Functional

Classification of Ventilator
Modes

Classification of ventilator
modes
Rationale - why classify modes of
ventilation rather than ventilators?
Criteria - how we define the different
types of breaths delivered with
mechanical ventilation?
Modes - what are the types of breaths
in the various breathing patterns?

Why classify modes?

More practical to describe delivered
breathing patterns than the internal
mechanisms of ventilators.
Old classification system grouped
ventilators according to their internal
mechanism of gas delivery.
The internal mechanism of the ventilator
determined the breathing pattern.

Current ventilators are

microprocessor controlled
Breathing patterns are a matter of the
software algorithms or if-then logic.
Software updates can quickly change
ventilator mode capabilities.
Think of current ventilators as having
three parts:
Computer
(timer)

Flow control
valve

Pressure
regulator

As a rule the computer is

programmed to control one
variable at a time.
The flow control valve for flow or volume
controlled ventilation.
The pressure regulator for pressure controlled
ventilation.
Time

Clinically important to know

whether the ventilator breath
is pressure controlled or
volume/flow controlled.

So how do you know what type

of ventilator breath is delivered?
Black Box
Input

[source gas
& electricity]

Ventilator
Control
System

Output
Analyze
Waveforms
[Flow,
Pressure]

You know what type of

ventilator breath is delivered
by the change in output.
Monitor the ventilator pressure and
flow waveforms when it is connected
to a test lung with normal compliance
and resistance.
Then change test lung to low C and
high R settings.
Which output waveform changes?
Pressure or flow?

Example
volume

flow

pressure

normal compliance

compliance

In volume controlled
ventilation,
the pressure developed during
inspiration must vary
with changes in the patients
compliance or resistance.

Example
flow

PIP
pressure

PIP

normal compliance

compliance

Volume control
Ventilator typically controls flow.
Flow over time = volume.
Since the flow pattern is controlled it
can be set as a:
Square or rectangular
Descending ramp
Sine

Now what has changed?

flow

pressure

normal compliance

compliance

In pressure controlled
ventilation,
the delivered tidal volume (or
flow) must vary
with changes in the patients
compliance or resistance.

Decreased flow = decreased volume

flow

pressure

normal compliance

compliance

In pressure controlled
ventilation:
The inspiratory pressure level or
limit is set.
The flow waveform is not controlled
by the ventilator.
Flow will vary as a function of the
difference in pressure between the
ventilator and the patients airway.

Chatburns Classification
System
Control system*
Phase variables
Conditional variables
Alarm systems

Ventilator control systems

Open or closed?
Closed feedback loop allows ventilator to
maintain preset parameters despite
changes in the patients lung compliance
or airway resistance.
For example 900C has 3 feedback loops
Inspiratory flow
Inspiratory pressure
Expiratory pressure

Closed Feedback Loop

Desired
Output

Comparison

Control circuit

Measurement

Actual
Output

Pressure regulated volume

control mode on the Servo 300
More appropriate to call it volume targeted
pressure control.
Its an example of pressure controlled
ventilation with a closed feedback loop for tidal
volume.
Breaths are pressure controlled - flow varies
with changes in C & R.
Ventilator automatically adjusts the level of
pressure control to maintain volume target.

The control variable can also

change within a breath.
In pressure augmentation the breath is
pressure controlled unless the target
volume is not reached
If the flow falls to the set peak flow rate
and the set volume has not been reached,
the computer switches to volume control
at the peak flow rate until the volume is
delivered.

Open control circuit

Desired
Output

Control Circuit

Actual
Output

Older ventilators
No automatic ventilator adjustments

Chatburns Classification
System
Control system
Phase variables *
Conditional variables
Alarm systems

Phase variables
trigger - Changeover from expiration
to inspiration (A)

limit - Inspiratory phase (I)

cycle - Changeover from inspiration to
expiration (B)
baseline - pressure during expiration
(E)

Phase variables (cont.)

E

I
p
r
e
s
s
u
r
e

TIME

Trigger
Patient initiated breaths are pressure or
flow/volume triggered.
Machine initiated breaths are time
triggered.
Old terminology called patient triggered
breaths assisted breaths and machine
triggered breaths controlled breaths.

Limit
Limit is a variable that is attained during inspiration
that does not end inspiration.
Typically the limit is what the ventilator controls
during inspiration and may be the control variable.
Volume limited inspirations require that the ventilator
controls flow/volume.
Pressure limited inspirations require that the ventilator
controls pressure.

Alarm limits are different. Alarm limits typically end

inspiration when reached. Ex, high airway pressure
alarm limit will end inspiration if the airway
pressure during an inspiration reaches the limit.

Control variable
Pressure control
Operator sets the pressure limit.
Inspiratory pressure does not go above
set pressure limit during inspiration.

Volume control
Operator sets tidal volume limit.
Inspiratory volume does not go above
set volume limit during inspiration

The control or limit variable does not

end inspiration!

Cycle
The parameter that ends inspiration: time,
volume, flow or pressure.
For example, pressure controlled breaths
are pressure limited and time cycled.
Volume controlled breaths are volume
limited and also may be time cycled.
Few critical care ventilators are pressure
cycled.

Baseline pressure
Refers to the lowest pressure during
exhalation.
Set by the PEEP or CPAP level.

Chatburns classification defines 2

breath types based on the phase
variables.
Mandatory breaths

Patient or machine triggered

Ventilator limited
Ventilator cycled

Spontaneous breaths
Patient triggered
Patient or ventilator limited
Patient cycled

A functional classification of
modes describes the breath type.
Does the ventilator do most of the
work of breathing?
Mandatory breaths
CMV or A/C
Volume Control
Pressure Control

Pressure Regulated Volume Control

(PRVC)

Or does more of the work of

breathing depend on the patient?
Spontaneous breaths
Pressure Support
CPAP
Bilevel
Airway Pressure Release Ventilation
(APRV)* - *may be more like pressure
control if there are frequent releases
to baseline.

Chatburns classification system

of breath types:
Based on the Equation of Motion
Pressure RespMus + Pressure Vent = PIP =
Volume

Compliance

Raw x Flow rate

Example
Peak Inspiratory Pressure =
800 ml

(20 cm H20/L/s x 1 L/s)

20 ml/cmH20
Peak Inspiratory Pressure = 60 cm H 20

The 60 cm H20 needed to deliver 800 mL

can be generated by the ventilator alone,
(mandatory)

ventilator
60 cm H20

diaphragm
0 cm H20

Or the 60 cm H20 needed to deliver 800 mL

can be generated by the patient alone,
(spontaneous)

ventilator
0 cm H20

diaphragm
60 cm H20

Or by a combination of both the ventilator

and the patient.

ventilator
50 cm H20

diaphragm
10 cm H20

Modes that allow both mandatory

and spontaneous breathing
Synchronized Intermittent Mandatory
Ventilation (SIMV)
Spontaneous breaths in between ventilator breaths.

The lower the SIMV rate, the greater the

patients work of breathing

Or Minimum Mandatory Ventilation (MMV)

Spontaneous breathing as long as the
specified minute ventilation is maintained.
May promote shallow rapid breathing

Conditional Variables
Determine breath to breath changes
Or within breath changes
Another example of the if-then
condition.
Example, in IMV mode if a mandatory
breath has already been delivered,
then the patient is allowed to breathe
spontaneously.

Assist-Control

P
r
e
s
s
u
r
e
IMV

P
r
e
s
s
u
r
e

Why isnt B pressure support?

Pressure waveform is not rectangular.

Modes
Continuous Mandatory
Ventilation (CMV)
Pressure Controlled
Volume Controlled

Intermittent Mandatory
Ventilation (IMV)
Mandatory and spontaneous

Spontaneous Ventilation
CPAP
Pressure support
Bilevel

Pressure Support
Considered a spontaneous mode of
ventilation
Patient must trigger the PS breath
Ventilator limits the level of inspiratory
pressure (PS level)
Patient cycles (ends) breath since PS
breaths end when a predetermined
flow is reached.

According to Chatburns
classification system, each
ventilator breath may have a
different set of control and
phase variables depending on
the mode of ventilation.

 Control Variables
Pressure
Volume
Flow

Phase Variables
Trigger
Limit
Cycle
Baseline

Conditional Variables
Sequence of different breath

types

PS
APS

MMV

PEEP

PS

PAV

APS
CAP

CSV

PT
IMV

MT
PEEP

PT

TC

PS

CSV

CT
MT

MT

IMV

VC PC
CMV

PS
CT

CMV
PT

CT

MT

PEEP
PEEP

PS

In summary
what used to be classified as a volume
cycled, constant flow generator with
assist/control mode would now be
called a volume cycled, flow-controller,
with continuous mandatory ventilation.
The new classification system provides
a way to describe the latest modes.

What mode is this?

What mode is this?

Whats this?

Whats this?
SIMV in PC with PS

PC machine
breath

PS

PS

PC machine
breath

Whats this?

Bilevel