VENTILATOR TRANSPORT :

mode and setting

Telly Kamelia
Pulmonology Division
Internal Medicine Department
Universitas Indonesia, School of Medicine
Dr. Cipto Mangunkusumo Hospital, Jakarta
 Commercial masks

Nasal masks Nose & Mouth masks Mouth masks

Nasal pillows Nasal masks Midi nasal masks Total masks Face masks Oracle
Mouth piece
Adams Ultra Mirage Comfort Curve NIV Helmet or Hood Comfort Full face
Breeze Comfort plus Simplicity Total Full Face Ultra Mirage
Swift Mirage Vista
Comfort Lite Profile Lite Mojo
Comfor Gel

Custom made masks Tracheostomies

Silicone masks

Gel masks
 No headgear
required
Must have good
teeth

A variety of mouth
pieces can be used for
Sip Ventilation.
 Selecting the right mask
1 Type of ventilator to be used:

Bi level ventilation can use a vented

mask or a vented circuit.

Built in exhale vents

Clinical situation: Hospital issues:
acute staff training
chronic local expertise
weaning availability

Choice
of
ventilator
Technical issues: Security issues:
leak compensation internal battery
different modes monitoring
PEEPe alarms
 portable ICU
Mode availability limited maximal
Monitoring limited expanded
Alarm function limited expanded
Handling simple complex
Trigger problems rarely possible
Leak compensation frequently limited
Oxygen blender depending always
CO2 re-breathing potentially no
Weight light heavy
Costs less expensive expensive
ASB Assisted Spontaneous Breathing -- untersttzte Spontanbeatmung, auch ASV = Assisted
Spontaneous Ventilation
ASV Adaptive Support Ventilation -- closed-loop Beatmung, weiter entwicklung von MMV
PSV Pressure Support Ventilation -- untersttzte Spontanbeatmung, siehe auch ASB
APRV Airway Pressure Release Ventilation
CPAP Continuous Positive Airway Pressure -- kontinuierlicher positiver Atemwegsdruck
BIPAP Biphasic Positive Airway Pressure -- zweiphasische positive Atem-Druckunterstzung
CPPV Continuous Positive Pressure Ventilation -- kontinuierliche berdruckbeatmung
CMV Continuous Mandatory Ventilation -- kontinuierliche, vollstndig mechanische Ventilation
PCMV (P-CMV) Pressure Controlled Mandatory Ventilation -- druckgesteuerte, vollstndig
mechanische Ventilation
VCMV (V-CMV) Volume Controlled Mandatory Ventilation -- volumengesteuerte, vollstndig
mechanische Ventilation
PC Pressure Control -- druckgesteuerte, vollstndig mechanische Ventilation
PCV Pressure Controled Ventilation -- druckgesteuerte, vollstndig mechanische Ventilation
VCV Volume Controled Ventilation -- volumengesteuerte, vollstndig mechanische Ventilation
S-CPPV Synchronized Continuous Positive Pressure Ventilation -- synchronisierte kontinuierliche
berdruckbeatmung
EPAP Expiratory Positive Airway Pressure -- positiver exspiratorischer Atemwegsdruck
HFPPV High Frequency Positive Pressure Ventilation -- Hochfrequenzberdruckbeatmung
HFOV High Frequency Oszillatory Ventilation -- Hochfrequenzbeatmung
HFV High Frequency Ventilation -- Hochfrequenzbeatmung
ILV Independent Lung Ventilation -- seitengetrennte berdruckbeatmung
IPAP Inspiratory Positive Airway Pressure -- positiver inspiratorischer Atemwegsdruck
IPPV Intermittend Positive Pressure Ventilation -- intermittierende berdruckbeatmung
S-IPPV Synchronized Intermittend Positive Pressure Ventilation -- synchronisierte intermittierende
berdruckbeatmung
IRV Inversed Ratio Ventilation -- Beatmung mit umgekehrten Atemphasen/Zeit-Verhltnis
LFPPV Low Frequency Positive Pressure Ventilation -- Niedrigfrequenzberdruckbeatmung
MMV Mandatory Minute Volume -- (vorgegebenes) maschinelles Minutenvolumen
PEEP Positive Endexpiratory Pressure -- positiver endexspiratorischer Druck
PNPV Positive Negative Pressure Ventilation -- Wechseldruckbeatmung
(S)IMV (Synchronized) Intermittent Mandatory Ventilation -- (synchronisierte) intermittierende
maschinelle Beatmung
ZAP Zero Airway Pressure -- Spontanatmung unter Atmosphrendruck
PPS Proportional Pressure Support -- proportionale druckuntersttzte Beatmung
ATC Automatic Tube Compensation -- Automatische Tubuskompensation
 ASSISTED MANDATORY

PRESSURE PSV PCV

CYCLE
VOLUME VSV VCV
CYCLE
 assisted mandatory

(CPAP) PSV/BiPAP-ST/ASB, PCV, PAV

Pressure Minimum breathing frequency set at the ventilator is higher
PSV/BiPAP-ST/ASB, PCV, PAV than the breathing frequency of the patient.
controlled Minimum breathing frequency set at the ventilator is lower
than the breathing frequency of the patient.

Volume VCV, V-CMV VCV, V-CMV

Minimum breathing frequency set at the ventilator is lower Minimum breathing frequency set at the ventilator is higher
controlled than the breathing frequency of the patient. than the breathing frequency of the patient.
 Important parameters
given - dependent

Inspiratory pressure
Exspiratory pressure
Driving pressure
Peak pressure
Breathing frequency
Tidal volume
Trigger sensitivity
Flow during Inspiration
Inspiration/Exspiration ratio; (Inspiration time)
Oxygen supplementation
Ventilation: mandatory versus assisted
 Ventilation: mandatory versus assisted

Mandatory ventilation Assisted ventilation

No action by the patient. Inspiratory efforts decrease pressure

in the mask and causes air flow in the circuit
> triggering of the ventilator.
Volume controlled ventilation
(VCV, V-CMV, MMV)

Set parameters:
tidal volume: 750 ml
breathing frequency 20/min
Peak flow: 70 l/min
PEEP 7 mbar

Dependent parameters:
Inspiratory pressure
flow
Pressure controlled ventilation
(PSV, PCV, BiPAP, ASB, PAV)

pressure rise exspiration

peak flow

inspiration inspiration
starts ends
Pressure controlled versus
Volume controlled
 CPAP
(continuous positive airway pressure)

pressure
[cmH2O]

time
[s]

pressure
[cmH2O]

CPAP continuous positive airway pressure

time
[s]
 CPAP
(continuous positive airway pressure)

continuously increased intrathoracic pressure

recruitment of atelectases
elevation of Functional Residual Capacity
improved haemodynamics in heart failure patients
Pressure controlled ventilation
(Pressure Support Ventilation PSV, BiPAP, ASB)

Set parameters:
Inspiratory pressure 20 cmH2O
PEEP 5 cmH2O
trigger sensitivity

Dependent parameters:
Tidal volume
Breathing frequency
I:E ratio
flow during in-/exspiration
 Pressure controlled ventilation
with backup (minimum) breathing frequency
(BiPAP-ST)

Set parameters:
Inspiratory pressure 20 cmH2O
PEEP 5 cmH2O
trigger sensitivity
minimum breathing
frequency 12/min
5s
5s
5s
5s Dependent parameters:
Tidal volume
Breathing frequency
I:E ratio
flow during in-/exspiration
 Pressure controlled ventilation
with minimum inspiratory time
(Pressure Controlled Ventilation, PCV)

1 sek
Set parameters:
Inspiratory pressure 20 cmH2O
PEEP 5 cmH2O
inspiratory time 1s

Dependent parameters:
Tidal volume
Breathing frequency
I:E ratio
flow during in-/exspiration
Pressure controlled ventilation
with volume compensation
(AVAPS, IVAP,.)

Set parameters:
Inspiratory pressure 20 cmH2O + 7
PEEP 5 cmH2O
minimum breathing frequency 12/min
minimum tidal volume: 400 ml
temporary increase of the inspiratory
pressure by 7 cmH2O to achieve
minimum tidal volume

Dependent parameters:
Tidal volume
Breathing frequency
I:E ratio
flow during in-/exspiration
 Proportional Assist Ventilation
(PAV)

Proportional Assist Ventilation provides dynamic pressure support

adjusted to the inspiratory effort of the patient.

The adverse effects of pathologic changes of the lungs with

increased Elastance (E) and Resistance (R) shall be balanced by PAV.

Target: Pressure support of the patients breathing with

optimized reduction of the work of breathing.
 Proportional Assist Ventilation
(PAV)

Conventional ventilator:

1. triggering
2. Continuous rise of pressure
 Proportional Assist Ventilation
(PAV)

PAV:

2. frequent assessments of the patients ventilatory

effort, and adaptation of pressure and flow to
1. triggering achieve optimized ventilatory support
by the ventilator.
Volume pre-set (VCV) Pressure pre-set
Constant inspiratory volume, (PCV/PSV)
Varying inspiratory pressure Varying inspiratory volume,
Constant inspiratory pressure

Advantage:
Stability of tidal volume even Advantage:
in case of increased airway Compensation for leakage,
resistance Best tolerated

Disadvantage: Disadvantage:
high inspiratory pressure, Instability of tidal volume
No leak compensation in case of increased airway
Home ventilation in Europe

Volume

Pressure

Lloyed-Owen et al. Eur Respir J 2005, 25: 1025-1031

100
90
80
70
60
50
40
30
20
10
0
1990 1992 1994 1996 1998 2000
Volume pre-set
Pressure pre-set spontaneous mode
Pressure pre-set controlled or assist-controlled mode

Schnhofer ERS Monograph 2001; 16: 259-273

 without leakage with leakage

small leak

huge leak

Pre-set Pressure Vol Pressure Vol

Mehta et al. Eur Respir J 2001; 17: 259-2

Volume versus pressure:
No differences in:
Improvements in sleep quality
Improvements in blood gases
But:
More side effects during volume pre-set

Windisch et al. Respir Med 2005; 99: 52-59

12 patients with chest wall deformity
already receiving pressure controlled ventilation (NIPPY 1)

Tuggey et al. Thorax 2005; 60: 859-864

Tuggey et al. Thorax 2005; 60: 859-864
Volume versus pressure:
No differences in:
Sleep quality
Blood gases
Quality of life
Physical activity
Spontaneous breathing

Tuggey et al. Thorax 2005; 60: 859-864

Higher leak volumes during pressure support

PSV/PCV: Increase in delivered inspiratory volume

in case of leakage

?
Increase in tidal volume Increase in leak volume

Tuggey et al. Thorax 2005; 60: 859-864

 Interaction

physiological Ventilator
respiratory
pump
 4 Phases

Pressure
1. Inspiratory
triggering

2. Inspiration
Flow
3. Termination
of inspiration

Volume 4. Expiration

Zeit
Nilsestuen et al. Resipr Care 2005; 50:202-23
Asynchrony between patient and ventilator
Problems:
Increased work of breathing
Need for sedation
Fighting the ventilator
Ventilation-Perfusion-Mismatch
Dynamic hyperinflation

Consequences:
Insuffizient ventilation
Withdrawal from NIV
Weaning failure
Prolonged ICU stay
Costs
Prognosis !
physiological respiratory ventilator
pump

work of breathing

spontaneous supported assisted controlled

 trigger insensitive Sensitive auto-
asynchrony trigger trigger triggering

trigger sensitivity to low

high level of PSV trigger sensitivity to high
hypercapnic encephalopathy
resistance changes
sedation
tubing leakage
sleep
intrinsic PEEP (COPD) cardiac oscillation
leakages (NIV)
tubing obstruction
 Basic set-up

Aims
subjective objective

improve improve
symptoms blood gases
 High inspiratory pressures
- negative consideration -

increase in high mask pulmonary gastric

leakage pressure hyperinflation distension

Discomfort / ineffective ventilation

Withdrawal of NIV
 High inspiratory pressures
- positive consideration -

augmentation of muscle
alveolar ventilation rest

Comfort / effective ventilation

Continuation of NIV
Bi-level positive pressure devices: settings
Pressure support: fixing EPAP and IPAP

EPAP: Expiratory Positive Airway Pressure

IPAP: Inspiratory Positive Airway Pressure
[IPAP EPAP] = PS (Pressure support)
Inspiration Flow

0
Expiration

IPAP

PAW

PS
EPAP

0
Inspiration Expiration
 How do I set the IPAP value?

IPAP: Inspiratory Positive Airway Pressure

IPAP EPAP = Pressure support (or PS)
PS = pressure support provided to the respiratory muscles to compensate for their
weakness and correct alveolar hypoventilation
In a given subject, relationship between PS and tidal volume (VT) is linear
Limits: leaks, tolerance, glottic closure
 How do I set the IPAP value?

Titration of PS must aim to:

- normalize PCO2 (Arterial blood sample or PtcCO2) and/or
- obtain a target VT of 7-8 ml/kg of ideal body weight
NB: Reliability of estimation of tidal volume (VT) by ventilator softwares varies
considerably from one device to another, and depends on pressure levels and leaks
 How do I determine the optimal EPAP value?

EPAP: Expiratory Positive Airway Pressure

Maintaining an expiratory flow through tubing mandatory to washout expired CO2
from single tube circuits and masks
EPAP increases FRC (improves ventilation in obese subjects)
EPAP prevents collapse of upper airways in subjects prone to sleep apnea-hypopnea
syndrome ( Pneumatic splint )
EPAP counteracts the negative effect of PEEPI on work of breathing
 How do I determine the optimal EPAP value?

Overlap syndromes and patients with sleep apnea-hypopnea syndromes: EPAP values
must be adjusted to stabilize upper airway
PEEPI: rarely > 4 cmH2O in COPD (but reported by group of Nicholas Hart as
potentially reaching 6-8 cmH2O); PEEPI also present in severe obesity (OHS)
KEY
 Advantages of Each Mode

Mode Advantages

Assist Control Ventilation (AC) Reduced work of breathing compared to

spontaneous breathing

AC Volume Ventilation Guarantees delivery of set tidal volume

AC Pressure Control Ventilation Allows limitation of peak inspiratory

pressures

Pressure Support Ventilation (PSV) Patient comfort, improved patient

ventilator interaction
Synchronized Intermittent Mandatory Less interference with normal
Ventilation (SIMV) cardiovascular function
 Disadvantages of Each Mode
Mode
Assist Control Ventilation (AC)
AC Volume Ventilation
AC Pressure Control Ventilation
Pressure Support Ventilation (PSV)
Synchronized Intermittent Mandatory
Ventilation (SIMV)
Disadvantages
Potential adverse hemodynamic effects,
may lead to inappropriate
hyperventilation
May lead to excessive inspiratory
pressures
Potential hyper- or hypoventilation with
lung resistance/compliance changes
Apnea alarm is only back-up, variable
patient tolerance
Increased work of breathing compared to
AC