aowrate control; 2, ambient compartment; 3 , ambient clutch plate; 4, air inlet filter; 5 , diaphragm;
6, pressure compartment; 7, pressure magnet; 8, pressure clutch plate; 9, ceramic switch; 10, exhalation valve; 11, micronebulizer; 12 , test lung
(patient); 13, sensitivity arm; 14, hand timer rod; 15, ambient magnet; 16, source gas inlet; 17, Venturi; 18, pressure limit arm; 19, air mix plunger;
20, inspiratory drive line; 21, mainstream line. (Courtesy 3m Canada Inc., London , Ontario.)
.

INSPIRATION

EXHALATION

FIG 26-3.
Pneumatic diagram of Bird Mark 7 ventilator. See text for description. (Courtesy 3M Canada Inc., London, Ontario.)

1. The inspiratory drive line (20), which powers the

microneLulizer (11) and pressurizes the exhalation valve

of gas delivered to the patient by way of the mainstream line

(21)

(10)

2. The jet of a Venturi (17) , which entrains room air

through the ambient air filter (4) and augments the ftowrate

As lung pressure increases, the pressure in the pressure

compartment also increases. This pressure tends to push the

332

The Bird Ventilators

,--.., large diaphragm to the left, and it opposes the attractive

forces between the pressure magnet and clutch plate. When

___., the back pressure is sufficient to move the clutch plate away
from the pressure magnet, the ceramic switch is moved
,..- ,completely to the left , cutting off the gas supply and thu s
terminating the inspiratory phase (Fig 26-3 ,B). In this state
\the exhalation valve empties via the jet in the microneb. ulizer, and the patient exhales to atmosphere through the
;-'exhalation valve. The ventilator is now ready for the next
inspiratory effort.
'"\

,-]Assist/Control Mode
The ventilator can be set to automatically cycle to the
'inspiratory phase without patient intervention by the action
~of the expiratory timer cartridge (Fig 26-4). The expiratory .

r--

timer assembly consists of a diaphragm (5), which operates

a spring-loaded (6) plunger and arm (4). During the inspiratory phase the cartridge is charged with source gas (1) by
way of the ceramic switch (2). When the expiratory timer
control valve (9) is closed , t he diaphragm remains pressurized (to the left) during the entire respiratory cycle, and no
motion is imparted to the arm (Fig 26-4,A and B).
When the expiratory timer control valve is opened, gas
leaves the cartridge at the metered rate through a drain hole
(8) in the pressure compartment (Fig 26- 4,C). Although
the control valve is open, the diaphragm remains charged
during inspiration because the supply of gas to the cartridge
exceeds the leak through the drain hole.
During the expiratory phase (Fig 26-4,D), when
source gas to the cartridge is discontinued, a check valve (7)
within the cartridge closes, and the cartridge begins to drain

A
\
\

,
3

~\

'
4 (l

\
\

-,

-,
....._

'

-~

........_

,--..,
I

FIG 26-4.
Expiratory timer cartridge. 1, source gas inlet; 2, ceramic switch; 3 , ambient clutch plate; 4, expiratory timer ann; 5, diaphragm; 6, spring;
7, check valve; 8, drain hole; 9, expiratory timer control. (Courtesy 3M Canada Inc . , London, Ontario.)
(

Ventilators

at a rate determined by the position of the control valve. As

the cartridge depressurizes , the spring gradually moves the
diaphragm and the arm to the right (Fig 26-4,D). When the
arm comes into contact with the ambient clutch plate (3),
the ceramic switch is moved all the way to the ON position.
When inspiration begins , the cartridge is immediately
charged (as in Fig 26-4,C) and reset for the next expiratory
phase.

Manually Cycled (see Fig 26-2, B)

The ventilator can be triggered manually by pushing the
hand timer rod (14) and moving the ceramic switch to the ON
position . Once inspiration is initiated , gas flow will continue until the cycling pressure is reached. Pulling the hand
timer rod before the cycling pressure is reached will manually terminate the inspiratory phase/

Ventilator Controls and Functions

Flowrate Control
The flowrate control is a simple needle valve that is
positioned between the source gas inlet -amrthe ceramic
switch. The control has a scale between OFF and the number
40, and although source gas to the ventilator is cut off when
the fl.owrate control is turned to the OFF position, the scale is
for reference only, and the numbers have no quantitative
meaning with respect to actual flowrate .
The flowrate control determines the rate of pressure rise
before cycling occurs and thus provides control over the

length of the inspiratory phase. However, a change in lung

ch~risti~S"""~r-i~ihe cycling pressure also will have an

effect on inspiration time.

Air Mix Plunger

When the ventilator is powered with oxygen, the position of the air mix plunger determines whether the concentration of oxygen delivered through the circuit is 100% or a
mixture thereof.
When the plunger is moved to the IN position (Fig 26S,A), source gas is diverted away from the Venturi {1) and
directed through a small hole (5) behind a reed (9). In this
setting 100% oxygen is delivered to the patient circuit by
way of the hole behind the reed, the jet of the microneb~
ulizer, and the drain hole of the expiratory timer cartridge
(provided the expiratory timer control is turned on).
The pressure balance hole (1 I) is used to facilitate the
motion of the plunger and has no other function in the air
mix plunger assembly.
With the plunger pulled out (Fig 26-S,B) a mixture of
air and oxygen is delivered to the patient circuit. The gas
mixture is the result of
1. The Venturi jet, which is powered by oxygen and
entrains room air by way of the ambient filter
2. The jet of the micronebulizer, which delivers 100%
oxygen in the breathing manifold
3. The drain hole of the expiratory timer cartridge
(provi~ed the expiratory timer control is turned on)

4
10

333

11

FIG 26-5.
Air mix plunger assembly. 1, Venturi; 2, spring; 3, air mix plunger; 4, 0-ring seals; 5, hole (100% source gas);
6, source gas inlet; 7, Venturi jet; 8, Venturi gate; 9, reed ; 10, safety catch; 11 , pressure balance hole. (Courtesy
3M Canada Inc ., London, Ontario.)

---....
34

The Bird Ventilators

However, the delivered gas mixture does not remain

_,Jnstant throughout the inspiratory phase because of the
~haracteristics of the Venturi. For example, as pressure in
;e patient circuit increases, the air entrained by the Venturi
...e:radually decreases so that toward the end of the inspiratory
.rnase, most of the gas delivered through the patient circuit
-"',Pginates from the jet of the micronebulizer and from the
.urain hole of the expiratory timer cartridge. As a result, the
- xygen concentration rises progressively during the inspiratory phase as the air entrained by the Venturi gradually
~creases.

Furthermore, toward the end of the inspiratory phase,

,ost of the gas from the jet of the Venturi backs up and
_f!ushes the ambient compartment with oxygen. Conse""'ilently, the gas initially entrained by the Venturi during the
-"~.,ext inspiratory phase will be rich in oxygen.
During extended ventilatory support where the delivery
--t' predictable oxygen concentrations is desirable, the ventilator must be connected to an oxygen blender. The blender
,.. ~vailable from the manufacturer) is connected to the source
gas inlet of the ventilator as demonstrated in Figure 26-18.
~ deliver specific oxygen concentrations when the air mix
~unger is pulled out, a reservoir bag is connected over the
.nbient air inlet filter and filled continuously from the
.h~ender.

'

Venturi Gate

The Venturi gate operates as a spring-loaded check

' tlve and is used to isolate the pressure compartment from
the ambient compartment. The gate provides three func) ns.
_, During inspiration when the air mix plunger is pushed
:, the gate prevents back flow from the pressure compart-9ent to the ambient compartment, which would otherwise
--ieate a leak in the system and interfere with the pressure'cling mechanism.
' The gate is spring-loaded to close(= 1.5 to 2 em H 20)
that during the expiratory phase the patient's inspiratory
effort can generate enough subambient pressure to trigger
' e ventilator. Without the spring-loaded gate the patient
would inspire gas from the ambient compartment, and a
"""eak inspiratory effort might not generate enough subat_.IQospheric pressure (in the pressure compartment) to trigger
-ie ventilator.
,....., The gate also provides unidirectional flow to prevent
.dbreathing in the event that source gas to the ventilator
~.ils . Provided the inspiratory effort is great enough to overcome the resistance of the ventilator and the Venturi gate,
' e gate opens during a spontaneous inspiration and the
patient inspires room air from the ambient air inlet filter.
----.11ring exhalation the gate closes, and the patient exhales
~rough the exhalation valve. This feature is obviated under
.tal gas failure when an oxygen blender is used since the

reservoir bag connected over the ambient air filter will eventually empty.

Pressure Limit Arm

The pressure limit mechanism selects the pressure at
which the ventilator will cycle to end the inspiratory phase
and thus provides control over tidal volume. The scale for
the pressure limit control is generally used for reference .
However, when the ventilator is properly calibrated, setting
the pressure limit arm to number 15 (on the scale) coincides
with a cycling pressure of 15 em H2 0.
It should be remembered from Chapter 9 that when the
cycling pressure is held constant, the tidal volume will not
remain constant but will in fact vary with changes in lung
characteristics.

Sensitivity Arm
The amount of inspiratory effort required to trigger the
ventilator is controlled by adjusting the sensitivity arm. The
arm positions the sensitivity magnet closer to or away from
its corresponding clutch plate. The closer the sensitivity
magnet is moved toward the clutch plate, the greater the
effort required to trigger the ventilator, and vice versa. The
scale for the sensitivity arm i~ also used for reference, but
normally, when the arm is moved to the number 15 (on-the
scale), an inspiratory effort of - 1.5 em H 2 0 is required to
trigger the ventilator.

Expiratory Timer Control

This needle valve controls the leak from the expiratory
timer cartridge (as described earlier) and is used to automatically cycle the ventilator.

Pressure Manometer
The pressure manometer is situated in the ambient compartment but samples the pressure in the pressure compartment. In the Bird Mark 7 the manometer is calibrated in two
scales ranging from -10 to 60 em H 20, and -7 to approximately 45 mm Hg.
Classification

Inspiratory Phase
The classification of the ventilator in the inspiratory
phase depends on the position of the air mix plunger. With
the plunger rrioved to the ouT position, the Venturi is engaged, and the ventilator operates as a constant pressure
generator for most of the inspiratory phase. However, toward the end of the inspiratory phase when less gas is entrained by the Venturi, most of the gas delivered is from the
high pressure source, and the ventilator approaches the
characteristics of a flow generator.
With the air mix moved to the IN position, all of the gas
delivered through the patient circuit originates from the 50

Ventilators

335

psi (=3500 em H2 0) source, and therefore the ventilator

must be classified as a constant flow generator.

Changeover from Inspiratory Phase to Expiratory

Phase
The changeover is pressure cycled and occurs at the
moment the pressure developed in the pressure compartment reaches a value determined by the setting of the pressure limit control.
The hand timer rod also provides a means of manually
cycling the ventilator to the expiratory phase.
Expiratory Phase
Since there is no built-in PEEP mechanism, lung pressure
empties to atmospheric level during the expiratory phase, and
the ventilator operates as a constant atmospheric-pressure generator.
Changeover from Expiratory Phase to Inspiratory
Phase
The ventilator can be triggered by an inspiratory effort
or after a predetermined time has elapsed, whichever occurs
first. The changeover can also be accomplished ~anually by
pushing the hand timer rod.
Table 26-1 summarizes the classification of the Bird
Mark 7 ventilator.

THE BIRD MARK 8

The functional pneumatic characteristic of the Bird
Mark 8 ventilator (Fig 26-6) is identical to the Mark 7
except that the Mark 8 has the added capability of generating flow during the expiratory phase. The expiratory flowgenerating mechanism, called the negative interrupter cartridge, is shown schematically in Figure 26-7.
The negative interrupter cartridge (3) consists of a
diaphragm and spring-loaded plunger. During the inspiratory phase (Fig 26-7 ,A) the cartridge is charged with

TABLE 26-1.

FIG 26-6.
Bird Mark 8 ventilator.

source gas by way of the ceramic switch. This moves the

diaphragm and plunger to the right and occludes the
pathway of source gas (1) to the expiratory drive line (4).
During exhalation (Fig 26-7 ,B) gas to the cartridge is cut
off and the plunger moves to the left. This action causes
source gas to pass through the expiratory drive line at a
rate determined by the setting of the negative generator
valve (2).
. Flow through the expiratory drive line can be used to
power various pneumatic components in the patient circuit,
such as a negative Venturi. In Figure 26-8 the Venturi is
positioned in the breathing manifold so as to generate negative pressure during the expiratory phase. The negative
generator valve controls the ftowrate of gas through the
expiratory drive line and thus controls the subatmospheric
pressure generated.
Figure 26-9 gives a general overview of the pneumatic
components of the Bird Mark 8 ventilator and includes the
circuit containing the negative Venturi.

Classification-The Bird Mark 7 Ventilator

Inspiratory Phase
Changeover I to E
Expiratory Phase
Changeover E to I

Air

m:ix;IN

Constant pressure generator

Constant flow generator*
Pressure cycled
Manually cycled
Constant atmospheric-pressure generator
Patient cycled

Time cycled
Manually cycled

Classification
Apart from the expiratory phase, the classification of
the Mark 8 is the same as the Mark 7. During the expiratory
phase the Mark 8 has the added option of generating negative pressure in the patient circuit. Therefore the ventilator
must also be classified as a constant negative-pressure generator. Table 26-2 summarizes the classification of the Bird
Mark 8 ventilator.

336

The Bird Ventilators

8

--4

.---.__

FIG 26-7.
Flow diagram of negative interrupter cartridge in Bird Mark 8 ventilator during inspiration (A) and exhalation (B). See text for
description. I , source gas inlet; 2, negative generator valve; 3, negative interrupter cartridge assembly; 4, expiratory drive line .
(Courtesy 3M Canada Inc ., London, Ontario.)

INSPIRATION

EXHALATION

.\

FIG 26-8.
Mark 8 or Mark 9 breathing head assembly. 1, inspiratory drive line; 2, exhalation valve; 3, micronebulizer; 4 , mainstream line;
5, . test lung (patient); 6, expiratory drive line; 7, negative Venturi. (Courtesy 3M Canada Inc ., London, Ontario.)

Ventilators

EXHALATION

13
INSPIRATION

---=:::::::::17

FIG 26-9.
Pneumatic diagram of Bird Mark 8 ventilator. 1, source gas inlet; 2, negative generator valve; 3, Venturi; 4, ceramic switch; 5, negative
generator cartridge; 6, flowrate control; 7, air mix plunger; 8, expiratory timer control; 9, pressure clutch plate; 10, pressure magnet; 11,
pressure compartment; 12, expiratory timer cartridge; 13, inspiratory drive line; 14, mainstream line; 15, negative Venturi; 16, expiratory
drive line; 17, test lung (patient). (Courtesy 3M Canada Inc., London, Ontario.)

337

..../

38--,.

The Bird Ventilators

l'A-.. \ E 26-2.
:Ias~ification-The

TABLE 26-3.
Bird Mark 8 Ventilator

- ~-----------------------------------------

ns!J, atory Phase

----

: h. Jeover I to E

:::t ---..,eover E to I
'Air mix

Constant pressure generator

Constant flow generator*
Pressure cycled
Manually cycled
Constant atmospheric-pressure generator
Constant negative-pressure generator
Patient cycled
Time cycled
Manually cycled

Classification-The Bird Mark 9 Ventilator

Inspiratory Phase
Changeover I to E
Expiratory phase
Changeover E to I

IN

""""'

f .......l BIRD MARK 9

--..._

.The Bird Mark 9 ventilator (Fig 26-10) is similar to the

s ~ Mark 8. They differ in that the Mark 9 has the following modifications:

J . A larger pressure magnet to provide higher cycling

p. sures
.
.-4 The manometer is calibrated from - 30 tq 200 mm
ho
~ . The Venturi has a dual range and cannot be bypassed .
1uc:. air mix plunger is now used to select the range of flow.
l ' he ouT position (high range) the upper limit of flow is
2'12 L!min at a back pressure of about 40 mm Hg. In the low
r ..--..~e the limit is 200 L!rnin at 25 mm Hg. 3

-{.; assification
----.

The classification of the Bird Mark 9 is summarized in

T~e 26-3 , and except for the inspiratory phase, it is iden4:--dl to that of the Bird Mark 8. During the inspiratory phase
t' \.Mark 9 cannot be classified as a constant flow generator
because the Venturi cannot be bypassed. Since the pressure
[ --..,erated by the Venturi is not very high , the ventilator
operates as a constant pressure generator for most of the
~ piratory phase.

FIG 26-10.
Rird Mark 9 ventilator.

'QIE BIRD MARK 10

-... The Bird Mark 10 (Fig 26-11) operates in the same
tushion as the Bird Mark 7 except that the Mark 10 has no
. mix plunger and therefore is set permanently on air
olfution. The Mark 10 has the added feature of automati,ly accelerating the flowrate toward the end of the inspiratory phase to compensate for leaks in the circuit.
~... Figure 26-12 demonstrates the essential components
of the leak-compensating mechanism. During inspiration
_Jurce gas (J) travels through the ceramic switch (6), pres..:.Irizes the diaphragm in the flow interrupter cartridge (5),
.... 1d powers the Venturi (3). When the terminal flow control

FIG 26-11.
Bird Mark 10 ventilator.

Constant pressure generator

Pressure cycled
Manually cycled
Constant atmospheric-pressure generator
Constant negative-pressure generator
Patient cycled
Time cycled
Manually cycled

Ventilators

339

I
I

-'FWi
J l ~.if
l

I. !

FIG 26-12.
Flow accelerator mechanism of Bird Mark 10 ventilator. A, 'Inspiratory phase, terminal flow control off. B, Inspiratory phase, terminal flow control
on. 1, Source gas inlet; 2, terminal flow control; 3, Venturi; 4, flow accelerator cartridge; 5 , flow interrupter cartridge; 6, ceramic switch. (Modified
from original. Courtesy 3M Canada Inc., London, Ontario .)

(2) is turned off, as in Figure 26-12, A, source gas is

prevented from pressurizing the diaphragm in the flow accelerator cartridge (4), and the ventilator operates in the
normal way.
When the terminal flow control is turned on (Fig 2612,B), source gas travels through the terminal flow control,
past the plunger in the flow interrupter cartridge and begins
to pressurize the diaphragm in the flow accelerator cartridge. Toward the end of inspiration, when the diaphragm
and plunger are moved completely to the left (Fig 26-13,
A), source gas travels past the plunger of the flow accelerator cartridge and augments the gas flow powering the jet of
the Venturi. This added flow increases the Venturi's output,
and the sudden back pressure generated in the pressure compartment cycles the ventilator to the expiratory phase.
During exhalation the diaphragm in the flow interrupter
cartridge is depressurized, and a spring moves the plunger
backward, allowing the gas from the terminal flow control
to drain into the ambient compartment by way of a bleed
hole in the interrupter cartridge (Fig 26-13,B).

Classification
The classification of the Bird Mark 10, as summarized
in Table 26-4, is similar to the Mark 7 with only one exception. Because the ventilator is on permanent air dilution,
the pressure generated by the Venturi is usually not very

high, and the ventilator operates as a constant pressure generator for most of the inspiratory phase.

THE BIRD MARK 14

The functional pneumatic characteristics of the Bird
Mark 14 (Fig 26-14) are nearly identical to those described
for the Mark 10. The only difference between th~ two is that
the Mark 14 has a larger pressure magnet and thus a greater
cycling pressure capability. Apart from this and a pressure
manometer calibrated between - 30 and 200 mm Hg, there
is little difference between the ventilators. The classification
of the Bird Mark 14 is summarized under the same heading
as the Mark 10.

BIRD CIRCUITS
Standard Breathing Head Assembly
The standard assembly, shown in Figure 26-15, consists of an exhalation valve and a rnicronebulizer. During
inspiration the inspiratory drive line (1) powers the micro nebulizer and pressurizes the exhalation valve. The mainstream
line (3) provides the bulk flow for lung inflation. During
exhalation gas to both lines is cut off, and the exhalation
valve empties through the jet of the rnicronebulizer.

.;